Allen Dobson, PhD Health Economist Co-Founder & President Dobson DaVanzo & Associates, LLC Dobson DaVanzo & Associates, LLC Vienna, VA 703.260.1760 www.dobsondavanzo.com
Discussion of Methods Used to Study the Reduction in Health Care Cost Through Dietary Supplements PRESENTED TO: NHRI & ANA Symposium PRESENTED BY: Al Dobson, PhD October 28, 2011 Chicago Dobson DaVanzo & Associates, LLC Vienna, VA 703.260.1760 www.dobsondavanzo.com 1
Introduction Nutrition is an input to and foundation for health and development. Interaction of infection and malnutrition is welldocumented. Better nutrition means stronger immune systems, less illness and better health. Healthy people are stronger, are more productive and more able to create opportunities to gradually break the cycles of both poverty and hunger in a sustainable way. Better nutrition is a prime entry point to ending poverty and a milestone to achieving better quality of life. World Health Organization 2
Presentation Overview Update to Prior Lewin Studies : A Study of the Health and Cost Effects of Five Dietary Supplements, 2004 An Evidence-Based Study of the Role of Dietary Supplements in Helping Seniors Maintain their Independence, 2006 Methodological Limitations to Longitudinal Observational Studies 3
The Dietary Supplements Selected for the Lewin Studies were Calcium with Vitamin D Folic Acid Omega-3 Fatty Acids Lutein with Zeaxanthin 4
Conceptual Framework for the Study Effect on Biological Markers Clinical Effects from Change in Biological Markers Cost Effects from Reduced Health Care Utilization 5
Key Findings: Calcium with Vitamin D There is considerable evidence supporting: the association of reduced bone loss and reduced fractures, with the best evidence supporting a reduction in hip fractures a reduction not only in the cost of the hospitalization to repair the hip, but also the post-acute stay for some portion of patients (about 25%) in a skilled nursing facility Cost offsets result from the potential avoidance of approximately 776,000 hospitalizations for hip fractures over five years, as well as avoided skilled nursing facility stays for some portion of patients. The five-year estimated net cost effect associated with avoiding hip fracture is approximately $16.1billion (savings to Medicare). 6
Key Findings: Folic Acid Of the approximately 44 million American women who are of childbearing age and not taking folic acid, if just 11.3 million began taking 400 mcg. of folic acid on a daily basis periconceptionally, 600 babies would be born without NTDs, saving as much as $344,700,000 in the first year as a result. Over five years, taking into account the cost of the supplement, $1.4 billion could potentially be saved. 7
Key Findings: Lutein with Z The estimate of the five-year (2008-2012) potential net savings from avoided transitions to dependency associated with a reduction in the relative risk of age-related macular degeneration (AMD) through daily intake of 6-10 mg of lutein with zeaxanthin is $3.6 billion. Across the five year period, approximately 190,927 individuals could avoid the transition to dependence either in the community or a nursing facility that would accompany a loss of central vision resulting from advanced AMD. 8
Key Findings: Omega-3 Fatty Acids The estimate of the potential five-year (2008-2012) savings in health care expenditures resulting from a reduction in the occurrence of coronary heart disease (CHD) among the over age-65 population through daily intake of approximately 1800 mg of omega-3 is $3.2 billion. Approximately 374,301 hospitalizations and associated physician fees due to CHD could be avoided. 9
Literature Contains Broad Evidence Base of Multiple Studies Calcium and vitamin D reduce bone loss and/or osteoporosis, especially among post-menopausal women Folic acid reduces the occurrence of neural tube defects (NTDs) if women consume the supplement before they become pregnant, and continue to do so in the early stages of pregnancy Omega-3 fatty acids reduce the relative risk of coronary heart disease (CHD) Lutein with zeaxanthin reduces the risk of age-related macular degeneration (AMD) 10
Why These 4 Supplements? Levels of Evidence RCT Cohort Study Cross sectional study Case Series Case Control study Single Case Report Opinions of expert based on experience 11
Study Methods -Cost Estimation CBO Scoring Methodology Gross Cost Size of the at-risk population (Medicare Trustees Report) Cost of supplement Take up rate Benefit Number of users achieving therapeutic effect Reduction in health service utilization Net Savings (2008-2012) Net Savings = Benefits less Costs 12
Methodological Limitations of Longitudinal Observational Studies Generalizability Loss to follow up and missing data Repeated measures on same individual Measurement at varying time points from symptom onset Assessing effect of treatment 13
Evaluating Longitudinal Observational Studies Source of cases True population based, catchment population, or consecutive series Timing of recruitment: First presentation of disease, or prevalent cases Inclusion criteria: Classification criteria, age, ethnicity 14
Evaluating Longitudinal Observational Studies (continued) Analyses: Methods and rationale Power to detect clinically meaningful change Handling of missing data Tests of internal and external validity Temporal effects Causality 15
Methodological Evaluation for Two Recent Studies... Criteria Mursu, 2011 Total Mortality with Multivitamins Klein, 2011 Risk of Prostate Cancer with Vitamin E Methods & Rationale Power to Detect Meaningful Change Handling of Missing Data Cox Proportional Hazard Model 40.2% deceased during study Not clear Proportional Hazard Model Tests of Internal & External Validity White women only results not confirmed in literature Interactions confound results of treatment in each group Temporal Effects Follow-up 22 years repeated measure Follow-up of 7 12 years Causality No No biological explanation Single Study 16
Conclusions A growing body of scientific research is beginning to provide important clues about how diet choices affect health. In some areas, the relationship between specific foods or dietary supplements and particular health outcomes is fairly clear; in other cases, more research is needed. The rapid expansion of the population age 65 and older has a number of economic implications. The people in this group, about 18 percent of the population, account for about 30 percent of all health care expenditures. 17
Discussion of Methods Used to Study the Reduction in Health Care Cost Through Dietary Supplements PRESENTED TO: NHRI & ANA Symposium PRESENTED BY: Al Dobson, PhD October 28, 2011 Chicago Dobson DaVanzo & Associates, LLC Vienna, VA 703.260.1760 www.dobsondavanzo.com 18
Nutrition Break Dobson DaVanzo & Associates, LLC Vienna, VA 703.260.1760 www.dobsondavanzo.com