Running head APPLICATIONS OF THE PRECEDE-PROCEED MODEL 1.docx
Actionable Risk and Receptivity to Change Summary v4
1. 1
Actionable Risk and Receptivity to Change
Background and Objectives
Chronicdiseasesare estimatedbythe CentersforDisease Control (CDC) toaffect more than 133 million
Americans ornearlyone intwo adults. Healthcare expendituresforchronicdiseasestake up75% of all healthcare costs
and chronicconditions cause seven outtendeathsperyearinthe U.S. alone1
. Forthese reasons,healthcare-related
actionable riskandpatientreceptivitytochange maybe intrinsicallyimportantconceptswhichhelpmold future
healthcare utilization,access,costs, aswell as populationqualityof life. The overlyingobjectivesassociatedwiththis
summaryof actionable riskandreceptivity tochange include identificationof actionable conditionscausinglarge
populationandhealthcare burdenonournational system;identificationof the elementsof change orientedtospecific
healthconditions;identificationof researchedconditionelements,whichmayalleviate the burdenof disease either
throughpreventionand/orcontrol; andsynthesisof these conceptstofurtherknowledgeof thistopicandhelpcreate
an actionable planfor xG Health. Subsequently, xGHealthmaybe ina pivotal positiontomake these healthcare
changesand improvementsmuchmore thana conversation. xGHealthcanbe a pioneeringbrandcreating
revolutionarystandards bywhichall U.S.healthcare ismeasuredandimprovedupon.
Health Promotion Objectives and Obstacles
Healthpromotionobjectives should focusonextendingthe spanof healthylife andreducingdifferencesamong
groupsper healthstatusthroughthe preventionof disease anddisability,aswellasimprovingqualityof life. Priority
areas should focuson healthpromotion,healthprotection,andclinical preventionbydevelopingaplanof care that
includesthe influence of biological,psychological,cognitive,social andcultural factorsintothe achievementof these
areas,while consideringthe influence anduniquenessof eachgroup.
Treatmentnon-adherence isaformidableobstacle forthese healthobjectives,andunderstandingthe interplay
withinsocial groupsisimportantforprevention. Treatmentnon-adherence affectspatientqualityof life,disease
progressionandprevention, andhealthcare costsandutilization,andisa complex webof personal,disease,treatment,
and relationshipfactors weighingfororagainstmaintainingtreatmentprotocol. Modifiable non-adherence factorsmay
include lackof disease understanding,conflictinghealthbenefits andinformation,dissatisfactionwithpractitioner or
poor physician-patientrapport, lackof condition chronicity understanding,negativelyperceivedcharacteristicsof the
treatmentsettingandtreatmentitself,absence of continuityof care,longwaittimes,and large spacingbetweenreferral
and appointment2
.
Conversely,there are sociallyactionablefactorsnoteasilyidentifiedoraddressedinthe clinical setting,which
may preventtreatmentpromotionandaction,aswell astreatmentadherence. These maybe brokendownintotwo
relative categories: Hierarchyof NeedsandRiskFactorelements. Hierarchyof Needsmaybe definedaselementslow
on the Hierarchyof Needspyramid, trumpingthe overall healthof the individual. These mayinclude: stable and
affordable housing,steadyaccesstofood,active andstable employmentorincome,risk of incarceration,andviolence
or crime affectingdailylife. Additionally,thereare multiple riskfactorswhichaffectadherence oroverall treatment by
activelyimpedingaccesstocare or qualityof care. These include: race, ethnicity,orgenderinequalityof care,lackof
social network,limitededucation,lackof accessto primarycare, under-utilizationorlongdistancestoPCP,lackof
coordinationof care or care gaps, terminationof medicalbenefits,multi-morbiditystatus,advancedage,unstable
mental health,lifestylefactors,medical copaysor costs withrespecttoincome,language barriers,andcultural
insensitivities orbarriers3
.
One methodusedtomeasure the effectof socioeconomicstatus(SES) disadvantage onhealthoutcomesisusing
the relative indexof inequality(RII) approach4
. Thisapproachregressessocio-economicstatusasa source of
inequalitiesinhealthbyusingthe proportionof the populationthathasa higherpositioninthe hierarchy. The RIIindex
givesa relative risk-likenumberthatmaybe interpretedlike relative riskandgivesanindicationtothe overall SESof the
individualorgroupinquestion5
. Thistool maybe usedto identifyindividualsorgroupswho,regardlessof current
overall healthstatus,maybe at increasedriskof future negative healthoutcomes. Forcase management,this maybe
2. 2
the bestpredictorof prospective healthoutcomesoutside of medical claimsdata andwouldneedtobe determinedfor
each outcome inquestion,i.e.cancer,diabetes,heartdisease,etc. Assigning‘relativerisk-like’weightsperpatientper
majordisease conditionwill allowforeachpatienttohave his/herindividual socio-economicriskstakenintoaccount
whenutilizingindividual DCGriskscores. These weightsmay be appliedto the DCG riskscoresto get the patients ‘true’
overall risk,allowingforre-prioritizationof these listspriortodistributiontocase management.
RII integrationwill be achievedthroughaseriesof logisticandlinearregressionmodelsanalyzingincome,race
and ethnicity,education,PCPutilization,multi-morbidstatus,smokingstatus,exercise status,medical benefit
informationandratioof premiums/copaystoincome,age,gender,employmentstatusandtypesof employment,
housingstability,dietinformation,mental healthstatus,total childrenandpregnancies,andviolence history.
Receptivity to Change
ReceptivitytoChange isatheoretical conceptthatsuggestseverypersonhas multipletimesintheirlife either
positivelyornegatively influencedbyinternalandexternal factorsmotivatingstagesof change. Inhealthcare,these
stagesare mostoftenidentifiedthroughthe Trans-theoretical Model (TTM),whichwasoriginallybuilttoapply tothe
behavioral change relatedtosmokingcessation6
.Since thattime, itsapplication hasbeenextendedtootherpreventive
healthconcepts suchas mammographyscreening, physical activity,andobesity7
.Bydeterminingwhatstage of
readinessthe patientoccupies,the providercanmore effectivelytailorinterventions.
Figure 1: Trans-theoretical Model of Change
The Trans-theoretical Model labelsthese stagesof change asPre-contemplation,Contemplation,Preparation,Action,
and Maintenance. Pre-contemplationisthe stage where people are notreadytomake changesto theirbehaviorwithin
the nextsix monthsor maybe unaware of the needtochange. Thisgroupis more likelytounderestimatethe prosof
changing,overestimate the consof changing,andoftenisnotaware of makingmistakes.Contemplationisthe stage
where people are intendingtostart a behaviorwithinthe nextsix months,andthe prosare equal to the consfor
changing. Preparationisthe stage where peopleare planningontakingactionwithinthe next30 days. Beingbetter
preparedandhavingsocial backing oftendefineschange adherence forthisgroup. Self-efficacyisincreasing,aswell.
Actionisthe stage where peoplehave changedtheirbehaviorwithinthe lastsix months. Thisgroupneedscommitment
solidificationtokeepprogressing. AndMaintenance isthe stage where peoplechangedtheirbehaviormore thansix
monthsago. Commitmentsolidificationisalsoaconcernforthisstage8
. Case managementmayelecttouse thissimple
tool inassessingindividualpatient’sreceptivitytochange stage,priortolarge resource allocation,tofostergreater
successratesin healthobjectives.
Physical Activity, Smoking/Alcohol Cessation, and Medication Adherence
Lack of physical activity,consumptionof tobaccoor alcohol,andmedicationnon-adherence are general riskfactors
seenacrossalmostall actionable medical conditionsaslifestylechoicesmade exclusivelybythe patient irrespectiveof
disease correlation. AccordingtoDPHHS, ‘25 centsof every health care dollar spenton the treatmentof diseasesor
disabilities… result frompotentially changeablebehavior’9
. Andthoughitisunderstoodhow these behaviorsaffect
overall healthandprogressiontodisease,understandingandchangingthe behaviorsfosteringthese lifestyle choices
remainselusive.
3. 3
One studyon the effectsof physical activity withsmokingcessationfoundthat whenpromotingphysical activityas
a smokingcessationaid, whenitwaspositivelypromotedforsmokingcessation,forcontrol of overall urgestosmoke,
and forits abilitytohelpthemquit,patientswere successful inintegratingphysical activityintotheirlives. This
increasedpatientself-efficacyandoutcome efficacybeliefsforsmokingcessation10
. Otherstudies have alsoaffirmed
the role of physical activityinminimizingdepressioninnewlydiagnosedandmulti-morbidpatients.
