Health for life

Helps stave off major ill health and dementia even for those getting started relatively late

Its never too late to get physically active, with even those starting relatively late in life reaping significant health benefits, finds research published online in the British Journal of Sports Medicine.

Four years of sustained regular physical activity boosted the likelihood of healthy ageing sevenfold compared with consistent inactivity, the findings show.

The researchers tracked the health of almost 3500 people, whose average age was 64, for more than eight years. All were participants in the English Longitudinal Study of Ageing, which involves a nationally representative sample of the household population of England, born on or before 29 February 1952.

The researchers wanted to quantify the impact of physical activity on the risk of developing long term conditions, depression, and dementia, and on the likelihood of "healthy ageing."

This is usually taken to mean not only an absence of major disease and disability, but also good mental health, the preservation of cognitive abilities, and the ability to maintain social connections/activities.

Theres a growing body of evidence to suggest that regular physical activity is essential for the maintenance of good health, while across the developed world, inactivity is ranked alongside smoking, excess drinking, and obesity as a leading cause of reduced life expectancy.

Participants described the frequency and intensity of regular physical activity they did in 2002-3, and then every subsequent two years until 2010-11.

Their responses were categorised as: inactive (no moderate or vigorous activity on a weekly basis); moderately active (at least once a week); and vigorously active (at least once a week).

Any changes in frequency and intensity were noted at the two yearly monitoring sessions: always inactive; became inactive; became active; always active.

Serious ill health, such as heart disease/stroke, diabetes, emphysema, or Alzheimers disease, was confirmed by medical records.

Cognitive abilities and mental health were assessed using a battery of validated tests, while disability was measured according to participants responses to questions about the ease with which they were able to carry out routine activities of daily living, and an objective test of walking speed.

Nearly one in 10 of the sample became active and 70% remained active. The rest remained inactive or became inactive.

At the end of the monitoring period almost four out of 10 had developed a long term condition; almost one in five was depressed; a third had some level of disability; and one in five was cognitively impaired.

But one in five was defined as a healthy ager. And there was a direct link to the likelihood of healthy ageing and the amount of exercise taken.

Those who had regularly indulged in moderate or vigorous physical activity at least once a week were three to four times more likely to be healthy agers than those who had remained inactive, after taking account of other influential factors.

Those who became physically active also reaped benefits, compared with those who did nothing. They were more than three times as likely to be healthy agers.

And those who sustained regular physical activity over the entire period were seven times as likely to be healthy agers as those who had consistently remained inactive.

"This study supports public health initiatives designed to engage older adults in physical activity, even those who are of advanced age," conclude the authors.

Im baaaaack!

When persons are admitted to a hospital, insurers payment rates are based on the diagnosis, not the number of days in the hospital (known as a "length of stay").  As a result, once the admission is triggered, the hospital has important economic incentive to discharge the patient as quickly as possible.  The Disease Management Care Blogs physician colleagues used to refer to this as "treat, then street."

Unfortunately, discharging patients too soon can result in readmissions.  Thats why the DMCB has agreed with others that diagnosis-based payment systems and a policy of "no pay" for readmissions were working at cross purposes.  Unified bundled payment approaches like this seem to be a good start.

But thats all theoretical.  Whats the science have to say?

Peter Kaboli and colleagues looked at the push-pull relationship between diagnosis-based payment incentives  and the likelihood of readmissions in a scientific paper just published in the Annals of Internal Medicine. 

The authors used the U.S. Veterans Administration (VA) Hospitals "Patient Treatment Files" to examine length of stay versus readmissions in 129 VA hospitals.  The sample consisted of over 4 million admissions and readmissions (defined as within 30 days and not involving another institution) from 1997 to 2010. The mean age started out at 63.8 years and increased to 65.5 years, while the proportion of persons aged 85 years or older increased from 2.5% to 8.8%. Over the years, admissions also grew more complicated with a higher rate of co-morbid conditions, such as diseases of the kidney (from 5% to 16%).

As length of stay went down, readmissions should have gone up, right?

The answer was yes and no.

Yes, if the data were trended over time: Over the 14 year period of observation, the number of days in the hospital (length of stay or LOS) decreased from 6.0 days to 4.3 days.  Yet, as LOS decreased, readmissions also decreased from 16.6% to 15.2%. 

The decreases held up when the LOS was risk-adjusted for hospital and patient characteristics.  There was also no increase in mortality rates

No, if hospitals were compared to each other:  Hospitals with risk-adjusted low lengths of stay had higher readmission rates compared to their average peers.  In that group, each day of saved LOS was associated with a 6% increased rate of 30-day readmissions.

It gets even more complicated.  As the LOS increased beyond the average, each additional day in the hospital was associated with a 3% increased rate of 30-day readmissions.

What should the DMCB learn from these data?  Keeping in mind that the VA is not necessarily generalizable to the typical community medical center,

1. Over 14 years of worth of VA data for 129 hospitals suggest it is possible to have your cake (a lower LOS) and eat it too (lower readmissions).  Thats the good news.

2. While overall performance improved over the years, between hospital comparisons showed there is a "U" shaped relationship between days in the hospital and the likelihood of readmission.  The DMCB agrees with the authors: premature discharge before the patient is ready is associated with an 6% per day readmission rate, while patients who are very sick and have to stay a few extra days in the hospital are also at risk to the tune of 3% per day.  Thats the sobering news.

What are the implications?

Overzealous efforts to discharge patients can backfire with readmissions.  It appears theres an optimum length of stay that minimizes, but will never eliminate, readmissions.

Patients who do go home "too soon" or need extra days in the hospital appear to be at special risk.  Accountable care organizations and population health management service providers should use this information to target patients at special risk of "treat, street and... repeat."