Download - Cost Of Obesity-Based Heart Risk In The Context Of Preventive And Managed Care Decision-Making: An NHANES Cross-Sectional Concurrent Study by John Frias Morales, Dr.BA, MS

NHANES Dissertation Design & MethodsProblem.

Medical processes match at-risk patients with obesity and

pre-clinical heart disease to beneficial anti-cholesterol, weight

loss, and lifestyle therapies (per 2013 American College of

Cardiology guidelines), but financing & scaling rules that

enable risk-reduction haven’t been defined.

• Research question: How does the relationship between

obesity and heart risk impact total medical costs?

• Purpose. Determine how obesity and healthy weight

depend on heart risk to amplify costs, and how disease-

free/normal patients differ from moderate heart risk

patients with obesity (pre-clinical well-appearing).

Design:

Cross-sectional for baseline cost estimates and service non-

use, as naturally distributed in the population. Exploratory

analysis for hypothesis generation and definition of stage-

contingent rules.

Methods

Who:

Adults (20-74 years old) representing the US

non-institutionalized population

• Not pregnant without outlier/rare diseases

• Disease-free and obesity-based heart risk

Measures of effect

• Mean costs difference relative

to normal/disease-free

• Magnitude of dependency

trend

Data description

• Patient-level service use (NHANES

public health data 2003-2012) mapped to

market prices (Healthcare Bluebook &

Micromedex Redbook) and estimates of

non-service use; and

• Clinical lab, exam, and vital sign data

mapped to risk of heart attack/stroke (10-

year calculator benefit groups, then

defaulting to low lifetime risk categories)

and body size.

Defining cost types

• Disease-free versus moderate

heart risk (incubating, well-

appearing), stratified by obesity

• Sub-clinical heart risk

(≥7.5%diabetics & genetic high

cholesterol) versus clinical

ASCVD (had severe event),

stratified by obesity

Statistical evaluation/test:

• Model main effects and moderation

interaction effects with R Sq,

• Hypothesis equivalence testing of mean

total cost by Wald F & T test for subgroups

• Estimated marginal means difference from

disease-free baseline for magnitude of

effects with Wald F and T test.

Comparator criteria

• Cost difference of higher risk

(10 year calculator) relative to

lower risk (30 year calculator)

cost

• R square of obesity-based

heart risk model compared to

industry actuarial risk

adjustment R square (Milliman)

John Frias Morales (2015) dissertation for Golden Gate University doctorate in business administration. Sources: NHANES 2003-2012, Healthcare Bluebook, Micromedex Redbook, AHA/ACC/TOS

obesity algorithm (Jensen and Ryan, 2013), AHA/ACC ASCVD 10-yr calculator (Goff, et. al., 2013) , and lifetime calculator (Lloyd-Jones, et. al., 2006) . The following are ineligible for inclusion because

other algorithms are more accurate for outlier populations: transplant, HIV, MS, dialysis/CKD, hepatitis, rheumatic, pregnant, <20 or 76+; and participants must have survey and exam.

Body size (BMI Category)

X

2

Medical costs(Rx, visits, hosp.)

Y

Heart risk (anti-cholesterol statin

benefit groups)

Z

Product term moderator

XZ

5

2

Dissertation findings applied to decision making

If heart risk is at this level…

…Then consider specific behavioral change and prevention order

sets (heart risk levels: with behavioral factor vs. w/o behavioral

factor)

Cost

difference

Not diabetic and at risk for

heart attack/stroke in the

short term

(10-year ASCVD calculator ≥7.5%)

1. Resolve depression, pain, gastric reflux, asthma, and thyroid hormones issues (w/ 2 factors vs w/o factors)

2. Moderation of alcohol binge drinking vs. binge drinkers

1. $4,748

2. $1,157

Diabetic and at risk for heart

attack/stroke in the long term (30-year CVD calculator ≥39%)

