Aging Outside the Box

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Aging Outside the Box

• Stanford Continuing Studies
• James F. Fries, MD
• November 7, 2007
• Slides Available at ARAMIS.Stanford.edu

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Class Schedule

• General Themes
  
• October 17 Longevity
• October 24 Compression of Morbidity
• October 31 Declining Disability
• November 7 Aging and Health Policy
• December 5 Synthesis and Application

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For a Letter Grade

• Pick an article, any article, from the course
  reader.
• Write a page, double-spaced, bullets allowed, on
  Why you should believe this paper
• Write a second page on Why you should not
  believe this paper.
• Email to jff_at_stanford.edu or mail to J. F. Fries,
  1000 Welch Road, Suite 203, Stanford, CA 94304
• Be ready to say a few words about your arguments
  at the last class meeting December 5

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National Long-Term Care SurveysDisability
Percentages Over Age 65
1982 1989 1994 1999 2004

Disabled, Any 26.5 24.8 23.2 21.2 19.0
Mild Disability (IADL) 5.7 4.5 4.4 3.3 2.4
Moderate Disability 6.8 6.6 6.1 6.3 5.6
Severe Disability 3.5 3.1 2.9 3.0 3.2

Institutionalized 7.5 6.9 6.3 4.9 4.0
Manton and Gu, 2006
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Recent Trends in Disability Among Older Americans
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Percentage of Disability Over Time Estimates by
Age Groups, NLTCS 1982-2004
Age Disability Level 1982 1989 1994 1999 2004 Relative Changes,
Age 65-74
Disabled 14.2 11.9 11.8 10.7 8.9 -37.3
Institution 2.0 1.9 1.6 1.4 0.9 -54.6
Age 75-84
Disabled 30.7 29.4 26.2 23.4 21.9 -28.7
Institution 8.1 7.0 6.3 4.3 4.1 -48.8
Age 85
Disabled 62.1 61.4 58.5 55.6 49.7 -20.0
Institution 27.2 26.1 24.6 19.5 15.6 -42.7
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Average Medicare Part A expenditures by
disability category and year (in 2004 dollars,
000s per person)
Age and disability level 1982 1989 1994 1999 2004
Total
Nondisabled 2.2 2.0 1.9 1.7 1.6
Five or six ADL 15.2 11.9 17.7 13.6 12.0
Institution 8.5 7.9 8.6 10.1 9.8
Age 65-84
Nondisabled 2.2 1.9 1.9 1.7 1.5
Five or Six ADL 17.4 11.7 10.5 14.9 12.5
Institution 9.8 9.3 6.6 12.8 10.8
Age 85
Nondisabled 2.9 2.8 2.0 2.6 2.3
Five or six ADL 8.4 12.4 17.4 11.1 10.9
Institution 6.7 6.0 7.1 7.3 8.8
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Causes of Disability Decline

• Have to (1) have greatly increased in use since
  1982, (2) apply to a lot of people, (3) have a
  substantial effect on disability in those people,
  and, preferably, (4) not have a large effect on
  increasing life expectancy
• Lifestyle smoking down, obesity up, exercise
  flat
• Medical anti-hypertensives, statins, low-dose
  aspirin, diabetes control, total joint
  replacement
• Social second-hand smoke, highways, air bags

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Total Joint Replacement Contributes to Declining
Disability Rates in Seniors

• James F. Fries, M.D.
• Eliza F. Chakravarty, M.D.
• Bharathi Lingala, Ph.D.
• Helen H. Hubert, Ph.D.
• Stanford University, Stanford CA

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Objective

• The National Long-Term Care Survey documented a
  nearly 2 annual decline in disability rates
  among seniors (age 65 years) from 1982 to 2004
• Objective To estimate how much of the national
  decline may be attributed to knee and hip joint
  replacement (TJR)

Manton KG, et al. PNAS 200610318374.
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Assumptions

• Observed decrease in disability is linear
• TJR has no significant effect on mortality
• Impact of TJR on disability remains constant over
  time
• Duration of effect of TJR is 10 years
• Benefit from individual TJR procedures is
  constant from 1982 to 2004

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Sources of Data

• U.S. population 65 years US. Census
• TJRs performed National Hospital Discharge
  Survey (CDC)
• Baseline disability (Health Assessment
  Questionnaire-Disability Index) ARAMIS dataset
• Disability improvement at 7-12 months following
  TJR (HAQ-DI) ARAMIS dataset

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Statistics

• Cohort study All ARAMIS participants who
  underwent TJR with HAQ-DI scores before and after
  compared with 12-month change data in
  participants without TJR.
• Case-Control study ARAMIS participants with TJR
  compared to controls matched on age (same year),
  gender, and baseline HAQ-DI (exact). Pair-wise
  t-tests
• Extrapolation Change in HAQ-DI prior to TJR
  extrapolated out 12 months and compared to
  observed HAQ-DI 12 months post TJR

