Abstract
Introduction
The population of the United States (U.S.) is aging and increases in chronic conditions are related to increasing age. 1 Current data indicate a decreasing rate of mortality for the top 3 leading causes of death, heart disease, cancer, and stroke, respectively, 2 which in turn results in more people living with chronic conditions. Furthermore, recent estimates by the United States Census Bureau place the number of residents in the U.S. in 2010 who are 65 years of age and over at approximately 40 million and project this number to rise to nearly 47 million by 2015. 3 Therefore, increases of numbers of older persons in our population coupled with the increased burden of chronic health conditions that are associated with aging will present the U.S healthcare system with a formidable challenge of delivering needed care.
Recent work has indicated that the aging of the U.S. population will place a considerable strain on social programs such as Medicare and Social Security and that the costs to these social programs may be underestimated based on different population forecasts. 4 It has also been demonstrated that much of the rise in costs for Medicare is attributable to the treatment of a few chronic conditions such as diabetes, hypertension, and arthritis in the outpatient setting 5 and that per capita costs due to aging will increase by 18% between 2000 and 2050, with heart and vascular conditions leading the way. 6
Despite these alarming statistics that describe the challenges of caring for chronic conditions on a macro level, there has been less discussion on the challenges of caring for this population at the primary caregiver level. Therefore, this work provides a picture of multiple chronic conditions and the resulting burden of disease among our aging population that will be requiring care from our nation’s primary care physicians at an increasing rate over the next several decades.
Methods
Data for these analyses were taken from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) survey; a cross-sectional, random-digit dialed, telephone survey conducted yearly in all 50 U.S. states, Guam, Puerto Rico, and the U.S. Virgin Islands. Data are weighted to state populations and combined to make aggregated estimates of the nation’s population. The median cooperation rate for the 2009 survey was 75.0% and the median Council of American Survey Research Organizations (CASRO) response rate was 52.5%. Further BRFSS documentation including survey design and survey metrics can be found elsewhere. 7
The survey collected information on the presence of 9 chronic health conditions including angina/coronary heart disease (CHD), arthritis, asthma, cancer, diabetes, heart attack, hypertension, obesity, and stroke. For 8 of the conditions, presence was determined by the question “Has a doctor or other health professional told you that you have or had [condition]?” Obesity was determined through calculation of body mass index (BMI) from self-reported height and weight and was determined to be a BMI of 30 kg/m2 or greater.
Estimates of prevalence, with 95% confidence limits, for each of the 9 health conditions, as well as the total number of co-morbid conditions, were made for four 10-year age categories beginning at age 50. The total sample size for these analyses was 275 954. Next, estimates of lifestyle burden and chronic disease burden were made for persons 50–64 years of age and persons 65 years of age and older. In this analysis, weighted estimates of persons, with 95% confidence intervals, who are limited in their activities of daily living, require use of assistive devices, and/or serve in a caregiving capacity were made and stratified by the number of reported chronic conditions. All analyses were conducted using SUDDAN® to take into account the complex sampling design of the survey.
Results
All conditions increased in prevalence as age increased, excluding asthma and obesity, which declined with age. The top 3 most prevalent medical conditions among those 50–59 years and 60–69 years of age were hypertension, arthritis, and obesity. Among those 70–79 years of age and in persons age 80 years and older, again, hypertension remained the most prevalent medical condition and arthritis remained the second most prevalent one, but cancer supplanted obesity for the third most prevalent disease in these age groups. Average number of conditions increased with age (Table 1).
Estimates of Chronic Conditions by Age Category for Older Americans, 2009*
Source: 2009 Behavioral Risk Factor Surveillance System (BRFSS). *Weighted Estimate, (95% Confidence Interval)
As the number of reported chronic conditions increased, both the report of activity limitations and use of assistive devices increased where more than one-third (37.1%) of persons 50–64 years of age and older with at least 2 chronic conditions reported having an activity limitation compared with nearly one-third (33.1%) of persons 65 years of age and older with at least 2 reported chronic conditions reported having an activity limitation and nearly 15 percent of persons 50–64 years of age reported the use of an assistive device compared with more than one-fifth (21.1%) of persons 65 years of age and older with at least 2 chronic conditions reported the use of an assistive device (Table 2).
