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Comprehensive clinical assessment of home‐based older persons within New Zealand: an epidemiological profile of a national cross‐section

Comprehensive clinical assessment of home‐based older persons within New Zealand: an... driven by falling fertility rates and Prapid increases in life expectancy. Objective: Since 2012, all community care recipients in New Zealand have undergone a The number of people aged 65 years or older standardised needs assessment using the Home Care International Residential Assessment (65+) worldwide is projected to grow from Instrument (interRAI-HC). This study describes the national interRAI-HC population, assesses its an estimated 524 million in 2010 to nearly data quality and evaluates its ability to be matched. 1.5 billion in 2050. Within New Zealand (NZ), Methods: The interRAI-HC instrument elicits information on 236 questions over 20 domains; the number of people aged 65+ years nearly conducted by 1,800+ trained health professionals. Assessments between 1 July 2012 and 30 doubled between the 1981 and 2013 Census, June 2014 are reported here. Stratified by age, demographic characteristics were compared to increasing from 309,795 (9.9%) to 607,032 2013 Census estimates and selected health profiles described. Deterministic matching to the (14.3%) people. By 2063, people aged 65+ Ministry of Health’s mortality database was undertaken. years are predicted to make up 23.8% of the Results: Overall, 51,232 interRAI-HC assessments were conducted, with 47,714 (93.1%) research total national population. In addition to the consent from 47,236 unique individuals; including 2,675 Māori and 1,609 Pacific people. Apart social and economic sequelae, the resultant from height and weight, data validity and reliability were high. A 99.8% match to mortality data increase in age-related chronic diseases is was achieved. challenging all modern health care systems Conclusions: The interRAI-HC research database is large and ethnically diverse, with high worldwide. NZ is no exception; the current consent rates. Its generally good psychometric properties and ability to be matched enhances approach to health and disability services its research utility. provision is considered unsustainable. Implications: This national database provides a remarkable opportunity for researchers to Policy makers and the health care sector are better understand older persons’ health and health care, so as to better sustain older people in responding by being continually and actively their own homes. engaged in refining and implementing fiscally responsible service delivery models Key words: interRAI instrument, community care assessment, epidemiology, national study, within the context of improving quality of older persons health care. Garnering apposite valid and reliable 1. School of Health Sciences, University of Canterbury, New Zealand 2. School of Nursing, Midwifery and Social Work, The University of Queensland 3. Department of Medicine, University of Otago, New Zealand 4. New Zealand Brain Research Institute 5. GeoHealth Laboratory, University of Canterbury, New Zealand 6. Department of Mathematics and Statistics, University of Canterbury, New Zealand 7. Department of Psychology, University of Canterbury, New Zealand 8. UC High Performance Computing, University of Canterbury, New Zealand 9. Canterbury District Health Board, New Zealand 10. Centre for Postgraduate Nursing Studies, University of Otago, New Zealand 11. School of Public Health and Health Systems, University of Waterloo, Ontario, Canada 12. GeoHealth Laboratory, University of Canterbury, New Zealand 13. Māori/Indigenous Health Institute (MIHI), University of Otago, New Zealand 14. Department of Psychological Medicine, University of Otago, New Zealand 15. Department of Economics and Finance, University of Canterbury, New Zealand 16. School of Public Health, Brown University, Rhode Island, USA Correspondence to: Professor Philip Schluter, School of Health Sciences, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand; e-mail: philip.schluter@canterbury.ac.nz Submitted: September 2015; Revision requested: November 2015; Accepted: December 2015 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2016; 40:349-55; doi: 10.1111/1753-6405.12525 2016 vol . 40 no . 4 Australian and New Zealand Journal of Public Health 349 © 2016 Public Health Association of Australia Schluter et al. Article empirical data is essential to inform future based clinical practice and policy decisions As of 30 June 2014, about 60,000 4,5 planning and funding decisions. through the collection and interpretation of standardised assessments of older people high quality data about the characteristics had been performed in NZ. It is anticipated In 2003, the NZ Guidelines Group noted and outcomes of persons across a variety that 46,000 home care assessments will be that large gaps existed between best and of health and social services settings. performed annually. While the information actual assessment processes and practices 6 The interRAI instruments are designed to gained is used primarily to inform person- within NZ. Inconsistent and unstandardised function as an integrated health information level decisions around care, opportunities assessments were considered to be a system employing a common method to exist to better understand older persons’ significant impediment, with a comprehensive assess complex populations from multiple health and their health care needs within evidence-based and standardised assessment health and social service sectors. Each their own home setting. Internationally, tool being one fundamental way to bridge 6 interRAI instrument is designed to use there are numerous activities and population this gap. A search and evaluation of available 17-20 person‐ level information to support care plan studies using the interRAI, but, as instruments was undertaken, which included development, quality improvement, resource yet, relatively little has been published in four comprehensive, six overview, and 7 allocation and outcome measurement. NZ. Critical to these investigations is an two screening tools. Although the Home understanding of the interRAI-HC population Care International Residential Assessment For a person to be eligible for public funding and the quality of the recorded data. Instrument (interRAI-HC) rated strongly, and services in NZ, a needs assessment While several international studies have a preferred instrument was not explicitly is required. NZ is the only country where 7 investigated aspects of interRAI-HC data recommended. Nonetheless, in 2004, five a standardised interRAI-HC has been 9,21-23 validity and reliability, its validity has District Health Boards (DHBs) – from the 20 implemented for the conduct of all community 8 only been examined in a small geographically that cover NZ – piloted the interRAI-HC. care assessments on older people needing localised Bay of Plenty study within NZ. This led to a successful business case for its publically funded long-term community Furthermore, while some NZ data have implementation across all DHBs presented services or aged residential care across a 4 4,10 been previously presented, no study in NZ to the NZ Government in 2007. The version nation. Individuals are referred by their has yet provided a comprehensive national developed was for use in community-based general practitioner, community health overview. Given the substantial investment populations at risk of admission to aged worker or hospital-based health professional by stakeholders and participants, and the residential care or requiring long-term for a needs assessment, and booked for an 9 research potential of the database, this study supports. After a period of introduction and appointment with an interRAI assessor. For aimed to provide a profile of a national training, facilitated by a NZ$19 million injection residential care, a person must have sufficiently 4 interRAI-HC participant cohort with a focus of government funds, all DHBs adopted this high needs that are definite and ongoing, on those aged 65+ years, an assessment of interRAI-HC. Thus, since 2012, community care and must be aged 65+ years (or 50+ years if 10 data quality and an evaluation of its ability to assessments for people needing publically unmarried without dependent children). be matched to other databases. funded long-term community services or The NZ version of the interRAI-HC includes aged residential care have all utilised this 236 individual questions, assessed over instrument. Referred by general practitioners, 20 domains, which generate 27 validated Methods community health workers or hospital-based instrument scores that guide patient The study involved a cross-section of a health professionals, interRAI-HC assessments treatment. The adaption of the interRAI-HC continuously recruited national cohort are conducted by trained health professionals for NZ included extensive Māori