Evidence-Based Prevention Improves Chronic Care Management Nancy A. Whitelaw, Ph.D. Director, Center for Healthy Aging The National Council on the Aging.

Evidence-Based Prevention Improves Chronic Care

Management

Nancy A. Whitelaw, Ph.D.

Director, Center for Healthy Aging

The National Council on the Aging

www.ncoa.org

February, 2005

As of February 4, approximately 160,172 people have died from chronic disease this year.

1993 vs. 2001: US adults reported:

Deterioration in:physical healthmental healthability to do their usual activities

Increase in “unhealthy days” 5.2 to 6.0 days

Adults 45-54 years old had consistently greater deterioration than younger or older adults.

“Honest doc--if I had known I was gonna to live this long, I’d have taken better care of myself.”

Center for Healthy Aging Increase the quality and accessibility of health

programming at community agencies serving older adults National Resource Center on Evidence-based

Prevention Evidence-based Model Health Programs Falls Free: National Falls Prevention Action Plan Moving Out: Best Practices in Physical Activity MD Link: Connecting Physicians to Model Health

Programs New Connections: Partnerships between PH and Aging Get Connected: Partnerships between MH and Aging

Overview

What are the real threats to health and function of older adults?

How should these threats be addressed? How do we strengthen community resources

and self-management support for prevention?

Health Status of Older Adults

88% - at least one chronic condition 50% - at least two chronic conditions 37% experience some activity limitation 27% assess health as fair or poor

42% of older African Americans 35% of older Hispanics

Chronic Conditions Among Persons 70+

0 10 20 30 40 50 60 70

Cancer

Stroke

Respiratory Diseases

Diabetes

Heart Disease

Hypertension

Arthritis

Percent

MenWomen

Chronic diseases account for 95% of health care expenditures

Leading Causes of Death, Age 65+ (2001)

Heart Disease 32% Cancer 22% Stroke 8% Chronic respiratory 6% Flu/Pneumonia 3% Diabetes 3% Alzheimer’s 3%

Underlying Risk Factors – “The Actual Causes of Death”

Behavior % of deaths, 2000 Smoking 18% Poor diet & nutrition/ 15%

Physical inactivity

Alcohol 4% Infections, pneumonia 3% Racial, ethnic, economic ?

disparities

Threats to Health and Well-being Among Seniors

35% age 65 – 74 report no physical activity 46% age 75+ report no physical activity 24% - obese 33% - fall each year 20% - prescribed “unsuitable” medications 34% - no flu shot 45% - no pneumococcal vaccine

Low Rates of Physical Inactivity

Older adults with low-socioeconomic status are at even greater risk of inactivity

No physical activity age 75+ 33% of males 50% of females

Obesity* Trends Among U.S. Adults BRFSS, 2001

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman) (Marx)

<10% 10%–14% 15%–19% 20%-24% 25%

Source: Behavioral Risk Factor Surveillance System, CDC.

Age Group18-29 30-39 40-49 50-59 60-69

1,200

900

600

300

0

per 10,000 people

Disability Increases with Age BUT Much Higher Rates Among the Obese* (Marx)

*Data based on 1996 National Health Interview SurveySources: National Business Group on Health; Rand Corp.

ObeseNon-Obese

Severe Obesity and Mortality

Severe obesity (BMI >45) lowers years of life by 13 years for white men and 8 years for white women age 20–30.

For blacks the loss was 20 years for men and 5 years for women.

Fontaine et al. JAMA 2003;289:187–193

Total Cardiovascular Disease Deaths, 1999

Age-adjusted death rates per 100,000 population (Marx)

Source: National Vital Statistics System, National Center for Health Statistics, CDC

190.5–230.8

231.1–250.0

255.5–284.8

285.1–354.9

United States - 172

Variation in Heart Disease Rates, Why? (Marx)

200% difference between high and low states

Nearly 2/3 of the difference in death rates is explained by differences in modifiable risks tobacco overweight high blood pressure high cholesterol physical inactivity diabetes