Estimates of Persons 50–64 Years of Age and Persons 65 Years of Age and Older Who Are Limited in Daily Activities and/or Serve in a Caregiver Role, by Number of Reported Chronic Conditions in the United States, 2009
Source: 2009 Behavioral Risk Factor Surveillance System. *Percentage estimates and 95% confidence intervals. ** “Are you limited in any way in any activities because of physical, mental or emotional problems? † “Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed or a special telephone?” ‡ “People may provide regular care or assistance to a friend or family member who has a health problem, long-term illness or disability. During the past month, did you provide any such care or assistance to a friend or family member?”
Caregiver status was relatively unchanged across the stratification of chronic diseases for each age category. It was noted that there was a larger proportion of caregivers in the 50–64 year category compared with the 65 years of age and older category, but that the proportions declined slightly with the addition of reported chronic conditions. However, the combination of caregiver status with either activity limitation or use of assistive devices demonstrated increases in prevalence as the number of reported chronic conditions increased and was seen in both age categories (Table 2).
Discussion
The information provided in this work demonstrates the prevalence of comorbid chronic conditions across older age groups in the U.S. population and that activity limitations and need for assistive devices increased as did the burden of chronic disease. It was noted that increasing numbers of chronic disease conditions in the 50–64 year age group produced greater proportions of persons who reported greater activity limitation and use of assistive devices compared with the older age group, which could be indicative of more severe disease processes in the younger population. Another finding of this study is that many of the people who are limited by chronic conditions are also providing care to others in need. It is hoped that this work will bring further attention to the potential future healthcare crisis that is facing our primary care physicians portended by an aging population and increase in chronic disease.
This problem is exemplified by a recent retrospective cohort study by Nie et al on 1.6 million Canadians. On average adults over the age of 65 in this study claimed over 70 medical cost events over a 1-year period, including visits to the primary care or specialist office, emergency room or hospital, and also including laboratory and radiology tests. 8 Several measures to curtail the increased morbidity of multiple chronic conditions have been suggested at different levels of the healthcare system and much discussion has focused on care management at the primary care level. 9
Overarching themes of care management at multiple levels include maintaining an active lifestyle both physically and socially at the individual level; providing updated advice and encouragement on the benefits of an active lifestyle at the provider level and the development of community opportunities for physical and social interaction for elders at the public health level. 10
At a more focused level, the management of persons with multiple chronic conditions by primary care physicians is an issue that is being studied.
According to the Medicare Beneficiary Survey 49% of claims for delivery of care in the Medicare population came from the physician office with general internists and family physicians providing most of these services. 11 Another study of the Medicare Beneficiary Survey using data from a 1992–2000 report revealed that patients with multiple chronic conditions and activities of daily living deficiencies accrued much higher actual annualized costs than the Medicare capitated payments predicted by the Centers for Medicare & Medicaid Services Hierarchical Condition Categories (CMS-HCC) risk-adjustment model. 12 This suggests that most internists and family physicians are likely being underpaid for their services.
Recent predictions suggest that the aging population will increase the workload of family physicians and general internists by 29% between 2005 and 2025. 13 Increasing workloads on primary care physicians could lead to inefficient care of multiple chronic conditions. Moreover, protocols for medical management that are disease specific will not be adequate; the patient would require more person-oriented management and are in greater need for services than typical primary care models of care can provide.