consultation consisting of people who had an interRAI-HC (mainly nurses and social workers). The to ensure that a framework to perform assessment between 1 July 2012 and 30 June assessment is used to ascertain a person’s culturally appropriate assessments was 2014 and who consented to their data being level of need, to develop a care plan and to established, and so that accurate, systematic used for planning and research purposes. identify appropriate services and support and comprehensive ethnicity data were made 10 4 options. Most assessments are conducted available. Therefore, the interRAI-HC is a Primary measures at the person’s home. Moreover, since June potentially important tool for generating Māori The assessments used InterRAI-HC 9.1© 2015, it has been mandated that each resident health data. As the primary purpose of using (interRAI Corporation, Washington, D.C., in a long-term care facility in NZ will receive the interRAI-HC is to standardise assessments 1994–2009) modified with permission for NZ a comprehensive interRAI at least twice a and treatments of older people, completion use under licence to the Ministry of Health. year, or when their health status changes, of all fields is compulsory. Participants are The interRAI-HC instrument consists of 236 to help provide better care. However, the explicitly asked if they would consent for their questions used to form 27 scales, including: implementation of this resident care interRAI de-identified interRAI-HC information to be a Depression Rating scale, the Changes has not been without challenges. used for planning and research purposes. in Health, End-stage disease and Signs and InterRAI information is stored electronically InterRAI is an international research and Symptoms (CHESS) scale, and the Activities and is National Health Index (NHI)-linked, clinical network, involving more than 30 of Daily Living (ADL) scale. The instrument is 14,16 using encryption for data security. The NHI countries, with a focus on the development partitioned into 20 domains named: is a unique identifier that is assigned to every and application of comprehensive A: Identification Information person who uses health and disability support assessment instruments to respond to the B: Intake and Initial History services in NZ. As such, many different data preferences and needs of persons with C: Cognition sources can potentially be brought together, complex health demands (see: www.interrai. D: Communication and Vision 13 and matched using the NHI. org). The goal is to promote evidence- E: Mood and Behaviour 350 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 4 © 2016 Public Health Association of Australia Older People Comprehensive clinical assessment of home-based older persons within New Zealand F: Psychosocial Well-being and observational time frames provided in Results G: Functional Status the manual and on the assessment form. Between 1 July 2012 and 30 June 2014, H: Continence A key added strength of the interRAI-HC 51,232 interRAI-HC assessments were I: Disease Diagnoses database is its ability to be matched to recorded. Of these, 47,714 consented records J: Health Conditions other routinely collected databases, such as (93.1%) appeared in the original research K: Oral and Nutritional Status mortality data through the NHI. For security database. However, 18 duplicate records were L: Skin Condition reasons, information is matched using a found, leaving 47,696 unique observations. M: Medications two-stage process, where the primary NHI Patients were free to choose up to three N: Treatment and Procedures identifier in the interRAI-HC database is also ethnic identifications. Instead of having O: Responsibility assigned a new encrypted NHI number by the three separate fields, the interRAI-HC dataset P: Social Support Ministry of Health. Information (such as date repeats line entries for the participants – each Q: Environmental Assessment of death) is then made available from the with their different ethnic identification. This R: Discharge Potential and Overall Status Ministry, identifiable via this new encrypted research database contained 399 people S: Discharge NHI number. The Ministry of Health issued its with two ethnic identifications and six people T: Assessment Information. mortality data in Microsoft Excel format. with three identifications. Using the priority Participants may self-identify up to a system, only one record per participant maximum of three ethnic groups. However, Statistical analysis for each assessment was preserved, leaving for our purposes, ethnicity was defined using Reporting of analyses followed the 47,285 observations. Finally, 49 participants a single priority classification. Māori has STrengthening the Reporting of were found to have a repeat interRAI-HC priority coding, followed by Pacific, Asian, OBservational studies in Epidemiology assessment during the study period. Due European and Other. European ethnicity 29 (STROBE) guidelines. Frequencies and to this negligible number, and for ease of classifications included ‘NZ European’ , ‘Other percentages were used to characterise the exposition, only the first assessment was used European’, and ‘European not further defined’ sample overall and by 10-year age band for the descriptive part of this paper – leaving identifications. stratifications. Ordinal logistic regression a research database containing a single models were employed to investigate assessment for 47,236 people. Procedure differences in the prevalence of health By November 2014, more than 1,800 health and health behaviour variables over age Demographic profile of the interRAI- professionals had been trained or were stratifications, which were treated as a HC cohort in training to be interRAI assessors in NZ. categorical variable to avoid any assumptions Overall, 29,076 participants (61.6%) were Assessors undertake a two-day training of linearity. Asymmetry between patterns female, 18,158 (38.4%) were male, and 2 program and competency is reviewed of values recorded as zero and non-zero (0.0%) had their sex listed as ‘unknown’; regularly. Quality is monitored at a national in height and weight variables was tested hereafter set to missing. In terms of ethnic level by a competency-based curriculum, using McNemar’s test. Matching to the identification, 2,675 (5.7%) reported being standardised training materials and mortality database was deterministic, using Māori, 1,609 (3.4%) Pacific, 1,055 (2.2%) Asian, associated e-learning, including a mandatory the encrypted NHI number issued by the 41,532 (87.9%) European and 365 (0.8%) as annual coding examination program. Ministry of Health in each dataset. All analyses being Other. For national comparisons (Table Assessors are able to consult with their were undertaken using SAS version 9.3 (SAS 1), the last two categories were combined. supervisors or the National interRAI Training Institute Inc., Cary, NC, USA), and α=0.05 Age is automatically generated within the team in Wellington if they have any questions. defined statistical significance for all tests. electronic interRAI database by subtracting Assessors use all sources of information Ethics the assessment date from the date of birth. and then exercise clinical judgement as Clearance for this study was given by the The majority of people in the database, some to the most appropriate answer based on Ministry of Health’s Health and Disability 45,418 individuals (96.2%), were aged 65+ standardised coding guidelines provided Ethics Committees (14/STH/140) and years; with 74 (0.2%) people <40 years, 16 in the instrument’s training manual. Most only includes de-identified data for those (0.0%) people <20 years and 1 person aged items permit the use of multiple information consenting to their use for planning and -1 year. The year of birth appeared to be sources including personal interviews, review research purposes. incorrectly entered for this last individual. of the chart, direct observation of the person, communication with informal caregivers and use of clinical communication between Table 1: Age distribution of the interRAI-HC cohort aged 65+ years (45,418 people) and the New Zealand health care staff (e.g. tracking forms, clinical population aged 65+ years usually resident at the 2013 Census (607,035 people). correspondence). However, a number of items interRAI-HC New Zealand population are restricted to recording only the person’s self-report (e.g. self-rated health; self-rated Age band (years) n (%) n (%) mood items dealing with depression, anxiety 65-74 7,421 (16.3) 346,134 (57.0) and anhedonia; personal goals of care). Most 75-84 18,351 (40.4) 187,584 (30.9) items also include standardised response sets 85-94 17,959 (39.1) 68,412 (11.3) with item definitions, inclusions/exclusions, 95+ 1,687 (3.7) 4,902 (0.8) 2016 vol . 40 no . 