Smokingcessationreadinesstochange usingthe TTMmodel assessespatientreadinesstoquitbyaskingevery
patienttobe evaluatedatevery medicalencounterforsmoking,advisingeverypatientateveryencountertostopor not
to start, evaluatingthe patient’scurrentmotivationstage (TTM) includingdiscussof barriersandprovidingeducation,
developingaquitplanwiththe patient,andarrangingcounseling,follow-upsandrelapse prevention. Overall,the
average patientwill quitsmoking4-5timesbefore successful cessation,andsituational awarenessof triggersand
interventionsappearmore successful thanpharmacologyinterventions10
. Anotherstudysuggestedlowerage and
higherself-efficacyscorespredictedreadinesstoquitsmokingandsupportedworksite smokinginterventionprograms
withformal cancerrisk feedbackasa key componentof the program11
. Additionally,patientspresentinginthe
emergencydepartment(ED) forrespiratorydistresswhocurrentlysmoke mayhave higherreadinesstochange than
othersmokers. Depressioninthispopulationisafactor and simultaneousinterventionforoverall cessationsuccessmay
be advantageous12
. Bothhighimportance of cessationandhighconfidence incessationwere TTMpredictorsof
successful cessationand/orreductionof smokingandunhealthyalcohol behaviour.
For medicationadherence,thereisclearevidence inthe literature thatoverall,educatedmenbetteradhere to
medicationprotocols thanothergroups. One studywith 379K Medicare and 659K commercial patients notedthe New
Englandregionwasmore adherentthanotherregions (51%,19% respectively) andthatyoungerage beneficiaries,lower
income beneficiariesandfemaleswere lessadherent13
. Menwere 10-14% more likelytoadhere toanti-diabeticand
anti-lipidemiadrugsthanwomeninthe Medicare populationandforthe commercial population,menwere15-25%
more likely toadhere toall three categoriesof drugsinthe studyprotocol. Interestingly,people youngerthan65 years
of age inthe Medicare populationwerelesslikelythanpeople 65+ yearsof age to adhere tomedicationprotocols,with
anti-hypertensivemedicationshavingthe lowestadherence at45.3%. For the commercial population,being45 yearsof
age or greatershowedpositive medicationadherence forall three categoriesof drugs.
Withreceptivitytochange,case managementmaywanttoutilize the TTMtool to access thoughtsaround
general lifestyle choice changes,suchasphysical activity,smoking andalcohol cessation,andmedicationadherence,as
these choices have huge impactsona wide range of healthoutcomesand disease progression. Gettingtothe marrowof
patientreadinesstochange maybe a great proxyforunderstandingperceiveddisease status, discerninghealth outcome
futures, andidentifyingthose whocanbe reasonable managedbycase managementingeneral.
Recommendations Across Conditions
The theoryof systemicinflammationasthe rootcause of chronic illnessisdeeplyrootedinmedicaldogma. This
theorysuggeststhatthoughthe inflammationprocessistypicallybeneficial for the identificationand eradicationof
injury, whenthe processdoesnotstopat the appropriate time,the inflammation thenbecomesdestructive. Itisthis
theoryof inflammationthatcoulddrive general, actionable riskpriorities,aschronicdiseasesoften maybe definedand
measured medicallybythistheoryof inflammation. Subsequently,the use of inflammationtestingorphyto-chemical
supplementation mayhelptomoderate the long-termeffectsof systemicinflammation. Medical recommendations for
the overall riskmediationof chronicinflammation mayinclude:
1. TestVitaminD levelsandoptimize levels withVitaminDsupplementation48,72,110,120,125,147
2. Testcytokine levels throughC-reactive proteinlabs (CRP) andstratifyall resultsintosignificantgroupsto
discern risk,where highlevelsof CRPequalshighrisk24,29,30,47,74
3. Prescribe chemo-preventiveagents,suchasNSAIDs, Metformin,low-doseaspirin,betablockers,herbals
(curcumin,greentea,parthenolide,resveratrol,lycopene,zeaxanthin,beta-carotene, unsaturatedfatty
acids,and glycyrrhizin)23,29,30,47,52,59,74,81,82,92,99
4. Testfor infectiousdisease(H.Pylori,chlamydiapneumonia,HepatitisBandC) 25,32,74,88,98,100,109
5. SupportHPV vaccinationinall females75, 91
4. 4
6. SupplementwithCalciumandanti-oxidantssuchasVitaminC,Selenium, VitaminE,Omega3 & 6, and
Alpha-LinoleicAcid30,47,48,72,83,110,125,135
7. Supplementwithprobiotics andbutyrate74,76
Actionable Conditions
Diabetes Mellitus (TypeII)
For 2014, the CentersforDisease Control (CDC) reportsDiabetesMellitusType II isestimatedto affect9.3%of
the entire U.S. populationand25.9% of all U.S. people 65+years of age. Directand indirectcostsaccountedfor$245
billionin2012, whichincludes$176 billioninmedical expendituresand$69 billionindisability,workloss,andpremature
death15
. Subsequently,thesesoberingstatisticsdrive the needfor assessing,monitoring,andactingonreadinessto
change stages and actionable risk inthe general diabeticpopulation.
Receptivitytochange studiesof diabeticpatientssuggestbothTTMstagesof change and diabeticmetrics may
be used to understand populations more likelytochange to overcome diabeticburden. WomenwithhighA1cvalues,
highhyperglycemicevents,highhypoglycemiceventsorpositive attitudestowardsmanagingdiabeteswere more likely
to be readyto change,according toone study14
. Medicationadherence wasbestforpatientswithA1cvalueslessthan
seven,suggestingself-empowermentwasenabledwhen outcomesmatchedeffort16
. Additionally,Asians,Whites,and
females mayhave betteroveralloutlook,confidence,glycemiccontrol,diet,self-monitoringof bloodsugar,medication
compliance,knowledge levels,andsocial supportfor theircondition17
. Advancedage wasassociatedwithlower overall
expectationsandreducedreadinesstochange withregardtolifestylemodifications18
.
One particularstudysuggestedacomputerizedsystemcalledPathwaystoChange(PTC),whenappliedtothe
Trans-theoretical Modelof Change (TTM) assessmentforhealthbehaviors,provedtohave asignificantinfluence on
diabeticpatientlifestyle choicesandmetricsof health,toincludecaloriesfromfat, fruitperday,and vegetableservings.
PTC providedself-care interventionsdeliveredbyphone andmail,withorwithoutpersonalcontact. PTCalsoappeared
to promote TTM stage progressionforimportantmarkerssuchasself-monitoringbloodglucoseinterventionand
initiatingsmokingcessation. PTC,andthe like interventions, hasthe potential toreacha large numberof individuals
whodo not participate incurrenthealthcare systemactively16
.
DiabetesMellitus Type II causeshighco-morbidityandisassociatedwithmultiple riskfactors,whichmayormay
not be actionable inthe clinical orresearchsetting. These include obesity,familyhistoryof DM, gestational diabetes,
lack of exercise,hypertension,heartfailure,coronaryartery disease,hyperlipidemia,race,AcanthosisNigricans,
polycysticovariansyndrome,infertility,metabolicsyndrome,beingfemale,H.Pylori,andchronicperiodontitis.
Actionable riskprioritiesmayinclude:
1. Promote post-partumglucose screeningafteragestational diabeticpregnancy,especiallythose onMedicaid
wholose coverage 60 days postpartum19
.
2. Promote lifestylechangesespeciallyinpeoplewhoare inactive, have familyhistoryof diabetes,orhistoryof
highbloodpressure20
.
3. Promote healthcare prevention coverage orlow deductiblesforconstantsubcutaneousinsulin infusionsand
inhaledinsulin/Epi-pens21
.
4. Monitordepressionasa proxyformedicationadherence22
.
Heart Disease
Accordingto the CDC, heartdisease isthe leadingcause of deathforbothmen and womeninthe U.S.,
accountingfor600,000 American deathseachyearand costingmore than $108.9 billionayearforbothdirectand
indirectexpenditures. Coronaryheartdisease (CHD) isthe mostcommontype of heartdisease accountingforover64%
of all heartdisease deathsannually25
. Keyriskfactorsinclude highbloodpressure,highLDLcholesterol,andsmoking,
where over49% of all heartdisease patientshave atleastone of these riskfactors. Other riskfactors may include: lack
of exercise,inadequatefruitandvegetable intake,psychosocialstress,diabetes,abdominalobesity/obesity,alcohol
5. 5
consumption,lowSES,loweducation,lowsocial support,oral disease,electro-cardiographicleftventricular
hypertrophy,childhoodobesity,hightriglycerides,low HDL,familyhistoryof premature deathof HD,polycysticovarian
syndrome,asthma,amenorrhea,preeclampsiaduringpregnancy,lowlevelsof sex hormonesinpostmenopausal
women,lupus,chronickidneydisease,earlyonsetof menopause,H.Pylori,Chlamydiapneumoniainfection,and
nonalcoholicfattyliverdisease. Actionableriskprioritiesmayinclude:
1. Promote lifestylemodificationandsymptomrecognitionwithHDpatientswhoare women26
.
