Improved Health David M. Cutler Harvard University - - PowerPoint PPT Presentation

Medical Care as a Cause of Improved Health

David M. Cutler Harvard University dcutler@harvard.edu

What matters for health?

30% 30% 44% 44% 50% 50% 40% 40% 27% 27% 25% 25% 49% 49% 50% 50% 9% 9% 7% 7% 50% 50% 46% 46% 60% 60% 41% 41% 20% 20% 47% 47% 43% 43% 10% 10% 26% 26% 15% 15% 11% 11%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Booske et t al.

• l. (2010)

Ford et al

• al. (2

(2007) Hunink k et t al.

• l. (1997)

McGin innis et al.

• l. (2002)

Park et al

• al. (2

(2015) Unit ited Healt lth Foundatio ion (2 (2016) DHHS S (1980)

Behaviors Social Circumstances, Environment, Genetics Medical Care

Biggest difference – cross-section v. time series

Health knowledge and technology is the same everywhere  most of difference due to behaviors and social factors Technology is a lot better now than then  medical care matters more

Expected age at death, by current age

65 67 69 71 73 75 77 79 81 83 85 1949–1951 1959–1961 1969–1971 1979–1981 1989–1991 1999–2001 2015

Change in Life Expectancy by Condition, 1990-2014

• 0.5

0.5 1 1.5 2

Other Other accidents Accidents Alzheimer's Parkinson's HIV Infant Mortality Other cancer Prostate Colon, rectum, anus Breast Trachea, Bronchus, and Lung Cerebrovascular Disease Heart Disease

Years of Life Expectancy

600 700 800 900 1,000 1,100 1,200 1,300 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Mortality Rates per 100,000

Counterfactual (rates per 100,000 at 92 mortality) Treatment Effect only Ischemic Heart Disease mortality (Actual) Treatment + Risk Factor (Total Effect Simulated)

Treatment effect Risk factor effect

Ischemic heart disease mortality rates per 100,000: Actual vs. simulated in elderly Medicare beneficiaries

Chernew et al., 2015, based on IMPACT model of Ford et al.

• 45,000
• 40,000
• 35,000
• 30,000
• 25,000
• 20,000
• 15,000
• 10,000
• 5,000

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Number of deaths prevented or postponed

Anti-hypertensive treatments (non-IHD cohort) Statins + Warfarin (primary prevention in non-IHD cohort) IHD ( ICD9 410.XX- 414.XX) hospitalized cohort (Aspirin, Beta-blockers, ACE inhibitors Resuscitation, Primary PCI and CABG) Statins + Warfarin (IHD cohort) Ace inhibitors & Beta Blockers (IHD cohort)

Estimated deaths prevented or postponed in the elderly United States population: Treatment effect in elderly Medicare beneficiaries

NHANES I NHANES II NHANES III 1999-2002 2003-2006 2007-2010 2011-2014 Hypertension (uncontrolled) 41% 29% 23% 20% 17% 15% 14% Hyperlipidemia (uncontrolled) 30% 21% 17% 16% 13% 12% Obese 15% 15% 23% 33% 35% 37% 39% Current Smoker 40% 36% 28% 24% 25% 22% 20% Diabetes (uncontrolled) 6% 10% 10% 12% 10% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Percent

Cardiovascular risk factors (20 years and older): age-sex adjusted to 2009-2010 NHANES

Trends in Risk Factor Control

My questions

• 1. How to get people to do what they want?
• Take meds, stop smoking, lose weight, avoid addictive substances
• How to talk to their doc about $$$
• Not all of this is medical, but some is
• 2. How to harness innovation of the medical system for good?
• Most important areas: Pain; dementia

The importance of pain