1. Depression, pain, gastric reflux, asthma, and thyroid hormones management (w/ 2 factors vs w/o factors)

2. Moderation of alcohol binge drinking vs. binge drinkers3. Prescription medication adherence vs non-Rx adherence4. Weight maintenance vs weight gain

1. $3,107

2. $1,885

3. $2,390

4. $3,325

Not diabetic and at risk for

heart attack/stroke in the long

term (30-year CVD calculator ≥39%)


2. Prescription medication adherence vs non-Rx adherence3. Weight maintenance vs weight gain

1. $1,490

2. $1,611

3. $552

Normal

(not diabetic, and 10-year

ASCVD calculator <7.5%, and

30-year CVD calculator <39%,

and did not have heart

attack/stroke)

1. Moderate or rigorous exercise at 120 minutes per week vs. less than 120 to zero

2. Weight maintenance vs weight gain

1. $825

2. $409

John Frias Morales (2015) dissertation for Golden Gate University doctorate in business administration. Sources: NHANES 2003-2012, Healthcare Bluebook, Micromedex Redbook, AHA/ACC/TOS obesity

algorithm (Jensen and Ryan, 2013), AHA/ACC ASCVD 10-yr calculator (Goff, et. al., 2013) , and lifetime calculator (Lloyd-Jones, et. al., 2006) . The following are ineligible for inclusion because other algorithms

are more accurate for outlier populations: transplant, HIV, MS, dialysis/CKD, hepatitis, rheumatic, pregnant, <20 or 76+; and participants must have survey and exam.

3

Dissertation findings applied to decision making

If heart risk is at this level……Then channel to a preventive program with these change

element.

Cost

difference in

behavioral

change

Heart attack/stroke survivor

(clinical atherosclerotic

cardiovascular disease)


2. Moderate or rigorous exercise at 120 minutes per week vs. less than 120 to zero

3. Prescription medication adherence (anti-cholesterol statin eligible) vs non-Rx adherence

1. $6,037

2. $4,601

3. $3,167

Familial high cholesterol (bad cholesterol LDL ≥190)

1. Moderate or rigorous exercise at 120 minutes per week (anti-cholesterol statin eligible) vs. less than 120 to zero

2. Moderation of alcohol binge drinking vs. binge drinkers

1. $3,088

2. $436

Diabetic and at risk for heart

attack/stroke in the short

term

(10-year ASCVD calculator ≥7.5%)

1. Resolve depression, pain, gastric reflux, asthma, and thyroid hormones issues (anti-cholesterol statin eligible) (w/ 2 factors vs w/o factors)

2. Moderation of alcohol binge drinking vs. binge drinkers3. Moderate or rigorous exercise at 120 minutes per week vs.

less than 120 to zero

1. $2,636

2. $2,062

3. $1,648

John Frias Morales (2015) dissertation for Golden Gate University doctorate in business administration. Sources: NHANES 2003-2012, Healthcare Bluebook, Micromedex Redbook, AHA/ACC/TOS obesity

algorithm (Jensen and Ryan, 2013), AHA/ACC ASCVD 10-yr calculator (Goff, et. al., 2013) , and lifetime calculator (Lloyd-Jones, et. al., 2006) . The following are ineligible for inclusion because other algorithms

are more accurate for outlier populations: transplant, HIV, MS, dialysis/CKD, hepatitis, rheumatic, pregnant, <20 or 76+; and participants must have survey and exam.

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Difference between Rx adherence & non-adherence(exploratory analysis for hypothesis generation)

5

Heart risk & obesity difference from disease-free




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Difference between binge drinkers & modest drinkers(exploratory analysis for hypothesis generation)

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Difference between fit and non-fit heart risk(exploratory analysis for hypothesis generation)

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Difference between weight gain and maintenance(exploratory analysis for hypothesis generation)

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(exploratory analysis for hypothesis generation)

Impact of obesity complications

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(exploratory analysis for hypothesis generation)

Impact of obesity complications