A Cost Analysis for a Hypertension Intervention: The Families Understanding Risk Reduction through Educational Reinforce

1. A Cost Analysis for a Hypertension Intervention:The Families Understanding Risk Reduction through Educational Reinforcement Study (FURRThER) Bernadette Boden-Albala, MPH, DrPH Co-Director, CTSA Community Engagement Resource Assistant Professor of Neurology and Public Health Columbia University, NY �

2. Presenter Disclosure Information Bernadette Boden-Albala, MPH, DrPH Financial Disclosures: NINDS 5 P50 NS049060-05 -SWIFT NINDS 29993 CDC SIPS - FURRThER Grant AHA Spotlight Speaker Series Desmoteplase Advisory Board

3. Concepts of awareness, knowledge, skill, and behavior related to stroke Prevention Primary and Secondary Risk Reduction Modification of behavior (physical activity, nutrition) Adherence strategies to HTN, diabetes Requires action over a long time period Preparedness Facilitate dialogue about stroke or heart attack Recall stroke warning signs Learn how to Call 911/Navigate the ED Requires short term skills with reinforcement

4. Hypertension Reduction Hypertension -major focus of prevention as leading risk factor for stroke and CVD Over 50% hypertensive individuals remain uncontrolled Primary/secondary prevention strategies have not been optimal, particularly among minority populations Unique social, cultural and behavioral factors contribute Gap application of effective programs Community Based Participatory Research sustainable lifestyle changes No real measure of cost

5. Translating knowledge into behavioral change

6. Prevention and Behavioral Economics  �There�s no reason to think that markets always drive people to what�s good for them.��Richard Thaler U Chicago

7. Compel Action through Structure 

8. �It doesn�t matter what you or I do.It�s how the whole group behaves.��Gary Becker, SM�53, PhD�55

10. Aims To evaluate the efficacy of a socially supportive, self-management intervention strategy in reducing blood pressure among a multi-ethnic cohort of stroke and TIA survivors. Working hypotheses: Multi-ethnic stroke and TIA survivors randomized to receive the intensive, culturally tailored, family-based intervention will have significantly lower systolic blood pressure at one year post stroke/TIA, versus those receiving enhanced usual care. To evaluate the efficacy of a socially supportive, self-management intervention strategy in reducing blood pressure among family members of stroke/TIA participants. Working hypotheses: Family members of stroke/TIA survivors randomized to receive the family-based intervention will have significantly lower systolic blood pressure at the end of the study period, when compared to those receiving enhanced educational materials and care.

11. FURRThER COST ANALYSIS 1) Construct a cost analysis from the societal perspective for the FURRThER intervention program targeted at self-management of hypertension. �Secondary Aims: Develop an exhaustive list of all resources likely to be used or affected by the FURRThER intervention, Measure the quantity of each type of resource and project the stream of future resources likely to be affected. Determine the prices for these resources using micro cost estimates as well as state and local data; model future prices. Conduct a sensitivity analysis

12. Families Understanding Risk Reduction through Educational Reinforcement The FURRThER Study 

14. Capturing Direct Health Care Use: Since we last spoke, how many nights did you stay in a hospital ward (not emergency room)? Have you stayed in a hospital ward overnight, what medical condition were you hospitalized for? Since we last spoke, how many visits did you make to an emergency room? If you went to the emergency room, what would you say the reason was? Since we last spoke, how many nights did you stay at a nursing home? Since we last spoke, how many visits did you make to a clinic or office to see a doctor or nurse? Since we last spoke, how many days has a nurse or other health care provider cared for you at home? Since we last spoke, how many days has a family member or friend provided care for you at home? Since we last spoke, how many prescribed medications did you take? Since we last spoke, how many times did you see a social worker or case manager?

15. �Value of Productive Activity Lost Due to Sickness and Premature Death Have you reduced the numbers of hours you work because of poor health? If so, by how many hours per week? Did you retire early because of poor health since we last spoke? If so, at what age did you retire, and at what age would you have retired if you were healthy? Have you reduced your hours of leisure because of poor health since we last spoke? If so, by how many hours per week? Have you reduced your hours of school work because of poor health since we last spoke? If so, by how many hours per week? Have you reduced your hours of house work because of poor health since we last spoke? If so, by how many hours per week?