4 Australian and New Zealand Journal of Public Health 351 © 2016 Public Health Association of Australia Schluter et al. Article Table 2: Sex and ethnic distributions of the interRAI-HC cohort aged 65+ years (45,418 people) and the New Zealand population (NZ pop ) aged 65+ years usually resident at the 2013 Census (607,035 people) stratified by 10-year age bands. 65-74 years 75-84 years 85-94 years 95+ years n n n n interRAI-HC NZ pop interRAI-HC NZ pop interRAI-HC NZ pop interRAI-HC NZ pop n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Sex Males 3,256 (43.9) 167,565 (48.4) 7,364 (40.1) 85,128 (45.4) 6,316 (35.2) 25,023 (36.6) 434 (25.7) 1,164 (23.7) Ethnicity Māori 879 (11.8) 22,188 (6.7) 1,033 (5.6) 8,505 (4.7) 338 (1.9) 1,416 (2.2) 21 (1.2) 75 (1.6) Pacific 489 (6.6) 9,225 (2.8) 670 (3.7) 3,693 (2.1) 269 (1.5) 741 (1.1) 12 (0.7) 27 (0.6) Asian 232 (3.1) 17,847 (5.4) 501 (2.7) 7,596 (4.2) 260 (1.4) 1,302 (2.0) 12 (0.7) 72 (1.5) European/Other 5,821 (78.4) 280,596 (85.1) 16,147 (88.0) 159,570 (89.0) 17,092 (95.2) 61,953 (94.7) 1,642 (97.3) 4,521 (96.3) a: 2 observations missing in the interRAI-HC for people aged 65-74 years; b: In the 2013 Census, 16,275 people aged 65-74 years had unstated ethnicity; 8,220 people aged 75-84 years had unstated ethnicity; 3,003 people aged 85-94 years had unstated ethnicity; 207 people aged 95+ years had unstated ethnicity. Table 2 presents the sex and ethnic Table 3: Distribution of selected health and health behaviour variables for the interRAI-HC cohort aged 65+ years distributions of the interRAI-HC cohort and (45,418 people) stratified into 10-year age bands. the national population usually resident at 65-74 years 75-84 years 85-94 years 95+ years n (%) n (%) n (%) n (%) the 2013 Census by 10-year age bands for Self-reported health those 65+ years of age. Given the nature and Excellent 203 (2.7) 460 (2.5) 585 (3.3) 59 (3.5) intent of the interRAI-HC, it is unsurprising Good 2,391 (32.2) 6,979 (38.0) 7,411 (41.3) 731 (43.3) that this cohort was relatively older than the Fair 2,696 (36.3) 6,492 (35.4) 6,161 (34.3) 488 (28.9) NZ population. In terms of sex, there was an Poor 1,287 (17.3) 2,370 (12.9) 1,771 (9.9) 165 (9.8) excess of around 5% in absolute percentages Could not (would not) respond 844 (11.4) 2,050 (11.2) 2,028 (11.3) 244 (14.5) of females assessed with the interRAI-HC in Smokes tobacco daily the 65–74 years and 75–84 years age groups, No 6,453 (87.0) 17,332 (94.5) 17,585 (97.9) 1,675 (99.3) compared to the NZ population. This excess Usually; not in last 3 days 177 (2.4) 195 (1.1) 76 (0.4) 1 (0.1) diminished in the 85–94 years age group Yes 791 (10.7) 823 (4.5) 294 (1.6) 11 (0.7) (to 1.4%), and males were over-represented Alcohol – highest number of drinks in any ‘single sitting’ in last 14 days in the 95+ years of age interRAI-HC group None 5,993 (80.8) 14,782 (80.6) 14,668 (81.7) 1,464 (86.8) (2.0%) compared to the NZ population. For 1 700 (9.4) 2,178 (11.9) 2,349 (13.1) 180 (10.7) ethnicity, Māori and Pacific people were 2-4 543 (7.3) 1,157 (6.3) 822 (4.6) 36 (2.1) over-represented and Asian people under- 5 or more 185 (2.5) 234 (1.3) 117 (0.7) 7 (0.4) represented in the interRAI-HC cohort for Cognitive skills for daily decision making the 65–74 years and 75–84 years age groups Independent 3,781 (51.0) 8,538 (46.5) 7,812 (43.5) 688 (40.8) compared to the NZ population. In the 85–94 Modified independence 1,149 (15.5) 3,183 (17.3) 3,499 (19.5) 341 (20.2) years and 95+ years age groups, both Māori Minimally impaired 1,228 (16.5) 3,108 (16.9) 3,176 (17.7) 303 (18.0) and Asian people were under-represented. Moderately impaired 854 (11.5) 2,300 (12.5) 2,271 (12.6) 219 (13.0) In terms of living arrangements, 21,492 Severely impaired 404 (5.4) 1,200 (6.5) 1,190 (6.6) 131 (7.8) (47.3%) of interRAI-HC people aged 65+ No discernible consciousness, coma 5 (0.1) 22 (0.1) 10 (0.1) 5 (0.3) years lived alone, 13,449 (29.6%) lived with Primary mode of locomotion their spouse/partner and no other, 4,629 Walking, no assistive device 3,099 (41.8) 6,277 (34.2) 3,797 (21.1) 163 (9.7) Walking, uses assistive device 3,604 (48.6) 10,776 (58.7) 12,979 (72.3) 1,328 (78.7) (10.2%) lived with their child (but not spouse/ Wheelchair, scooter 478 (6.4) 731 (4.0) 545 (3.0) 79 (4.7) partner), 3,196 (7.0%) lived with non- Bed-bound 240 (3.2) 567 (3.1) 637 (3.5) 117 (6.9) relative(s), 2,650 (5.8%) had various other Falls living arrangements, and 2 (0.0%) recorded No fall in last 90 days 4,757 (64.1) 11,127 (60.6) 10,102 (56.3) 805 (47.7) missing values. In the 2013 NZ Census, nearly Last fell 31-90 days ago 674 (9.1) 2,016 (11.0) 2,081 (11.6) 212 (12.6) two-thirds of people (62.1%) aged 65+ years One fall in last 30 days 1,028 (13.9) 2,989 (16.3) 3,496 (19.5) 409 (24.2) were living with a partner. Two plus falls in last 30 days 962 (13.0) 2,219 (12.1) 2,277 (12.7) 261 (15.5) Bladder continence Health and health behaviour profile Continent 4,499 (60.6) 10,490 (57.2) 9,474 (52.8) 722 (42.8) of the interRAI-HC cohort Continent with catheter 303 (4.1) 852 (4.6) 953 (5.3) 93 (5.5) Indicator health and health behaviour profiles Infrequently incontinent 656 (8.8) 1,595 (8.7) 1,718 (9.6) 167 (9.9) of the interRAI-HC cohort when stratified Occasionally incontinent 560 (7.5) 1,645 (9.0) 1,768 (9.8) 196 (11.6) by age are given in Table 3. The prevalence Frequently incontinent 1,030 (13.9) 2,829 (15.4) 3,087 (17.2) 370 (21.9) of ‘good’ or ‘excellent’ self-reported health Incontinent 355 (4.8) 930 (5.1) 947 (5.3) 139 (8.2) increased with advancing age stratification, No urine output in last 3 days 18 (0.2) 10 (0.1) 10 (0.1) 0 (0.0) from 34.9% in those aged 65–74 years to a: 3 observations missing; b: 5 observations missing; c: 1 observation missing; d: 2 observations missing. 352 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 4 © 2016 Public Health Association of Australia Older People Comprehensive clinical assessment of home-based older persons within New Zealand 46.8% in those aged 95+ years (p<0.001). In Undoubtedly, NZ’s interRAI-HC database Data reliability – comparing contrast, 77% of people aged 65+ years in the is large and rapidly growing. With 93.1% multiple records NZ Census had good, very good or excellent of assessed people consenting for their Examining records from the 49 interRAI self-rated health. For non-smoking, the information to be used in planning and participants who had repeat assessments, the prevalence increased from 87.0% in those research, analyses will have high statistical length between their successive assessments aged 65–74 years to 99.3% in those aged power, are likely to suffer from negligible ranged from 12 days to 20.1 months, with 95+ years (p<0.001). The NZ Census revealed non-sampling biases and are likely to a median of 5.1 months. In one instance that 58.7% of people aged 65+ years who yield generalisable findings. Moreover, the (2.0%) a participant’s age was given as 1 year answered the smoking status question interRAI-HC database captures people of younger at an interview 4.4 months after reported that they never smoked regularly, different ethnic identifications in sufficient the first; the sex of that same patient was a further 34.8% were ex-smokers and 6.5% numbers to make valid epidemiological classified as female at the first assessment and were regular smokers. investigations and comparisons. Within the male in the second assessment; and another cohort studied here, 2,675 Māori and 1,609 Significant age effects (all p <0.001) were also participant had self-identified ethnicity Pacific people were included. In population seen for all other variables in Table 3, with classified as Māori at the first interview but health terms, this is among the largest cohort older interRAI-HC people reporting lower European at the second interview. of Māori people with a comprehensive health levels of alcohol consumption, increased Non-zero height information was available profile readily available for research. levels of modified or impaired cognitive from 22 (44.9%) interRAI participants at function, greater need for assisted or wheeled A notable feature of this interRAI-HC cohort both assessments, with a median difference primary mode of locomotion, higher levels of was that Māori and Pacific people were between second and first measurements of fall frequencies and less bladder continence over-represented in the 65–74 years and -0.5 cm (interquartile range [IQR]: -4 to 2 cm; than their younger counterparts. 