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Aging Outside the Box

Aging Outside the Box. Stanford Continuing Studies James F. Fries, MD November 7, 2007 Slides Available at ARAMIS.Stanford.edu. Class Schedule. General Themes October 17 – Longevity October 24 – Compression of Morbidity

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Aging Outside the Box

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  1. Aging Outside the Box Stanford Continuing Studies James F. Fries, MD November 7, 2007 Slides Available at ARAMIS.Stanford.edu

  2. 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

  3. 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@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

  4. National Long-Term Care SurveysDisability Percentages Over Age 65 Manton and Gu, 2006

  5. Recent Trends in Disability Among Older Americans

  6. Percentage of Disability Over Time Estimates by Age Groups, NLTCS 1982-2004

  7. Average Medicare Part A expenditures by disability category and year (in 2004 dollars, 000’s per person)

  8. 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

  9. 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

  10. 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 2006;103:18374.

  11. 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

  12. Sources of Data • U.S. population ≥ 65 years: US. Census • # TJR’s 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

  13. 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

  14. TJR rates by Year

  15. Change in disability/pain over one year for subjects with TJR * p < 0.05 ** p < 0.01 *** p < 0.001

  16. Change in disability/Pain over one year without TJR ** p < 0.01 *** p < 0.001

  17. Case/Control Analysis Matched for age (year), gender, and HAQ-DI (exact)

  18. 12-month disability = 1.74 expected HAQ-DI -1.46 observed HAQ-DI = 0.28 HAQ-DI Units

  19. Figure 2 12-month pain = 2.20 expected score -1.32 observed score = 0.88 units

  20. Summary * Four-fold increase in TJR in seniors from 1982-2004

  21. Master Equation Change in Nationwide disability due to TJR = (Δ 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

  22. Sensitivity Analyses

  23. 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

  24. Health Improvement Programs: Randomized Trials in Seniors Fries et al, Health Affairs, 1998

  25. Improved Self-Efficacy Reduction in Health Risks Increased Self-Management Targeting High-Risk Persons Targeting Chronic Disease Advance Directives: Humanizing the Last Year Health Improvement and Cost Reduction Programs in Senior Populations: Goals

  26. 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 5:1 • 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

  27. 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 • Goals:health up, risks down, costs neutral or down = a new Medicare benefit

  28. 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.

  29. 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

  30. Smoking Passive Smoking Inactivity Obesity Lipids Inflammation Salt Fiber Screenings:mam, col, pap, bp, eye, bmd Alcohol Caffeine Sun Seat Belts Vehicles Highways Aspirin Pollution Vaccines PRIMARY PREVENTION

  31. Aspirin Hypertensive control Lipid control Diabetes control Beta blockers Bone strengthening Fall Prevention Self-management Medical errors Plus: Primary prevention approaches SECONDARY PREVENTION

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