NIH GUIDE, Volume 21, Number 12, March 27, 1992

PA NUMBER:  PA-92-62

P.T. 34




  Health Care Economics 

National Institute on Aging

Agency for Health Care Policy and Research


The National Institute on Aging (NIA) and the Agency for Health Care

Policy and Research (AHCPR) invite qualified researchers to submit new

and supplemental applications for research projects that focus on the

distribution of the elderly population across geographic areas; the

factors influencing this distribution; and the social, economic and

health services impacts of these distributions.

Congress, reflecting the imputed pressures on community services,

housing, and health care that are associated with elderly population

concentrations, has expressed interest in the NIA funding research that

would "be helpful in gauging migration patterns of older Americans and

in determining the impact that high concentrations of older Americans

place on local service organizations and medical programs."

The spatial distribution of the American population 65 years of age and

over has never been uniform; it has grown even less uniform over the

past quarter-century, with a number of geographic areas, such as

Florida and Arizona, accounting for both larger numbers and proportions

of the elderly.  These are areas of "elderly concentration."  They are

established cities (or subdivisions within them) and new communities;

they are also smaller rural communities from which younger persons have

emigrated disproportionately. (See also the Health and Effective

Functioning of Older Rural Populations, NIA 1991.)

Migration by elderly persons, however, especially to retirement

destinations, has been the primary determinant of these recent

geographic concentrations.  Such movements may not continue.

Predicting their future pattern and volume will require understanding

such influences as:

o  Selective recruitment of older persons by competing localities,

including nontraditional retirement destinations.  Local economic

factors like housing costs and interest rates.  State of national and

regional economies.

o  Patterns of "continuation migration" and "reverse migration" among

the older-old.  Relation of socioeconomic status and other demographic

characteristics to choice of destination.

o  Relative distribution of mortality improvements at the oldest ages.

Changes in age, health status, and economic security at retirement.

Many data sources -- continuing national surveys, ad hoc studies at the

state and local levels -- may be drawn upon.  Baseline data from an

important new source, the NIA funded longitudinal Health and Retirement

Study, will be available in mid-1993.  It includes a 100 percent

oversample of the State of Florida and is likely to be especially

helpful to understanding these influences on elderly migration.

Reciprocal concerns address the changed composition of public sector

budgets and a possibly diminished revenue base in areas of "elderly

concentrations."  Evidence from the limited research that has been

conducted on these issues suggests that such concerns may be

exaggerated:  i.e., traditional retirement destinations, most notably

those in southern and southwestern states, appear to attract

populations self-selected for higher income, better health, and strong

social supports.  The demand for public services actually may be lower

and net economic benefits higher.  As these migrants age, however,

pressures on community resources (e.g., public transportation,

emergency medical services, home care, long-term care, and, perhaps,

income support) may be expected to rise.  "Reverse migration" from

these centers may alter the extent -- and even the direction -- of some

of these pressures.  The factors influencing "reverse migration" have

not been studied extensively.

Still less well researched are the dynamics and consequences of the

concentration of the elderly resulting from the non-migration of aging

persons who, through choice or circumstance, remain in their community

and "age in place."  A number of older cities, especially in the

midwestern, middle Atlantic, and northeastern states, have experienced

a loss of younger population of reproductive age during recent decades

of economic dislocation.  At the same time, improvements in mortality

at more advanced ages have accounted for unprecedented survival to

older age:  many of these cities thus have become areas of relative

elderly concentration.

Analyses of the characteristics of residents alone cannot adequately

address the issues of the service demands on, or economic adjustments

required of, areas with high densities of older persons.  The service

delivery systems in these communities, for example, not only respond

to, but also shape, the demand for aging-related services.  Economies

of scale may be obtained in such populations, with the result that

organizing and delivering commonly needed services (e.g. specialized

transportation or libraries, day care or AD patients, home health

assistance), will be effectively lowered.  These communities of elderly

concentration also afford opportunities for specialized markets and

innovative services to develop, such as social HMOs or strategic

interventions to avert physical disability and fiscal dependency, which

may constrain costs to public and private sector budgets.  The extent

to which these possibilities are being realized must be studied

systematically for a more rounded picture of both the determinants and

the consequences of elderly population concentrations.


The Public Health Service (PHS) is committed to achieving the health

promotion and disease prevention objectives of "Healthy People 2000,"

a PHS-led National activity for setting priority areas.  Potential

applicants may obtain a copy of "Healthy People 2000" (Full Report:

Stock No. 017-001-00474-0) or "Healthy People 2000" (Summary Report:

Stock No. 017-001-00473-1) through the Superintendent of Documents,

Government Printing Office, Washington, DC 20402-9325 (telephone



Applicants for research grants may be made by public and  private,

for-profit and non-profit organizations, such as universities,

colleges, hospitals, or laboratories.  Women and minority

investigators, in particular, are encouraged to apply.  Foreign

institutions are welcome to apply but are advised to consult NIA or

AHCPR staff before applying and are strongly encouraged to apply in

collaboration with a U.S. institution.


