Health Related Quality of Life among Older People with Vision Impairment John E. Crews, DPA CDC’s...
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Transcript of Health Related Quality of Life among Older People with Vision Impairment John E. Crews, DPA CDC’s...
Health Related Quality of Life among Older
People with Vision Impairment
John E. Crews, DPACDC’s Vision Health Initiative
November 6, 2015
National Center for Chronic Disease Prevention and Health Promotion
Vision Health Initiative
Quotidian
Outline
Describe public health model Populate model with vision examples Surveillance Introduce WHO ICF Framework Vision & eye health disparities Vision and Health-Related Quality of Life Implications of findings for Vision Rehab Intervention & intervention design Begins to tell the complex story of aging
and vision impairment
Public Health MonitoringSurveillance
Public Health ResearchRisk/Disparity
Public Health InterventionWhat works?
Public Health ImpactImplementation
Problem Response
Public Health Model
Surveillance
• Surveillance is the foundation of public health
• Population based• Driven by rigor and science• Cannot underestimate or over estimate a
problem• Without sound surveillance, all other
decisions may be incorrect
6
How many people experience vision impairment??
7
Population Estimates
• Prevalence and estimated population of people who are visually impaired remains problematic
• 3.3 million (40+) (Eye Diseases Prevalence Research Group, 2004)
• 5.7 million (65+) (Crews, Jones, & Kim, 2006)• 14 million (12+) (Vitale, Cotch, & Sperduto,
2006)• 21.2 million (18+) (Pleis & Lethbridge-Cejku,
2007) • Desire to have large numbers
Estimate depends on what you ask
• Disease: macular degeneration, cataract (cataract removed), glaucoma – Self report vs clinical examination
• Impairment: difficulty seeing• Activity performance: read newspaper print,
recognize friend across the street• Environment: Can you drive at night in unfamiliar
neighborhoods?• No gold standard question for vision surveys
9
Surveillance Gap
• No vision surveillance system in the US.• Therefore, no systematic effort to
harmonize questions, create conceptual clarity, or establish comparability.
• Consequences:– Vision public health research appears
fragmented.– Creates distinct disadvantage to inform
decision making.
10
Supplement to American Journal of Ophthalmology
Convened national/international panel of experts
Identified strategies to improve vision surveillance in US
Papers address disparities
Guide investigators and encourage harmonization of vision data
Forecasting studies
• Cases of cataract expected to increase from 20.5 million to 30.1 million from 2010 to 2020.
• Glaucoma is expected to increase from 2.2/2.7 million to 7.3 million in 2050.
• Cases of early macular degeneration expected increase from 9.1 million in 2010 to 17.8 million in 2050.
• Diabetic retinopathy will triple from 5.5 million cases in 2005 to 16 million in 2050.
Status of Vision Surveillance
• Recall surveillance is foundation of public health.
• Substantial knowledge base, but, perhaps, not organized in way to move a public health agenda.
• Existing knowledge makes case for the magnitude of the problem.
13
Public Health MonitoringSurveillance
Public Health ResearchRisk/Disparity
Public Health InterventionWhat works?
Public Health ImpactImplementation
Problem Response
Public Health Model
Are people with vision impairment different from the general population?
15
Risk/ Disparity/ Effects of Vision Impairment
Second step in the public health model is to determine whether or not a problem is evenly distributed across the population
Age group, gender, race/ethnicity , co-morbidity, health behaviors, health outcomes, SES Status, social outcomes, quality of life, health-related quality of life.
Accounts for much research in vision Identifies where the action is. Targets
interventions.
Self reported no, little, & moderate/severe difficulty seeing by age
BRFSS, 2006-2010
Severity of Vision Impairment by Sexfor People Aged ≥65 Years
BRFSS. 2006-2010
Severity of Vision Impairment by Race/Ethnicity for People Aged ≥ Years
BRFSS, 2006-2010
Vision Impairment and Co-morbid Conditions
• Represents huge emerging issue• Represents another range of
disparities• Vision largely excluded from
initiatives to address multiple chronic conditions (MCCs)
20
Rank Diseases Present % w/ both
1 Arthritis, visual impairment 44
2 Visual impairment, high blood pressure 40
3 Arthritis, high blood pressure 34
4 Any heart disease, visual impairment 17
5 Visual impairment, hearing loss 15
6 Any heart disease, hearing loss 14
7 Any heart disease, HBP 13
8 Arthritis, hearing loss 12
9 Diabetes, visual impairment 12
10 Cancer, visual impairment 10
Comorbid Chronic Conditions Among Women aged 65+
Fried, at al, 1999
Findings from NHIS
NHIS Vision Questions: Do you have any trouble seeing, even when wearing
glasses or contact lenses?
