Brief Summary: A Study of Chronic Illness in Vermont

A chronic medical condition is one that places significant limitations on the patient and requires ongoing intervention and interaction with medical services. National research found that in 2005, nine of every ten dollars spent for medical care on American adults (excluding dental care and expenses for medical equipment and supplies) was spent to treat persons with chronic conditions[1]. The same research found that 36% of Americans between 18 and 34 years of age, and over 90% of Americans over 65 years of age, had at least one chronic condition. This chapter explores chronic illness in Vermont and its impact on medical costs and utilization.

Chronic Illness Outline
This chapter describes the following:

What is chronic illness?
Data source and methodology
Which chronic illnesses are most prevalent in Vermont?
How can hospitalizations for chronic illness be prevented?
Further study in chronic illness

For a brief summary of the findings, continue on; for a more in-depth read on chronic illness click here

General Findings
Cost of chronic illness in Vermont: Vermont inpatient data indicate that over half of all inpatient stays in Vermont include a diagnosis for at least one chronic condition. In the age group over 65 years, this jumps to 84% of all hospitalizations. The health care cost and utilization impact of these hospitalizations is considerable.

Hospital charges for Vermont hospitalizations involving a diagnosis for a chronic condition are on average $7,000 more than hospitalizations that did not involve a chronic condition[2].
Lengths of stay for chronic condition hospitalizations averaged 1.7 days longer than other stays[3].

Smoking cessation: Several of the most prevalent chronic illnesses in Vermont (ischemic heart disease, pulmonary heart disease, chronic obstructive pulmonary disease (COPD), and adult asthma) can be prevented or managed through lifestyle choice. Smoking cessation is of primary importance in the prevention of these conditions:

Ischemic heart disease is the most prevalent chronic illness in Vermont. Patients with a history of tobacco use are almost three times more likely to be hospitalized for ischemic heart disease than those without a history of tobacco use;
Chronic obstructive pulmonary disease (COPD) is diagnosed in over 10% of Vermont hospitalizations. Tobacco use is the primary cause of COPD, which in turn is a major cause of pulmonary heart disease. Smoking reduction would have a direct impact on the incidence of both of these diseases.
Asthma attacks are a common cause of costly emergency room visits. Smoking and second-hand smoke are among the known triggers of adult asthma attacks[4].

Policy that focuses on smoking cessation in Vermont has the potential to reduce or prevent some of the resource intensive hospitalizations that drive health care costs.

Geographic link between risk factors and disease: Maps of risk factor and disease prevalence by Vermont County illustrate a clear geographic link. For example, hypertension, diabetes, and tobacco use are all risk factors of ischemic heart disease. These risk factors are most prevalent in Rutland, Franklin, Bennington, and Orleans counties. Ischemic heart disease is also diagnosed most often in these counties. Understanding the geographic spread of risk factors can help to target intervention programs to prevent the development of chronic illness.

The 2009 Quality Report chapter on chronic illness examines the most prevalent chronic conditions in Vermont and describes how at least some hospitalizations for these conditions can be reduced through lifestyle changes, medication, and proper outpatient care. This chapter also looks at the areas of highest disease and risk factor prevalence within the state. Finally, the chapter presents areas of further study that have potential to inform health care policy and prevention programs, including state and federal statistics regarding chronic illness in Vermont, emerging research linking chronic illness to socio-economic status, and a developmental chronic care cost calculator.

Recommendations
Focus on prevention
Chronic illnesses are often times managed or possibly prevented through lifestyle choice, medication, and effective outpatient care. There is clear evidence that hospitalizations involving each of these chronic illnesses are more expensive and require more resources than stays that do not involve a chronic illness. Programs and initiatives focusing on prevention is an effective strategy for preventing unnecessary hospitalizations for chronic illness, and thereby reducing health care costs.

Of primary importance is the fact that all of these illnesses are strongly affected by tobacco use. Chronic respiratory disease is diagnosed in over 12% of Vermont hospitalizations each year. Tobacco use is a major cause of respiratory disease. Focused smoking cessation programs would directly impact these hospitalizations. When left unchecked, chronic respiratory disease can often lead to heart problems. Targeted smoking cessation programs therefore have the potential to reduce hospitalizations beyond respiratory illness.

Ischemic heart disease, the most common chronic illness in Vermont, has risk factors in addition to tobacco use, including high blood pressure, high cholesterol, diabetes, and obesity. Over 10,000 hospitalizations involving ischemic heart disease diagnosis occur in Vermont each year. Hospital charges for ischemic heart disease are a conservative $6,000 more than stays that do not involve ischemic heart disease. Preventing unnecessary hospitalizations through lifestyle choice (smoking cessation and healthy weight management) and effective outpatient treatment (hypertension, cholesterol, and diabetes) has the potential to vastly impact health care costs.

Further study in chronic illness
Smoking cessation and other intervention programs will be most effective when targeting the greatest “at risk” population. Further study in the following areas is recommended to identify and target this population:

The hospital discharge data used in this report highlights specific Vermont counties in which risk factors such as tobacco use and hypertension are most prevalent (Rutland, Bennington, Franklin, and Orleans counties). Additional data regarding Vermonters treated at neighboring state hospitals is needed to develop a complete description of chronic illness in the state.
Emerging national research suggests that prevalence of chronic illness is linked to socio-economic status. It is recommended that further study be performed to see if these national trends are consistent within Vermont[5].
State and federal statistics provide detailed demographic information about lifestyle risk factors such as tobacco use and obesity. It is recommended that this information is also utilized to create prevention programs that target the greatest “at risk” audience.

Finally, as emphasis on the prevention of chronic illness rises, new tools are becoming available to capture the full burden of chronic care on the health care system. The developmental Chronic Care Cost Calculator highlighted in this chapter is one tool that has the potential to capture chronic care costs in Vermont and warrants further study.

[1] Machlin, S., Cohen J. and Beauregard, K. Health Care Expenses for Adults with Chronic Conditions, 2005. Statistical Brief #203. May 2008. Agency for Healthcare Research and Quality, Rockville, MD.

[2] Using hospital discharge data (see Data Source and Methodology section): $17,000 versus $9,700, effect size 0.31

[3] Using hospital discharge data (see Data Source and Methodology section): 5.3 days versus 3.6 days, effect size 0.25
[4] United States Environmental Protection Agency: “Indoor Environmental Asthma Triggers - Secondhand Smoke”, September 07, 2007
[5] Wier, L. (Thomson Reuters), Merrill, C.T. (Thomson Reuters), and Elixhauser, A. (AHRQ). Hospital Stays among People Living in the Poorest Communities, 2006. HCUP Statistical Brief #73. May 2009. Agency for Healthcare Research and Quality, Rockville, MD