Source: Byers et al. Prev Med 1998;27(3):311–16

High Rates of Diabetes 17 Million Americans

6% of population

18% of 65+

Greater in minority populations Diabetes diagnosed at age 40 leads to a

loss of 11.6 years in men and 14.3 years in women. More years of life are lost in blacks than in whites. Narayan et al. JAMA 2003;290:1884–1890

Smoker

Overweight

Inactive Ratio

11% 58% 5.5

Source: Jones et al. Arch Intern Med 2002;162:2565–71

Non Smoker

Normal Weight

Active

Predicted Likelihood of Developing Coronary Heart Disease, Stroke, or Diabetes by Age

65 (Marx) Men, Aged 50

Disability Index, by Age and Health RiskUniversity of Pennsylvania Alumni

63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 780.0

0

0.05

0.10

0.15

0.20

0.25

0.30

Dis

abili

ty Index

Age

Risk based on body mass index, smoking, exercise; 0-3 point scale for each; low = 0–2points, moderate = 3–4 points, high = 5–9 points.Note: A disability index of 0.1 = minimal disability.Source: Vita et al. N Engl J Med 1998;338(15):1035–41

High risk

Moderate risk

Low risk

Progression of disability delayed approximately 7 years in low risk vs. high risk.

Serious Consequences of Falls

Falls are common 30% age 65+ years 50% age 80+ years

As a result of a fall injury: 1.6 million were treated in EDs 400,000 were hospitalized 11,600 died

At age 75+, those who fall are 4-5 times more likely to stay in a long term care facility >1 year

Falls cost > $15 billion/year

Falls Are Predictable (RF= Risk Factor)

0102030405060708090

100

1 RF 2 RF 3 RF 4 RF 5+RF

% whofall

Risk Factors

strength, balance/ gait vision, postural BP Depression, arthritis Foot problems Medications Environmental hazards Fear of falling

Negative Effects of Depression

15-20% of older adults - clinically significant depression

Major depression prevalence: Primary care (5-10%)

Home care (15% - 26%)

Late-life depression associated with: Functional impairment, lower quality of life,

poorer medical outcomes, increased costs and suicide

Serious Consequences of Medication Errors

Seniors consume 1/3 of all prescription drugs

33 inappropriate prescription drugs

6.5 million older adults use one or more

7,000 deaths per year due to adverse drug events

5th leading cause of death for older adults

The annual cost of treating medication-related errors exceeds $177 billion/year

Institute of Medicine. (1999) To err is human: Building a safer health system. Kohn, L., Corrigan, J., Donaldson, M. (Eds.) National Academy Press, Washington D.C.

Federal Spending in Billions, 2000

$0

$50

$100

$150

$200

$250

$300

Medicare Medicaid AoA NCCDPHP

“No longer is each risk factor and chronic illness being considered in isolation.

Awareness is increasing that similar strategies can be equally effective in treating many different conditions.”

Epping-Jordon, WHO, 26 March 2004

How Should these Threats be Addressed?

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Outcomes

Social Ecologic Model of Healthy Aging

Individual

Interpersonal

Organizational

Community

Public Policy

McLeroy et al., 1988, Health Educ Q; Sallis et al., 1998, Am J Prev Med

What the Social-Ecological Perspective Says

The health and well-being of older adults will be improved only if we work from a broad perspective.

Comprehensive planning and partnerships at all levels are required.

Harassing individuals about their bad habits has very little impact.

Changes at the individual level will come with improvements at the organizational, community and policy levels.

www.who.int/topics/ageing/en/

Community Resources, Why?

Ensure that care is centered on older adult and family

Support self management and behavior change

Provide critical prevention programming: physical activity; falls prevention; dietary modification

Provide key supportive services Facilitate care coordination Outreach, information and referral

Self-Management Support, What?

Emphasize the patient’s central role in

managing her/his health Use effective self-management support

strategies assessment, goal-setting, action planning,

problem solving and follow-up peer support groups; peer health mentors

Include physical activity More intensive problem-solving therapy if

depressed.

How Do We Strengthen Community Resources and Self- Management Support for Prevention?

Old question: Does what we are doing work?

New question: Can we do what is known to work? What do we know works? How well do we know it and understand it? About whom do we know it?

