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A Culture of Wellness & Prevention

by Barry Bittman, MD

“Health is a state of complete physical, mental and social well-being,
and not merely the absence of disease or infirmity.”

— World Health Organization, 1948

Wellness is no longer a fad. 

When I began to develop integrative healthcare strategies more than two decades ago, such was not the case. For our hospital, wellness initially became integrally connected to prevention with a dedicated focus on reducing or eliminating potentially modifiable disease-related risk factors.  Our program is best described as: a comprehensive evidence-based strategy that empowers and enables people to take an active and meaningful role in their health and well-being.  

We envision the patient at the hub of a wheel with spokes radiating outward to healthcare professionals and programs. Two decades after introducing our strategy, this conceptual framework became widely-recognized and accepted as patient-centered care.  The critical need for this approach in our present healthcare environment is supported by the distressing rise of both the incidence and prevalence of potentially preventable diseases.  

Undoubtedly the failure to adequately offer and prioritize evidence-based prevention strategies is likely one of the most remarkable factors contributing to our present healthcare crisis.  This is best exemplified by cardiovascular disease and diabetes, two diseases for which healthcare spending has and continues to outstrip available resources.  

According to the CDC, “in 2006, of all Americans who died of cardiovascular diseases, 151,000 were younger than age 65. Heart disease and stroke also are among the leading causes of disability in the United States, with nearly 3 million people reporting disability from these causes.  Death rates alone cannot describe the burden of heart disease and stroke. The cost of cardiovascular diseases in the United States, including health care expenditures and lost productivity from deaths and disability, is estimated to be more than $503 billion in 2010.”

As noted in a remarkable study published in the American Journal of Preventive Medicine, for a population aged 30-84, 44% of all deaths were due to heart disease.  The researchers developed a model “to calculate the number of deaths that would be prevented or postponed if perfect care for heart disease prevention and treatment were achieved.”  They define perfect care as “the elimination of risk factors and the prescription of all effective medications before and between acute events, and the delivery of all effective therapies to individuals suffering an acute heart disease event.”  They concluded that “nearly 90% of the impact from perfect care for heart disease would accrue from interventions before and between acute events.  The impact of risk-factor interventions before or between events is amplified by the fact that these interventions also reduce the risk of death from other chronic diseases” (The Comparative Effectiveness of Heart Disease Prevention and Treatment Strategies – Volume 36, Issue 1, Pages 82-88.e5, January 2009).

According to the CDC, “from 1980 through 2007, the number of Americans with diabetes tripled (from 5.6 million to 17.4 million).”  The American Diabetes Association noted that an additional 5.7 million people are undiagnosed, and 57 million have pre-diabetes.  Furthermore, 1.6 million new cases of diabetes are diagnosed in people aged 20 years and older each year (data from the 2007 National Diabetes Fact Sheet).

While the immense challenges of cardiovascular disease and diabetes alone threaten a viable healthcare economy, when one factors in the growing incidence and prevalence of overweight and obesity, it becomes obvious that without the implementation of widespread effective evidence-based prevention strategies, any future healthcare system is literally doomed. 

According to recent data, “the overall self-reported obesity prevalence in the United States was 26.7%.  By state, obesity prevalence ranged from 18.6% in Colorado to 34.4% in Mississippi; only Colorado and the District of Columbia (19.7%) had prevalences of <20%; nine states had prevalences of ≥30%” (Morbidity and Mortality Weekly Report – August 3, 2010).

The need to develop expertise in both prevention and reduction of modifiable risk factors is now center stage.  According to a recent New England Journal of Medicine article (September 30, 2010) concerning healthcare reform by Howard Koh, MD, MPH and Kathleen Sebelius, MPA, “starting January 1, 2011, Medicare will cover, without cost or sharing, an annual wellness visit that includes a health risk assessment and a customized prevention plan.  Full coverage of many USPSTF (US Preventive Services Task Force)-recommended services will also be available under Medicare with no cost sharing.”

The choice of whether or not a hospital should offer prevention and wellness services is no longer in question.  The writing is on the wall — and the wall (our present healthcare system) is crumbling.  Failure to become familiar with and offer a delivery system that fosters health — even in the absence of disease — is a harbinger of failure from many perspectives.  These perspectives range from quality of life to on-the-job performance, to healthcare affordability and ultimately to the survival and sustainability of our healthcare system.  

How can we apply insights on prevention and modifiable risk factor reduction to the challenges we presently face in community medicine?  The answer lies in the integration of personalized evaluations and treatment plans conducted by nurses, nutritionists, counselors, exercise specialists, pharmacologists and other ancillary support members within a comprehensive whole person or patient-centered team approach.

This strategy integrates three cornerstones of wellness — nutrition, exercise and stress reduction — into a system of comprehensive patient management and empowerment processes that enable each person to receive personalized continuous care that builds upon their respective strengths while supporting their specific areas of need.

You’re probably asking yourself if such an approach is financially feasible in our stressed economic environment.  If we had to address the entire population with such intensity of care, the answer would be a resounding, NO!  

However, prior to answering that question, consider the Medical Expenditure Panel Survey (MEPS) of the Agency for Healthcare Research and Policy (AHRQ).  They noted the following eye-opening statistics: “five percent of the population accounts for almost half (49 percent) of total health care expenses. The 15 most expensive health conditions account for 44 percent of total health care expenses.  Patients with multiple chronic conditions cost up to seven times as much as patients with only one chronic condition.  The lower 50% of spenders accounted for three percent of the total national healthcare dollar.”  When one factors in 2009 US healthcare expenditures of $2.47 trillion compared to the entire federal budget $2.7 trillion, the true extent of our economic challenge translated into deficit spending is revealed.

A comprehensive plan that specifically addresses the top 5-10% of patients who utilize the most resources as well as the individuals with potentially modifiable risk factors can be rationalized from many perspectives.  The potential return on investment (ROI) alone for this population justifies considerable investment as well as carefully designed multi-site longitudinal research studies focused on critical bio-psych-social and financial outcomes. 

Without question, a reasonable strategy for effectively solving our present healthcare crisis must include a dedicated focus on the disproportionate population that utilizes the most resources.  

We must realize that the wellness movement — a fad just over two decades ago — now holds great promise as an integral strategy within successful  healthcare delivery systems.  In order to advance our healthcare system, we must lead the charge — becoming proactive rather than reactive — to effectively address rapidly accelerating disease incidence and prevalence.  Growing trends in inactivity and unhealthy lifestyles must be countered with novel comprehensive initiatives that foster healthier communities. 

There’s never been a better time to develop a new comprehensive patient-centered healthcare system that coordinates prevention, wellness, early diagnosis and ongoing care in a manner that enables each healthcare team player to effectively, efficiently and compassionately address the needs of those we are entrusted to serve.

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