sonoma state university prevention & the healthcare crisis 2004
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Reducing Health Care Costs by Reducing the Need and Demand
For Medical Services
• Overall costs were $838 billion in 1992, or more than $3,000 per person.
• More than 30 million Americans are uninsured, partly because of rising premium costs.
• The approach largely ignored focuses on reducing the need and demand for medical services.
Preventive Health and Cost Savings
• treatment of hypertension
• reducing the rate of low-birth-weight infants
• smoking cessation
• nutrition education and weight reduction
• exercise and stress management
• appraisal of health risk
The main reason to invest in prevention is to promote health and extend life, improve functioning and prevent suffering.
» "The Role of Prevention in Health Reform", Russell, Louise B., Ph.D., The New England Journal of Medicine, July 29, 1993;329 (5):352-354.
Cardiovascular disease
The estimated cost for cardiovascular disease in 1994 by the American Heart Association is 128 billion dollars.
1 of 2 women in the US dies of heart disease or stroke
• less than 33% identified heart disease as the leading cause of death.
• More women identified breast cancer as the leading cause of death.
• Although 90% of the women reported that they would like to discuss heart disease or risk reduction with their physicians, more than 70% reported that they had not.
Walter C. Willet MD MPHProfessor of MedicineChairman of the Department of NutritionHarvard
• Moderately easily achieved lifestyle intervention* results in 82% reduction risk of coronary artery disease…. This is much more important than Statins
*No cigarette smoking, moderate physical activity and easy diet changes
Nutrition is the Keystone of Prevention
The prevention of disease could result in enormous cost savings to physicians and hospitals.
» Kretchmer, Norman, The American Journal of Clinical Nutrition, 1994;60:1.
The Lyon heart trial
o Adjusted risk ratios ranged from 0.28 to 0.53
o The protective effect of the Mediterranean dietary pattern was maintained up to 4 years after the first infarction
» Circulation 1999 Feb 16;99(6):779-85
Mediterranean dietary pattern in a randomized trial: prolonged survival and possible reduced cancer rate
During a follow-up of 4 years. reduction of risk in experimental subjects compared with control subjects was:
• 56% (P=.03) for total deaths
• 61% (P=.05) for cancers
• 56% (P=.01) for the combination of deaths and cancers.
» Arch Intern Med 1998 Jun 8;158(11):1181-7
To Supplement or Not To Supplement: Is it a Question?
• improved intakes of certain micronutrients in particular vitamins C, E and beta-carotene would reduce health care costs by 25% for cardiovascular disease, 16% to 30% for a variety of major cancers and 50% for cataracts.
» Lachance, Paul A., Ph.D., DSc, Rutgers, The State University of New York, New Brunswick, NJ 08903-0231, U.S.A.)
Exercise
Americans would pay almost any price for a pill that contained all the benefits associated with exercise: increased life expectancy, improved mental health, and decreased disability. Scientific research has shown repeatedly that exercise can benefit both the body and mind.
• Statement of Dr. Terrie WetleDeputy Director,
National Institute on AgingSenate Special Committee on Aging
Hearing on Healthy Aging September 14, 1999
Physical Activity and Prevention
• Self-directed, moderate-level physical activities which include gardening, yard work and walking with a goal of 30 minutes of activity per day at least 5 days per week.
» "Public Health Focus: Physical Activity and the
Prevention of Coronary Heart Disease", Morbidity and Mortality Weekly Report, September 10, 1993;42(35):669-672
Physical Activity and Prevention
• Coronary artery disease cost $47 billion.
• Cost of physical inactivity was $5.7 billion.
• Elevated serum cholesterol (>than 200 ug/dL) cost of $7 billion.
• For each quality-adjusted life-year gained the direct cost was $1,395
Physical Activity and Prevention
• Physical activity classes 2 to 3 times per week, for 30 to 45 minutes per session
• For each worker, the intervention program saved $679 in medical claims per year, a return of $6.85 on each dollar invested.
• Other examples of work-site programs have been estimated to cost employers about $100 to $400 per employee, per year. The estimated rate of return is about $513 per employee per year, including reduced health care cost and reduced loss of productivity.
Emotion, Cancer and Heart Disease
• Specific emotional factors are 6 times more predictive of those who will develop cancer or coronary heart disease than cholesterol, blood pressure or smoking in following over 2,000 subjects in Germany over a 13 year period.
– "Emotional Health, Cancer and Heart Disease", Crawford, Robert J.M., The New Zealand Medical Journal, March 1993;10:87
Psychosocial Components
• psychosocial treatment can improve survival.• Those who had a mild or moderate depression had
a risk-adjusted 6.5-fold higher likelihood of death compared to MI patients who were not depressed.
• Those who had psychological stress upon entry into the program had a 3.5-fold increase in the risk of a subsequent cardiac event in the next 2 years.
Job Stress and the Risk of Coronary Heart Disease
• 6895 men & 3,413 women between 35 and 55 followed for 5.3 years
• imbalances between personal efforts and rewards were associated with a 2.15-fold higher risk of new coronary heart disease.
• Job strain and high job demands were not related to coronary heart disease.
• Low job control was strongly associated with new disease.
– "Two Alternative Job Stress Models and the Risk of Coronary Heart Disease," Bosma PH, et al, Am J Public Health, January 1998; 88(1):68-74
"hostility" is cardio-toxic
• Large National Institute of Health studies ultimately demonstrated that it is this "hostility" component of Type-A behavior which is cardio-toxic and coronary-prone
» Mark Goodman, Ph.D., M.A. "Pilot Findings of a Percutaneous Transluminal Coronary Angioplasty Restenosis Prone Prevention Program," Mayo Clinic Proceedings, May, 1997;172:487
Walter C. Willet MD MPHProfessor of MedicineChairman of the Department of NutritionHarvard
• Moderately easily achieved lifestyle intervention* results in 82% reduction risk of coronary artery disease…. This is much more important than Statins
*No cigarette smoking, moderate physical activity and easy diet changes
Ornish’s Lifestyle Demonstration Project
• Angiographically documented CAD severe enough to warrant revascularization.
• The cost of the 1-year program averaged $7,000 per person.
• Reduction in angina comparable to that achieved with revascularization
• The average cost for PTCA (with cardiac catheterization) was $31,000, and for CABG was $46,000.
• The average cost savings per patient was $29,529
Survival curves
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1 2 3 4 5 6 7 8 9 10 11
decades
% su
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survival b
Reducing Health Care Costs by Reducing the Need and Demand
For Medical Services• Widespread implementation of preventive
strategies requires a collaboration among business, labor, the insurance industry, government and universities.
• Reducing the need and demand for medical services is a positive solution bringing better health for the individual and ultimately lowering health care costs.
» Fries, James F., et al, The New England Journal of Medicine, July 29, 1993;329(5):321-325.
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