BEING ALIVE AND WELL AT WIND RIVER
>Being Alive = Avoiding Premature Death
>Being Well = Not needing high medical expenditures
Methods
• I H S RPMS database
• Tabulation
• Cox Proportional Hazards Model for survival data
• Logistic Regression
Premature Death
• Figure 1--Numbers of Deaths by Age by Diagnosis
o







Two Peaks in Age of Death, Early (35-39) Late (70-74)
Early Death
Mainly Alcohol
Coroner’s “Unnatural Deaths”
(Accidents, Homicides, Suicides)
Drugs
Late Death
Major Disease (Diabetes, Heart Disease, Lung Disease)
Figure 1
Numbers of Deaths by Age and Diagnoses
140
120
Shoshone/Arapaho
Un-Natural
100
Alcohol Deaths
# Deaths
Diabetes
80
Heart
Tobacco/No Alcohol
Lung Cancer, Emphas, COPD
60
Colon Cancer
Combined Drugs
40
Cannabis
Opiates
20
Amphetamines
Cocaine
0
Sedative/Anxiolitic
100-104
95-99
90-94
85-89
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
1-4
0
Age of Death
Premature Death
 Coroner’s “Unnatural Deaths” are Accidents,
Homicide, and Suicide
Figure 1 shows these deaths are mainly young deaths
Figure 2 shows that these deaths are not only young
but also largely “alcohol and/or drug” related (76%)
 By contrast, 22% of “Natural Deaths” are alcohol or
drug related
Figure 2
Manner of Death by Alcohol & Drug Use1
450
400
350
#
D
e
a
t
h
s
300
250
Total Deaths by Category
200
Deaths w/Substance Abuse "Alcohol or
Drug Related"
150
100
50
0
Unnatural
Accident
Homicides
Suicides
1 Coroner notes drug or alcohol related, labeled substance above.
Natural
Premature Death
Table 2g--Odds Ratios=the odds of those with a diagnosis dying
compared to the baseline with no diagnoses
Figure 2g--Years lost= Life Expectancy of Baseline minus Life
Expectancy of those positive for a diagnosis listed in Table 2g
Alcohol alone increased Odds of Death 7.4 times, 32.5 years of
life lost, 113 younger deaths
Alcohol and drugs alone increased Odds of Death 16.9 times,
42.3 years of life lost, 31 younger deaths
Alcohol and Tobacco alone increased Odds of Death 5.0 times,
19.6 years of life lost, 220 younger deaths
Alcohol, Drugs, Tobacco alone increased Odds of Death 7.2
times, 26 years of life lost, 110 younger deaths
Table 2g
What increases the odds of death at Wind River?
Survival 1
Main Effects
BMI 2
Depression
PTSD/Stress 3
Colon Cancer
Odds
Ratio
0.84
0.74
0.73
1.21
z
-3.46
-5.83
-3.60
1.33
P>|z|
0.001
0.000
0.000
0.185
2.34
0.91
2.08
2.21
5.10
3.07
4.20
7.36
5.34
5.01
4.40
16.92
6.32
7.16
6.31
8.61
-0.74
7.34
2.05
6.54
4.82
7.51
17.52
11.80
16.22
14.24
14.31
4.43
15.91
12.64
0.000
0.457
0.000
0.040
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
Years 5
Under 55
# Patients lost/gained
# Dead
4713
1.9
337
4481
2.2
329
1246
4.1
86
83
0.0
5
Over 55
#Dead
315
379
71
44
Interaction 4 Way
Alcohol
Drugs
Tobacco
Major
Disease 4
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
3
4
5
0
0
0
0
1
1
1
1
0
0
0
0
1
1
1
1
0
0
1
1
0
0
1
1
0
0
1
1
0
0
1
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
4350
742
3036
981
86
29
247
97
396
135
1263
544
81
15
591
213
-9.6
0
-7.6
-17.6
-18.7
-14.4
-32.5
-24.2
-18.6
-19.0
-42.3
-41.2
-26.0
-22.1
Survival Analysis -- Cox Proportional Hazards Model
Body Mass Index (BMI), BMI >= 30
Post Traumatic Stress (PTSD)
Major Disease - Diabetes, Heart Disease, Lung Disease (COPD, Emphasema, Lung Cancer)
" - " means years lost
105
33
68
40
7
3
16
11
113
28
220
72
31
5
110
41
81
267
47
215
0
15
5
23
23
43
34
131
0
1
7
28
Premature Death
 Alcohol, and interactions with Alcohol, in Table 2g had a total of
620 early deaths compared to 267 late deaths
By contrast, Major Disease and interactions with Major Disease
had a total of 233 early deaths and 723 late deaths
This is consistent with Figure 1
Table 2g also showed Depression and PTSD/Stress with a small
positive treatment effect that increased life expectancy a small
amount over the baseline—a hint about what can help
Premature Death
Figure 3—Survival Curves from the data in Table 2g
oThe vertical axis shows the proportion of patients alive and the
horizontal axis shows analysis time/age
oThe curves drop with age, from all patients alive to all dead
o Life Expectancy is the median, the point where half are alive and
half dead.
