Health on the Homefront:

Transcription

1 Risk Factor Questionnaire (PARFQ) Process Jessica L Newton, MPH PMP Disclaimer The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, the U.S Government, or the Commonwealth of Virginia. 1

2 Overview Our organization s roles Description of physical activity related deaths Analytical approach Findings and recommendations Navy and Marine Corps Public Health Center (NMCPHC) MISSION: As the Navy and Marine Corps center for public health services, we provide leadership and expertise to ensure mission readiness through disease prevention and health promotion in support of the National Military Strategy. Functions: Survey, consult, develop, and shape public health for the Navy and Marine Corps, working primarily with public health providers and policy makers in support of readiness for all Sailors and Marines. Support health readiness for operating forces and shore command stakeholders across the full range of military commands and civilian organizations in Navy, Marine Corps, and joint environments. 2

3 Health Analysis Department MISSION: To provide expertise and leadership to improve the value of Navy health care and operational force readiness through clinical health analysis, epidemiologic, and evidence-based methods. VISION: The Health Analysis Department is the credible, relevant, and respected leader in health analysis within the Navy and Marine Corps and the broader Military Health System. HA products drive more effective health care standards and practices to improve clinical outcomes and reduce costs. Background Twice a year, all Sailors must complete a physical fitness assessment (PFA) that tests strength and aerobic capacity. Prior to participation in the PFA, sailors undergo various levels of screening to identify those at risk for sudden cardiac illness during exercise. Over the past ten years, Navy experienced 44 deaths associated with physical activity. Navy leadership charged Navy medicine to improve its pre-exercise risk screening process. 3

4 Physical Health Fitness on the Associated Homefront: Deaths by Fiscal Year Assessing Resource Demand for Treatment of Mild Traumatic Brain Injury in Navy Medicine Ambulatory Clinics All sailors: Complete 13- question survey prior to participation in each biannual PFA. If response: Medical provider must clear for participation in PFA. 4

5 Assessing Resource Demand for Treatment of Mild Traumatic Brain Injury in Navy Medicine Ambulatory Clinics Atherosclerosis may predispose someone to sudden death while stressing the heart during exercise. Sometimes the underlying pathology is not known, so risk can never be reduced to zero. Angina Reversible Due to blood flow reduction Occurs with large plaque Myocardial Infarction Irreversible Due to absent blood flow Occurs with clot *Newer plaques may be smaller, but less stable 10 5

6 Doctor, Should I run the fitness test? Age? Cholesterol? Aspirin? Family History? Fragile coronary plaques? Arterial narrowing? Hypertension? Controlled? Currently active? Risk is Never Zero Rear Admiral Jack Darby, USN

7 3 = All rain All clouds Current screening 4 = All rain Some clouds Desired screening 5 = Most rain Few clouds 6 = Some rain clouds 7

8 Methods Methods Historical Data: Surveillance data, epidemiologic principles Literature: US Preventive Services Task Force (USPSTF) studies; extensive review of sports medicine industry standards Other authorities and service branches: Army - Soldier s individual responsibility Marine Corps - Stratified risk (Age > 45 AND lacks current physical exam AND Navy Annual Health Evaluation) Risk Factor Worksheet Air Force - Stratified risk (Fitness Screening Questionnaire - FSQ) to identify highest risk group for screening Armed Forces Epidemiology Board (AFEB) Coronary Artery Disease (CAD) risk factor analysis during the periodic medical examination 15 Annually, 600K questionnaires are completed. 220K (37%) annual initial medical visits. 75K answered yes to cardiac risk related question (includes age). 19K annual that were NOT cleared Cardiac items were marked. (Other items may have caused them to not be cleared, e.g. injury) 3% of all 600k questionnaires 8

9 Sta rt Q 1 Q 2 Q3 Q 4 Medical Evaluation Marine Corps Process Q1: 46 or over? Q2: Current physical exam or Navy Annual Health Evaluation? Q3: Heart disease or high blood pressure requiring restriction in physical activity or seeking medical treatment? Q4: Change in history? Take fitness test 17 Sta rt Take fitness test Q 1 Q 2 Q 3 Q 4 Q 5 Medical Evaluatio n Air Force Process Q1: Unexplained chest discomfort Unusual or unexplained shortness of breath Dizziness, fainting, or blackouts associated with exertion Other medical problems from safely participating Q2: 35 years of age Q 3: Physical activity 30 minutes x 3 days/week x last 2 months? Q4: Smoked tobacco in the last 30 days? Diabetes? Uncontrolled blood pressure? Uncontrolled cholesterol? Family history of heart disease > 45 years for males; > 55 years for females Q5: Cleared on current PHA? (More stringent criteria for Air Force Reserves and Air National Guard) 18 9