Are you blind or unable to see at all?
14.6% report trouble seeing or blind
Prevalence of eight chronic conditions among people aged ≥65 years
Hyper
tent
ion
Heart
Disea
se
Stro
ke
Arth
ritis
Asth
ma
Cance
r
Kidn
ey
Diabe
tes
0
10
20
30
40
50
60
7061.8
29.9
8.6
50.3
10.7
23.6
4.3
19.8
23
Data source: NHIS, 2007-2011
Prevalence of eight chronic conditions among people aged ≥65 years
Hyper
tent
ion
Heart
Disea
se
Stro
ke
Arth
ritis
Asth
ma
Cance
r
Kidn
ey
Diabe
tes
0
10
20
30
40
50
60
7061.8
29.9
8.6
50.3
10.7
23.6
4.3
19.8
24
Data source: NHIS, 2007-2011
• What is the prevalence of vision impairment among people with chronic diseases?
25
Percent of people age ≥65 years with chronic conditions reporting vision
impairment
Hyper
tens
ion
Heart
Disea
se
Stro
ke
Arth
ritis
Asth
ma
Cance
r
Kidn
ey
Diabe
tes
0
5
10
15
20
25
30
35
16.419.5
25.5
18.3 19.916.4
29.4
19.9
26Data source: 2007-2011 NHIS
Percent of people with chronic conditions reporting vision
impairment
Hyper
tens
ion
Heart
Disea
se
Stro
ke
Arth
ritis
Asth
ma
Cance
r
Kidn
ey
Diabe
tes
0
5
10
15
20
25
30
35
16.419.5
25.5
18.3 19.916.4
29.4
19.9
27Data source: 2007-2011 NHIS
Percent of men & women with chronic conditions reporting vision impairment
0
5
10
15
20
25
30
35
14.616.4
23.4
16.6 16.7 15.3
29.3
17.3
17.8
22.9
27
19.321.7
17.4
29.5
22.2
MenWomen
28
Differences Significant for hypertension, heart disease, arthritis, asthma, & diabetes. Data source: 2007-2011 NHIS
Percent of men & women with chronic conditions reporting vision impairment
0
5
10
15
20
25
30
35
14.616.4
23.4
16.6 16.7 15.3
29.3
17.3
17.8
22.9
27
19.321.7
17.4
29.5
22.2
MenWomen
29
Differences Significant for hypertension, heart disease, arthritis, asthma, & diabetes. Data source: 2007-2011 HNIS
Prevalence of vision impairment among people w/ chronic conditions by age group
Hyper-tension
Heart Dis-ease
Stroke Arthri-tis
Asthma Cancer Kidney Dia-betes
65-74 14.4 17 24 16 18.6 13.4 26.7 19.2
75-85 16.7 19.4 23.9 18.2 20.2 16.7 29 19.5
85+ 24.6 27.1 32.4 27.7 28 26 38 25.8
2.5
12.5
22.5
32.5
65-74 75-85 85+
So . . .
• What are the effects of comorbid conditions among people with vision impairment?
31
Prevalence of self-reported fair/poor health among people with chronic conditions w/ and w/o vision
impairment
Hyper
tens
ion
Heart
Dis...
Stro
ke
Arth
ritis
Asth
ma
Cance
r
Kidn
ey
Diabe
tes
0
10
20
30
40
50
60
70
80
25.8
38.744.5
27.232.8
24.5
57.6
36.8
46.5
61.4 57.8
47.755.6
44.6
72.6
57.5
No VIVI
32
Data source: NHIS 2007-2011
International Classification of Functioning, Disability and Health
33
Historical struggle to understand disablement
Social & policy efforts have struggled to describe and respond to disability (cognitive, sensory, & mobility limitations).