2. Monitorbias incare and adverse eventsinwomenwithheartdisease. Womenare more likelytohave non-
obstructive coronaryarterydisease thanmen. Womenare lesslikelytohave catheterizationsor
revascularizationsorreceive otherevidence-basedtherapiessuchasreperfusiontherapy,earlyaspiring or
betablockertreatment. Womenare at higherriskforreceiving overdosesoranti-plateletandanti-thrombin
agentsand are also at higherriskforbleedingif theyhave hadanon-ST-segmentelevationACS. Cardiac
rehabreferral anddropoutratesare highestinwomen26
.
3. Monitordepressionandanxietyasaproxyfor adherence toprotocols. Womenhave higherratesof
depressionafterdiagnosis,leadingtohighermortality,morbidity,andreadmissions26
.
4. Encourage cardiac imagingpriorto all non-cardiaclow-risksurgeryatall specialtylevels27
.
5. Monitorbilateral cardiaccatheterizationsinCADpatients,astheyare more costly,introduce infectionsand
are oftennotneeded27
.
6. Monitorunder-intensificationof insulintreatmentof diabeticsubpopulations includingpeoplegreaterthan
75 yearsof age,women,andpatientswithpoorhistorical medicationadherence28
.
7. Use the FraminghamRiskScore tool and the Ankle-brachial index tobetterclassifyriskof non-traditional risk
factors associatedwithCHD31
.
8. Monitorcreatinine rise of 2-foldor25% forAKIafterCABG. AKI predictslongerintensive care,hospital
stays,and extendedcare needs33
.
9. Tele-monitorheartfailurepatientstoincrease self-care efficacy withinsixmonths. Withequipment
monitoringweight,bloodpressure,pulse rate andoxygensaturation, patientsbecome aware of their
‘normal’vital statistics. Interactionwiththe monitoringnurse was neededfortimelyfeedbackforself-care
changesand behavior34
.
Studiesinreadinesstochange forheart disease patientswere drivenbyclassicheartdisease biometricslike stenosis
change and medicationadherence,notTTMstagesof change. These studiessuggestthatheartdisease patients witha
historyof angina,more cardiac lesions,andmore severelystenosedlesionswere lesslikelytobe involvedwithlifestyle
changesfor CHD. Adherence todietandlifestylerecommendationswasthe biggestdeterminantof change indiameter
stenosis,notage or disease severity36
.Femalesandthe elderly are lesslikelytoparticipateincardiacrehabilitation
programs. More successful patientswereobese,hadundergone previousCABGsurgery,andhadinsulin-dependent
diabetes. Unsuccessful patientsreportedhigherincidence of previouspercutaneoustransluminal coronaryangioplasty
(PTCA),unstable angina,hypertension,diabeteswithend-organdamage,andasmokinghistory37
. Additionally,the
desire tobe healthydrove the adherence tomedication,thuspromotingthe patient’sabilitytomake the connection
betweenthe needtotake medicationandthe consequencesof notdoingso. Makingthe connectionbetweenthe
medicine’seffectivenesswiththe patient’ssymptomswasimportanttoadherence.Beingconnectedtotheirhealthcare
providerandfamilyandhavingenvironmental cuesasreminderstotake theirmedicationsalsoincreasedadherence.
Understandingthe symptomsof heartfailure andrecognizingpersonal symptomsassymptomsof heartfailure
increasedadherence.Physical symptoms‘reminded’patients totake medication. Barrierstomedicationadherence
includedpill size/difficultyswallowing,costof medication,difficultschedule,frequentdosing,andside effects38
.
Cancer
The National CancerInstitute (NCI) estimates1,665,540 new, all-sitecancercasesand 585,720 estimateddeaths
fromall-site cancerfor2014. Approximately66.1% of all all-site cancerpatientssurvive atleastfive yearspost-cancer
diagnosis, andwithinitialandannual directmedical costsaveraging$73,369 and $56,445 respectively perpatient,
cancer isa large populationburdenneedingprevention,earlydetection,andsmartintervention39
. Additionally, the
6. 6
diagnosisof cancerisone of the top ‘teachable moments’inapatient’slife forpromotingsmokingandalcohol
cessation, however, itisunderusedinthe clinical setting40
.
Studiesof readinesstochange forcancerconcentrate on behaviors,markers,and biometrics,andare tailored
towardsspecificcancertypes. Forinstance, prostate andbreastcancer survivorswere goodrecipients forhealth
promotionmaterialsbecauseof their overallperceptionof goodhealth,withthe majorityof both genders wanting
mailingswithin0-6monthsof diagnosis toimplementactionablechanges. There were statisticaldifferences inrace and
gender,withwhite femaleswith breastcancerbeingthe mostreceptivetothe healthpromotionmaterials. Women
were alsomore likelytoadhere tofive fruitsandvegetables aday,vitaminsupplementation,andadhere andknowif
theywere on a low-fatdietcomparedtomen. However,menwere more likelytoexercisepriortoandafter the
diagnosisthanwomen. Andwomenweremore likelytochange dietthanexercise. Womenwere more likelythanmen
to be current smokersevenafterdiagnosisof cancer41
.
For skincancer,womenwere more likelytodecrease sunexposure thanmen,withmendoingmore activities
unrelatedtosunbathingthanwomen. Additionally,people ages30-60 and greaterthan 60 were more likelytodecrease
sunexposure thanpeople <30years of age. However,youngpeople lessthan30 and womenwere more likelyto
protectthemselvesfromthe sunviasunscreenandclothingthanmen.Currentsunbeduserswere the leastlikelytobe
readyto change theirbehavior. Current sunbeduserswere more likelytohave animmigrantbackgroundandskintypes
III-VI(darkercomplexions), andwanttoenhance visual appearance andoverall wellness42
. People greaterthan 65 had
the lowestreadinesstoincrease sunscreenuse. Subjectswithhigh skinUV-sensitivity(skintype I-II) werethe most
readyto increase sunprotection,exceptforsunbedusers. Menare more likelytobe diagnosedwithamalignantskin
tumor andlesslikelytobe concernedaboutskincancer. Thiscorrespondstomore unintentional sunexposure inmen
than women,due towomen‘sunbathing’more thanmen,butmenhavingequal ormore exposure. Menwere less
preparedtomake changesto theiroverall riskbecause theydidnotperceivethe risktobe severe43
.
For people atriskforcolorectal cancer (CRC), studiessuggestviewsonreadinesstochange screeningbehavior
were troubledbyinvasivenessof the proceduresassociatedwithscreening. Womenwere lesslikelytohave colorectal
screeningsdue tobodilyintrusion,perforationanxiety,andembarrassment(stressanddistress). Menwere lesslikelyto
have themdue to procrastinationwithunderlyingfatalism, thoughtsof itbeingunnecessary,anddue touncomfortable
vulnerabilityof the screening(stressandprocrastination). However,womenwere more likelytohave CRCscreenings
due beingmore likelytohave consistentphysicianrelationships,beingmore screeningknowledgeable andbeingbetter
able to voice viewsonscreening. Overall,people whowereolderor had priorcoloncancer screeningswere more likely
to have future colorectal screenings. U.S.adults50 to 59 yearsof age were the leastlikelytohave hadanyCRC
screeningat63.40% and adults70-75 yearsof age where the mostlikelytohave CRCscreeningsat82.30%.
Furthermore,29.1% of U.S. menreportedneverbeingscreenedforCRC,thoughwomenwere notsignificantlymore
adherentat28.3%. More Asian,Native Hawaiian, PacificIslander, andnon-Hispanics(38.2%) reportedneverbeing
screenedthanmembersof otherracial andethnicgroups,resultinginastatisticallysignificantproportionaldifference.
Black people were the mostadherentwith a72.4% screeningrate,translatingtoat most,at 10.6% difference between
racial groups forCRC screening adherence. Additionally,nearly37% of people withlessthanahighschool diploma
reportedneverbeingscreened. People withhighereducationswerestatisticallymore likelytohave CRCscreening,with
the largestdifference inproportionsbeing12.3% (college degree vs.didnotgraduate fromhighschool). Overall,race,
gender, andeducationlevels doappearto playa role inwho seekscolorectal cancerscreenings forprevention44,45
.
Prostate cancer isestimatedtoaffect233,000 menthisyearand represents 14.0% of all new cancercases
identified. Five-yearsurvivalwithprostate cancerisveryhighat 98.9%, attributingtoonly5.0% of all cancer deaths.
Thisequatestoapproximately15%of all menhavinga diagnosisof prostate cancerduringsome time intheirlives46
.
Riskfactors forprostate cancer include: AfricanAmericanrace,familyhistoryof cancer,diabetes, sexual inactivity,
erectile dysfunction,baldingpatternbythe age of 45, frequentaspirinusage, obesity orhighPSA levels. Actionable risk
prioritiesmayinclude:
1. Monitorosteoporosisandbone mineral densityinmenonadjuvantdeprivationtherapy(ADT) especially6-
12 monthsaftertherapy,as ADT deprivesmenof androgensincreasingbone mineral loss. Inadditionto
7. 7
monitoring,Bisphosphatetherapymaybe needed. Use anti-resorptive therapytopreventfracturesinmen
withlowBMD47,48
.
2. Promote andmonitorthe use of radiotherapyoverdifferentfractionationradiotherapyforcost-inhibition,
time-effectiveness,andbetterpainandrecoveryeffectsforpatientswith metastaticbone disease and
advancedcarcinomaof the prostate47
.
3. Educate and level-setexpectationswithroboticprostatectomy. Patientswithroboticprostatectomyhave
unrealisticexpectationsandthus,experience more painandmore negativeoutcomesresultinginhigher
overall costs47
.
Breastcancer is estimatedtoaffect232,670 womenthisyearand represents 14.0% of all new cancer cases
identified,aswell. Five-yearsurvival withbreastcancerislowerthanprostate cancerat 89.2%, attributingto6.8% of all
cancer deaths. Additionally,12.3%of all womenwill be diagnosedwithbreastcancerat some pointduringtheir
lifetime. Riskfactorsforbreastcancerare numerousandreflectthe range of researchdevotedtobreastcancer
preventionand treatment49
. These include: familyhistoryof breast,endometrial orovariancancer,insulinresistance
syndrome/diabetes,PCOS,obesity/central obesity,physical inactivity,geneticmutationssuchasGilbertSyndrome,
BRCA 1, 2, or 3, Ashkenazi Jew genetics,Klinefeltersyndrome,Li-Fraumenisyndrome,Cowdensyndrome,beingof
IcelandicoriginorPeutz-Jegherssyndrome,birthweightover4000 grams, higherparity,youngage of firstbirth,lackof
breastfeeding,hormone use,delayedchildbearingand decreasednumberof births,late menopause,nulliparity,age,
radiationexposure,fatintake,alcoholconsumption,weightgainafterhighschool andmenopause, smoking, breast
densityandfibroidpresence. Actionableriskprioritiesmayinclude:
1. Monitorthe unnecessaryuse of Herceptin(Transtuzumab)onHER2 receptor-positivebreastcancers,asonly
abouthalf of HER2-positive cancersbenefitfromHerceptin,makingthisacostlyand unproductive therapy.
Geneticprofilingof HER2 cancer couldelucidate treatmentoptionspriortounnecessaryandcostly
treatment50
.
2. Recommendgeneticprofilingof womenwithafamilyhistoryof breast,ovarian,orendometrial cancer51
.
3. Recommend Tamoxifenandlow-dose SSRIforwomenwhohave hadoophorectomiesandhave come off
hormone replacementtherapy51
.
4. Monitoradverse effectsof Tamoxifentherapywithoutlow-dose SSRI51
.
5. Treat highc-peptide levelsand insulinresistance asamarkerfor all cancers52
.
6. RecommendNSAIDKetorolacastherapyaftermastectomytocontrol relapse rate aftersurgeryandbetter
four-yearoutcomes53
.
7. Recommendsimple(total)mastectomyoversubcutaneousmastectomyforeffectiveness54
.
8. Performbone mineral density (BMD) testingonpre-menopausalwomenwithbreast orovarian cancer inthe
primaryand specialtycare settingsforchangesinBMD overtime duringchemotherapy. Use anti-resorptive
therapyto preventfracturesinwomenwithlow BMD55
.
Endometrial andovariancancersare estimatedtoaffect52,630 and21,980 womenthisyearandhave an
incidence rate of 3.2% and 1.3% of all newcancercases identified,respectively. Diagnosisof eitherof these cancersis
relativelylowat2.7% for endometrial cancerand1.3% for ovariancancer,but five-yearsurvival ratesforovariancancer
bottomout at 44.6%, thoughendometrial cancerisalmostdouble at81.5%56
. Riskfactorsfor these twocancersmirror
breastcancer riskfactors almost completely;however, there are additional factorsexclusive tothisareaof the body
such as pelvicinflammatorydisease,perineal talcexposure,extremesinlatitude andVitaminDdeficiency,andHuman
PapillomaVirus(HPV). Additionally,actionableriskprioritiesmayinclude:
1. Accurate stagingfor cancer removal basedontype of cancer (genetictesting) 57
.
2. Eliminate waittimesfortherapypost-operatively,asitisa riskfactor for reoccurrence57
.
3. Vaccinate all womenwhoare notHPV carrierswithHPV vaccine. CertainHPV genotypesare associatedwith
ovariancancer58
.
4. Promote education andmonitorwomenwith PCOSandinsulinresistance forovariancancer,whichare all
highlycorrelated59
.
8. 8
5. Promote the use of 3x a weekanalgesictoreduce the riskof ovarian/endometrialcancerbymoderating
inflammationinthe body forwomenwithPCOS,endometriosis,andpelvicinflammatorydisease (PID) 60
.
6. Promote andmonitorthe use of statinsasanti-canceragentsto treatovariancarcinoma viaapoptosisand
preventionof reoccurrence61
.
Melanomaof the skinisthe mostprevalentof skincancerswith76,100 people affectedthisyear,accountingfor
4.6% of all newcancer casesidentified. Additionally,2.1% of all menand womenwill be diagnosedwithmelanomaof
the skinat some pointintheirlifetime. Five-yearsurvival ratesaverage 91.3% of all melanomacases,estimatingover
960,000 caseslivingwithmelanomain2011 alone62
. Riskfactorsforskincancer include: sunbathing,sunbeduse,
unintentional sunexposure, skintypesI-II,familyhistory of melanoma,blisteringsunburnsbetween15and 20 yearsof
age,alcohol consumptionandphysical inactivity,HIV positive status,highBMIandbloodpressure,beingmale,smoking,
priorradiationtherapyforcancer, exposure toarsenic,industrial coal tar,creosote,orparaffinoil,exposure to
ultravioletlighttreatmentforpsoriasis,sub-cutaneousHPV,long-termorsevere skininjuryorinflammation,freckles,
presence of atypical naevi,signsof photo-aging,havingoutdooroccupationsorhobbies,lighteye orhaircolor,
advancedage,livinginasunnyclimate, beingamajororgan transplantrecipient, andactinickeratosis. Actionablerisk
prioritiesmayinclude:
1. Educate and screen all majororgan transplantrecipientsforskincancer. TreatmentssuchasVoriconazole
put patientsatheightenedriskforskincancer. Those at highestriskhave the greatesttime lagsince
transplant,have the highestage attransplant,are the patientswiththe fairestskin,have hadaprior skin
cancer diagnosis,andhadthe longestexposure time to immuno-suppressants63
.
2. Educate and monitorlivertransplantrecipientsforskincancerwhose livertransplantetiologywasalcoholic
cirrhosis64
.
3. Screenpatientswithregularalcohol consumptionforskincancer65
.
4. Educate and monitorpatientsonthe increasedskincancerriskassociatedwith Thiazines,cardiacdrugs
(Amiodarone,Diltiazem) formore thanthree months,Azathioprine, andinductiontherapy
(ATG/thymoglobulin/OKT3) 65,66
.
5. Educate and monitoradjuvantradiotherapypatients,especiallythose withAT>=50 Gy per dose,forskin
reactionsor changeswhichmayleadto cancer67
.
6. Educate and monitorall patientswithpastandpresentutilization of oral methoxsalen photochemotherapy,
such as PsoralenandUltraviolet-A Light(PUVA),fortreatmentof psoriasis68
.
7. Educate and monitorpatientsonthe influence of arsenicinthe watersupplyforincidence/prevalence of
skincancer69
.
8. Educate and monitorpatientswithroutine topical applicationof coal tarsolutionindosesordinarilyusedin
treatingdermatological disease,especiallypatientswithcontactdermatitisof the scalpor otherareas. Coal
tar treatmentsare often soldover-the-counter(OTC) 70
.
Colonandrectal cancer are estimatedtoaffect136,830 people thisyearandhave a combined incidence rate of
8.2% of all newcancer casesidentified. Diagnosisof colon/rectal cancerisapproximately4.7% and the five-yearsurvival
rate forall colon/rectal cancerpatientsisestimatedat64.7%71
. Riskfactors associatedwithcolon/rectalcancerinclude:
Westerndietwithlowfruit,vegetable andfiberintake,malnutrition,beingmale,certaingeographical regions,African
Americanornon-Hispanicwhite,redandprocessedmeats,redmeatscookedathightemperatures,excessive alcohol
consumption,animal fatconsumption,obesity/highwaist-hipratio,inflammatoryboweldisease (IBD),ulcerative colitis
(UC),Crohn’scolitis,advancedage,H.Pylori infection,gastricdysplasiaandsimilarconditions,Type IIdiabetes,hyper-
insulinemia,physicalinactivity,smoking,elevatedgrowthhormone levelsasaresultof pituitaryadenoma,highlyrefined
carbohydrate consumption,low calciumconsumption,low antioxidantconsumption,low folate/multivitamin
consumption,familyhistoryof coloncancer,PPIusage,lackof VitaminD,environmentandfood-borne mutagens,and
intestinal pathogens. Additionally,actionable riskprioritiesmayinclude:
1. Educate patientsonlifestyle changestoincludecessationof smoking,limitedredandprocessedmeat
consumption, andmaximizingfruitsandvegetables72
.
9. 9
2. Screenall patientswithprior/knownH.Pylori orotherkindsof gastricabnormalitiesfor neoplasmsof the
colonthroughsigmoidoscopy73
.
3. Testfor internal opportunisticpathogensdue tounbalancedmicrobiome,moderate toheavyantibiotics
have beenused,patientshave takenPPIsorNSAIDs,patientshave Crohn’sdisease,Ulcerative colitisor
smokes. Opportunisticpathogenssetthe stage forintestinal inflammationthatleadstocoloncancer77
.
4. Educate and monitorCrohn’sdisease patientsforclinicallyrelevantdysbiosisof the microbiotacausing
inflammationandcancer78,79
.
Pancreaticcancer isestimatedtoaffect46,420 people annually,representing2.8% of all new cancercases for
2014. It isestimatedthat43,538 people were affectedin2011 bythisdisease andthe five-yearsurvivalrate isan
abysmal 6.7% for all pancreaticcancerpatients80
. Riskfactorsmayinclude: alcoholismandheavydrinking,chronic
pancreatitis,germlinemutationssuchasBRCA1and 2, AshkenazicJewishrace,Peutz-Jegherssyndrome,hereditary
pancreatitis,ataxia-telangiectasia,familial atypical multiplemole melanoma,non-polyposiscolorectal cancer(Lynch
syndrome),andhereditarybreastandovariancancer,smoking,obesity,diabetes,lackof exercise,radiationexposure,
lack of folate,abdominal fatness,redmeatintake,occupationalexposures,advancedage,AfricanAmericanrace,
chroniclivercirrhosis,highcholesteroldiet,priorcholecystectomy,H.Pylori infection,HepatitisBvirus,lowVitaminD,
beingmale, drinkingcoffee, andhavinganon-Otype blood. Actionablerisk prioritiesmayinclude:
1. ScreenDM Type IIpatients,alcoholicpancreatitispatients,andpatientswithafamilyhistoryof pancreatic
cancer for chemo-prevention techniquesandindicatorsof increasedrisk81
.
2. Monitorand educate patientswithpancreatic canceraboutthe riskinvolvedwithcachexia. Cachexiaisa
resultof gastrointestinal functi8onandlossof appetite,aswell asmassive lossof adiposeandmuscle tissue
because of change inlipidandproteinmentalism. Cachecticpatientswithpancreaticcancerhave lower
protein,albumins,andhemoglobinthannon-cachecticpancreaticcancerpatients,makingthemunlikely
candidatesforresectionsurgeryandthose withsurgerymore susceptible topost-surgeryweightlossand
mortality84
.
3. Screenandtreat all high-riskpatients,chronicpancreatitispatients,andpancreaticcancerpatientsfor
HepatitisBinfection. HepatitisBisan independentriskfactorforpancreaticcancer and resolvingthe
infectionhadabetterprognosisthanpatientswithactive disease85
.
4. Testand educate patientswithafamilyhistoryof pancreatic,breast,orovariancancerfor germline
mutationsinDNA. Promote cessationof smokingforthese patients,assmokingactsasan independentrisk
factor and lowersthe age of onset of thisaggressive cancerbyapproximatelytwodecades. Inpatients
havinggermline mutations,promotecessationof alcohol,aswell86
.
5. Educationand monitorforincreasedriskof perioperativemyocardial infarction(PMI) postpancreatic
resection,especiallywithinthe firstpostoperativeweek. Mostpatientsexperiencingthisoutcome were
fromthe non-stemi groupandwere clinicallyasymptomatic. PMIrangesfrom1-3% for low-riskpatientsand
as highas 38% for high-riskpatients. Post-pancreatectomyhemorrhagewasthe mostrelevantunderlying
riskfactor for PMI,as well87
.
6. Testpatientspriorto cholecystectomyforpancreaticcancerviaCA-19-9 biomarkerorothertests,such as
pancreaticenzyme functiontests. Cholecystectomywithin12monthsof pancreaticcancerdiagnosisresults
indecreasedone yearsurvival forthese patients,especiallypatientswithjaundice,weightloss,and
steatorrhea89
.
Lung and bronchuscancersare estimatedtoaffect224,210 people annually,representing13.5% of all new
cancer casesfor 2014. It isestimatedthat402,326 people were affectedin2011 by thisdisease andthe five-year
survival rate isverylowat 16.8% for all lungcancer patients90
. Riskfactorsmayinclude: smoking,passive smoke
inhalation,advancedage,radonandasbestosexposure,environmentalpollution,occupational exposures,beingfemale,
AfricanAmericanrace,pre-existinglungdisease suchasasthmaor COPD,HPV or a familyhistoryof lungcancer,lowSES,
priorpneumonia,HIV,insulinresistance ordiabetes,oropium use. Actionable riskfactorsmayinclude:
1. Promote smokingcessation91
2. Promote ventilationtechniquesforhigh-riskenvironmental exposuresandoccupations91
10. 10
3. Promote whole foodsdiet91
4. Screenall lungcancer patientsforcardiaccomorbiditypriortoradiotherapyforlungcancer. Radiotherapy
putspatientsat riskfor radiation-inducedlungtoxicitywithinsix monthsof treatmentinitiation.
Identificationof these patientsmayenable dose escalationforlow-riskpatientsandmayalsoenable dose
reduction/redistributionforhigh-riskpatientstoavoidside effects93
.
Liverand intrahepaticbilecancersare estimatedtoaffect33,190 people annually,representing2.0%of all new
cancer casesfor 2014. It isestimatedthat45,942 people were affectedin2011 by thisdisease andthe five-yearsurvival
rate isverylowat 16.6% of all patientswith livercancer94
. Riskfactorsmayinclude: HepatitisBandC infection,
alcoholiclivercirrhosis, auto-immune liverdisease,inherited ornon-inherited hemochromatosis,nonalcoholicfattyliver
disease,aflatoxinexposure,smoking,diabetes/metabolicsyndrome,obesity,vinyl chloride exposure,coffee
consumption,Westerndietlackingfruits,vegetablesandfiber,endstage liverdisease,disordersof ironmetabolism
causingironoverload,Beckwith-Wiedemannsyndrome,hemo-hypertrophy, familial adenomatouspolyposis, Gardner’s
syndrome,liverflukesfromimproperlycookedfish,gallstones, inflammatorybowel disease,primarysclerosing
cholangitis,alpha1-antitrypsindeficiency,exposure tothorotrast,beinganelderlyman,familyhistoryof livercancer,
colorectal cancerresectionsurgery,andprimarybiliarycirrhosis. Additionally,actionable riskprioritiesmayinclude:
1. Monitorpatientshavinghadsurgical resectionof the colonforMetachronouslivermetastatis95
.
2. Screenandmonitorall diabeticandmetabolicsyndrome patientsforlivercancer,especiallythose under65
yearsof age96
.
3. Screenandmonitorall hypothyroidpatientsforlivercancer. Screenandcorrecthypothyroidisminpatients
to helppreventlivercancer97
.
4. In primarycare,promote the use of non-invasive fibrosisfornon-alcoholicfattyliverdiseaseandalcohol-
induceddiseasesof the liver100
.
5. OfferHepatitisA andB, flu,andpneumococcal vaccinesasearlyaspossible,due toweakerantigenic
response asliverdiseaseprogresses100
.
Oral cavityandpharynx cancers are estimatedtoaffect42,440 people annually,representing2.5%of all new
cancers for2014. It is estimatedthat281,591 people wereaffectedin2011 bythisdisease andthe five-yearsurvival
rate is62.7% for all patientswith oral cavitycancer101
. Riskfactorsinclude: HPV orH. Pylori infection, smoking/tobacco
use,alcohol consumption, familyhistoryof oral cancer,HIV infection, majororgantransplant recipient,
immunosuppressivetherapy(IBD,transplants),low intake of fruitsandvegetables ornutrientdeficiency, low SES, poor
oral hygiene orperiodontal disease, chroniccandidiasis orherpesvirus, low intakesof vitaminEor carotenoids,and
chewingbetel quid. Additionally,actionable riskfactorsmayinclude:
1. Monitorand educate patientwithmajororgantransplantsandinflammatorybowel disease whoare taking
immunosuppressivetherapydrugsforlipandtongue cancer102
.
2. Educate physicians,dentistandpatientsonthe linkbetweenHPV,H.Pylori,HIV,andHerpesvirusandoral
cancer102
.
3. Educate dentists,providerand patientshow chronicoral candidiasisandperiodontal diseasemaybe triggers
for oral cavitycancer103,104
.
Osteoporosis
Osteoporosisisestimatedtoaffect5.3millionmenandwomenover50 yearsof age inthe U.S., representing
approximately9%of all adultsover50. Additionally,therewere 306,000 dischargesin2010 for hipfracture inthe U.S.,
withan average lengthof stayof 5.8 days. It isestimatedbythe National Institute of Health(NIH) thatmore than40
millionAmericansare atincreasedriskforbone fracture due to osteoporosis,makingthispreventableandtreatable
disease importantforcontainingmedical costsandoverall utilizationburden105
.
Osteoporosisisa‘silentdisease’becausebone losshasno initial outwardsigns. Like all otherdiseases,certain
riskfactors suchas beingawoman,beingof advancedage,havinga small frame,beingWhite orAsian, beinga
transplantrecipient,havingahistoryof breastor prostate cancer,havinglimitedornoindependence/beingdisabled, or
11. 11
havinga familyhistoryof osteoporosisare notchangeable. However,thisdiseaseishighlydependentonlifestyle
choicesforthe preventionordelayof clinical symptoms. These include: low estrogenortestosterone,menopause,
anorexianervosa,calciumandvitaminDintake,medicationuse suchaschroniccorticosteroidtherapy,activitylevel,
smoking,drinking,havingpriorlow-impactfractures,havingH.Pylori infection,usingPPIs/SSRIs,andhavingperiodontal
disease. Actionable riskfactorsmayinclude:
1. Standardize screeningtools,processes,education,counselingandremindersacrossspecialtiesandpractices
comingintocontact withpatientsmostlikelytohave osteoporosis106
.
2. Offercontinuededucationcredits(CE) formedical professionals onosteoporosis107
.
3. Patientsbenefitedmostfromeducationdeliveredfromapanel of expertswhoengagedthe audience107
.
4. Resistance andweight-bearingactivitiesshouldbe promotedinlow BMDwomen,eveninadvancedage
givenenoughstability,toreduce the riskof fracture andfalls108
.
5. Educate and monitorpatientstakingPPIs,SSRIs,Thyroxine,Benzodiazepines,andanti-epilepticdrugsfor
bone loss110
.
6. Testall patientswithlongdisease durationorthose onhighcumulative glucorticoid use forbone loss
includingIBDpatients,transplantpatients,andarthriticpatients111
.
7. Screenmenwithprostate cancerreceivingADTdeprivationtherapyforBMD loss47
.
8. Screenwomenwithbreast,ovarian,cervical orendometrialcancerreceivingchemotherapyforBMDloss55
.
9. Screenpatientstakingchemotherapyagents,prostaglandins,calciumgluconate,highlevelsof VitaminA or
D, Phenytoin,Heparinandingestinglarge amountsof fluorine. HypervitaminosiswithVitA andD,
prostaglandinsandcalcium gluconate are typicallypresentinearlychildhoodator nearbirth110
.
10. Promote whole foodsdietwithhighdairyintake.
Auto-immuneDiseases
The National Institute of Health(NIH) estimatesupto23.5 millionAmericanssufferfromanauto-immune
disease,withthe incidencerisingeveryyear. Accordingtoresearchers,there are approximately80-100 differentauto-
immune diseases,whichare chronicandsometimes,life-threatening. Annual directcostsare estimatedbythe NIHto
be approximately$100 billion. Some of the more prevalent auto-immune diseasesare: Hashimoto’sThyroiditis,
SystemicLupusErythematosus,Sjogren’sSyndrome,Anti-phopholipidSyndrome,PrimaryBiliaryCirrhosis,Auto-immune
Hepatitis,Graves’Disease,Scleroderma, andRheumatoid Arthritis112
. Riskfactorsinclude: familyhistoryof auto-
immune disease,beingfemale,havingbeenpregnant,smoking,periodontitis, advancedage,nulliparity,PCOSor
amenorrhea,obesity,highserumcholesterol,coffeeoralcohol consumption, chronicgranulomatousdisease (CGD), low
VitaminDand lackof breastfeeding. Additionally,actionable riskprioritiesmayinclude:
1. Monitorand educate all patientswith chronicgranulomatousdiseaseaboutthe riskof developingauto-
immune diseases. Thiswill minimize unnecessaryinvasive proceduresandallow earlyinstitutionof
appropriate therapytocontrol inflammationandreduce risksof long-termcomplications113
.
2. Monitorand educate patients onstatinsasa potential triggerfor auto-immunedisease inpatients,
especiallywomen. Systemicimmunosuppressive therapymayassistinthisissue114
.
3. Monitorand educate patientsonCyclosporinetherapyforauto-immunediseases forCyclosporine-induced
nephropathy. Thisriskisreducedbydosingnomore than 5 mg per day forthisdrug115
.
4. Educate physiciansandpatientsonthe riskassociatedwithMinocycline,asemisynthetictetracycline
antibioticwidelyprescribedforthe treatmentof inflammatoryacne andrheumaticdiseases,asthe drug
may induce Lupusand Auto-immuneHepatitis116
.
5. Educate physiciansandpatientsonthe riskassociatedwithbiologicsusedoff-labelforSystemicAuto-
immune diseasesof severeinfectionsandhighermortality,especiallyinolderpeople andwithrepeated
dosing. These include Rituximab,Infliximab,Etanercept,andAdalimumab117
.
6. Educate physiciansandpatientsonthe risksassociatedwithglucagon-like peptide 1agonists,suchas
Liraglutide,astheymayinduce auto-immune hepatitis,especiallyinwomen118
.
7. MonitorpatientswithRheumatoidArthritis(RA)formarkersandeventsof heartdisease andcardiovascular
disease (CVD) 119
.
12. 12
8. Educate patientsandphysiciansthatcorticosteroids,whichare the firstline of defense forRA,increase the
riskof cardiovascular(CV) death,especiallyinthose receivinggreaterthan7.5 mg a daydosingformore
than six months119
.
9. Educate patientsandphysiciansthatanti-rheumaticdrugssuchas Methotrexate andotherDMARDSmay
minimize the corticosteroidandCVDrisk,especiallywithpatientsof advancedage orpriorCV event. Folic
acid shouldbe supplementedwithMethotrexate forCVDprotectiontobe effective. RiskprofilingforCVD
riskprior to statintherapymaybe warranted119
.
10. Educate physiciansandpatientswithRA onthe increasedriskof seriousinfectionsanddeath,especially
patientsonsteroidsorbiologicsforRA therapy121
.
11. Promote influenzaandpneumococcal vaccinationsforall RA patientsdue tohighriskof infectionand
mortality. Promote the use of Zostavax forpatientsover50 yearsof age for shinglespreventionof RA
patients121
.
12. Promote the testingandmonitoringof RA patientsbone mineral densityforbone lossdue toRA therapy
and disease durationeffects111
.
Asthma
The CDC estimatesasthmaprevalence tobe around25.5 millionadultsandchildren. Thishighprevalence of
chronicdisease accountedfor1.3 millionhospital outpatientvisits,1.8millionemergencydepartmentvisits,and
439,000 hospital inpatientvisitsin2010, withthe average staydurationbeing3.6 days122
. Andthoughthe mortalityrate
isrelativelylow at1.1 per100,000 patients,the incidence isrisingeveryyearandthe overall burdenof chroniccare for
thispopulationisvery highatan estimated$18 billionayearforindirectanddirectcosts,according to the AAFA123
. Risk
factors forasthma include: prenatal tobaccosmoke exposure,malnutritionanddiet,antibioticuse,c-sectiondelivery,
lack of breastfeeding,low SES,bronchialandrespiratoryinfections/viruses,exposuretoanimalsorrodents,VitaminD
deficiency,race,obesity,smoking,allergies,eczema,exposure towoodoroil smoke,sootor exhaust,GERD,allergic
rhinitis,oracetylsalicylicacidexacerbatedrespiratorydisease. Actionableriskprioritiesmayinclude:
1. Educate physiciansandpatientsonthe long-termeffectsof certainmedications,suchasnon-selective beta
blockers,ASA/NSAIDS,ACEinhibitors,andAERDs,astheycan induce asthmaticattacksdays or evenyears
aftermedicationinitiation124
.
2. Monitorand educate physiciansandpatientsonthe linkbetweenasthmaandoverall systemicinflammation
elevation. Asthmaticshave agreatertendencytohave othermarkersof inflammation,suchasserum
cholesterol andotherCHDmarkers126
.
3. Classifypatientsusingthe Step4/5/6methodto identifypatientsmostatriskforfuture asthma
exacerbations127
.
4. Promote influenzavaccinationforpeople sixmonthsof age orgreater128
.
5. Tailoremergencydepartmentdischarge paperstothe patienttoinclude avisual severityscale forthe
patientandparentsto increase primarycare follow-upappointments129
.
Figure 2: Visual SeverityScale
6. Monitorand educate asthmaticpatientsontheirincreasedriskof chronickidneydisease. Screeningrenal
functionroutinelymaybe warranted. Riskmaybe an artifact of therapiesoroverall inflammation130
.
7. Educate physiciansonthe linkbetweenGERS,ARand AERD as commoncomorbiditiesamongadultswith
asthma. These conditionsmaycomplicate asthmaandincrease hospitalization,EDadmissions,and
outpatientcare. Treatmentof these underlyingconditionswilllessenasthmaburden132
.
8. Educationphysiciansonthe correlationbetweenasthmaandfertilityforfemale patients. Muchlike
sarcoidosis,asthmahasa negative effectonfertility131
.
13. 13
ChronicObstructivePulmonary Disease(COPD)
Accordingto the National HealthInterview Surveyconductedbythe National CenterforHealth Statistics(NCHS),
approximately12.7 millionpeople hadbeendiagnosedwithCOPDin2011, withthe numberof deathsestimatedtobe
between60,000 and 70,000 in 2009. It isestimatedthat715,000 dischargesin2010 were COPD-related,witha
discharge rate of 23.2 per10,000 persons. Directandindirectcostswere estimatedtobe approximately$49.9 billionin
2010, includingindirectmortalitycosts133
. RiskfactorsforCOPD include: smokingorpriorsmoking,occupational
hazards,respiratoryorbronchial infections,familyhistoryof COPD,advancedage,low SES,havingasthmaorairway
hyper-responsiveness,havingsystemicinflammation,havingGERD,beingsedentary,andhavingperiodontitis.
Additionally,actionable riskprioritiesmayinclude:
1. Monitorand educate patientsonincreasedriskof COPDreadmissionwithlowerFEV andlowerPO2values.
Physiciansshouldbe monitoringpatientswithhighvaluesandalsopatientswithatleastthree COPD
admissionsinayearfor elevatedreadmissionpotential134
.
2. Promote higherlevelsof usual physical activityinCOPDpatients134
.
3. Monitorand educate patientsonthe negative effectsof passivesmokinginhalationandtakinganti-
cholinergicdrugsonCOPD134
.
4. Promote whole foodsanddietarychangestoCOPDpatients,asthese hadaninverse effectonFEV1 levels135
.
5. Educate and screenpatientsforelevatedarterial stiffnessviaarterial pulse wavevelocity(PWV) due tothe
associationof thisconditiontoCOPD136
.
6. Vaccinate COPDpatientannuallyforfluandpneumonia137
.
7. Promote pulmonaryrehabilitationimmediatelyfollowingpost-acute exacerbationstopreventnew
exacerbationsandreduce severityof them137
.
8. Screenpatientsforanemiaandtreatanemicpatientstolessenerythropoietinlevelsandinflammatory
response138
.
9. Monitorand educate COPDpatientswithmetabolicsyndrome ordiabetesonthe heightenedriskof
infectionanddeathuponadmissionforCOPDdue to reducedglucose tolerance duringexacerbationevent.
Emphasisshouldbe onreducing corticosteroiddose,asthisincrease COPDinflammation139
.
10. Monitorand educate patientsandphysiciansonthe correlationbetweenCOPDexacerbationandGER
symptoms,eveninthe presenceof anti-refluxmedications140
.
11. Screenall COPD,diabetic,CVD,rheumatoidarthritisandosteoporosispatientsforperiodontal disease asan
exacerbationmechanismforworseningCOPD141
.
ChronicKidney Disease(CKD)
The CentersforDisease Control estimatedmore than10% of U.S. adults or 20 millionpeople aged20and older
for 1999-2010 had CKD142
. Additionally,the UnitedStatesRenal DataSystemestimatedfor2011, the overall perperson
peryear (PPPY) costsforpatientswith only CKDreached$22,348 for Medicare patients65+ and $16,086 for patients50-
64 yearsof age. For patientswithCKDand diabetes,the perpatientperyear(PPPY) costsrose as highas $27,651 for
AfricanAmericansin2011 and for patientswithCHFandCKD, estimateswere ashighas$40,377 per year143
. Risk
factors forCKD include:obesity,negativelifestylechoicestoincludediet,diabetes,hypertensionorCVD,60+ yearsof
age,familyhistoryof CKD,race,auto-immune disease orsystemicinflammation,prone toUTIsor urinarystones,urinary
tract obstructionor neoplasia,exposure tocertainchemicalsorenvironmental conditions,low SESorlow education,
recoveryfroman acute kidneyinjury,reductioninkidneymass,exposure tocertaindrugs,orlow birthweight.
Additionally,actionable riskprioritiesmayinclude:
1. MonitorCKD patientsforinter-relatedCVD, suchas stroke andsubclinical cerebrovasculardisease,
especiallywhile receivingdialysis. Intravenousthrombolysismaybe indicatedinthese situations144
.
2. Screenall CKD foranemiadue to reducedproductionof the hormone erythropoietin,hemolysis,iron
deficiency,andVitaminB12deficiency,especiallystages3,4, and 5 patients. Earlytreatmentof anemiacan
improve qualityof lifeandthe needforblood transfusionorhospitalization145
.
14. 14
3. Treat acidosiswithoral alkali to slow the progressionof kidneydisease. Metabolicacidosisisacommon
complicationof chronickidneydisease andthere isevidence acidosisisnotonlya consequence of CKD,but
a contributorto it146
.
4. Target bloodpressuresbelowthe 50th
percentile forage,sex,andheightforall CKDpatients. The consensus
practice guidelinesendorse the use of ACEsandARBs forbloodpressure control toachieve betterCKD
outcomes,however,only24-58%of patientswithCKDare prescribedone of these classesof drugs148
.
5. Monitorand educate patientsonthe additional riskof footproblemsassociatedwithCKDanddiabetesdue
to additional disease pathwaysintroducedbythe co-morbidityof CKDwithdiabetes. These patientsare less
likelytohave self-efficacyand more likelytobe depressed149
.
6. Educate patientsandphysiciansonthe increasedriskof developingperipheral arterial disease(PAD) when
CKD ispresent. Markersfor PADinclude c-reactive protein,white bloodcount,fibrinogen,uricacidlevels,
glycosylatedhemoglobin,insulin-resistance,andcystatinc150
.
Case Management Recommendations
The followinggeneral recommendationsforprioritizingpatientsoncase managementlistsandassessing
individualpatientcase managementobjectives representan initial selectionfromthe precedingresultsfoundinthe
literature:
1. Use RII concepts to assessthe impactof individual social factorsondisease categories,suchas cancer, heart
disease,etc. Use regression modelingtoassessthe impactof social factorson the likelihood(orseverity)
of differentactionable conditions atthe individualpatientlevel. The independentvariableswouldconsistof
the sociallyactionable riskfactorsin#2.
2. Utilize RIItoreprioritize patients fromthe DCGmodel. ApplyRIIrelative risk‘weights’toindividual DCGrisk
scoresto demonstrate social burdenonoverall riskperpersonperdisease. Sociallyactionableriskfactors
may include income, race andethnicity,education,PCP utilization,multi-morbidstatus,smokingstatus,
exercise status,medical benefitinformationandratioof premiums/copaystoincome,age,gender,
employmentstatusandtypesof employment, housingstability (changesof addressasproxy),diet
information,mentalhealthstatus, total childrenandpregnancies,andviolence history. DetailedEMRand
claimsdata mayalso be neededtodevelopthese sociallyactionable parametersformodeling. Forcase
managementpurposes,itmaybe that highDCG scores correlate heavilywithnegative socialfactors.
