Evidence-Based Prevention Improves Chronic Care Management

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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

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

• 1993 vs. 2001 US adults reported
• Deterioration in
• physical health
• mental health
• ability 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.

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

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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?

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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

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Chronic Conditions Among Persons 70
Chronic diseases account for 95 of health care
expenditures
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Leading Causes of Death, Age 65 (2001)

• Heart Disease 32
• Cancer 22
• Stroke 8
• Chronic respiratory 6
• Flu/Pneumonia 3
• Diabetes 3
• Alzheimers 3

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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

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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

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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

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Obesity Trends Among U.S. Adults BRFSS,
2001(BMI ?30, or 30 lbs overweight for 54
woman) (Marx)
lt10 1014
1519 20-24 ?25
Source Behavioral Risk Factor Surveillance
System, CDC.
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Disability Increases with Age BUT Much Higher
Rates Among the Obese (Marx)
1,200
Obese
Non-Obese
900
per 10,000 people
600
300
0
60-69
30-39
40-49
50-59
18-29
Age Group
Data based on 1996 National Health Interview
Survey Sources National Business Group on
Health Rand Corp.
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Severe Obesity and Mortality

• Severe obesity (BMI gt45) lowers years of life by
  13 years for white men and 8 years for white
  women age 2030.
• For blacks the loss was 20 years for men and 5
  years for women.
• Fontaine et al. JAMA 2003289187193

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Total Cardiovascular Disease Deaths,
1999Age-adjusted death rates per 100,000
population (Marx)
190.5230.8 231.1250.0 255.5284.8 285.1354.9
United States - 172
Source National Vital Statistics System,
National Center for Health Statistics, CDC
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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 199827(3)31116
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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 200329018841890

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Predicted Likelihood of Developing Coronary Heart
Disease, Stroke, or Diabetes by Age 65 (Marx)
Men, Aged 50
Smoker Overweight Inactive
Ratio
Non Smoker Normal Weight Active
11
58
5.5
Source Jones et al. Arch Intern Med
2002162256571
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Disability Index, by Age and Health Risk
University of Pennsylvania Alumni
0.30
0.25
0.20
High risk
Disability Index
0.15
Moderate risk
0.10
Low risk
0.05
0.00
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
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Age
Progression of disability delayed approximately 7
years in low risk vs. high risk.
Risk based on body mass index, smoking,
exercise 0-3 point scale for each low
02 points, moderate 34 points, high 59
points. Note A disability index of 0.1
minimal disability. Source Vita et al. N Engl J
Med 1998338(15)103541
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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 gt1
  year
• Falls cost gt 15 billion/year

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Falls Are Predictable (RF Risk Factor)
who fall
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Risk Factors

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

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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

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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.
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Federal Spending in Billions, 2000
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How Should these Threats be Addressed?

• 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

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Outcomes
Improved Outcomes
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Social Ecologic Model of Healthy Aging
McLeroy et al., 1988, Health Educ Q Sallis et
al., 1998, Am J Prev Med
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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.

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

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Self-Management Support, What?

• Emphasize the patients 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.

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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?

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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)

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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

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RE-AIM www.re-aim.org
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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?

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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

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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.

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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?

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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?

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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?

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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?

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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?

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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.

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NCOAs Center for Healthy Aging and AoAs
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.

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CHA Nancy Whitelaw, PhD nancy.whitelaw_at_ncoa.org

• 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/