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

2. 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. 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 94304jff@stanford.edu Be ready to say a few words about your arguments at the last class meeting December 5

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6. 6 National Long-Term Care Surveys Disability Percentages Over Age 65 Manton and Gu, 2006 19821989199419992004 Disabled, Any26.524.823.221.219.0 Mild Disability (IADL)5.74.54.43.32.4 Moderate Disability6.86.66.16.35.6 Severe Disability3.53.12.93.03.2 Institutionalized7.56.96.34.94.0

7. 7 Recent Trends in Disability Among Older Americans

8. 8 Percentage of Disability Over Time Estimates by Age Groups, NLTCS 1982-2004 Age & Disability Level 19821989199419992004 Relative Changes, % Age 65-74 Disabled14.211.911.810.78.9-37.3 Institution2.01.91.61.40.9-54.6 Age 75-84 Disabled30.729.426.223.421.9-28.7 Institution8.17.06.34.34.1-48.8 Age 85+ Disabled62.161.458.555.649.7-20.0 Institution27.226.124.619.515.6-42.7

9. 9 Average Medicare Part A expenditures by disability category and year (in 2004 dollars, 000’s per person) Age and disability level 19821989199419992004 Total Nondisabled2.22.01.91.71.6 Five or six ADL15.211.917.713.612.0 Institution8.57.98.610.19.8 Age 65-84 Nondisabled2.21.9 1.71.5 Five or Six ADL17.411.710.514.912.5 Institution9.89.36.612.810.8 Age 85+ Nondisabled2.92.82.02.62.3 Five or six ADL8.412.417.411.110.9 Institution6.76.07.17.38.8

10. 10 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

11. 11 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

12. 12 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.

13. 13 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

14. 14 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

15. 15 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

16. 16 TJR rates by Year

17. 17 Change in disability/pain over one year for subjects with TJR * p < 0.05 ** p < 0.01 *** p < 0.001

18. 18 Change in disability/Pain over one year without TJR ** p < 0.01 *** p < 0.001

19. 19 Case/Control Analysis Matched for age (year), gender, and HAQ-DI (exact)

20. 20 12-month disability = 1.74 expected HAQ-DI -1.46 observed HAQ-DI = 0.28 HAQ-DI Units

21. 21 Figure 2 12-month pain = 2.20 expected score -1.32 observed score = 0.88 units

22. 22 Summary Study Design Outcome Variable Baseline Value Change Score Cohort HAQ-DI1.46-0.10 Pain1.73-0.47 Case-Control HAQ-DI1.24-0.14 Pain1.56-0.30 Extrapolation HAQ-DI1.51-0.28 Pain1.75-0.88 * Four-fold increase in TJR in seniors from 1982-2004

23. 23 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

24. 24 Sensitivity Analyses Δ HAQBaseline HAQ TJR In pop. Duration (Years) Δ Disability % of Change 0.101.5 12 %10 0.084 0.101.0 12 %10 0.126 0.101.5 12 %5 0.042 0.101.5 12 %15 0.126 0.151.5 12 %10 0.126 0.151.0 12 %10 0.189 0.151.5 12 %5 0.063 0.251.5 12 %10 0.4522

25. 25 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

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

27. 27 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

28. 28 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

29. 29 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

30. 30 Conclusions Theory, 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.

31. 31 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

32. 32 PRIMARY PREVENTION 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

33. 33 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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