Shame, isolation, removal, institutionalization, discomfort, fear
Civil War and WW-I response—institutional care
WW-II—employment, reintegration Developmental disabilities--removal Vietnam—civil rights
Models of Disablement
Nagi’s disablement model,1960s ADLs—Katz: bathing, toileting, dressing,
eating IADLs—Lawton: housework, meds, money,
shopping Disability as consequence of disease/ injury Linear models; Disability ≠ disease WHO 2001 International Classification of
Functioning, Disability and Health
Experience of Disability led to Social Model of Disability
Disability is dimensional
Disability is dynamic
Disability Research & Interventions must embrace these qualities
Fit between the person and the environment
Goals of public health
Prevent disease, injury, and disability Uneasy relationship with disability People with disabilities, including people
with vision impairment, are largely viewed as a failure of public health
And therefore, not of interest.
Vision’s Place in This Debate
Vision impairment is generally the negative outcome—to be avoided
Much confusion within the discipline regarding what we mean by “vision” or “vision impairment
Disease, function (20/200), activity (read), work disability (participation)
No gold standard vision questions If reframed, I can show place of vision
impairment in public health
Impairment of Structure or
Function
Activity Limitation
Participation Restriction
Disorder/Disease ICD-9/10
Personal Factors
Environmental Factors
ICF Conceptual Model
17
Functioning at Body, Person, and Societal Levels
• Disease/Disorder--ICD 9 • Body Function and Structures
– Impairments focused on body systems• Activities
– Activity limitations —e.g., self care, mobility, communication, controlling behavior
• Participation– Participation restrictions—e.g., friends, family,
work, school, community, & civic engagement• Environmental Factors
– Built, Attitudinal, Policy– May be barriers or facilitators (positive or
negative)
18
Utility of ICF
• Common language• Can be used for international comparisons• Is dimensional• Can track dynamic changes• Can be used at person, group, or
population level• Neutral terms• Classification system—does not replace
survey questions20
Employ ICF
• Want to demonstrate utility of ICF framework to better understand effects of vision impairment and effects of vision impairment and comorbid conditions
42
Back to Public Health Model
• Surveillance—how big is problem• Research—what are the disparities?• Use ICF to understand disparities.
43
Public Health MonitoringSurveillance
Public Health ResearchRisk/Disparity
Public Health InterventionWhat works?
Public Health ImpactImplementation
Problem Response
Public Health Model
• Remember 19.9% of people age 65+ years report diabetes.
• Of that group, 17.3% of men & 22.2% of women report vision impairment.
45
Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 16.3 NaN NaN NaN
5
15
25
35
45
55
65
Pe
rce
nt
Crews, Jones, & Kim, 2006
Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 16.3 40.1 NaN NaN
5
15
25
35
45
55
65
Pe
rce
nt
Crews, Jones, & Kim, 2006
Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 16.3 40.1 36.6 NaN
5
15
25
35
45
55
65
Pe
rce
nt
Crews, Jones, & Kim, 2006
Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 16.3 40.1 36.6 52.8
5
15
25
35
45
55
65
Pe
rce
nt
Crews, Jones, & Kim, 2006
Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 6.2 NaN NaN NaN
2.5
7.5
12.5
17.5
22.5
27.5
32.5
37.5
42.5
47.5
Crews, Jones, & Kim, 2006
Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 6.2 21.6 NaN NaN
2.5
7.5
12.5
17.5
22.5
27.5
32.5
37.5
42.5
47.5
Crews, Jones, & Kim, 2006
Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 6.2 21.6 17.2 NaN
2.5
7.5
12.5
17.5
22.5
27.5
32.5
37.5
42.5
47.5
Crews, Jones, & Kim, 2006
Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 6.2 21.6 17.2 31.4
2.5
7.5
12.5
17.5
22.5
27.5
32.5
37.5
42.5
47.5
Crews, Jones, & Kim, 2006
Percent Reporting Worse Health for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 10.3 NaN NaN NaN
2.5
7.5
12.5
17.5
22.5
27.5
32.5
37.5
42.5
47.5
Crews, Jones, & Kim, 2006
Percent Reporting Worse Health for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 10.3 25 NaN NaN
2.5
7.5
12.5
17.5
22.5
27.5
32.5
37.5
42.5
47.5
Crews, Jones, & Kim, 2006
Percent Reporting Worse Health for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 10.3 25 19.9 NaN
2.5
7.5
12.5
17.5
22.5
27.5
32.5
37.5
42.5
47.5
Crews, Jones, & Kim, 2006
Percent Reporting Worse Health for Adults 65+ w/ & w/o Diabetes and Vision Impairment,
Health Interview Survey, 1997-2004
No Diabetes, No VI VI Only Diabetes Only Both Diabetes & VI
Series1 10.3 25 19.9 31.7
2.5
7.5
12.5
17.5
22.5
27.5
32.5
37.5
42.5
47.5
Crews, Jones, & Kim, 2006
The Effects of Stroke and Vision Impairment
Remember, 8.6% of people age 65+ years report stroke.