75–84 years age groups compared to the range: -10 to 11 cm). Absolute differences NZ population. While ethnic inequities in in assessed height had median 2.5 cm (IQR: Data integrity – missing values access to primary health care remain in 1 to 6 cm; range: 0 to 11 cm). For weight, NZ, and Māori and Pacific people carry a Missing data were rare. Five or fewer non-zero information was recorded from 21 disproportionate burden of disease, this observations were missing for each of the (42.9%) participants, with a median difference over-representation is important to address demographic, heath and health behaviour between second and first measurements of in any strategies aimed at this population of profiles presented. However, not all recorded 0 kg (IQR: -1 to 7 kg; range: -12 to 20 kg), and people in community based care. However, values were necessarily accurate. Age, for absolute differences having median 5 kg (IQR: given that community care assessment is example, ranged from -1 to 109 years, with 1 to 8 kg; range: 0 to 20 kg). predicated on a deterioration of health status, 16 (0.0%) people aged <20 years. While it the differential over-representation of Māori is impossible for a participant to be aged NHI matching and Pacific people is also a likely reflection ‘-1’ year, disabled children may be cared for Overall, 99 (0.2%) participants in the interRAI- of a poorer overall health status. Conversely, by ageing care services and so these values HC database were unable to be matched to Māori were under-represented in the 85–94 cannot be discounted. Within the interRAI the Ministry of Health’s mortality database. years and 95+ years age-bands. Explanations dataset for those aged 65+ years, there From these, six were easily identified as a may include reduced access to health were no missing values for height or weight. formatting error, common to Excel (where assessment or a relatively healthy group of However, 16,083 (35.4%) people had a height one file contained the identifier in exponent ‘older old’ Māori, although the latter seems recorded as 0 cm, a further 532 (1.2%) people form: i.e. ‘2.54E+7’ rather than ‘25400000’ in less likely given the patterns observed in had height recorded as being between 0 the other file) and, when corrected, left 93 the younger age groups. Caution is required cm and 100 cm, and three had their height unmatched participants. From the 47,143 in generalising about the health status and recorded as being 240+ cm. Moreover, 13,263 matched interRAI-HC participants, 14,204 needs of older old Māori from these data. (29.2%) people had a recorded weight of (30.1%) had a date of death recorded. The When considering the distribution of selected 0 kg, a further 34 (0.1%) between 0 kg and time from interRAI-HC assessment date to health and health behaviour variables for the 25 kg, and four (0.0%) people had their recorded date of death was negative for interRAI-HC cohort aged 65+ years stratified weight recorded as being 200+ kg. Overall, 10 (0.1%) individuals, ranging from -1 day into 10-year age bands, the significant age 11,323 (24.9%) participants had both height to -20.9 years, with median -4.4 months. effects observed were all consistent with and weight measurements recorded as zero, Checking the raw data, it appeared that the expected age-related declines. This said, of and 27,395 (60.3%) participants had both three most extreme negative times were a assessed people aged 95+ years, 46.8% had height and weight measurements recorded result of miscoding contained within the good or excellent self-reported health, 40.8% as greater than zero. There was significant Ministry of Health’s mortality file rather than had independent cognitive skills for daily asymmetry between zero and non-zero the interRAI-HC database. decision making and 88.4% walked with or height and weight recordings (p<0.001), without an assistive device as their primary with 4,760 (10.5%) people having a weight mode of locomotion. Discussion recorded as being above 0 kg but having height recorded as being 0 cm, whereas 1,940 In terms of the interRAI-HC data quality, Considerable clinical and scientific effort has (4.2%) people had weight recorded as 0 kg variable completion rates were very been expended in establishing the interRAI but height as above 0 cm. high, with few missing values – a likely instruments for health care sector use 4,9,31 4,5,14 consequence of having largely compulsory both internationally and nationally. 2016 vol . 40 no . 4 Australian and New Zealand Journal of Public Health 353 © 2016 Public Health Association of Australia Schluter et al. Article questions. Data validity was also high information sources and assessors’ large and important population health as the interRAI embodies standardised clinical judgement, and the difficulty in effects. Reducing the impact of stroke and 31,34 psychometrically validated instruments, eliciting some fields are likely to affect the dementia on older people, for example, is a and predominantly uses variables with psychometric properties of some variables NZ Government priority area, yet relatively defined response categories. However, errors and may introduce an array of reporting little is known about the factors or drivers of were apparent when the instrument deviated and coding biases (e.g. recording null values outcomes for such people. Using interRAI-HC from this structure – as seen with height and for variables with compulsory response and NHI linked data, such knowledge deficits weight elicitation and recording. Body size requirements). Without due diligence, this can be redressed. Moreover, interRAI-HC – commonly assessed using the body mass may lead to erroneous descriptions or assessments will direct interventions to areas index (BMI), which is composed of height and relationships. While the community care of identified need and allow introduced weight measurements – and weight stability assessments are standardised and have changes to be monitored and their are important individual and population national implementation and coverage, Māori population level impacts evaluated over time. 11,35 health parameters for ageing people. With and Pacific people are much less likely to With interRAI-HC assessments longitudinally nearly 30% of the interRAI cohort having a engage with primary health care than their repeated, supplemented by NHI linked zero weight recorded and nearly 40% having European/Other counterparts; and many data, an unparalleled opportunity exists for an undefined BMI value, a significant gap in more are entirely invisible to the system until researchers to gain a better understanding of these individual and population profiles exist. they suffer an acute episode that requires the needs of older people within their home Further investigation into the underlying hospital care. Non-participants are likely to and as they transition into residential care in causes of these aberrant data are required, have importantly differential health profiles, NZ. When translated, this will facilitate older but when physical measurement proves to which will introduce external validity bias in people to live better for longer, and also to be logistically impossible or unacceptable to associated epidemiological investigations. stay appropriately supported in their homes the person being assessed then alternative Until the extent of the interRAI-HC non- for longer. Ultimately, this is a desirable approaches, such as self-report, may be a participation rates is known, the magnitude outcome for all interested parties – especially useful alternative. These or other strategies to of this bias cannot be quantified. Finally, on older adults. redress difficulties associated with height and a technical note, the growth of interRAI-HC weight elicitation require development for participation is such that transferral and Acknowledgements these variables to have utility in contributing statistical analysis of its associated database to our understanding of health outcomes for will soon outstrip the computer capacity We would like to thank Andrew Downes older people. of many researchers using stand-alone (National interRAI Software Service Manager, machines. However, collaboration with Data reliability from the available repeated HealthShare Ltd.), Lynda Wheeler (National data scientists and involvement of super- assessments was generally good, although interRAI Training Manager, Technical Advisory computers will negate this issue, and indeed a 2% error rate in ‘fixed’ variables (age, sex Services), Vij Kooyela (National interRAI facilitate the development of an even richer and ethnicity) was observed. For repeated Manager - Data Analysis and Reporting evidence base. height and weight measurements that were Service, Technical Advisory Services), Chris above zero, some relatively large differences Set against these limitations, the interRAI Lewis, Simon Ross, Ross Judge, Dr Brigette were also noted, although the number offers many promising opportunities Meehan (National interRAI Services Manager, of available valid repeat measurements for regional, national and international Technical Advisory Services) and Lacey was too small to make a formal statistical comparative studies using the same Langlois (Canadian Institute of Health 5,9,18 assessment. Data matching to mortality standardised measures. Moreover, within information (CIHI) but seconded to Ministry of records, deterministically done using the NZ, through the matching with NHI numbers, Health in 2014). 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Comprehensive clinical assessment of home‐based older persons within New Zealand: an epidemiological profile of a national cross‐section

