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Evidence-Based Prevention Improves Chronic Care
Management
Nancy A. Whitelaw, Ph.D.Director, Center for Healthy AgingThe 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 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.
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“Honest doc--if I had known I was gonna to live this long, I’d 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+
0 10 20 30 40 50 60 70
Cancer
Stroke
Respiratory Diseases
Diabetes
Heart Disease
Hypertension
Arthritis
Percent
M enWomen
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% Alzheimer’s 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 5’4” woman) (Marx)
<10% 10%–14% 15%–19% 20%-24% 25%
Source: Behavioral Risk Factor Surveillance System, CDC.
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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
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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
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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
190.5–230.8231.1–250.0255.5–284.8285.1–354.9
United States - 172
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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 1998;27(3):311–16
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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 2003;290:1884–1890
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SmokerOverweight
Inactive Ratio
11% 58% 5.5
Source: Jones et al. Arch Intern Med 2002;162:2565–71
Non SmokerNormal Weight
Active
Predicted Likelihood of Developing Coronary Heart Disease, Stroke, or Diabetes by Age
65 (Marx) Men, Aged 50
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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
Disa
bilit
y In
dex
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 riskModerate risk
Low risk
Progression of disability delayed approximately 7 years in low risk vs. high risk.
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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 >1 year
Falls cost > $15 billion/year
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Falls Are Predictable (RF= Risk Factor)
0102030405060708090
100
1 RF 2 RF 3 RF 4 RF 5+RF
% whofall
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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/yearInstitute 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
$0
$50
$100
$150
$200
$250
$300
Medicare Medicaid AoA NCCDPHP
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“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?
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Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health SystemResources and Policies
Community Health Care Organization
Chronic Care Model
Outcomes
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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
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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 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.
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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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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.
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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/