But of that group, 25.5% report vision problems.
Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Stroke and Vision
Impairment, Health Interview Survey, 1997-2004
No VI, No Stroke
VI Only Stroke Only
Both VI & Stroke
Series 1 16.4 NaN NaN NaN
5
15
25
35
45
55
65
Perc
en
t
Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Stroke and Vision
Impairment, Health Interview Survey, 1997-2004
No VI, No Stroke
VI Only Stroke Only
Both VI & Stroke
Series 1 16.4 40.1 NaN NaN
5
15
25
35
45
55
65
Perc
en
t
Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Stroke and Vision
Impairment, Health Interview Survey, 1997-2004
No VI, No Stroke
VI Only Stroke Only
Both VI & Stroke
Series 1 16.4 40.1 49.6 NaN
5
15
25
35
45
55
65
Perc
en
t
Moderate/Severe Difficulty Walking ¼ Mile for Adults 65+ w/ & w/o Stroke and Vision
Impairment, Health Interview Survey, 1997-2004
No VI, No Stroke
VI Only Stroke Only
Both VI & Stroke
Series 1 16.4 40.1 49.6 64.6
5
15
25
35
45
55
65
Perc
en
t
Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Stroke and Vision Impairment,
Health Interview Survey, 1997-2004
No VI No Stroke
VI Only Stroke Only Both VI & Stroke
Series 1 6 NaN NaN NaN
2.57.5
12.517.522.527.532.537.542.547.5
Perc
en
t
Crews, Jones, Kim, 2006
Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Stroke and Vision Impairment,
Health Interview Survey, 1997-2004
No VI No Stroke
VI Only Stroke Only Both VI & Stroke
Series 1 6 21.6 NaN NaN
2.57.5
12.517.522.527.532.537.542.547.5
Perc
en
t
Crews, Jones, Kim, 2006
Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Stroke and Vision Impairment,
Health Interview Survey, 1997-2004
No VI No Stroke
VI Only Stroke Only Both VI & Stroke
Series 1 6 21.6 27.5 NaN
2.57.5
12.517.522.527.532.537.542.547.5
Perc
en
t
Crews, Jones, Kim, 2006
Moderate/Severe Difficulty Shopping for Adults 65+ w/ & w/o Stroke and Vision Impairment,
Health Interview Survey, 1997-2004
No VI No Stroke
VI Only Stroke Only Both VI & Stroke
Series 1 6 21.6 27.5 40.6
2.57.5
12.517.522.527.532.537.542.547.5
Perc
en
t
Crews, Jones, Kim, 2006
Percent Reporting Worse Health Adults 65+ w/ & w/o Stroke and Vision
Impairment, Health Interview Survey, 1997-2004
No VI No Stroke
VI Only Stroke Only Both VI & Stroke
Series 1 10.2 NaN NaN NaN
2.57.5
12.517.522.527.532.537.542.547.5
Perc
en
t
Crews, Jones, Kim, 2006
Percent Reporting Worse Health Adults 65+ w/ & w/o Stroke and Vision
Impairment, Health Interview Survey, 1997-2004
No VI No Stroke
VI Only Stroke Only Both VI & Stroke
Series 1 10.2 25 NaN NaN
2.57.5
12.517.522.527.532.537.542.547.5
Perc
en
t
Crews, Jones, Kim, 2006
Percent Reporting Worse Health Adults 65+ w/ & w/o Stroke and Vision
Impairment, Health Interview Survey, 1997-2004
No VI No Stroke
VI Only Stroke Only Both VI & Stroke
Series 1 10.2 25 27 NaN
2.57.5
12.517.522.527.532.537.542.547.5
Perc
en
t
Crews, Jones, Kim, 2006
Percent Reporting Worse Health Adults 65+ w/ & w/o Stroke and Vision
Impairment, Health Interview Survey, 1997-2004
No VI No Stroke
VI Only Stroke Only Both VI & Stroke
Series 1 10.2 25 27 37.9
2.57.5
12.517.522.527.532.537.542.547.5
Perc
en
t
Crews, Jones, Kim, 2006
Effects of Vision & Comorbid Conditions
Associated with decreased activity Associated with decreased social roles Associated with poorer health Vision and multiple chronic conditions have
propelling negative effect. An effect that requires attention.