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Wiley
Copyright
© 2016 Public Health Association of Australia
ISSN
1326-0200
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1753-6405
DOI
10.1111/1753-6405.12525
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27197797
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Abstract

driven by falling fertility rates and Prapid increases in life expectancy. Objective: Since 2012, all community care recipients in New Zealand have undergone a The number of people aged 65 years or older standardised needs assessment using the Home Care International Residential Assessment (65+) worldwide is projected to grow from Instrument (interRAI-HC). This study describes the national interRAI-HC population, assesses its an estimated 524 million in 2010 to nearly data quality and evaluates its ability to be matched. 1.5 billion in 2050. Within New Zealand (NZ), Methods: The interRAI-HC instrument elicits information on 236 questions over 20 domains; the number of people aged 65+ years nearly conducted by 1,800+ trained health professionals. Assessments between 1 July 2012 and 30 doubled between the 1981 and 2013 Census, June 2014 are reported here. Stratified by age, demographic characteristics were compared to increasing from 309,795 (9.9%) to 607,032 2013 Census estimates and selected health profiles described. Deterministic matching to the (14.3%) people. By 2063, people aged 65+ Ministry of Health’s mortality database was undertaken. years are predicted to make up 23.8% of the Results: Overall, 51,232 interRAI-HC assessments were conducted, with 47,714 (93.1%) research total national population. In addition to the consent from 47,236 unique individuals; including 2,675 Māori and 1,609 Pacific people. Apart social and economic sequelae, the resultant from height and weight, data validity and reliability were high. A 99.8% match to mortality data increase in age-related chronic diseases is was achieved. challenging all modern health care systems Conclusions: The interRAI-HC research database is large and ethnically diverse, with high worldwide. NZ is no exception; the current consent rates. Its generally good psychometric properties and ability to be matched enhances approach to health and disability services its research utility. provision is considered unsustainable. Implications: This national database provides a remarkable opportunity for researchers to Policy makers and the health care sector are better understand older persons’ health and health care, so as to better sustain older people in responding by being continually and actively their own homes. engaged in refining and implementing fiscally responsible service delivery models Key words: interRAI instrument, community care assessment, epidemiology, national study, within the context of improving quality of older persons health care. Garnering apposite valid and reliable 1. School of Health Sciences, University of Canterbury, New Zealand 2. School of Nursing, Midwifery and Social Work, The University of Queensland 3. Department of Medicine, University of Otago, New Zealand 4. New Zealand Brain Research Institute 5. GeoHealth Laboratory, University of Canterbury, New Zealand 6. Department of Mathematics and Statistics, University of Canterbury, New Zealand 7. Department of Psychology, University of Canterbury, New Zealand 8. UC High Performance Computing, University of Canterbury, New Zealand 9. Canterbury District Health Board, New Zealand 10. Centre for Postgraduate Nursing Studies, University of Otago, New Zealand 11. School of Public Health and Health Systems, University of Waterloo, Ontario, Canada 12. GeoHealth Laboratory, University of Canterbury, New Zealand 13. Māori/Indigenous Health Institute (MIHI), University of Otago, New Zealand 14. Department of Psychological Medicine, University of Otago, New Zealand 15. Department of Economics and Finance, University of Canterbury, New Zealand 16. School of Public Health, Brown University, Rhode Island, USA Correspondence to: Professor Philip Schluter, School of Health Sciences, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand; e-mail: philip.schluter@canterbury.ac.nz Submitted: September 2015; Revision requested: November 2015; Accepted: December 2015 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2016; 40:349-55; doi: 10.1111/1753-6405.12525 2016 vol . 40 no . 4 Australian and New Zealand Journal of Public Health 349 © 2016 Public Health Association of Australia Schluter et al. Article empirical data is essential to inform future based clinical practice and policy decisions As of 30 June 2014, about 60,000 4,5 planning and funding decisions. through the collection and interpretation of standardised assessments of older people high quality data about the characteristics had been performed in NZ. It is anticipated In 2003, the NZ Guidelines Group noted and outcomes of persons across a variety that 46,000 home care assessments will be that large gaps existed between best and of health and social services settings. performed annually. While the information actual assessment processes and practices 6 The interRAI instruments are designed to gained is used primarily to inform person- within NZ. Inconsistent and unstandardised function as an integrated health information level decisions around care, opportunities assessments were considered to be a system employing a common method to exist to better understand older persons’ significant impediment, with a comprehensive assess complex populations from multiple health and their health care needs within evidence-based and standardised assessment health and social service sectors. Each their own home setting. Internationally, tool being one fundamental way to bridge 6 interRAI instrument is designed to use there are numerous activities and population this gap. A search and evaluation of available 17-20 person‐ level information to support care plan studies using the interRAI, but, as instruments was undertaken, which included development, quality improvement, resource yet, relatively little has been published in four comprehensive, six overview, and 7 allocation and outcome measurement. NZ. Critical to these investigations is an two screening tools. Although the Home understanding of the interRAI-HC population Care International Residential Assessment For a person to be eligible for public funding and the quality of the recorded data. Instrument (interRAI-HC) rated strongly, and services in NZ, a needs assessment While several international studies have a preferred instrument was not explicitly is required. NZ is the only country where 7 investigated aspects of interRAI-HC data recommended. Nonetheless, in 2004, five a standardised interRAI-HC has been 9,21-23 validity and reliability, its validity has District Health Boards (DHBs) – from the 20 implemented for the conduct of all community 8 only been examined in a small geographically that cover NZ – piloted the interRAI-HC. care assessments on older people needing localised Bay of Plenty study within NZ. This led to a successful business case for its publically funded long-term community Furthermore, while some NZ data have implementation across all DHBs presented services or aged residential care across a 4 4,10 been previously presented, no study in NZ to the NZ Government in 2007. The version nation. Individuals are referred by their has yet provided a comprehensive national developed was for use in community-based general practitioner, community health overview. Given the substantial investment populations at risk of admission to aged worker or hospital-based health professional by stakeholders and participants, and the residential care or requiring long-term for a needs assessment, and booked for an 9 research potential of the database, this study supports. After a period of introduction and appointment with an interRAI assessor. For aimed to provide a profile of a national training, facilitated by a NZ$19 million injection residential care, a person must have sufficiently 4 interRAI-HC participant cohort with a focus of government funds, all DHBs adopted this high needs that are definite and ongoing, on those aged 65+ years, an assessment of interRAI-HC. Thus, since 2012, community care and must be aged 65+ years (or 50+ years if 10 data quality and an evaluation of its ability to assessments for people needing publically unmarried without dependent children). be matched to other databases. funded long-term community services or The NZ version of the interRAI-HC includes aged residential care have all utilised this 236 individual questions, assessed over instrument. Referred by general practitioners, 20 domains, which generate 27 validated Methods community health workers or hospital-based instrument scores that guide patient The study involved a cross-section of a health professionals, interRAI-HC assessments treatment. The adaption of the interRAI-HC continuously recruited national