o The Survival Curves drop more quickly for patients with early
death diagnoses
o Curves drop fastest in this order: (1) Alcohol and Drugs, (2)
Alcohol, (3) Major Disease, (4) baseline, and (5) PTSD/Stress
Premature Death
 Are injuries/accidents the leading cause of death?
 Previous data suggested this, but lacked context with
comorbid variables and medical and behavioral histories
 Table 3g shows the effect of injuries in the context comorbid
variables and histories
 Injuries alone do not increase the Odds of Death, Odds
Ratio=.88, 34 younger deaths & 27 older deaths
 Injuries with Major Disease, increased the Odds of Death 2.0
times, 5.4 years of life lost, 27 younger deaths & 195 older
deaths
 Injuries with Alcohol/Drugs, increased the Odds of Death 5.4
times, 20.9 years of life lost, 263 younger deaths & 31 older
deaths
Table 3g
Table 3g
How do injuries increase the odds of death at Wind River?
Survival 1
Main Efects
BMI 2
Depression
PTSD/Stress 3
Odds
Ratio
0.83
0.77
0.74
z
-3.63
-4.95
-3.50
P>|z|
0.000
0.000
0.000
Years 5
# Patients lost/gained
4713
1.9
4481
1.9
1246
4.1
Interaction 3-way
Injuries
0
0
0
0
1
1
1
1
Alcohol
Major
or Drugs Disease4
0
0
0
1
1
0
1
1
0
0
0
1
1
0
1
1
1
2
3
4
5
Survival Analysis -- Cox Proportional Hazards Model
Body Mass Index (BMI), BMI >= 30
Post Traumatic Stress (PTSD)
Major Disease=
ease = Diabetes, Heart Disease, & Lung Disease
"-" = years lost
2.44
6.27
5.42
0.88
1.96
5.4
4.49
10.03
20.46
16.36
-0.92
6.67
18.69
15.65
0.000
0.000
0.000
0.356
0.000
0.000
0.000
5623
1023
1111
360
1763
700
1553
673
-9.9
-21.5
-22.7
0.5
-5.4
-20.9
-17.7
Under 55
# Dead
139
40
234
71
34
27
263
89
Over 55
# Dead
101
287
38
97
27
195
31
144
HIGH Medical Costs
Figure 4g—The Cost of Wellness
o Referred Care (Contract Health) Costs for 14 years, FY2000-FY2014,
excluding Medicare and Medicaid costs.
o 102.5 million spent, 4.6 million, under age 15, and 97.9 million age 15
and over. (Medicare/Medicaid covers many younger and many older
patients). Table 4g covers ages 15 and up, most without alternative
resources, private insurance low.
o Four risk factors analyzed: Alcohol/Tobacco, Weight, Negative Emotions,
Injuries—potentially preventable factors.
o Odds of being a High Cost Case (over $25,000) is a function of the
number of risk factors a patient has
oAverage Odds Ratio with: One risk factor=3.7 , Two risk factors=10.4,
Three risk factors=19.1, Four risk factors 38.7
Table 4g
The Price of Wellness: Prediction of High-Cost Cases
Risk Factors 4-Way Interaction
raction
1 1
z 7
# Patients 9
Alcohol/ Weight 3 Negative Injuries 5 Odds 6
# Patients Average
Total Cost
Potential
Tobacco 2
Emotions 4
Savings 8
Ratio
Significance
Cost
(Sum)
extraHICOST
0
0
0
0
(baseline)
387
6,583.95
2,547,989
-2
0
0
0
1
3.6
3.6
169
8,708.14
1,471,676
358,988
0
0
0
1
0
4.1
4.1
164
8,647.53
1,418,195
338,427
0
0
1
0
0
3.7
4.1
209
8,461.94
1,768,545
392,500
0
0
0
1
1
11.7
7.9
150
15,582.82
2,337,423
1,349,830
3
0
1
0
1
8.9
6.4
115
20,153.66
2,317,671
1,560,517
0
0
1
1
0
10.4
7.6
168
13,157.32
2,210,430
1,104,326
0
0
1
1
1
19.2
9.7
133
18,558.25
2,468,247
1,592,582
0
Subtotals
1495
16,540,176
6,697,170
5
1
0
0
0
3.4
4.3
428
8,613.22
3,686,458
868,528
4
1
0
0
1
12.9
10.1
499
15,625.72
7,797,234
4,511,843
9
1
0
1
0
10.7
9.4
542
13,994.27
7,584,894
4,016,393
5
1
1
0
0
7.5
7.5
368
12,247.31
4,507,010
2,084,116
5
1
0
1
1
22.6
13.2
982
19,689.09 19,334,686
12,869,247
26
1
1
0
1
18.4
11.50
399
17,761.67
7,086,906
4,459,910
16
1
1
1
0
16.3
11.2
489
16,432.43
8,035,458
4,815,907
12
1
1
1
1
38.7
15.6
964
24,232.43 23,360,063
17,013,135
39
Subtotals
4671
81,392,709
50,639,078
116
Grand Total
6166
97,932,885
57,336,248
121
1 Sky Blue = Combinations with 1 of 4 risk factors; Green = 2 of 4 risk factors; Aqua Blue = 3 of 4 risk factors; Orange = 4 of 4 factors.
2 Alcohol and/or drugs
3 Weight=BMI >= 30
4 Negative Emotions = Depression and/or Trauma and /or Panic, Anxiety
5 Injuries >= 4 injury visits: Impact injuries, e.g. fractures, contusions (accidents/violence)
6 Logisitic Regression, predicting HICOST patients >= $25,000
7 All z values are statistically significant, p > |zp > |z| = .000
8 Potential Savings = (Average Category Cost - Baseline Average Cost) x # of Patients in Category
9 extraHICOST patients >= $100,000
High Medical Costs
In Table 4g, costs for Alcohol/Tobacco and interactions with
this factor, totaled 81.4 million
Costs without Alcohol/Tobacco and interactions with it
totaled 16.5 million, a difference of 64.9 million
The number of extra high-cost patients (>$100,00), with
Alcohol/Tobacco and its interactions, outnumbered the
patients without this risk factor 116 to 5.
High Medical Costs
Table 5g – Referred Care Cost Summary
Analysis I summarizes Table 4g
Analysis II adds Major Disease and drops Weight
In both analyses, Alcohol/Tobacco & its interactions, have higher
total costs than the other risk factors and their interactions
 For Alcohol/Tobacco higher costs are related to higher patient
numbers (prevalence)
 Slightly higher average costs (per patient costs) are associated
with the other risk factors due to lower prevalence
 The Costs for Alcohol/Tobacco (81.4 million) are much greater
than the costs for Major Illness (41.4 million) in spite of higher
per patient costs for Major Illness
Table 5g
Referred Care Cost Summary 1
Analysis II
Analysis I
Risk Factors
Cost Sums 2
Patient
Numbers 3
Patient
Averages 4
Alcohol /
Tobacco
Weight
Negative
Emotions
Injuries
81.4 million 51.8 million 66.7 million 66.2 million
Alcohol/
Tobacco
Negative
Emotions
Injuries
Major
Disease
81.4 million 66.7 million 66.2 million 41.4 million
4671
2845
3592
3411
4671
3592
3412
1886
$17,425
$18,191
$18,582
$19,400
$17,425
$18,583
$19,397
$21,964
1 Referred Care Costs were used over a 14 year period, FY2000-FY2014. These data were analyzed using logistic regression, with costs
predicted by risk factors, using a 4-way interaction model. Analysis I uses Alcohol/Tobacco X Weight X Negative Emotions X Injuries
with a prevention goal, while Analysis II uses Major Disease instead of Weight, Alcohol/Tobacco X Negative Emotions X Injuries X
Major Disease.