10 Primary Screening Assumptions Time (minutes) Medical history 5 Record review 5 Blood pressure Cholesterol Clinical Wage Costs CPT Code Cost* $7.68 AMBULATORY BP MONITORING ( ) $34.36 LIPID PANEL - Fasting lipid profile, including total cholesterol, LDL, HDL, and triglycerides. $ $14.29 (LDL) = $34.36 Blood glucose $5.89 Fasting blood glucose C-reactive protein $7.75 C-REACTIVE PROTEIN Electrocardiogram (EKG) ELECTROCARDIOGRAM $18.59 COMPLETE 42 $24.50 $ Secondary Screening Assumptions Stress test CT angiography Abdominal aortic aneurysm Clogged Carotid arteries Clinical Time Medical Salary CMAC 90 $52.50 $ $ $ $8.75 $ $8.75 $ CARDIOVASCULAR STRESS TEST CT HRT W/3D IMAGE (Physician $ or Technical $225.39) ULTRASOUND EXAM AAA SCREEN EXTRACRANIAL STUDY Physician $ Technical $

11 Cost Benefit Analysis Summary Current PARFQ screening process costs ~$32M Service member lost labor for medical visit Medical provider cost Cost of medical procedures Benefits of stratified-risk process Eliminate unnecessary time away from work site Increased readiness via fewer false-positive evaluations Reduced process variation yields more consistent results Annual cost of stratified-risk process ~$12M Net annual cost avoidance ~$20M 21 Considered Courses of Action 1. change in current PARFQ process ~$32M annual cost for a process no more effective than PHAs and pre-physical fitness assessment questions 2.Stratified risk-management process ~ $12M annual cost without accepting any unnecessary risk ~ $20M annual cost avoidance over COA 1 3.Discontinue pre-pfa screening entirely, maintaining PHAs and prephysical fitness assessment questions ~ $7M annual residual cost shifted to PHA ~ $25M annual cost avoidance 11

12 Recommended Navy Process Sta rt Take PFA Q 1 Q 2 Q 3 Q 4 Q 5 Medical Evaluatio n Two responses => run PFA Navy Process Q1: Without previous medical evaluation and clearance: Unexplained chest discomfort Unusual or unexplained shortness of breath Dizziness, fainting, or blackouts associated with exertion Other medical issues (including bone and joint problems) that would keep you from safely participating Q2: 35 years of age Family history of sudden death before the age of 50 years Q3: Physically inactive? <30 minutes x 3 days/week x last 2 months Q4: Smoked tobacco in the last 30 days? Diabetes? Uncontrolled blood pressure? Uncontrolled cholesterol? Family history of heart disease (at any age) > 45 years for males; > 55 years for females Q5: PHA out of date? 23 Annual Cost Analysis COA2 Initial PARFQ Completion Primary Medical Screen (CV) Secondary Medical Screen (CV) Medical Screen (non-cv) Total Annual Cost: $1.2M $4.2M $1.0M $5.1M $11.5M Current Annual Cost: $32M Annual Savings: $20M 12

13 Decision Comprehensive analysis resulted in a significant opportunity for improvement and cost avoidance Additional benefits include: reduction in time away from the worksite, increase in readiness via fewer false-positive evaluations, and reduction in process variation. Stratified risk process assumes no additional risk; yields an estimated annual cost-avoidance of $20 Million The Navy Surgeon General endorsed the recommendation, and the Navy will revise the physical activity screening process as recommended. During subsequent review we added questions that help comply with pregnancy related directives. 13

14 Setting Expectations 28 14

15 Summary Our organization s roles Description of physical activity related deaths Analytical approach Findings and recommendations Questions?? 15

16 Contact: Jessica Newton, MPH PMP Acting Head, Health Analysis, NMCPHC Health Analysis Department Website: 16