Therefore,itisexpectedthatmostpatientswill onlybe re-prioritizedwithintiersasaresultof social burden
analysis (Tier1= case management;Tier2=healthmanagement,physical therapy,Rx management,etc.;Tier
3=healthmaintenance andprevention).
Recommendations3-8 utilize the same approach: Increase certainpatients’riskscores(patientswhonearlyfall
intosevere healthcategories)sothattheirprioritizationisincreasedandsotheycanreceive case managementor
healthmanagementsearlierinordertopreventthemfromreachingthe severe healthcategories.
3. Identify patientscurrentlyusinghigh-riskmedications andtherapies,suchascorticosteroids, biologics
(Rituximab,Infliximab,Etanercept,Adalimumab,etc),ADTradiotherapy,glucagon-like peptide1agonist
(Liraglutide,etc),non-selectivebeta-blockers,ASA/NSAIDS,ACEinhibitors,AERDs(ValproicAcid,Phenytoin,
Carbamazepine,Phenobarbital), Cyclosporine therapy,Minocycline,Tamoxifen,Immuno-suppressive
therapy(Voriconazole,etc),Thiazines,Amiodarone,Ditiazem, Azathioprine, PsoralenorPUVA,
chemotherapy,prostaglandins,calciumgluconate, Heparin,Benzodiazepines(Clonazepam, Diazepam,
Lorazepam), orProtonPumpInhibitors(PPIs). Then,identifypatientscurrentlyusingrisk-lowering
medicationsandtherapies,suchas Metformin,TamoxifenwithSSRIs,Ketorolac,anti-resorptivetherapy,
and analgesics. Compare currentcountsof the high-riskmedications tothe risk-loweringmedications per
patienttoassessthe average relative riskof medicationuse,basedonthe general theoryof inflammation
medical model. Weightswillbe risk-orientedandwillalwaysincrease individualDCGriskscores. Most
priorityandtiershiftswill be withinthe middle-tiercase managementandhigh-tiercase management
patients.
15. 15
4. Identify patientswith moderatelyhighorhigh recentC-reactive lablevels. Divide the average DCGrisk
scoresof those withhighlevelsbythe average riskscore of those withmoderatelyhighlevels. Use thisratio
as a weighttoincrease the DCG score of those withmoderatelyhighlevelsinordertoincrease their
opportunitiesforhealthorcase management.
5. Identifypatientswith recenthigh-normal A1clevels. Compare the average high-normalA1cpatients’
prospective DCGriskscoresto the average highA1c patients’DCGriskscores. Use the ratioof the two
averagestogenerate a DCG riskscore weight forthe high-normal A1cgroup as a meansto increase theirrisk
score and get themmanagedearlier. Thisweightwillcapture known pre-diabeticpatientsandwill mostly
affectlowand moderate tierpatients withinter- andintra-tiershifting.
6. Identifypatients withnoinfluenzaorpneumococcal vaccination forthe year. Patientswithnocurrent
vaccinationswill be assigned tothe highestvaccination groupandpatientswithonly the influenzaor
pneumococcal vaccinationwill be assigned tothe middle vaccination group. Usingthe prospectiveinpatient
likelihoodorERlikelihoodmodels,average the DCGriskscoresper vaccinationgrouptobuild DCG riskscore
weightsforestimatingdiseaseintensification. Thismetricwill mostlikelycause little case managementtier
shifting,butmayre-organize the priorityof patientswithintiers.
7. Identifypatientswith currentbloodpressuresoverthe 50th
percentile forage,sex,andheight. Create two
or more patient groups associatedwithvaluesoverthe 50th
percentile perpatient. Generate DCGriskscore
weightsfromthe average prospective DCGscores of patientswithineachsignificantlydifferent blood
pressure groupforestimatingprogressionof disease. Increasingthe riskscoresof patientsabove the 50th
percentile inbloodpressure will enablethemtoreceive earliermanagementandcouldprevent
exacerbationsof otherconditions. Thistechnique couldcause patientstomove withincase/health
managementtiers.
8. Identifypatientswith priormajororgantransplantsorall-site cancersforbone mineral densitytesting.
Patientswithbothcancerand organ transplant histories should be assigned tothe highestgroupand
patientswithcanceror organ transplant history shouldbe assigned tothe middle group.GenerateDCGrisk
score weightsfromthe average prospectiveDCGscoresof patientswithineach andapplythese weightsto
those assignedtothe middle group,increasingtheiropportunityfortimelymanagement.Thismetricwill
mostlikelycause littletiershiftingbetweenhealthandcase management,butmayre-organizethe priority
of patientswithintiers.
9. Findthe general relativerisksassociatedwithsocial factors andmedical markers onindividualdiseases,to
measure theiroverall influence.
10. Assesseachpatientfromthe final reprioritizedlist forreadinesstochange usingTTM.
Conclusion and Summary
In summary,mostchronicconditionshave ahighdegree of lifestylechoice influence andthese lifestylechoices,
coupledwithsocial,medical,andinterventionalco-factors,create unique opportunitiesconsideredtobe healthcare-
relatedactionable risks. These risksare heavilymediatedbypatients’receptivitytochange andthese twoconceptsare
the drivingforce forthissummary. Ultimately, withthe objectiveof controllinghealthcare utilization,access, andcosts,
and improvingqualityof life forall patients byanticipatingthe unexpected throughbetterscienceanddelivery,xG
Healthisleadingthe way to a more sustainable future foreveryone.
16. 16
Bibliography
1. http://www.cdc.gov/chronicdisease/pdf/2009-power-of-prevention.pdf
2. JinJ, SklarGE, Min SenOh V,ChuenLi S. Factorsaffectingtherapeuticcompliance:A review fromthe patient's
perspective. TherClinRiskManag. 2008;4:269–86.
3. Alter,HarrisonJ. "Social Determinantsof Health:FromBenchtoBedside." JAMA 174.4(2014): 543-545. Web.
4. Merletti,Franco,ClaudiaGalassi,andTeresaSpadea."The socioeconomicdeterminantsof cancer."
EnvironmentalHealth 10.Suppl 1 (2011): S7. Web.
5. Sergeant,J.C. "Relative indexof inequality:definition,estimation,andinference." Biostatistics 7.2(2005): 213-
224. Web.
6. Prochaska,J.O.;DiClemente,C.C. “Stagesandprocessesof self-change of smoking:towardanintegrative model
of change. “ J ConsultClin Psychol1983 Jun;51(3):390–5. Accessed2009 Mar 18.
7. Prochaska,J.O.;Norcross,J.C.;DiClemente,C.C.Changingforgood:the revolutionaryprogramthatexplainsthe
six stagesof change and teachesyouhow to free yourself frombadhabits.New York:W.Morrow; 1994. ISBN 0-
688-11263-3.
8. http://www.prochange.com/transtheoretical-model-of-behavior-change
9. US Departmentof Healthand HumanServices.Preventionmakescommon“cents.”
http://aspe.hhs.gov/health/prevention/.AccessedMarch19, 2013.
10. Woody,Delinda,Claire Decristofaro,andBettyG. Carlton."Smokingcessationreadiness:Are yourpatientsready
to quit?"Journalof theAmerican Academy of NursePractitioners 20.8 (2008): 407-414. Web.
11. Schnoll,RobertA.,C.S. Boyd,Hao Wang, Paul F. Engstrom, Eric Ross,Elyse Slater,Andrew Balshem, Teresa
Hennigan-Peel,SusanHigmanTofani,MarkJ.Cornfeld,JamesS.Babb,andSuzanne M. Miller."Change in
Worksite SmokingBehaviorFollowingCancerRiskFeedback:A PilotStudy." American Journalof HealthBehavior
29.3 (2005): 215-227. Web.
12. Bock, BethC, Ernestine Jennings,Bruce MBecker,RobertPartridge,andRaymondSNiaura."Characteristicsand
predictorsof readinesstoquitamongemergencymedical patientspresentingwithrespiratorysymptoms."
InternationalJournalof Emergency Medicine 4.1 (2011): 24. Web.
13. Couto,J.E., J.M. Panchal,L.S. Lal,T.J. Bunz,J.E.Maesner,T. O’Brien,T.Khan. “Geographicvariationin
medicationadherence incommercial andMedicare partD populations.” JManag CarePharm ;20 (8);834-42.
Web.
14. Beaton,Sj,Jm Sperl-Hillen,A VonWorley,DBaumer,OdFernandes,andHtDavis."Pdb49 The EffectOf
ReadinessToChange OnMeasuresOf DiabetesControl AndAttitudesTowardsDiabetes." Valuein Health 12.3
(2009): A106. Web.
15. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf
