Informal Caregiver Assistance among Adults with Cardiovascular Disease in Ohio

1. Informal Caregiver Assistanceamong Adults with CardiovascularDisease in Ohio Deborah A. Levine, MD, MPH Assistant Professor of Medicine Division of General Internal Medicine Division of Health Services Management & Policy The Ohio State University

2. Co-Investigators • Sudeep Karve, PhD • Eric Seiber, PhD • Al Dembe, ScD • Andrew Slivka, MD • Bo Lu, PhD

3. Cardiovascular Disease (CVD) in Ohio • Leading cause of death in the US and Ohio accounting for 35-40% of deaths • Prevalence is increasing in US and Ohio • Self-reported prevalence of CVD in Ohio adults (OFHS 2008) • Heart attack (5.4%) • Coronary heart disease (6.3%) • Stroke (3.5%) • Congestive heart failure (3.0%) • Effect of CVD prevalence on use and costs of health care and non-health care services are unknown

4. CVD and Caregiver Assistance • CVD associated with increased: disability, need for home and community-based services and caregiver assistance, even long-term • Caregiver assistance may have adverse effects on caregiver, health care system, and employers • Caregiver assistance important for adult Medicaid recipients with CVD • Amount and cost of caregiver assistance for adults with CVD in Ohio are unknown

5. Study Aims • To assess current prevalence of informal caregiver assistance for adults reporting a history of CVD for the state of Ohio. • To determine whether caregiver assistance for adults with CVD is higher among the four priority CVD populations for the state of Ohio: men, African-Americans, Appalachians, and those living in poverty. • To estimate the cost of caregiver assistance for adults with CVD in Ohio using 2007 US Bureau of Labor Statistics wage rates. • To estimate the amount and cost of caregiver assistance for adults with CVD in Ohio who are Medicaid recipients.

6. Methods: Patient Population • Ohio Family Health Survey 2008 • 7,040 adults aged ≥18 years with history of CVD (heart attack, coronary heart disease, stroke or congestive heart failure (CHF)) • 42,681 adults aged ≥18 years without CVD • Compared amount of self-reported informal caregiver assistance, measured in mean hours per person per month, by CVD status

7. Methods: Outcome Definition • Caregiver assistance: “currently need any of the following types of assistance [because of health problems]” • Assistance with personal care (hygiene, feeding) • Domestic assistance (housekeeping, transportation) • Help with household maintenance (painting, yard work) • Social or emotional support (companionship, recreation) • Coordinating health care (making medical appointments) • Assistance managing financial affairs • Other kinds of assistance • “How many hours of assistance do you currently require on average for the types of assistance that were just mentioned?”

8. Methods: Analysis • Two-part regression model • First part: logistic regression models estimated the probability of reporting informal caregiver assistance for respondents with and without CVD, before and after adjusting for covariates • Second part: ordinary least squares regression examined the association of CVD category with natural logarithm of informal caregiver assistance hours per month for respondents who reported any informal caregiver assistance • Combined results of two models to obtain an estimate of the average effect of CVD on monthly hours of informal caregiver assistance required per person (unconditional effect of CVD) • Regression model results were retransformed to hours • Statistical analysis: STATA • Complex sampling design • Weighted results

9. Methods: Regression Model *Co-morbidity included hypertension, diabetes, cigarette smoking

10. Methods: Cost Analysis • Used market price of equivalent service/worker to estimate opportunity cost for the time of an informal caregiver • Estimated the annual cost of informal caregiver assistance attributable to CVD: • Multiplied the adjusted monthly hours of informal caregiver assistance per person attributable to CVD by the 2007 US Bureau of Labor Statistics median wages for a home health aide ($9.15/hour) • Multiplied by 12 (months per year) • Multiplied by the population estimate of the number of adults Ohioans with CVD in 2008 • Repeated analysis for recipients of any Medicaid and recipients of Medicaid and Medicare