16. Transportation costs Think of the health care facility that you have visited most often since we last spoke: What modes of transportation did you use? (bus, subway, train, walking, etc.) � How long did it take you to get there, door-to-door? If you or a caregiver drove to the facility: 1. What is the zip code of your residence? 2. What is the zip code of your primary health care facility? 3. Were there tolls? If so, how much how much did it cost? 4. Did you pay for parking? If so, how much did it cost?

17. When you participate in the FURRThER intervention, what modes of transportation did you use? (bus, subway, train, walking, etc.). How long did it take you to get there, door-to-door? If you or a caregiver drove to the facility: 1. What is the zip code of your residence?. 2. What is zip code of your primary health care facility? 3. Were there tolls? If so, how much did it cost? 4. Did you pay for parking? If so, how much did it cost? How long do you spend at each session at the FURRThER program? Do you hire childcare for the times that you attend a session of the FURRThER program? If so, for how many hours? How much does this childcare cost you, per hour?

18. Non-Medical Care Costs Thinking about your current health, Do friends and family members help you with everyday tasks that researchers ask you to perform? How many friends and family members would you say help you each week? About how many hours per week have each of these friends or family spent in helping with your care?

19. Results 102 participants (247 family members) Mean age 63 (range 25 -92); 43% female Race-ethnic breakdown is 23 %white, 24% black 53% Hispanic. Mean SBP 148 mmHG (median 144) Mean DBP 80 mmHG (median 80)

20. Calculating Price of Resource Professional and staff time will be valued using imputed hourly wage rates based on annual salary plus fringe rates for paid staff Non-medical supply prices (based directly on the expenditure ) Training and non-medical supply costs will be amortized over the expected life of the program, where appropriate. RESULTS 405 minutes 6 sessions [3 in person (90 minutes), 3 phone 45 minutes)] 90 minutes consenting and follow-up with MD participants $ 5 dollars average print material cost $ 6 in transportation 1 -4 people 1 PARTICIPANT [8 hours at $22 per hours] + 5 + 6= $186 a person 2 in FAMILY [ (8 hours at $22 per hours)] + 10 / 2 + 5 + 3 = $96 a person

21. Patient costs The amount of time and cost of patients spend seeking treatment valued as wage rate Treatment 25 hours Resources 6 hours Cost of unpaid care provided by family or friends will be valued at the average hourly total compensation rate for civilian workers ( Bureau of Labor Statistics (BLS). 4 hours per day 5 days a week The cost of missed work, missed school, or volunteering will be also be valued at the wage rate for civilian workers using BLS data.

22. Prices Associated with Health Care Use Medicare Paid Prices : Emergency room visits Average 3 visits [$1350] Hospitalizations Average 1 visit [$2375] Physician visits * 4 but wide variability (0-16) [$930] Nursing home care 1 month for some most none Drug purchases (Drug Topics Red Book) $156 out of pocket expenses calculating total All other costs will be determined by national, or where available, regional, averages by ICD-9 code Adjusted for regional differences rural v. urban and patient characteristics *

23. Handling retired participants.  Estimate the value of the best opportunity of their time For older individuals estimate wage data: using the wages of working individuals matched by age and gender using projections based on life cycle estimates of the wage rate For informal caregivers home production will be valued at its market price (the costs associated with paying a market provider for the same services ***

24. Challenges Preparedness is now, prevention is forever Long term sustainable change required for prevention is difficult. Think outside the box Structures to compel action for prevention and preparedness Role of Social Support � family and friend networks Cost Analysis for family low cost great benefit?

26. Thank You Dr Guijing Wang [Program Officer] Dr Elizabeth Wilde Dr Peter Meuning Ms Laura Evensen. MPH Ms Karen Lord Mr Harmon Moats, MPH Ms Veronica Perez, MS Ms Carly Klein Ms Leigh Quarles, MPH