The primary mechanisms for support of this initiative are the research

project grant (R01), program project grant (P01), First Independent

Research Support and Transition (FIRST) Award (R29), (the AHCPR does

not support the FIRST Award) conference grant (R13), individual

fellowships (F32, F33).


Detailed research studies on a wide range of topics are needed to

expand policy-relevant knowledge on concentrated elderly populations,

beginning with the analyses of recent patterns and trends of elderly

migration.  These will form the basis for estimating the demographic

forces that will influence the extent and nature of elderly population

redistribution over the next several decades.  Related research

projects will describe and analyze the significant influences of---and

upon---ecological factors in areas of elderly concentration.

Applications proposing to address the aforementioned broad issues are

encouraged, especially those that focus on specific research topics

illustrated by the following examples:

A.  Determinants of Elderly Population Concentration

Areas of "elderly concentration" must be defined in terms that allow

spatial, demographic, and sociopolitical analysis over time.  The

forces by which areas become disproportionately elderly are variously

categorized, and the relative role of each is likely to have a

different impact on future trends.

o  What are the appropriate geographic boundaries for describing,

analyzing, and comparing areas of existing elderly concentration:

state, county, standard Metropolitan Area, city, subdivision?  How do

these alternatives accommodate research concerns for

homogeneity/heterogeneity in elderly populations?

o  What are the relative contributions attributable to in-migration and

to the "aging in place" of longer-term residents in specific areas with

a high concentration of elderly inhabitants?  Do the two populations

differ in terms of socioeconomic factors, health status, patterns and

intensity of health services utilization, and other factors?

o  What is the relative strength of each of the determinants for

elderly migrants in choice of destination:  e.g., climate, housing,

employment opportunities, health care, recreation, cost of living,

friendship and kinship networks?  How do these differ among those who

do not migrate, who "age in place," and whose communities have become

areas of elderly concentration?

o  Do established communities of elderly concentration continue to

attract successive cohorts of elderly migrants?  Do these new migrants

differ significantly from their predecessors?

o  In what ways does growth in the elderly concentration of an area

correlate with change in the demographic composition of the reciprocal

(i.e., non-aged) population?

B.  Health Services System Adaptations

The health services systems in areas of elderly concentration are

likely to reflect adaptation to the nature and needs of the population.

Such adjustments may be structural or procedural, and may have

statewide impacts.

o  Do elderly migrants carry private health insurance ("medigap"

policies) supplementary to Medicare to the same extent, and for

comparable benefit coverage, as do non-migrants?  Is this coverage

reflective of policies purchased before or after migration?  In what

ways are the premium and benefit structures different in areas of

elderly concentration?

o  How do Medicaid programs of states in which areas of elderly

concentration are located reflect special needs and demand for services

by this population?  In what ways has the entitlement/benefit/payment

structure of the state Medicaid program been changed in direct response

to these elderly?  Have Medicaid waivers been used to provide

non-traditional benefits?

o  Does the distribution of physician services---by urban/rural

location, by specialty, by type of practice arrangement---reflect

special accommodation to the ambulatory care needs in areas of elderly

concentration? To what extent does this distribution reflect a

redistribution within the state (e.g., from rural to urban, from

surgery to geriatrics, from solo to group practice) or migration from

other states?

o  Are age-specific and diagnosis-specific rates of hospitalization,

length of stay, or hospital costs different among areas of elderly

concentration, especially between populations who have migrated and

those who have aged in place?

o  How does the employment/deployment of nursing personnel in areas of

elderly concentration differ from that of other areas?  Are nurses

working disproportionately in special hospital units, long-term care

facilities, ambulatory care settings, home care agencies?  Are there

manifest areas of nursing shortage in the community at large that can

be attributed to the elderly concentration?  How do local nursing

salaries respond to these shortages?

C.  Environmental Adaptations

Many environmental hazards to the health and functioning of the elderly

can be addressed at the community level. Do areas of elderly

concentration implement such controls and, to what effect and at what


o  Are injuries sustained in falls actually reduced through

macro-environmental interventions, e.g., in architecture, street and

traffic planning?  Is the social and physical mobility of frail or

impaired elderly enhanced by these same interventions?  Is the micro-

environment of housing planned or retrofitted to reduce falls or to

enhance access and mobility?  Does such micro-adaptation increase or

diminish the long-term real value of housing to individuals and


D.  Social Supports in Areas of Elderly Concentration

Social support networks generally are thought to be well established

among elderly migrants at the time of their relocation.

o  How do these supports (including those of adult children), and the

systems of exchange and reciprocity, change for the migrant once

resident in an area of "elderly concentration?"  Do social support

networks become narrowed to other elderly migrants and what are the

consequences for health and functioning?  What are the consequences for

use of formal institutional or community-based services?  How are

crises, such as death of a spouse or of close friends, dealt with in

these new support networks?

o  In what way do these differ among elderly non-migrants, i.e., those

who have "aged in place" and whose adult children have migrated?





