Evidence-Based Prevention Improves Chronic Care Management Nancy A. Whitelaw, Ph.D. Director, Center...
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Transcript of Evidence-Based Prevention Improves Chronic Care Management Nancy A. Whitelaw, Ph.D. Director, Center...
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/