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TJR rates by Year
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Change in disability/pain over one year for
subjects with TJR
p lt 0.05 p lt 0.01 p lt 0.001
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Change in disability/Pain over one year without
TJR
p lt 0.01 p lt 0.001
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Case/Control Analysis
Matched for age (year), gender, and HAQ-DI (exact)
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12-month disability 1.74 expected HAQ-DI -1.46
observed HAQ-DI 0.28 HAQ-DI Units
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Figure 2
12-month pain 2.20 expected score -1.32
observed score 0.88 units
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Summary
Study Design Outcome Variable Baseline Value Change Score
Cohort HAQ-DI 1.46 -0.10
Pain 1.73 -0.47
Case-Control HAQ-DI 1.24 -0.14
Pain 1.56 -0.30
Extrapolation HAQ-DI 1.51 -0.28
Pain 1.75 -0.88
Four-fold increase in TJR in seniors from
1982-2004
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Master Equation

• Change in Nationwide disability due to TJR
• (? HAQ/ Baseline HAQ) x cumulative proportion
  with TJR x duration of response
• (0.10/1.5) x 0.12 x 10 years
• 0.08 reduction in disability attributable to
  TJR
• 4.0 of the 2 decline in nationwide disability

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Sensitivity Analyses
? HAQ Baseline HAQ TJR In pop. Duration (Years) ? Disability of Change
0.10 1.5 12 10 0.08 4
0.10 1.0 12 10 0.12 6
0.10 1.5 12 5 0.04 2
0.10 1.5 12 15 0.12 6
0.15 1.5 12 10 0.12 6
0.15 1.0 12 10 0.18 9
0.15 1.5 12 5 0.06 3
0.25 1.5 12 10 0.45 22
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Conclusions

• TJR has made a small but detectable impact on
  national disability rates
• The benefits of TJR are greater in the pain
  domain than in disability reduction
• Different approaches to estimating the disability
  reduction yield reasonably similar estimates
• Approximately 2-8 of the national disability
  decline since 1982 is attributable to increased
  numbers of knee and hip replacement operations

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Health Improvement Programs Randomized Trials
in Seniors
Fries et al, Health Affairs, 1998
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Health Improvement and Cost Reduction Programs in
Senior Populations Goals

• Improved Self-Efficacy
• Reduction in Health Risks
• Increased Self-Management
• Targeting High-Risk Persons
• Targeting Chronic Disease
• Advance Directives Humanizing the Last Year

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Parameters of Programs that Improve Health and
Save Money

• Program cost 100/year or less (medical costs per
  senior per year 6,000). Design ROI 51
• Multiple interventions in one
• Multiple contacts through the year
• Tailored interventions - to each his or her own
  health improvement program
• Not doctor/hospital/one-on-one based too
  expensive
• Computer-driven, mail (and increasingly Web)
  delivered
• Focus on big, modifiable health and cost issues

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Senior Risk Reduction Program

• Medicare Demonstration Program 2007-2010
• Tailored health improvement and cost reduction
  programs (HRA based)
• Potential established by RAND randomized trial
  design by MedSTAT
• Five interventions best in class, two control
  groups, three years, 85,000 subjects, independent
  assessment of results
• Goalshealth up, risks down, costs neutral or
  down a new Medicare benefit

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ConclusionsTheory, Longitudinal Studies,
Population Surveys, and Randomized Trials
document that

• Disability has been decreasing by 2 or more per
  year in the U.S.for at least 10 years. Mortality
  rates are decreasing at only 1 a year,
  documenting Compression of Morbidity
• Health enhancement programs can improve health
  and reduce costs in mature adult populations
• The Senior Risk Reduction Demonstration is a
  randomized controlled trial which could lead to
  better senior health and lower medical costs
• Further Compression of Morbidity is feasible but
  not inevitable.

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HOW CAN IT BE ACHIEVED?

• Self-Efficacy
• Health Policies
• Targeted Postponement of Morbidity
• Behavioral Health Risk Reduction
• Medical Primary Prevention
• Medical Secondary Prevention
• Social and Environmental Policies

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PRIMARY PREVENTION

• Smoking
• Passive Smoking
• Inactivity
• Obesity
• Lipids
• Inflammation
• Salt
• Fiber
• Screeningsmam, col, pap, bp, eye, bmd

• Alcohol
• Caffeine
• Sun
• Seat Belts
• Vehicles
• Highways
• Aspirin
• Pollution
• Vaccines

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SECONDARY PREVENTION

• Aspirin
• Hypertensive control
• Lipid control
• Diabetes control
• Beta blockers

• Bone strengthening
• Fall Prevention
• Self-management
• Medical errors
• Plus Primary prevention approaches

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