NIH and ADAMHA policy is that applicants for NIH/ADAMHA clinical

research grants and cooperative agreements will be required to include

minorities and women in study populations so that research findings can

be of benefit to all persons at risk of the disease, disorder or

condition under study; special emphasis should be placed on the need

for inclusion of minorities and women in studies of diseases, disorders

and conditions which disproportionately affect them.  This policy is

intended to apply to males and females of all ages.  If women or

minorities are excluded or inadequately represented in clinical

research, particularly in proposed population-based studies, a clear

compelling rationale should be provided.

The composition of the proposed study population must be described in

terms of gender and racial/ethnic group, together with a rationale for

its choice.  In addition, gender and racial/ethnic issues should be

addressed in developing a research design and sample size appropriate

for the scientific objectives of the study.  This information should be

included in the form PHS 398 in Section 2, 1-4 of the Research Plan AND

summarized in Section 2, E, Human Subjects.

Applicants/offerors are urged to assess carefully the feasibility of

including the broadest possible representation of minority groups.

However, NIH recognize that it may not be feasible or appropriate in

all research projects to include representation of the full array of

United States racial/ethnic minority populations (i.e., Native

Americans (including American Indians or Alaskan Natives),

Asian/Pacific Islanders, Blacks, Hispanics).  The rationale or studies

on single minority population groups should be provided.

This policy applies to all studies submitted under this program

announcement.  The usual NIH policies concerning research on human

subjects also apply.  For foreign awards, the policy on inclusion of

women applies fully; since the definition of minority differs in other

countries, the applicant must discuss the relevance of research

involving foreign population groups to the United States' populations,

including minorities.

If the required information is not contained within the applicant, the

review will be deferred until the information is provided.  Peer

reviewers will address specifically whether the research plan in the

application conforms to these policies.  If the representation of women

or minorities in a study design is inadequate to answer the scientific

question(s) addressed AND the justification for the selected study

population is inadequate, it will be considered a scientific weakness

or deficiency in the study design and will be reflected in assigning

the priority score to the application.  All applications are required

to address these policies.  NIH funding components will not award

grants that do not comply with these policies.


R01, R29, F32, F33, and K04 applications will be reviewed for

scientific and technical merit by an appropriate Initial Review Group

of the Division of Research Grants.  All other applications (K01, P01,

and R13) will be reviewed by an appropriate Institute review group.

Secondary review will be by the corresponding National Advisory

Council.  Applications compete on the basis of scientific merit.


Applicants are to use the research project application form PHS 398

(rev. 9/91) that is available at the applicant's institutional research

office and from the Office of Grants Inquiries, Division of Research

Grants, National Institutes of Health, Westwood Building, Room 449,

Bethesda, MD 20892, telephone 301/496-7441.  Individual fellowship

applicants must use PHS 416-1 (revised 7/88).  To expedite the

application's routing, please check the box on the application face

sheet indicating that the application is in response to this

announcement and type (next to the box) "Causes & Effects of Elderly

Population Concentrations, PA-92-62."  The application (with five

copies) must be mailed to:

Division of Research Grants

National Institutes of Health

Westwood Building, Room 240

Bethesda, MD  20892**

If applying for an F32, the application and two copies need to be sent

to the above address.

Receipt dates for Research Project Grant, Career Development Award, and

FIRST Award applications are February 1, June 1, and October 1 of each

year.  Those for the individual fellowship (F32, F33) applications are

January 10, May 10, and September 10.


Although it is not required, potential applicants are encouraged to

discuss the project with program staff in advance of formal submission.

This may be accomplished by calling the program office listed below.

For substantive issues and to obtain information on research resources,


Behavioral and Social Research Program

National Institute on Aging

Gateway Building, Room 2C-234

Bethesda, MD  20892

Telephone:  (301) 496-3136

Division of Primary Care

Center for General Health Services Extramural Research

Agency for Health Care Policy and Research

2101 E. Jefferson Street, Suite 502

Rockville, MD  20852

Telephone:  (301) 227-8357

For fiscal and administrative matters, contact:

Ms. Linda Whipp

Grants and Contracts Management Office

National Institute on Aging

Gateway Building, Room 2N-212

Bethesda, MD  20892

Telephone:  (301) 496-1472

Mr. Ralph Sloat

Chief of Grants Management Branch

Agency for Health Care Policy and Research

2101 E. Jefferson Street, Suite 601

Rockville, MD  20852

Telephone:  (301) 227-8447


This program is described in the Catalog of Federal Domestic Assistance

No. 93.866.  Agency Research Awards will be made under the authority of

the Public Health Service Act, Title III, Section 301 (Public Law

78-410, as amended; 42 USC 241 and 41 USC 289) and be subject to PHS

Grant Policies and Federal Regulations 42 CFR Part 52 and 45 CFR Part

74.  This program is not subject to Health Systems Agency review.


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