AoA Initiative - Evidence-Based Programs Disease self-management (5)

Diabetes Heart disease Depression Chronic Disease Self-Management

Program (2)

Physical activity (3) Falls prevention (2) Nutrition (2) Medication management (1)

Doing What Works

Evidence of problem: The burden is great. Evidence of effective interventions: The

science is convincing. Core features of an effective program: Fidelity

is possible. Requirements for successful implementation

Reach Effectiveness Adoption Implementation Maintenance

RE-AIM www.re-aim.org

Partners and Planning – (P)RE-AIM

Find your partners - aging, health, research

Identify and review evidence of health conditions and risk factors for older adults in the community Surveillance data

Other surveys

Review scientific evidence on proven, effective interventions or models Identify core components of effective programs

Which specific program components contributed to the positive results?

Partners and Planning – (P)RE-AIM

Select interventions/models Appropriate for targeted conditions or risk

factors

Suitable for targeted populations and locations

Feasible to implement – can preserve core components

Suitable for adoption by a variety of agencies, staff with different skills

Communicate – to community leaders, media, older adults, other stakeholders

Detail the Translation: Developing “Your” Program

Detail the following: (RE-AIM) Reach; Effectiveness

Adoption; Implementation; Maintenance

Fidelity A: The program you develop retains the core components from the original intervention studies. Tracking Changes Tool

Fidelity B: The program you implement retains the core components from the developed program.

Reach and Retention - People

The number, proportion, and representativeness of individuals who participate in a given program.

Key questions: How many people are in the target population? How do I reach and retain these high risk,

diverse older adults? What percent of the target population actually

learns about the program? Are those who become “enrolled” the ones who

have the most to gain? Do participants truly reflect the targeted

population?

Adoption - Organizations

The number, proportion, and representativeness of settings and staff who are willing to offer the program.

Key questions: How many organizations could implement this

program? “Readiness” Are these organizations connected to high risk

populations? How many of these organizations will actually

operate the program? What will motivate these organizations to

participate?

Implementation - Organizations

How closely do the agency and staff follow the program that was developed. This includes “fidelity” of delivery and the time and cost of the program.

Key questions: How many staff within a setting will try this? Does training and supervision support

implementation? Do data systems support implementation? Do work flow processes support implementation? Do policies and procedures support implementation?

Maintenance – People and Organizations

The extent to which a program or policy becomes part of the routine organizational practices and policies.

At the individual level, the long-term effects of a program on outcomes (perhaps 6 or more months).

Key questions: Can organizations sustain the program over time? Does the program produce lasting effects at

individual level? Are those persons and settings that show

maintenance those most in need?

Effectiveness - People

The impact of the model program on important outcomes. Unintended, adverse consequences or negative

effects Quality of life Health status of participants Health status of the targeted community Costs Satisfaction of participants, staff and agencies

Can you replicate findings from original studies?

The Challenge and the Opportunity

Older adults suffer from chronic diseases, injuries and disabling conditions.

Preventable diseases account for nearly 70% of all medical care spending.

Growing evidence base indicates that changes in lifestyle at any age can improve health & functioning.

People want to change unhealthy habits, but need support.

The health care sector alone can not improve the health of older adults with chronic conditions.

Community agencies are important partners in facilitating improved health and lower costs.

NCOA’s Center for Healthy Aging and AoA’s National Resource Center

Collaborate with diverse organizations to contribute to a broad-based national movement.

Identify, translate and disseminate evidence on what works – scientific studies and best practices.

Promote community organizations as essential agents for improving the health of older adults.

Advocate for greater support for strong and effective community programs.

Provide clearinghouse and technical assistance.

CHA: Nancy Whitelaw, [email protected]

www.cdc.gov/ncipc/factsheets/falls.htm

www.cdc.gov/nccdphp/ www.cdc.gov/aging/pdf/State_of

_Aging_and_Health_in_America_2004. pdf

www.mib.com/kd/html/Aging-Related_Slides.html

www.cms.hhs.gov/medicare/ www.who.int/topics/ageing/en/ www.healthyagingprograms.org www.improvingchroniccare.org/