BEING ALIVE AND WELL AT WIND RIVER >Being Alive = Avoiding Premature Death >Being Well = Not needing high medical expenditures

Methods• I H S RPMS database• Tabulation • Cox Proportional Hazards Model for survival data• Logistic Regression

Premature Death

• Figure 1--Numbers of Deaths by Age by Diagnosiso Two Peaks in Age of Death, Early (35-39) Late (70-74) Early Death Mainly Alcohol Coroner’s “Unnatural Deaths” (Accidents, Homicides, Suicides) Drugs Late Death Major Disease (Diabetes, Heart Disease, Lung Disease)

0

20

40

60

80

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140

0 1-4

5-9

10-14

15-19

20-24

25-29

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70-74

75-79

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100-104

# D

eath

s

Age of Death

Figure 1Numbers of Deaths by Age and Diagnoses

Shoshone/Arapaho

Un-Natural

Alcohol Deaths

Diabetes

Heart

Tobacco/No Alcohol

Lung Cancer, Emphas, COPD

Colon Cancer

Combined Drugs

Cannabis

Opiates

Amphetamines

Cocaine

Sedative/Anxiolitic

Premature Death

Coroner’s “Unnatural Deaths” are Accidents, Homicide, and SuicideFigure 1 shows these deaths are mainly young deathsFigure 2 shows that these deaths are not only young but also largely “alcohol and/or drug” related (76%) By contrast, 22% of “Natural Deaths” are alcohol or drug related

1 Coroner notes drug or alcohol related, labeled substance above.

0

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100

150

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350

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450

Unnatural Accident Homicides Suicides Natural

Figure 2Manner of Death by Alcohol & Drug Use1

Total Deaths by Category

Deaths w/Substance Abuse "Alcohol orDrug Related"

#

Deaths

Premature DeathTable 2g--Odds Ratios=the odds of those with a diagnosis dying compared

to the baseline with no diagnosesFigure 2g--Years lost= Life Expectancy of Baseline minus Life Expectancy of

those positive for a diagnosis listed in Table 2gAlcohol alone increased Odds of Death 7.4 times, 32.5 years of life lost,

113 younger deathsAlcohol and drugs alone increased Odds of Death 16.9 times, 42.3 years of

life lost, 31 younger deathsAlcohol and Tobacco alone increased Odds of Death 5.0 times, 19.6 years

of life lost, 220 younger deathsAlcohol, Drugs, Tobacco alone increased Odds of Death 7.2 times, 26 years

of life lost, 110 younger deaths

Table 2g

What increases the odds of death at Wind River?Survival 1

Odds Years 5 Under 55 Over 55Main Effects Ratio z P>|z| # Patients lost/gained # Dead #DeadBMI 2 0.84 -3.46 0.001 4713 1.9 337 315Depression 0.74 -5.83 0.000 4481 2.2 329 379PTSD/Stress 3 0.73 -3.60 0.000 1246 4.1 86 71Colon Cancer 1.21 1.33 0.185 83 0.0 5 44

Interaction 4 WayAlcohol Drugs Tobacco Major

Disease 4

0 0 0 0 4350 105 810 0 0 1 2.34 8.61 0.000 742 -9.6 33 2670 0 1 0 0.91 -0.74 0.457 3036 0 68 470 0 1 1 2.08 7.34 0.000 981 -7.6 40 2150 1 0 0 2.21 2.05 0.040 86 7 00 1 0 1 5.10 6.54 0.000 29 -17.6 3 150 1 1 0 3.07 4.82 0.000 247 -18.7 16 50 1 1 1 4.20 7.51 0.000 97 -14.4 11 231 0 0 0 7.36 17.52 0.000 396 -32.5 113 231 0 0 1 5.34 11.80 0.000 135 -24.2 28 431 0 1 0 5.01 16.22 0.000 1263 -18.6 220 341 0 1 1 4.40 14.24 0.000 544 -19.0 72 1311 1 0 0 16.92 14.31 0.000 81 -42.3 31 01 1 0 1 6.32 4.43 0.000 15 -41.2 5 11 1 1 0 7.16 15.91 0.000 591 -26.0 110 71 1 1 1 6.31 12.64 0.000 213 -22.1 41 28