2 There are 16 terms or rows in a 4-way interaction, and to get the cost of the risk factor the costs are summed over the 8 terms
that are positive for that risk factor, (e.g. Alcohol/Tobacco).
3 Patient Numbers are calculated by adding the number of patients for each of the interaction terms that are positive for the risk
factor.
4 Patient Averages are Cost Sums divided by Patient Numbers.
Conclusion
Priority Attention to Alcohol/Substance Treatment and
Prevention is needed to save lives and reduce medical
costs
 What would Priority Attention look like?
 Integration across institutions:
Indian Health service, Tribal Treatment Programs,
Vocational Rehabilitation, Legal System (Jails),
Schools, Places of Employment (Casinos),
Local Inpatient Treatment, Department of Family
Services
Conclusion
Use technology to improve the integration, quality,
availability, and efficiency, and monitoring of
treatment.
• Computer Based Interventions and Treatment
• Followed by group counseling (covering topics
initiated on the computer)
• Individual Counseling as needed after the above
• Use of smart phones for monitoring and positive
interventions for younger people.
Conclusion
 Treatment is completed under the direction of a Clinical
Supervisor, following clinical treatment plans
• Treatment teams may involve different institutions
• The clinical supervision by a licensed professional
(MD if needed), and on site treatment, would qualify
the computer based, group or individual treatment
for insurance reimbursement, helping sustain the
programs
• Individual incentives given to clients to promote
continuation and completion
Addendum
Substance Abuse has comorbid conditions—Depression
PTSD/Stress, Anxiety/Panic, Conduct problems
(see Table 6g)
These comorbid conditions need treatment for substance
treatment to be effective—conversely treatment for
depression & PTSD/Stress is not effective when clients are
using alcohol/drugs (see Table 7g)
Computer_based treatment can be effective in treating
depression & PTSD/Stress, assisting counselors with less
familiarity with the topic
Table 6g
Emotions and Substance Abuse
OddsOdds
RatioRatio
ALCOHOL
Depression
PTSD/Stress
Anxiety/Panic
Conduct
COMBINED DRUGS
Depression
PTSD/Stress
Anxiety/Panic
Conduct
TOBACCO
Depression
PTSD/Stress
Anxiety/Panic
Conduct
BMI (food)
Depression
PTSD/Stress
Anxiety/Panic
Conduct
zz
P<|z|
P>|z|
2.46
1.34
1.50
1.94
18.99
4.28
7.42
11.71
0.000
0.000
0.000
0.000
3.37
1.52
1.65
3.13
17.25
5.13
7.08
16.74
0.000
0.000
0.000
0.000
2.61
1.71
1.77
1.38
21.53
6.94
10.14
5.51
0.000
0.000
0.000
0.000
1.61
1.23
1.30
0.76
11.07
3.20
5.15
-4.85
0.000
0.001
0.000
0.000
Table 7g
How to Handle Emotions: Alcohol and Drugs vs Treatment
Depression
2-Way Interaction
Alcohol or
Drugs 1
Depression 2
0
1
1
1
0
1
Odds
Ratio
0.82
3.79
2.26
z
-2.08
24.78
10.37
P > |z|
0.038
0.000
0.000
Years 3
lost/gained
1.3
-17.8
-9.7
PTSD/Stress
2-Way Interaction
Alcohol or
Drugs 1
0
1
1
PTSD 4
1
0
1
Odds
Ratio
0.65
3.49
2.28
z
-2.89
24.43
7.98
p> |z|
0.004
0.000
0.000
Years 3
lost/gained
4.5
-16.9
-8.6
1 Patients with a drug or alcohol diagnosis or both
2 Patients of ages 15-100 with a depression diagnosis with at least 5 treatment
visits
treatment
visits
3 "-" means Years lost
4 Post-traumatic Stress Disorder