Oral Health & Vision Impairment
Data Set: 2008 National Health Interview Survey
• Established 1957• Samples 35,000 household and 87,500 people
annually • Multistage area probability design permits
representative sample of households • 2008 Oral Health Supplement in Adult File• 2008 Vision Supplement in Adult File
Definition of Vision Impairment
“Do you have any trouble seeing even with glasses or contacts?”
“Have you EVER been told by a doctor or other health professional that you had any of the following conditions: Macular degeneration, diabetic retinopathy, glaucoma, or cataract?”
Outcome variables
Self-reported perceived oral health (very good to good/ fair to poor),
Teeth problems (toothache/sensitive teeth, bleeding gums, crooked teeth, broken/missing teeth, stained/discolored teeth, loose teeth, broken/missing fillings),
Mouth problems (pain in jaw, sores in mouth, difficult eating, bad breath, dry mouth.)
Self-Reported Oral Health Status
How would you describe the condition of your mouth?
Very good, good, fair, poor
Teeth Problems
Question stem: During the past six months, have you had any of the following problems? Toothache/sensitive teethBleeding gums, Crooked teeth,Broken/missing teeth,Stained/discolored teeth, Loose teeth not due to an injury, Broken/missing fillings
Mouth Problems
Question stem: During the past 6 months, have you had any of the following problems that lasted more than a day? (Y/N)Pain in jaw, Sores in mouth, Difficult eating or chewing, Bad breath, Dry mouth.
RESULTS
Oral Health Age ≥ 40 YearsMouth Condition
NHIS, 2008
How would you describe the condition of your mouth?
Visually Impaired No Vision Impairment
Age 40-64
Age 65+ Age 40-64
Age 65+
Fair/Poor
45.0% 36.3% 24.5% 23.5%
Oral Health Age ≥ 40 YearsMouth Condition
NHIS, 2008
How would you describe the condition of your mouth?
Visually Impaired No Vision Impairment
Age 40-64
Age 65+ Age 40-64
Age 65+
Fair/Poor
45.0% 36.3% 24.5% 23.5%
Oral Health Age ≥ 40 YearsProblems with Mouth among those
having teeth., NHIS, 2008
Vision Impairment
No Vision Impairment
Pain in jaw 12.3% 5.1%
Sores in mouth
9.2% 4.1%
Difficulty eating
18.6% 7.0%
Oral Health Age ≥ 40 YearsProblems with Teeth among those
having teeth. NHIS, 2008
Vision Impairment
No Vision Impairment
Toothache/ Sensitive teeth
36.8% 21.2%
Bleeding Gums
17.2% 8.5%
Broken/Missing Teeth
34.9% 18.9%
Loose teeth 9.9% 4.6%
Heath Status among those having teeth.