1 Survival Analysis -- Cox Proportional Hazards Model2 Body Mass Index (BMI), BMI >= 303 Post Traumatic Stress (PTSD)4 Major Disease - Diabetes, Heart Disease, Lung Disease (COPD, Emphasema, Lung Cancer)

5 " - " means years lost

Premature Death

Alcohol, and interactions with Alcohol, in Table 2g had a total of 620 early deaths compared to 267 late deaths

By contrast, Major Disease and interactions with Major Disease had a total of 233 early deaths and 723 late deaths

This is consistent with Figure 1Table 2g also showed Depression and PTSD/Stress with a small

positive treatment effect that increased life expectancy a small amount over the baseline—a hint about what can help

Premature Death Figure 3—Survival Curves from the data in Table 2goThe vertical axis shows the proportion of patients alive and the

horizontal axis shows analysis time/ageoThe curves drop with age, from all patients alive to all deado Life Expectancy is the median, the point where half are alive and

half dead.o The Survival Curves drop more quickly for patients with early

death diagnoses o Curves drop fastest in this order: (1) Alcohol and Drugs, (2)

Alcohol, (3) Major Disease, (4) baseline, and (5) PTSD/Stress

Premature Death Are injuries/accidents the leading cause of death? Previous data suggested this, but lacked context with comorbid

variables and medical and behavioral histories Table 3g shows the effect of injuries in the context comorbid

variables and histories Injuries alone do not increase the Odds of Death, Odds Ratio=.88,

34 younger deaths & 27 older deaths Injuries with Major Disease, increased the Odds of Death 2.0 times,

5.4 years of life lost, 27 younger deaths & 195 older deaths Injuries with Alcohol/Drugs, increased the Odds of Death 5.4 times,

20.9 years of life lost, 263 younger deaths & 31 older deaths

Table 3g Table 3g How do injuries increase the odds of death at Wind River?

Survival 1Odds Years 5

Main Efects Ratio z P>|z| # Patients lost/gainedBMI 2 0.83 -3.63 0.000 4713 1.9Depression 0.77 -4.95 0.000 4481 1.9PTSD/Stress 3 0.74 -3.50 0.000 1246 4.1

Interaction 3-way

Injuries Alcohol Major Under 55 Over 55or Drugs Disease4 # Dead # Dead

0 0 0 5623 139 1010 0 1 2.44 10.03 0.000 1023 -9.9 40 2870 1 0 6.27 20.46 0.000 1111 -21.5 234 380 1 1 5.42 16.36 0.000 360 -22.7 71 971 0 0 0.88 -0.92 0.356 1763 0.5 34 271 0 1 1.96 6.67 0.000 700 -5.4 27 1951 1 0 5.4 18.69 0.000 1553 -20.9 263 311 1 1 4.49 15.65 0.000 673 -17.7 89 144

1 Survival Analysis -- Cox Proportional Hazards Model2 Body Mass Index (BMI), BMI >= 303 Post Traumatic Stress (PTSD)4 Major Disease=ease = Diabetes, Heart Disease, & Lung Disease5 "-" = years lost

HIGH Medical CostsFigure 4g—The Cost of Wellnesso Referred Care (Contract Health) Costs for 14 years, FY2000-FY2014, excluding

Medicare and Medicaid costs.o 102.5 million spent, 4.6 million, under age 15, and 97.9 million age 15 and

over. (Medicare/Medicaid covers many younger and many older patients). Table 4g covers ages 15 and up, most without alternative resources, private insurance low.

o Four risk factors analyzed: Alcohol/Tobacco, Weight, Negative Emotions, Injuries—potentially preventable factors.

o Odds of being a High Cost Case (over $25,000) is a function of the number of risk factors a patient has

oAverage Odds Ratio with: One risk factor=3.7 , Two risk factors=10.4, Three risk factors=19.1, Four risk factors 38.7