cohort are conducted by trained health professionals for NZ included extensive Māori consultation consisting of people who had an interRAI-HC (mainly nurses and social workers). The to ensure that a framework to perform assessment between 1 July 2012 and 30 June assessment is used to ascertain a person’s culturally appropriate assessments was 2014 and who consented to their data being level of need, to develop a care plan and to established, and so that accurate, systematic used for planning and research purposes. identify appropriate services and support and comprehensive ethnicity data were made 10 4 options. Most assessments are conducted available. Therefore, the interRAI-HC is a Primary measures at the person’s home. Moreover, since June potentially important tool for generating Māori The assessments used InterRAI-HC 9.1© 2015, it has been mandated that each resident health data. As the primary purpose of using (interRAI Corporation, Washington, D.C., in a long-term care facility in NZ will receive the interRAI-HC is to standardise assessments 1994–2009) modified with permission for NZ a comprehensive interRAI at least twice a and treatments of older people, completion use under licence to the Ministry of Health. year, or when their health status changes, of all fields is compulsory. Participants are The interRAI-HC instrument consists of 236 to help provide better care. However, the explicitly asked if they would consent for their questions used to form 27 scales, including: implementation of this resident care interRAI de-identified interRAI-HC information to be a Depression Rating scale, the Changes has not been without challenges. used for planning and research purposes. in Health, End-stage disease and Signs and InterRAI information is stored electronically InterRAI is an international research and Symptoms (CHESS) scale, and the Activities and is National Health Index (NHI)-linked, clinical network, involving more than 30 of Daily Living (ADL) scale. The instrument is 14,16 using encryption for data security. The NHI countries, with a focus on the development partitioned into 20 domains named: is a unique identifier that is assigned to every and application of comprehensive A: Identification Information person who uses health and disability support assessment instruments to respond to the B: Intake and Initial History services in NZ. As such, many different data preferences and needs of persons with C: Cognition sources can potentially be brought together, complex health demands (see: www.interrai. D: Communication and Vision 13 and matched using the NHI. org). The goal is to promote evidence- E: Mood and Behaviour 350 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 4 © 2016 Public Health Association of Australia Older People Comprehensive clinical assessment of home-based older persons within New Zealand F: Psychosocial Well-being and observational time frames provided in Results G: Functional Status the manual and on the assessment form. Between 1 July 2012 and 30 June 2014, H: Continence A key added strength of the interRAI-HC 51,232 interRAI-HC assessments were I: Disease Diagnoses database is its ability to be matched to recorded. Of these, 47,714 consented records J: Health Conditions other routinely collected databases, such as (93.1%) appeared in the original research K: Oral and Nutritional Status mortality data through the NHI. For security database. However, 18 duplicate records were L: Skin Condition reasons, information is matched using a found, leaving 47,696 unique observations. M: Medications two-stage process, where the primary NHI Patients were free to choose up to three N: Treatment and Procedures identifier in the interRAI-HC database is also ethnic identifications. Instead of having O: Responsibility assigned a new encrypted NHI number by the three separate fields, the interRAI-HC dataset P: Social Support Ministry of Health. Information (such as date repeats line entries for the participants – each Q: Environmental Assessment of death) is then made available from the with their different ethnic identification. This R: Discharge Potential and Overall Status Ministry, identifiable via this new encrypted research database contained 399 people S: Discharge NHI number. The Ministry of Health issued its with two ethnic identifications and six people T: Assessment Information. mortality data in Microsoft Excel format. with three identifications. Using the priority Participants may self-identify up to a system, only one record per participant maximum of three ethnic groups. However, Statistical analysis for each assessment was preserved, leaving for our purposes, ethnicity was defined using Reporting of analyses followed the 47,285 observations. Finally, 49 participants a single priority classification. Māori has STrengthening the Reporting of were found to have a repeat interRAI-HC priority coding, followed by Pacific, Asian, OBservational studies in Epidemiology assessment during the study period. Due European and Other. European ethnicity 29 (STROBE) guidelines. Frequencies and to this negligible number, and for ease of classifications included ‘NZ European’ , ‘Other percentages were used to characterise the exposition, only the first assessment was used European’, and ‘European not further defined’ sample overall and by 10-year age band for the descriptive part of this paper – leaving identifications. stratifications. Ordinal logistic regression a research database containing a single models were employed to investigate assessment for 47,236 people. Procedure differences in the prevalence of health By November 2014, more than 1,800 health and health behaviour variables over age Demographic profile of the interRAI- professionals had been trained or were stratifications, which were treated as a HC cohort in training to be interRAI assessors in NZ. categorical variable to avoid any assumptions Overall, 29,076 participants (61.6%) were Assessors undertake a two-day training of linearity. Asymmetry between patterns female, 18,158 (38.4%) were male, and 2 program and competency is reviewed of values recorded as zero and non-zero (0.0%) had their sex listed as ‘unknown’; regularly. Quality is monitored at a national in height and weight variables was tested hereafter set to missing. In terms of ethnic level by a competency-based curriculum, using McNemar’s test. Matching to the identification, 2,675 (5.7%) reported being standardised training materials and mortality database was deterministic, using Māori, 1,609 (3.4%) Pacific, 1,055 (2.2%) Asian, associated e-learning, including a mandatory the encrypted NHI number issued by the 41,532 (87.9%) European and 365 (0.8%) as annual coding examination program. Ministry of Health in each dataset. All analyses being Other. For national comparisons (Table Assessors are able to consult with their were undertaken using SAS version 9.3 (SAS 1), the last two categories were combined. supervisors or the National interRAI Training Institute Inc., Cary, NC, USA), and α=0.05 Age is automatically generated within the team in Wellington if they have any questions. defined statistical significance for all tests. electronic interRAI database by subtracting Assessors use all sources of information Ethics the assessment date from the date of birth. and then exercise clinical judgement as Clearance for this study was given by the The majority of people in the database, some to the most appropriate answer based on Ministry of Health’s Health and Disability 45,418 individuals (96.2%), were aged 65+ standardised coding guidelines provided Ethics Committees (14/STH/140) and years; with 74 (0.2%) people <40 years, 16 in the instrument’s training manual. Most only includes de-identified data for those (0.0%) people <20 years and 1 person aged items permit the use of multiple information consenting to their use for planning and -1 year. The year of birth appeared to be sources including personal interviews, review research purposes. incorrectly entered for this last individual. of the chart, direct observation of the person, communication with informal caregivers and use of clinical communication between Table 1: Age distribution of the interRAI-HC cohort aged 65+ years (45,418 people) and the New Zealand health care staff (e.g. tracking forms, clinical population aged 65+ years usually resident at the 2013 Census (607,035 people). correspondence). However, a number of items interRAI-HC New Zealand population are restricted to recording only the person’s self-report (e.g. self-rated health; self-rated Age band (years) n (%) n (%) mood items dealing with depression, anxiety 65-74 7,421 (16.3) 346,134 (57.0) and anhedonia; personal goals of care). Most 75-84 18,351 (40.4) 187,584 (30.9) items also include standardised response sets 85-94 17,959 (39.1) 68,412 (11.3) with item definitions, inclusions/exclusions, 95+ 1,687 (3.7) 4,902 (0.8) 2016 vol . 40 no . 