Age ≥ 40 Years, NHIS, 2008
Vision Impairment
No Vision Impairment
Excellent/ Very good, good
64.6% 84.8%
Fair/ Poor 35.4% 15.2%
Odds Ratio of Oral Health Problems among people with vision impairment ,
Age 40 Years, 2008 NHIS
Vision ImpairmentAge 40-64
years
Vision Impairment
Age ≥ 65 years
Fair/ Poor Oral Health
1.67 1.23
Mouth Problems
2.31 1.58
Teeth Problems
1.79 1.35
Health Related Quality of Life as Outcome Measure
Health Related Quality of Life Disparitiesfrom BRFSS
Health Related Quality of Life Life Satisfaction Disability Self-reported health Physically unhealthy days Mentally unhealthy days Activity limitation days
Vision Questions
• How much difficulty, if any, do you have reading print in newspaper, magazine, recipe, menu, or numbers on the telephone?
• How much difficulty, if any, do you have in recognizing a friend across the street?
• Response categories: No difficulty, little difficulty, moderate difficulty, extreme difficulty, unable to do because of eyesight
HRQoL Questions
• Self-Rated Health (excellent, very good, good, fair, poor)
• Physically Unhealthy Days: “Now thinking about your physical health, which included physical illness and injury, for how many days during the past 30 was your physical health not good?
• Mentally Unhealthy Days: Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”
HRQoL Questions
Activity Limitation Days: “During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?” Life Satisfaction: “In general, how satisfied are you with your life?” Disability: “Are you limited in any way in any activities because of physical, mental, or emotional problems?” and “Do you now have any health problems that requires you to us special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?”
HRQoL Questions
• Valid indicators of service needs• Valid indicators of intervention
outcome
91
Life Dissatisfaction by Severity of Vision Impairment
among people age ≥ 65 years, BRFSS, 2006-2010
No Difficulty Little Duifficlty Severe Difficulty 0
1
2
3
4
5
6
7
8
9
2.4
4.2
8.4
92
Crews, Chou 2014
Disability by Severity of Vision Impairment
among people age ≥ 65 years, BRFSS 2006-2010
No Difficulty Little Difficulty Severe Difficulty0
10
20
30
40
50
60
31.6
41.2
53.6
93Crews, Chou et al 2014
Fair/Poor Health bySeverity of Vision Impairment
among people age ≥ 65 years, BRFSS 2006-2010
No Difficulty Little Difficulty Severe Difficulty0
5
10
15
20
25
30
35
40
45
50
23.5
29.5
43
94Crews, Chou, et al, 2014
Frequent (14+) unhealthy days by severity of vision impairment among people aged ≥65 years, BRFSS
2006-2010
Phys
ical
ly U
nhea
lthy
Days
Men
tally
Unh
ealth
y Day
s
Activ
ity Lim
itatio
ns D
ays
05
1015202530
14.5
4.87.3
18.3
7.39.7
28.3
1115.7
No DifficultyLittle DifficultySevere Difficulty
95
Crews, Chou, et al, 2014
Logistic Regression
Fair/ Poor Health
Life Dissatisfaction
Disability
No VI 1.0 1.0 1.0
Little VI 1.20 1.53 1.47
Moderate/Severe VI
1.80 2.21 2.01
Crews et al, 2012
Potential Solutions
Improved access and utilization of eye care and vision rehabilitation—no “system” of vision care .
Increased engagement of chronic disease providers to address needs of constituents with vision impairment. Stanford Health Promotion materials, for example, are
not accessible to people with vision impairment Improved tailored efforts to promote health
among people with vision impairment Integrate nutrition (low salt, low fat) into meal
preparation Integrate exercise, conditioning, falls prevention into
O&M Health outcomes are measurable
Vision Rehabilitation Outcomes
Using the ICF model, Vision Rehabilitation Intervention occurs at the activity level; outcomes occur at the social participation level.
Given the evidence, vision rehabilitation has potential to address health and can result in measureable health outcomes.
Next steps in public Health Model
• The future: Development and implementation of health promoting interventions targeted to people with vision impairment
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A Game Changer
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Institute of Medicine Report on Vision and Public Health
• vision and eye health surveillance• vision health disparities• prevalence & effects of comorbid
conditions • access and utilization of eye care, • health for people with vision impairment. • public and private collaborations at the
community, state, and national levels to elevate vision and eye health as a public health issue
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Vision and Eye Health Surveillance System
Develop, test, and implement a vision and eye health surveillance system using existing surveys, as well as administrative and electronic data sources.
Provide population estimates of vision loss function, eye diseases, as well as barriers and facilitators to access to eye care at the national, state, and community levels.
