Tuesday, June 3, 2014

Perspectives on Exercise for Elders

Despite its busy travel schedule, the Population Health Blog had a chance to check out "Lifestyle Interventions and Independence for Elders" (or "LIFE") study that was published online in the May 27 issue of JAMA.

Over 14,000 persons over the age of 70 were screened at 8 medical centers for participation in the study.  To be eligible, candidates had to be sedentary (less that 20 minutes a week of regular physical activity), mobile (could walk 400 yards over 15 minutes), without any cognitive impairments and otherwise medically fit.

Participants were randomly assigned to either:

1) The exercise intervention, which consisted of 2 classes per week plus individualized home-based activity 3 to four times a week.  The goal was to achieve 30 minutes of walking daily, 10 minutes of leg lefts using ankle weeks and 10 minutes of balance training.  The cost was $1815 per participant per year.

2) The education intervention, which consisted of weekly workshops for 26 weeks with monthly sessions for follow up.  The classes included 10 minutes upper extremity stretching and flexibility exercises

Of the 1635 who were accepted, 818 were randomly assigned to the "exercise" group, while 817 were assigned to the "education" group. The average age of the participants was 79 years, approximately two thirds were women, 18% were African-American and the average body mass index was a hefty 30.

After an average of 2.6 years, more than half (59%) went on medical leave of variable duration.  Ultimately 63% of the sessions were attended. Loss to follow-up averaged 4% per year. Yet, using an intention to treat analysis, the authors found that ultimately 70% of those in the physical activity group were able to complete the 400 yards vs. 65% in the health education group. 

That 5% difference amounts to a "number necessary to treat" or NNT of approximately 20.

The PHB's takeaways:

1) This was an elegant study that demonstrates exercise for the elderly can lead to a clinically and statistically significant reduction in age-related declines in mobility.  We've intuited that "exercise is a good thing" for grandma, but now we know it.

But there is bad news:

2) Lest anyone believe that this single piece of evidence will prompt the U.S. health care system to cover preventive exercise classes for the elderly: it won't.  Medicare's definition of "medically necessary" is too full of loopholes ("condition," "accepted standards" and "coverage decisions") and is being held hostage by  Medicare's vast and hidebound bureaucracy.

3) The criteria were relatively narrow (already able to walk 400 yards and without any co-morbid conditions) and the exercise program was unique.  Would persons only able to walk 300 yards benefit from a less proscribed version of LIFE?  How about persons with diabetes? We don't know.

4) $1815 per member per year or $151 per member per month, whatever the merits of LIFE, is unaffordable.  If that was 818 persons in an average Medicare Advantage health plan, that's almost $1.5 million in additional expense to ultimately benefit 5%, or about 40 individuals.

5) The bad news is that with or without exercise, about a third (30% and 35%) of otherwise mobile, if sedentary, healthy seniors are destined to experience a significant decline in that mobility. 

No comments: