Ray Baxter on Healthy Behavior Change
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Raymond J. Baxter, PhD, senior vice president, Community Benefit, Research and Health Policy at Kaiser Permanente presents a keynote address at the Forum for Healthy Behavior Change in Washington, D.C. on May 16, 2013. Dr. Baxter addresses the need to create systematic changes that eventually become habits, to encourage healthy behavior change and combat the obesity epidemic.
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Ray Baxter on Healthy Behavior Change
- 1. Forum for Connecting Health Care to Healthy Choices #hbc13
- 2. Behavior Change: A Total Health Imperative RAYMOND J. BAXTER, PHD Senior Vice President, Community Benefit, Research and Health Policy, Kaiser Permanente
- 4. Environmental and Social Factors 20% Family History and Genetics 30% Personal Behaviors 40% Source: Determinants of Health and Their Contribution to Premature Death, JAMA 1993 Health is driven by multiple factors that are intricately linked – of which medical care is one component. Medical Care 10% Drivers of Health Health is About More Than Access to Care
- 5. Actual Causes of Death in the U.S. in 1990 and 2000 *Data are from McGinnis and Foege. Percentages are for all deaths. Actual Cause Number (and %) 1990* Number (and %) 2000 Tobacco 400,000 (19%) 435,000 (18.1%) Poor diet and physical inactivity 300,000 (14%) 400,000 (16.6%) Alcohol consumption 100,000 (5%) 85,000 (3.5%) Microbial agents 90,000 (4%) 75,000 (3.1%) Toxic agents 60,000 (3%) 55,000 (2.3%) Motor vehicle 25,000 (1%) 43,000 (1.8%) Firearms 35,000 (2%) 29,000 (1.2%) Sexual behavior 30,000 (1%) 20,000 (0.8%) Illicit drug use 20,000 (<1%) 17,000 (0/7%) Total 1,060,000 (50%) 1,159.000 (48.2%) Many Factors Shape Health
- 6. We Have to Disrupt Current Defaults
- 7. Diabetes Cardiovascular Disease Cancer Chronic Respiratory Disease Support Individuals Encourage Groups Change Communities Track Outcomes 4 Diseases, 4 Risk Factors* 4 Kaiser Permanente Actions *Aligns with World Health Organization’s framework for monitoring non-communicable diseases An Integrated Approach to Diseases and Risk Factors
- 8. Deploying Kaiser Permanente Assets for Total Health 1 Neighborhood / Community Society Individual / Family Home / School / Worksite Community Health Initiatives Environmental Stewardship Clinical Prevention Access to Social and Economic Supports Health Education Public Education Worksite Wellness Public Policy Research Physical and Mental Health Care Walking Promotion Purchasing and Employment Practices We Have to Deploy All Our Assets for Total Health
- 9. What We’re Up Against
- 10. What We’re Up Against
- 11. Susan Roberts, Wk Kellogg Foundation, 2005 What We’re Up Against
- 12. Pre-Diabetes, 2013: 852,031 Diabetes, 2013: 477,383 $3.48 Billion/Year Source: Kaiser Permanente Care Management Institute, Pre-Diabetes Cohort Data, 2013. Projected cohort costs estimated based on average annual medical expenditures from Vojta et al, Hlth Aff, Jan 2012. If we do nothing, more than half will become diabetic by 2023, adding $3.2 billion/year in costs Failure to Act Is Not an Option
- 13. Help me build self-efficacy and leverage my habits to make sustained behavior change. BOOST ME CONNECT ME CELEBRATE ME Celebrate and reinforce my ongoing successes. ENGAGE ME Get me started on my journey to better health. OUTSIDE INFLUENCES • Programs and policies • Social and economic factors • Physical environments • Family, community and social networks NEIGHBORHOOD DIGITAL CLINICAL WORKPLACE SCHOOL HOME Behavior Change Pathway SIMPLIFY IT for ME Help me make easy, small changes that lead to bigger success. GUIDE ME Advise, support, coach and help me develop a shared plan. KNOW ME Know what change I want to make, my motivation and what is important to me. Idealized Behavior Change Navigation Help me find my way by linking me to internal and external resources, connecting with others. 1 3© 2013 Copyright, Kaiser Permanente, All rights reserved DATA
- 14. Changing Norms and Behavior: Tobacco Smoking prevalence among California adults, 1984-2010 Source: Behavioral Risk Factor Surveillance System (BRFSS) 1984-2010. The data are weighed to the 2000 California population. California Department of Public Health, California Tobacco Control Program, April 2011.
- 15. Changing Norms and Behavior: Auto Safety
- 16. Changing Norms and Behavior: Breastfeeding Sources: 1970–1998, Ross Mothers Survey; 1999–2007, Centers for Disease Control and Prevention, National Immunization Survey.