4 Australian and New Zealand Journal of Public Health 351 © 2016 Public Health Association of Australia Schluter et al. Article Table 2: Sex and ethnic distributions of the interRAI-HC cohort aged 65+ years (45,418 people) and the New Zealand population (NZ pop ) aged 65+ years usually resident at the 2013 Census (607,035 people) stratified by 10-year age bands. 65-74 years 75-84 years 85-94 years 95+ years n n n n interRAI-HC NZ pop interRAI-HC NZ pop interRAI-HC NZ pop interRAI-HC NZ pop n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Sex Males 3,256 (43.9) 167,565 (48.4) 7,364 (40.1) 85,128 (45.4) 6,316 (35.2) 25,023 (36.6) 434 (25.7) 1,164 (23.7) Ethnicity Māori 879 (11.8) 22,188 (6.7) 1,033 (5.6) 8,505 (4.7) 338 (1.9) 1,416 (2.2) 21 (1.2) 75 (1.6) Pacific 489 (6.6) 9,225 (2.8) 670 (3.7) 3,693 (2.1) 269 (1.5) 741 (1.1) 12 (0.7) 27 (0.6) Asian 232 (3.1) 17,847 (5.4) 501 (2.7) 7,596 (4.2) 260 (1.4) 1,302 (2.0) 12 (0.7) 72 (1.5) European/Other 5,821 (78.4) 280,596 (85.1) 16,147 (88.0) 159,570 (89.0) 17,092 (95.2) 61,953 (94.7) 1,642 (97.3) 4,521 (96.3) a: 2 observations missing in the interRAI-HC for people aged 65-74 years; b: In the 2013 Census, 16,275 people aged 65-74 years had unstated ethnicity; 8,220 people aged 75-84 years had unstated ethnicity; 3,003 people aged 85-94 years had unstated ethnicity; 207 people aged 95+ years had unstated ethnicity. Table 2 presents the sex and ethnic Table 3: Distribution of selected health and health behaviour variables for the interRAI-HC cohort aged 65+ years distributions of the interRAI-HC cohort and (45,418 people) stratified into 10-year age bands. the national population usually resident at 65-74 years 75-84 years 85-94 years 95+ years n (%) n (%) n (%) n (%) the 2013 Census by 10-year age bands for Self-reported health those 65+ years of age. Given the nature and Excellent 203 (2.7) 460 (2.5) 585 (3.3) 59 (3.5) intent of the interRAI-HC, it is unsurprising Good 2,391 (32.2) 6,979 (38.0) 7,411 (41.3) 731 (43.3) that this cohort was relatively older than the Fair 2,696 (36.3) 6,492 (35.4) 6,161 (34.3) 488 (28.9) NZ population. In terms of sex, there was an Poor 1,287 (17.3) 2,370 (12.9) 1,771 (9.9) 165 (9.8) excess of around 5% in absolute percentages Could not (would not) respond 844 (11.4) 2,050 (11.2) 2,028 (11.3) 244 (14.5) of females assessed with the interRAI-HC in Smokes tobacco daily the 65–74 years and 75–84 years age groups, No 6,453 (87.0) 17,332 (94.5) 17,585 (97.9) 1,675 (99.3) compared to the NZ population. This excess Usually; not in last 3 days 177 (2.4) 195 (1.1) 76 (0.4) 1 (0.1) diminished in the 85–94 years age group Yes 791 (10.7) 823 (4.5) 294 (1.6) 11 (0.7) (to 1.4%), and males were over-represented Alcohol – highest number of drinks in any ‘single sitting’ in last 14 days in the 95+ years of age interRAI-HC group None 5,993 (80.8) 14,782 (80.6) 14,668 (81.7) 1,464 (86.8) (2.0%) compared to the NZ population. For 1 700 (9.4) 2,178 (11.9) 2,349 (13.1) 180 (10.7) ethnicity, Māori and Pacific people were 2-4 543 (7.3) 1,157 (6.3) 822 (4.6) 36 (2.1) over-represented and Asian people under- 5 or more 185 (2.5) 234 (1.3) 117 (0.7) 7 (0.4) represented in the interRAI-HC cohort for Cognitive skills for daily decision making the 65–74 years and 75–84 years age groups Independent 3,781 (51.0) 8,538 (46.5) 7,812 (43.5) 688 (40.8) compared to the NZ population. In the 85–94 Modified independence 1,149 (15.5) 3,183 (17.3) 3,499 (19.5) 341 (20.2) years and 95+ years age groups, both Māori Minimally impaired 1,228 (16.5) 3,108 (16.9) 3,176 (17.7) 303 (18.0) and Asian people were under-represented. Moderately impaired 854 (11.5) 2,300 (12.5) 2,271 (12.6) 219 (13.0) In terms of living arrangements, 21,492 Severely impaired 404 (5.4) 1,200 (6.5) 1,190 (6.6) 131 (7.8) (47.3%) of interRAI-HC people aged 65+ No discernible consciousness, coma 5 (0.1) 22 (0.1) 10 (0.1) 5 (0.3) years lived alone, 13,449 (29.6%) lived with Primary mode of locomotion their spouse/partner and no other, 4,629 Walking, no assistive device 3,099 (41.8) 6,277 (34.2) 3,797 (21.1) 163 (9.7) Walking, uses assistive device 3,604 (48.6) 10,776 (58.7) 12,979 (72.3) 1,328 (78.7) (10.2%) lived with their child (but not spouse/ Wheelchair, scooter 478 (6.4) 731 (4.0) 545 (3.0) 79 (4.7) partner), 3,196 (7.0%) lived with non- Bed-bound 240 (3.2) 567 (3.1) 637 (3.5) 117 (6.9) relative(s), 2,650 (5.8%) had various other Falls living arrangements, and 2 (0.0%) recorded No fall in last 90 days 4,757 (64.1) 11,127 (60.6) 10,102 (56.3) 805 (47.7) missing values. In the 2013 NZ Census, nearly Last fell 31-90 days ago 674 (9.1) 2,016 (11.0) 2,081 (11.6) 212 (12.6) two-thirds of people (62.1%) aged 65+ years One fall in last 30 days 1,028 (13.9) 2,989 (16.3) 3,496 (19.5) 409 (24.2) were living with a partner. Two plus falls in last 30 days 962 (13.0) 2,219 (12.1) 2,277 (12.7) 261 (15.5) Bladder continence Health and health behaviour profile Continent 4,499 (60.6) 10,490 (57.2) 9,474 (52.8) 722 (42.8) of the interRAI-HC cohort Continent with catheter 303 (4.1) 852 (4.6) 953 (5.3) 93 (5.5) Indicator health and health behaviour profiles Infrequently incontinent 656 (8.8) 1,595 (8.7) 1,718 (9.6) 167 (9.9) of the interRAI-HC cohort when stratified Occasionally incontinent 560 (7.5) 1,645 (9.0) 1,768 (9.8) 196 (11.6) by age are given in Table 3. The prevalence Frequently incontinent 1,030 (13.9) 2,829 (15.4) 3,087 (17.2) 370 (21.9) of ‘good’ or ‘excellent’ self-reported health Incontinent 355 (4.8) 930 (5.1) 947 (5.3) 139 (8.2) increased with advancing age stratification, No urine output in last 3 days 18 (0.2) 10 (0.1) 10 (0.1) 0 (0.0) from 34.9% in those aged 65–74 years to a: 3 observations missing; b: 5 observations missing; c: 1 observation missing; d: 2 observations missing. 352 Australian and New Zealand Journal of Public Health 2016 vol . 40 no . 4 © 2016 Public Health Association of Australia Older People Comprehensive clinical assessment of home-based older persons within New Zealand 46.8% in those aged 95+ years (p<0.001). In Undoubtedly, NZ’s interRAI-HC database Data reliability – comparing contrast, 77% of people aged 65+ years in the is large and rapidly growing. With 93.1% multiple records NZ Census had good, very good or excellent of assessed people consenting for their Examining records from the 49 interRAI self-rated health. For non-smoking, the information to be used in planning and participants who had repeat assessments, the prevalence increased from 87.0% in those research, analyses will have high statistical length between their successive assessments aged 65–74 years to 99.3% in those aged power, are likely to suffer from negligible ranged from 12 days to 20.1 months, with 95+ years (p<0.001). The NZ Census revealed non-sampling biases and are likely to a median of 5.1 months. In one instance that 58.7% of people aged 65+ years who yield generalisable findings. Moreover, the (2.0%) a participant’s age was given as 1 year answered the smoking status question interRAI-HC database captures people of younger at an interview 4.4 months after reported that they never smoked regularly, different ethnic identifications in sufficient the first; the sex of that same patient was a further 34.8% were ex-smokers and 6.5% numbers to make valid epidemiological classified as female at the first assessment and were regular smokers. investigations and comparisons. Within the male in the second assessment; and another cohort studied here, 2,675 Māori and 1,609 Significant age effects (all p <0.001) were also participant had self-identified ethnicity Pacific people were included. In population seen for all other variables in Table 3, with classified as Māori at the first interview but health terms, this is among the largest cohort older interRAI-HC people reporting lower European at the second interview. of Māori people with a comprehensive health levels of alcohol consumption, increased Non-zero height information was available profile readily available for research. levels of modified or impaired cognitive from 22 (44.9%) interRAI participants at function, greater need for assisted or wheeled A notable feature of this interRAI-HC cohort both assessments, with a median difference primary mode of locomotion, higher levels of was that Māori and Pacific people were between second and first measurements of fall frequencies and less bladder continence over-represented in the 65–74 years and -0.5 cm (interquartile range [IQR]: -4 to 2 cm; than their younger counterparts. 