Table 4g The Price of Wellness: Prediction of High-Cost Cases Risk Factors 4-Way Interaction 1 raction 1Alcohol/ Weight 3 Negative Injuries 5 Odds 6 z 7 # Patients Average Total Cost Potential # Patients 9Tobacco 2 Emotions 4 Ratio Significance Cost (Sum) Savings 8 extraHICOST

0 0 0 0 (baseline) 387 6,583.95 2,547,989 -- 20 0 0 1 3.6 3.6 169 8,708.14 1,471,676 358,988 00 0 1 0 4.1 4.1 164 8,647.53 1,418,195 338,427 00 1 0 0 3.7 4.1 209 8,461.94 1,768,545 392,500 00 0 1 1 11.7 7.9 150 15,582.82 2,337,423 1,349,830 30 1 0 1 8.9 6.4 115 20,153.66 2,317,671 1,560,517 00 1 1 0 10.4 7.6 168 13,157.32 2,210,430 1,104,326 00 1 1 1 19.2 9.7 133 18,558.25 2,468,247 1,592,582 0

Subtotals 1495 16,540,176 6,697,170 51 0 0 0 3.4 4.3 428 8,613.22 3,686,458 868,528 41 0 0 1 12.9 10.1 499 15,625.72 7,797,234 4,511,843 91 0 1 0 10.7 9.4 542 13,994.27 7,584,894 4,016,393 51 1 0 0 7.5 7.5 368 12,247.31 4,507,010 2,084,116 51 0 1 1 22.6 13.2 982 19,689.09 19,334,686 12,869,247 261 1 0 1 18.4 11.50 399 17,761.67 7,086,906 4,459,910 161 1 1 0 16.3 11.2 489 16,432.43 8,035,458 4,815,907 121 1 1 1 38.7 15.6 964 24,232.43 23,360,063 17,013,135 39

Subtotals 4671 81,392,709 50,639,078 116Grand Total 6166 97,932,885 57,336,248 121 1 Sky Blue = Combinations with 1 of 4 risk factors; Green = 2 of 4 risk factors; Aqua Blue = 3 of 4 risk factors; Orange = 4 of 4 factors. 2 Alcohol and/or drugs 3 Weight=BMI >= 30 4 Negative Emotions = Depression and/or Trauma and /or Panic, Anxiety 5 Injuries >= 4 injury visits: Impact injuries, e.g. fractures, contusions (accidents/violence) 6 Logisitic Regression, predicting HICOST patients >= $25,000 7 All z values are statistically significant, p > |zp > |z| = .000 8 Potential Savings = (Average Category Cost - Baseline Average Cost) x # of Patients in Category 9 extraHICOST patients >= $100,000

High Medical CostsIn Table 4g, costs for Alcohol/Tobacco and interactions with

this factor, totaled 81.4 million

Costs without Alcohol/Tobacco and interactions with it totaled 16.5 million, a difference of 64.9 million

The number of extra high-cost patients (>$100,00), with Alcohol/Tobacco and its interactions, outnumbered the patients without this risk factor 116 to 5.

High Medical CostsTable 5g – Referred Care Cost SummaryAnalysis I summarizes Table 4gAnalysis II adds Major Disease and drops WeightIn both analyses, Alcohol/Tobacco & its interactions, have higher total costs

than the other risk factors and their interactions For Alcohol/Tobacco higher costs are related to higher patient numbers

(prevalence) Slightly higher average costs (per patient costs) are associated with the

other risk factors due to lower prevalence The Costs for Alcohol/Tobacco (81.4 million) are much greater than the

costs for Major Illness (41.4 million) in spite of higher per patient costs for Major Illness

Table 5g

Referred Care Cost Summary 1

Analysis I Analysis II

Alcohol / Negative Alcohol/ Negative MajorRisk Factors Tobacco Weight Emotions Injuries Tobacco Emotions Injuries Disease

Cost Sums 2 81.4 million 51.8 million 66.7 million 66.2 million 81.4 million 66.7 million 66.2 million 41.4 millionPatientNumbers 3 4671 2845 3592 3411 4671 3592 3412 1886PatientAverages 4 $17,425 $18,191 $18,582 $19,400 $17,425 $18,583 $19,397 $21,964

1 Referred Care Costs were used over a 14 year period, FY2000-FY2014. These data were analyzed using logistic regression, with costs predicted by risk factors, using a 4-way interaction model. Analysis I uses Alcohol/Tobacco X Weight X Negative Emotions X Injuries with a prevention goal, while Analysis II uses Major Disease instead of Weight, Alcohol/Tobacco X Negative Emotions X Injuries X Major Disease.2 There are 16 terms or rows in a 4-way interaction, and to get the cost of the risk factor the costs are summed over the 8 terms that are positive for that risk factor, (e.g. Alcohol/Tobacco).3 Patient Numbers are calculated by adding the number of patients for each of the interaction terms that are positive for the risk factor.4 Patient Averages are Cost Sums divided by Patient Numbers.

Conclusion

Priority Attention to Alcohol/Substance Treatment and Prevention is needed to save lives and reduce medical costs

What would Priority Attention look like? Integration across institutions: Indian Health service, Tribal Treatment Programs, Vocational Rehabilitation, Legal System (Jails), Schools, Places of Employment (Casinos), Local Inpatient Treatment, Department of Family Services

Conclusion

Use technology to improve the integration, quality, availability, and efficiency, and monitoring of treatment.• Computer Based Interventions and Treatment • Followed by group counseling (covering topics initiated on the computer)• Individual Counseling as needed after the above• Use of smart phones for monitoring and positive interventions for younger people.

Conclusion

Treatment is completed under the direction of a Clinical Supervisor, following clinical treatment plans• Treatment teams may involve different institutions• The clinical supervision by a licensed professional (MD if needed), and on site treatment, would qualify the computer based, group or individual treatment for insurance reimbursement, helping sustain the programs• Individual incentives given to clients to promote continuation and

completion

Addendum

Substance Abuse has comorbid conditions—Depression PTSD/Stress, Anxiety/Panic, Conduct problems (see Table 6g)These comorbid conditions need treatment for substance treatment to be effective—conversely treatment for depression & PTSD/Stress is not effective when clients are using alcohol/drugs (see Table 7g)Computer_based treatment can be effective in treating depression

& PTSD/Stress, assisting counselors with less familiarity with the topic

Odds Ratio z P<|z| Odds Ratio z P>|z|ALCOHOL

Depression 2.46 18.99 0.000PTSD/Stress 1.34 4.28 0.000Anxiety/Panic 1.50 7.42 0.000Conduct 1.94 11.71 0.000

COMBINED DRUGSDepression 3.37 17.25 0.000PTSD/Stress 1.52 5.13 0.000Anxiety/Panic 1.65 7.08 0.000Conduct 3.13 16.74 0.000

TOBACCODepression 2.61 21.53 0.000PTSD/Stress 1.71 6.94 0.000Anxiety/Panic 1.77 10.14 0.000Conduct 1.38 5.51 0.000

BMI (food)Depression 1.61 11.07 0.000PTSD/Stress 1.23 3.20 0.001Anxiety/Panic 1.30 5.15 0.000Conduct 0.76 -4.85 0.000

Emotions and Substance AbuseTable 6g

Table 7g

How to Handle Emotions: Alcohol and Drugs vs Treatment

Depression

2-Way InteractionAlcohol or

Drugs 1 Depression 2 Odds Ratio z P > |z|

Years 3 lost/gained

0 1 0.82 -2.08 0.038 1.31 0 3.79 24.78 0.000 -17.81 1 2.26 10.37 0.000 -9.7

PTSD/Stress

Alcohol or Odds Years 3Drugs 1 PTSD 4 Ratio z p> |z| lost/gained

0 1 0.65 -2.89 0.004 4.51 0 3.49 24.43 0.000 -16.91 1 2.28 7.98 0.000 -8.6

1 Patients with a drug or alcohol diagnosis or both2 Patients of ages 15-100 with a depression diagnosis with at least 5 treatment visitstreatment visits3 "-" means Years lost4 Post-traumatic Stress Disorder

2-Way Interaction