- 17. Source: EPA, 2013 Changing Norms and Behavior: Waste
- 18. The Road Ahead is Challenging… But We Can Find a Way
- 19. Forum for Connecting Health Care to Healthy Choices #hbc13
Editor's Notes
- KP Diabetes Cohort data – cost and prevalence data showing the iceberg we are about to hit, all of which ties back to activity and diet; why KP has such a major stake in behavior change.This analysis has been a real call to action for KP. It shows the incidence and costs of the # of prediabetic members we have identified in 2013 10 years down the road if we do nothing. These #s are based on the annual conversion rates we saw in the Diabetes Prevention Program study (i.e., the control group) and average annual cost data from other published data. In this analysis, we looked at the cumulative conversion rate for our 2013 prediabetes cohort over the next 10 years, and do not include the costs of KP members who become prediabetic after 2013 or any membership growth, so in many respects this estimate is quite conservative. The big point is that it will wipe out much of the very hard and excellent work we are doing to control costs and make sure Kaiser Permanenete can continue to be an affordable option for people. And more importantly, it represents significant health burden and a substantial reduction in quality of life for close to 500,000 people who have entrusted their health to us.Additional notes on how these estimates were constructed: 852,301 members with pre-diabetes based on HgA1c and/or fasting plasma glucose test results. This is 13% of non-diabetic KP membership age 10-75Diabetes HEDIS definition includes both type 1 and type 2. Type 1 diabetes accounts for approximately 5% of all diagnosed cases of diabetes so we inferred that the # is 477, 383.Per cost data reported in Health Affairs re: DM burden, adults with diabetes = $11,700 average annual expenditure per person; $4,400 per adult with no diabetes. So this equals $7300 additional spending per person with DM. $7300 x 477,383 = 3.48 billion per year excess cost for current diabetes.With no intervention (e.g. the DPP control group), we expect to see 29% develop diabetes over 3 years, per the original DPP outcomes study. Per NCAL DOR study, KP’s pre-diabetic members converted to diabetes at about 32% over 3 years, so our own experience is consistent with DPP. Applying these rates to our current membership with diabetes, we would see 247,167 new cases of T2DM by 2016Based on the 10-year DPP data, we expect to see 52% develop diabetes over 10 years. This would amount to about 443,197 new cases by 2023.If we apply the cost estimate, this would be an additional $3.24 billion in 2023 alone (since cost we have estimated is yearly). Avoidable cost if diabetes is prevented.
- Tobacco control is a familiar example of how we brought it all together:Started with a series of reports from the Surgeon General on the health consequence of smoking starting in 1967Smoking laws – in restaurants, office buildings, etcSocial marketing and package labelsSignificant taxes on cigarettes which reduced consumption and played a major role in preventing kids from starting.Also individual focused interventions – clinical practice protocols where doctors engaged patients who smoked, and asked about their smoking on pre-visit questionaires that patients filled out in the waiting roomSupported by brief negotiation and access to quit lines, nictone patches, social support, etc.And this is the impact – huge declines in smoking rates. From 27% in 1984 to just over 10% 27 years later in CA where we were among the first to enact
- [MORE TPs from Harvard Case Study coming]-- Roadways were designed to safety standards – great work by Transportation Safety Research Board and other bodies; people know what to expect w/ road conditions (human factor design), we now have rumble strips and lane markers on highways let us know when we are crossing the lane. -- Cars were designed to be safer – automatics seatbelts, airbags, a raise in the bar on car safety standards starting with tremendous advocacy efforts in the 1970s -- Large role for laws – mandatory seat belts, child restraints, etc.-- Social norms – esp around drunk driving – MADD, sobriety check points, great programming focusing on educating the public and those who serve them -- bar tenders (i.e. Friday Night Live, designated driver programs) and penalties for those who serve minors. And we are starting to make progress making streets safer for pedestrians and people who bike with Complete Streets efforts, safe routes programs, traffic calming measures like sidewalk bump-outs at intersection, local laws that increase penalties for speeding in school zones and other places where there are a lot people walking. Big area where we need to redouble our efforts so streets are safe for all users. And we have made major progress in this area. Green bars represents the actual number of fatalities as millions of new drivers took to the road over the last 50 + years, while the line graph here shows the declince in the fatality rate per 100 million Vehicle Miles Traveled, which is the more instructive figure for these purposes. http://www-nrd.nhtsa.dot.gov/Pubs/811363.PDF
- Breastfeeding is an interesting example because it is something we used to do so well. BF initiation rate in 1900 was 100%, but by 1971 it had fallen to 25% as formula was introduced and heavily marketed, stigma developed around breastfeeding and women entered the workforce in a major way. Now we have been abole get BF initiation rates back up above 70%. It took comprehensive action addressing both interventions focusing on influencing individual behavior as well as changes in policies and institutional practices. Lactation counselors/nurses available 24hrs at hospitals. They can be at a woman’s bedside after giving birth to teach her how to breastfeed immediatelyPamphlets, videos and posters at the doctors office.Doctors had to be educated about their role in promoting breastfeeding.Active role of groups like La Leche League, which is the largest and often best recognized breastfeeding coalition.Employers now have lactation rooms. Many states and locales have policies requiring workplaces larger than certain size have an accommodation. Hospital practices to promote breastfeeding including rooming in, skin-to-skin contact and prohibitions on marketing of formula. This is really an international movement that’s just starting to take hold in the US. KP just made a commitment to have all of our hospitals certified as Baby Friendly Hospitals or implementing similar requirements by the end of this year, and we are on track to do that.Breastfeeding is an example of comprehensive change. Working at all levels. Importantly – it’s also an example of how efforts at all levels can change norms.http://www.ncbi.nlm.nih.gov/books/NBK52681/From: Rates of BreastfeedingThe Surgeon General's Call to Action to Support Breastfeeding.Office of the Surgeon General (US); Centers for Disease Control and Prevention (US); Office on Women's Health (US).Rockville (MD): Office of the Surgeon General (US); 2011.
- From a completely different domain – ecology and the environment: getting America to recycleSocial marketing – evocative – touching on our valuesLegislation including anti-littering laws and requirements for recycling at homeEnvironmental design -- making the environmentally healthy choice the easy choice at the point of decisionThis shows the progress we’ve been making in recycling over the last 10 years. Municipal solid waste diverted from landfills, primarily by residential households. These are national figures which mask some huge local variation. But as a nation, we recyelced 85 million tons of solid waste, or 35%, up from 6% in 1960.