Therefore, primary care researchers have currently produced 3 geriatric-focused models of care including Guided Care, the Geriatric Resources for Assessment and Care of Elders (GRACE), and the Program for All-inclusive Care for the Elderly (PACE), which have been suggested to increase both the effectiveness and efficiency of complex primary care by promoting comprehensive patient assessments, evidence-based care and treatment, inclusion of family members in care and coordination of specialty treatment. 14
The Guided Care model sends a registered nurse to a patient’s home to conduct an assessment and to determine the patient’s needs. The nurse then consults with the primary care physician, the patient and the caregiver to create 2 comprehensive, evidence-based plans of care. In this model, the nurse coordinates care and monitors the patient’s chronic conditions and provides support to the caregiver all under the direction of the primary care physician. 15
The GRACE model is a team approach to providing care for elderly patients who have complicated chronic conditions. In this team approach, a home visit is first made by a nurse practitioner and a social worker to conduct and overall assessment of the patient’s needs. Subsequently, this team then meets with a larger group including a geriatrician, a pharmacist, a physical therapist, a mental health social worker and a community-based liaison to develop an individualized care plan for the patient. This plan is then presented to the primary care physician to modify the plan. 16
The PACE model uses a similar team approach to GRACE model for the care of chronic conditions among older patients. Patients are eligible for enrollment at 55 years of age. In this model, the support that is provided is community based and delivered in settings such as day centers, clinics, patient homes, nursing homes, and hospitals. This program has been in existence for over 2 decades and has proven to be a cost-effective model of care.17,18
As seen in these analyses, arthritis, hypertension, obesity, and cancer are some of the most prevalent conditions affecting older Americans. Of these, all but cancer is treated regularly and effectively treated by primary care providers. Thus using even more general models of care such as the Chronic Care Model to better manage these conditions in the primary care setting can deliver superior patient care and health outcomes. 19 However, these superior outcomes cannot be realized without accounting for the differential between costs incurred and reimbursed for the treatment of complex, chronically ill patients. Emphasis on practice redesign to reward clinics that use the Chronic Care Model within the Patient Centered Medical Home (PCMH) may help reduce costs by rewarding integration and collaborative care required for patients with multiple chronic diseases. As well, values within the PCMH model supports personalized, systematic, comprehensive patient-centered care while protecting patients from overtreatment. 20 Pilot studies are ongoing in PCMH demonstration clinics to assess the effect of paying clinics for providing specific PCMH components such as care management fees. 21 Furthermore, some research suggests that practices that work using PCMH concepts is correlated with greater preventive services delivery to reduce the development of chronic disease. 22
As demonstrated in these analyses, patients with multiple chronic conditions will have an increasing need for assistive devices and caregiving services. Our analyses also demonstrate that 1 of 5 persons 65 years of age and older provide care for a friend or family member with health problems and the costs related to the need for caregiving can be quite significant. For example, in a Canadian study of 136 family caregivers of patients requiring palliative care, the mean monthly cost of care per patient was $24 549 (2008 CDN$), and 70% of this cost was attributed to family caregivers’ time. 23 By centralizing care in an ideal medical home, patients would not need to travel to several sites, limiting the cost and opportunity cost of caregivers and improving the quality of life for patients.
Caregivers are faced with a difficult task of providing care to others that can sometimes create negative health effects. Several studies have examined the physical and mental burdens of caregiving and how perceptions of burden differ among caregivers. One recent study conducted among 10 687 care givers found that those who reported a heavy burden for informal caregiving also reported significantly worse self-reported health compared with non-care givers. However, care givers who did not see their informal care giving responsibilities as being burdensome did not have significantly lower self-reported health compared with non-care givers. 24 In fact, another study conducted in Connecticut among 4041 caregivers found that respondents did not necessarily report poor physical or mental health outcomes unless there were unmet needs such as lack of respite and inadequate income. 25 These findings suggest that programs that target unmet needs for informal caregivers can actually create an environment that is beneficial to those in need of care while at the same time not unduly creating physical and mental health burdens for the care giver. Programs that help educate caregivers and help caregivers identify community resources can help mitigate any negative effects of long-term caregiving.
Several limitations should be noted in this study. The first is that the Behavioral Risk Factor Surveillance System (BRFSS) survey is limited in the number of chronic conditions that are enumerated. There are other chronic conditions such as Chronic Obstructive Pulmonary Disease (COPD) and diagnosed depression that can contribute to a person’s disability and are not collected in this survey. Therefore, the estimates of multiple chronic conditions presented in this study could be conservative. A second limitation of this study is that it is conducted by means of a telephone interview and there is a possibility of response bias. This bias could influence the numbers of conditions reported as well as reported activity limitations, use of assistive devices and care giving status. A final limitation of this study is that it is cross-sectional in nature. The associations that are found in this survey do not indicate directionality, as this data was collected at 1 point in time. It is not possible to determine if the presence of the chronic condition came about before the experienced activity limitation or the presence of care giving. Regardless of these limitations, the robust estimates of association between chronic conditions, activity limitation and age do present a clear picture of the issues that are being seen in the practice of primary care for an aging society.
In summary, as our population ages, we are faced with managing an increasing number of chronic medical conditions as well as the co-morbidities associated with those chronic conditions. Older Americans are possibly further burdened with providing care for family members who suffer from similar maladies, but are unable to care for themselves. This situation creates difficulty for all persons involved including providers, patients and family members. Therefore, the challenge facing our U.S. healthcare system is to provide models of healthcare that can provide fair reimbursement to those who provide superior quality care, while being cost-effective and at the same time maintaining the dignity of family-members. Evaluation of the quality and cost-effectiveness of models focusing on geriatric care, the Chronic Care Model, or the PCMH are necessary.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.