National Opinion Research CenterNORC
Establish standardized vision and eye health indicators (expert advisory panel)
Identify data sources
Estimate the prevalence and disparities in vision, eye health, and eye care utilization
Quotidian
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Man is the only animal that laughs and weeps; for he is the only animal that is struck with the difference between the way things are and the way they ought to be.--William Haslett
Thank you
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Thank you very much!
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For more information, please contactJohn E. Crews, DPA
at [email protected] 488 1116
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: [email protected] Web: http://www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
National Center for Chronic Disease Prevention and Health Promotion
Vision Health Initiative
If no convinced, let me share one more piece of evidence
Health related Quality of Life among people age 40-64.
Used same vision and HRQoL questions from BRFSS
Vocational rehabilitation is big business Outcomes probably not as desirable as we
wish Concerns: education, employer attitudes,
transportation, technology,
Life Dissatisfaction, Disability & Fair/Poor Health among People with no, little & severe
vision impairment, ages 40-64
Life Dissatisfac-tion
Disability Self-Reported Health
No Difficulty 3.7 19.3 12.4
Little Difficulty 6 27.4 17.8
Severe Diffi-culty
13.3 41.2 33
2.5
12.5
22.5
32.5
42.5
Frequent physically unhealthy days, frequent mentally
unhealthy days, and frequent activity limitation days
by severity of vision impairment, BRFSS, 2006-2010
Frequent Physical Unhealthy Days
Frequent Men-tally Unhealthy
Days
Frequent Activity Limitation Days
No 9.2 7.7 5.5
Little 12.7 11.7 8.5
Severe 23.7 21.7 17.8
2.5
7.5
12.5
17.5
22.5
Findings
Given the findings of HRQoL among those over 65 years, these findings are not unexpected.
Mentally unhealthy days and life dissatisfaction is greater among those 40-64.
What if we look at these data by employment status?
Case definitions
Nine employment questions in BRFSS Working: working for wages or self
employed Not working: unemployed less than or more
than one year Excluded: student, homemaker, retired,
unable to work Working: No Difficulty: 75%; Little
Difficulty: 72%; Severe Difficulty: 59%
Fair/Poor Healthby employment status & severity of vision impairment
No Difficulty Little Difficulty Severe Difficulty
Employed 7.6 9.6 17.8
Not Em-ployed
26.7 38.3 55.2
5
15
25
35
45
55
Life Dissatisfaction by employment status & severity of vision impairment
No Difficulty Little Difficulty Severe Difficulty
Employed 2.5 3.7 6.5
Not Em-ployed
7.4 12 23.3
2.5
7.5
12.5
17.5
22.5
Frequent Physically Unhealthy Daysby employment status & severity of vision impairment
No Difficulty Little Difficulty Severe Difficulty
Employed 4.9 9.6 10
Not Em-ployed
22.1 30.1 44.1
2.57.5
12.517.522.527.532.537.542.547.5
Frequent Activity limitation Daysby employment status & severity of vision impairment
No Difficulty Little Difficulty Severe Difficulty
Employed 1.9 2.7 5.1
Not Em-ployed
16.4 23 36.7
2.5
7.5
12.5
17.5
22.5
27.5
32.5
37.5
Disabilityby employment status & severity of vision impairment
No Difficulty Little Difficulty Severe Difficulty
Employed 13.1 18.5 23.7
Not em-ployed
31 42.4 58.6
5
15
25
35
45
55
65
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Frequently Mentally Unhealthy Daysby employment status & severity of vision impairment
No Difficulty Little Difficulty Severe Difficulty
Employed 5.5 7.5 12.3
Not Em-ployed
17.9 24.2 37.8
2.5
7.5
12.5
17.5
22.5
27.5
32.5
37.5
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What to make of these findings
• Healthy Worker Effect• Same factors that predict health, predict work—
education, income• Workers may have access to better food, more
opportunities for exercise, better healthcare• Working may improve mood
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In addition
• These finding argue for:• Improved access to health care• Improved health promoting activities
(decreased obesity, decreased smoking, increased exercise, improved nutrition)
• Better management of chronic conditions—especially diabetes and depression
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