75–84 years age groups compared to the range: -10 to 11 cm). Absolute differences NZ population. While ethnic inequities in in assessed height had median 2.5 cm (IQR: Data integrity – missing values access to primary health care remain in 1 to 6 cm; range: 0 to 11 cm). For weight, NZ, and Māori and Pacific people carry a Missing data were rare. Five or fewer non-zero information was recorded from 21 disproportionate burden of disease, this observations were missing for each of the (42.9%) participants, with a median difference over-representation is important to address demographic, heath and health behaviour between second and first measurements of in any strategies aimed at this population of profiles presented. However, not all recorded 0 kg (IQR: -1 to 7 kg; range: -12 to 20 kg), and people in community based care. However, values were necessarily accurate. Age, for absolute differences having median 5 kg (IQR: given that community care assessment is example, ranged from -1 to 109 years, with 1 to 8 kg; range: 0 to 20 kg). predicated on a deterioration of health status, 16 (0.0%) people aged <20 years. While it the differential over-representation of Māori is impossible for a participant to be aged NHI matching and Pacific people is also a likely reflection ‘-1’ year, disabled children may be cared for Overall, 99 (0.2%) participants in the interRAI- of a poorer overall health status. Conversely, by ageing care services and so these values HC database were unable to be matched to Māori were under-represented in the 85–94 cannot be discounted. Within the interRAI the Ministry of Health’s mortality database. years and 95+ years age-bands. Explanations dataset for those aged 65+ years, there From these, six were easily identified as a may include reduced access to health were no missing values for height or weight. formatting error, common to Excel (where assessment or a relatively healthy group of However, 16,083 (35.4%) people had a height one file contained the identifier in exponent ‘older old’ Māori, although the latter seems recorded as 0 cm, a further 532 (1.2%) people form: i.e. ‘2.54E+7’ rather than ‘25400000’ in less likely given the patterns observed in had height recorded as being between 0 the other file) and, when corrected, left 93 the younger age groups. Caution is required cm and 100 cm, and three had their height unmatched participants. From the 47,143 in generalising about the health status and recorded as being 240+ cm. Moreover, 13,263 matched interRAI-HC participants, 14,204 needs of older old Māori from these data. (29.2%) people had a recorded weight of (30.1%) had a date of death recorded. The When considering the distribution of selected 0 kg, a further 34 (0.1%) between 0 kg and time from interRAI-HC assessment date to health and health behaviour variables for the 25 kg, and four (0.0%) people had their recorded date of death was negative for interRAI-HC cohort aged 65+ years stratified weight recorded as being 200+ kg. Overall, 10 (0.1%) individuals, ranging from -1 day into 10-year age bands, the significant age 11,323 (24.9%) participants had both height to -20.9 years, with median -4.4 months. effects observed were all consistent with and weight measurements recorded as zero, Checking the raw data, it appeared that the expected age-related declines. This said, of and 27,395 (60.3%) participants had both three most extreme negative times were a assessed people aged 95+ years, 46.8% had height and weight measurements recorded result of miscoding contained within the good or excellent self-reported health, 40.8% as greater than zero. There was significant Ministry of Health’s mortality file rather than had independent cognitive skills for daily asymmetry between zero and non-zero the interRAI-HC database. decision making and 88.4% walked with or height and weight recordings (p<0.001), without an assistive device as their primary with 4,760 (10.5%) people having a weight mode of locomotion. Discussion recorded as being above 0 kg but having height recorded as being 0 cm, whereas 1,940 In terms of the interRAI-HC data quality, Considerable clinical and scientific effort has (4.2%) people had weight recorded as 0 kg variable completion rates were very been expended in establishing the interRAI but height as above 0 cm. high, with few missing values – a likely instruments for health care sector use 4,9,31 4,5,14 consequence of having largely compulsory both internationally and nationally. 2016 vol . 40 no . 4 Australian and New Zealand Journal of Public Health 353 © 2016 Public Health Association of Australia Schluter et al. Article questions. Data validity was also high information sources and assessors’ large and important population health as the interRAI embodies standardised clinical judgement, and the difficulty in effects. Reducing the impact of stroke and 31,34 psychometrically validated instruments, eliciting some fields are likely to affect the dementia on older people, for example, is a and predominantly uses variables with psychometric properties of some variables NZ Government priority area, yet relatively defined response categories. However, errors and may introduce an array of reporting little is known about the factors or drivers of were apparent when the instrument deviated and coding biases (e.g. recording null values outcomes for such people. Using interRAI-HC from this structure – as seen with height and for variables with compulsory response and NHI linked data, such knowledge deficits weight elicitation and recording. Body size requirements). Without due diligence, this can be redressed. Moreover, interRAI-HC – commonly assessed using the body mass may lead to erroneous descriptions or assessments will direct interventions to areas index (BMI), which is composed of height and relationships. While the community care of identified need and allow introduced weight measurements – and weight stability assessments are standardised and have changes to be monitored and their are important individual and population national implementation and coverage, Māori population level impacts evaluated over time. 11,35 health parameters for ageing people. With and Pacific people are much less likely to With interRAI-HC assessments longitudinally nearly 30% of the interRAI cohort having a engage with primary health care than their repeated, supplemented by NHI linked zero weight recorded and nearly 40% having European/Other counterparts; and many data, an unparalleled opportunity exists for an undefined BMI value, a significant gap in more are entirely invisible to the system until researchers to gain a better understanding of these individual and population profiles exist. they suffer an acute episode that requires the needs of older people within their home Further investigation into the underlying hospital care. Non-participants are likely to and as they transition into residential care in causes of these aberrant data are required, have importantly differential health profiles, NZ. When translated, this will facilitate older but when physical measurement proves to which will introduce external validity bias in people to live better for longer, and also to be logistically impossible or unacceptable to associated epidemiological investigations. stay appropriately supported in their homes the person being assessed then alternative Until the extent of the interRAI-HC non- for longer. Ultimately, this is a desirable approaches, such as self-report, may be a participation rates is known, the magnitude outcome for all interested parties – especially useful alternative. These or other strategies to of this bias cannot be quantified. Finally, on older adults. redress difficulties associated with height and a technical note, the growth of interRAI-HC weight elicitation require development for participation is such that transferral and Acknowledgements these variables to have utility in contributing statistical analysis of its associated database to our understanding of health outcomes for will soon outstrip the computer capacity We would like to thank Andrew Downes older people. of many researchers using stand-alone (National interRAI Software Service Manager, machines. However, collaboration with Data reliability from the available repeated HealthShare Ltd.), Lynda Wheeler (National data scientists and involvement of super- assessments was generally good, although interRAI Training Manager, Technical Advisory computers will negate this issue, and indeed a 2% error rate in ‘fixed’ variables (age, sex Services), Vij Kooyela (National interRAI facilitate the development of an even richer and ethnicity) was observed. For repeated Manager - Data Analysis and Reporting evidence base. height and weight measurements that were Service, Technical Advisory Services), Chris above zero, some relatively large differences Set against these limitations, the interRAI Lewis, Simon Ross, Ross Judge, Dr Brigette were also noted, although the number offers many promising opportunities Meehan (National interRAI Services Manager, of available valid repeat measurements for regional, national and international Technical Advisory Services) and Lacey was too small to make a formal statistical comparative studies using the same Langlois (Canadian Institute of Health 5,9,18 assessment. Data matching to mortality standardised measures. Moreover, within information (CIHI) but seconded to Ministry of records, deterministically done using the NZ, through the matching with NHI numbers, Health in 2014). 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