Caroline Helwick

December 02, 2014

NEW ORLEANS — The mortality rate among seniors varies tremendously across the United States and much of this variation can be explained by behavioral and community support factors that can be changed, according to America's Health Rankings Senior Report.

"Our objective was to examine the geographic variation in premature mortality among seniors and identify characteristics of states with low rates," said Anna Schenck, PhD, from the University of North Carolina at Chapel Hill. "What we learned was that preventable unhealthy behaviors and conditions are important to look at, especially smoking and obesity, even at age 65 and older," Dr Schenck said.

The report was presented during a special symposium on seniors' health here at the American Public Health Association 142nd Annual Meeting.

America's Health Rankings is the longest running annual assessment of the nation's health on a state-by-state basis. The goal of the report is to provide insights that will lead to public health measures to improve the health of seniors and yield data that can help track progress in health promotion.

The premature mortality rate is defined as the number of deaths per 100,000 people 65 to 74 years of age. "The average lifespan is nearly 80 years of age. Mortality in the 65- to 74-year-old population reflects at least 5 potential years of life lost," Dr Schenck explained.

The researchers examined a number of conditions that might be associated with premature mortality, including community and environmental characteristics, health behaviors such as smoking, obesity, and inactivity, and healthcare provider variables such as access to a physician.

The lowest premature mortality rate was in Hawaii, followed by Colorado, Connecticut, California, and Minnesota. Mississippi had the highest rate; in fact, death rates in seniors 65 to 74 years in Mississippi were 1.8 times those of seniors in Hawaii.

Table. Factors Linked to Premature Death

Factor r
Strong correlation  
   Being able-bodied –0.80
   Education level –0.74
   Physical inactivity 0.72
   Smoking 0.65
Moderate correlation  
   Obesity 0.52
   Poverty 0.47
   Food insecurity 0.45


There was a significant correlation with premature death for social support and for rates of preventable hospitalizations, which are influenced by both the underlying health of seniors and available community resources, Dr Schenck reported.

A shortfall in the availability of geriatricians was moderately correlated with premature death, but access to a dedicated healthcare provider, home healthcare, and community support were not.

The researchers performed a multivariate analysis to determine indicators for further study. "We wanted the most parsimonious of models, but also one that would explain the significant proportion of the variance in rates of premature mortality across the states," said Dr Schenck.

On multivariate analysis, smoking, obesity, disability, education level, preventable hospitalizations, and access to home healthcare were correlated with premature death. "Education was marginal, but the model was better with education in it," she explained. "Overall, this model explained nearly 90% of the variance across states."

"Notable in their absence were factors that we traditionally look at," she added. "We think of healthcare for seniors as being about medical care, but a sufficient supply of geriatricians or dedicated healthcare providers did not turn out to be significant predictors in the multivariate model."

The 2014 data showed that, as a group, seniors are becoming more active, said Sarah Midler, MPM, from Arundel Street Consulting in St. Paul, Minnesota, which produced the report.

Physically Active Seniors

Nationally, the prevalence of physical inactivity decreased significantly, from 30.3% in 2013 to 28.7% in 2014. Inactivity increased in only one state, Kentucky, where 38.2% of seniors reported being inactive.

Rates of obesity did not change nationally, and were stable at around 25%. However, rates decreased in the District of Columbia (19.1%) and increased in Kentucky (29.1%) and Nevada (25.1%). The prevalence of smoking was 8.7% nationally, but varied from a low of 4.7% in Utah to a high of 14.3% in Nevada.

"Programs that focus on these behaviors may increase state rates of high health status," said Midler.

Dr Schenck acknowledged that data from America's Health Rankings are limited because they are "ecological" — that is, they are applicable on a state level, and the relations observed might not indicate correlations at the individual level.

The multiple factors are also "intertwined" and therefore hard to single out. "Are there high rates of disability in a state because it has a higher rate of smokers? Are there higher rates of preventable hospitalizations because smoking rates are high? We can't tease these things out," said Dr Schenck.

States like Mississippi, Alabama, and Louisiana have most of the problems, while Minnesota and Hawaii are healthier.

Nevertheless, the study highlights some potential factors that might be "worth exploring," she said, both in terms of their underlying causes and their possible interventions. "This type of analysis points out that it is important to understand the influence on states' abilities to lower smoking and obesity rates in seniors, for example. Some states are doing better than others. Why is that?"

Health status data on seniors more or less mirror the data for younger individuals in terms of best and worst states, said David Hartley, PhD, from the University of Southern Maine in Portland.

"In a state-by-state comparison, some states usually fall out. You see that that states like Mississippi, Alabama, and Louisiana have most of the problems, while Minnesota and Hawaii are healthier," he told Medscape Medical News.

Even within states, there are regions that are healthier than others; therefore, there is a need to drill down even further than these data go, he said.

"My own research is in rural health," Dr Hartley said. "You will find that subsections of the culture within a state are less educated, more rural, have lower-income populations, and there is an acceptable pattern of how you live your life. In trying to change health-related behaviors, we are up against behavioral cultural norms."

Dr Hartley said he believes that data such as these can at least help public health officials spot trends and perhaps discover what interventions are making a difference in the healthier states.

Dr Schenck chairs the scientific advisory committee for America's Health Rankings and receives funding from the United Health Foundation. Ms Midler works for Arundel Street Consulting, which receives funding each year from the United Health Foundation to manage America's Health Rankings. Dr Hartley has disclosed no relevant financial relationships.

American Public Health Association (APHA) 142nd Annual Meeting. Abstract 309888. Presented November 19, 2014.


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