11. CVD Prevalence in Ohio, Overall and by Age Group, 2008

12. Characteristics of Adults with CVD in Ohio, 2008

13. Characteristics of Adults with CVD in Ohio, 2008

14. Characteristics of Adults with CVD in Ohio, 2008

15. Percentage of Adults with Cardiovascular Disease (CVD) Reporting Informal Caregiver Assistance in Ohio, Overall and by Age, 2008

16. Percentage of Adults with Cardiovascular Disease Reporting Informal Caregiver Assistance in Ohio by Type of Cardiovascular Disease, 2008

17. Percentage of Adults with Cardiovascular Disease Reporting Informal Caregiver Assistance in Ohio, by Gender and Age, 2008

18. Percentage of Adults with Cardiovascular Disease Reporting Informal Caregiver Assistance in Ohio, by Race/Ethnicity, 2008

19. Percentage of Adults with Cardiovascular Disease Reporting Informal Caregiver Assistance in Ohio, by Region, 2008

20. Percentage of Adults with Cardiovascular Disease Reporting Informal Caregiver Assistance in Ohio, by Poverty Level, 2008

21. Cost of Informal Caregiver Assistance Attributable to Cardiovascular Disease (CVD) among Adults in Ohio, 2008 *Adjusted for age, gender, race/ethnicity, region, poverty level, education, marital status, number of adults in household, health insurance, co-morbidity, health status, and number of hospitalizations in last year.

22. Cost of Informal Caregiver Assistance Attributable to Cardiovascular Disease (CVD) among Adults in Ohio, 2008

23. Adult Medicaid Recipients with CVD • Approximately 120,000 adults with CVD are recipients of Medicaid of whom 65% report informal caregiver assistance. • The average yearly cost of informal caregiver assistance attributable to CVD was $694 per person. • Approximately 71,000 adults with CVD are recipients of Medicaid and Medicare of whom 65% report informal caregiver assistance. • The average yearly cost of informal caregiver assistance attributable to CVD was $1471 per person.

24. Type of Informal Caregiver Assistance among Adults Reporting Help with Only One Activity

25. Limitations • Self-report of informal caregiver assistance may underestimate infrequent assistance • Self-report of CVD • Severity of CVD, onset of CVD, quality of CVD care, dementia, rehabilitation cannot be assessed • Limited to community-dwelling adults • No direct measure of caregiver assistance by type, provider, or disease (due to CVD or other condition) • Cost estimates used median hourly wage for a home health aide but some informal care may or may not be performed by a home health aide (e.g., social/emotional support)

26. Conclusions • Informal caregiver assistance for adults with CVD in Ohio is substantial and costly. • Approximately 50% of community-dwelling adult Ohioans with CVD report informal caregiver assistance. • Priority CVD populations reported more informal care: • Non-Hispanic blacks • Hispanics • Appalachians • Adults living in poverty • Stroke and CHF had highest rates of informal care. • Estimated 2008 annual cost of informal caregiver assistance attributable to CVD was $563 million for Ohio.

27. Policy Implications • Expand or more efficiently allocate resources to provide home and community-based care. • Assess availability and quality of current resources and programs to provide home and community-based care, particularly for the elderly. • Develop and implement programs to identify care needs. • Focus on vulnerable populations (non-Hispanic blacks, Hispanics, those living in Appalachia, those living in poverty, the elderly, women) who may require ancillary health care and social services. • Coordinate home-based and community resources across agencies. • Streamline the applications for services by patients and their caregivers.

28. Policy Implications To address caregiver burden: • Ensure adequate availability and duration of family medical leave for employed caregivers. • Increase the availability and health insurance coverage of respite care. • Ensure the availability and health insurance coverage of counseling and support services.

29. Acknowledgements • Melissa Senter, MA, MPH • Rosemary Duffy, DDS, MPH • Barry Jamieson, MA • Find full report at: http://grc.osu.edu/ofhs