An Assessment of the Diagnosed Prevalence of Diseases in Men 50 Years of Age or Older

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Objective:

A lack of focus on certain men's health problems has led to significant morbidity and mortality in aging men. Managed care must begin to focus on the conditions that are most prevalent in this fast-growing population in an effort to improve the quality of care. To assist in achieving this goal, a naturalistic retrospective study assessing the prevalence of the 10 leading disorders in men older than the age of 50 was conducted, with an additional focus on men eligible for Medicare.

Methods:

Claims data were obtained from the Integrated Health Care Information Solutions National Managed Care Benchmark database (Waltham, Mass), that includes data from 30 health plans covering more than 25 million lives, and from the Centers for Medicare & Medicaid Services, representing men from a 5% random sample of Medicare-eligible patients. Men older than 50 years of age were included in the study. The prevalence of all diseases was determined in the 2003 calendar year for each population. Prevalence was calculated by dividing the number of diagnosed cases of a disease by the total person-time observations within the 2003 period.

Results:

The results indicate that cardiovascular (ie, coronary artery disease [CAD], hypertension, and arrhythmias), urological (ie, enlarged prostate and prostate cancer), and musculoskeletal disorders (ie, osteoarthritis and bursitis) comprise 70% of the 10 leading diseases. CAD and hypertension ranked first and second across all age categories, whereas enlarged prostate ranked fourth. In men older than 50, diabetes ranked third, whereas cataracts ranked third in Medicare-eligible men.

Conclusion:

The diseases identified in this study have the potential to cause significant clinical and economic implications when poorly treated or undertreated. Therefore, there is a need to institute early treatment for these conditions before they progress and require more extensive and costly interventions.

(Am J Manag Care. 2006;12:S83-S89)

Over the course of the past decade there has been an increased focus and awareness on women's health issues in the public sector, yet this same push has not been equally demonstrated for men's health. National data on morbidity indicate men and women have similar levels of illness; however, the general belief is that the level of illness in women is much higher,1 which may partially account for the differences in public focus. Men's health is differentiated as a disease or condition that is more attributable to risk factors and treatment interventions that are primarily indicated for men. Although the value of gender-specific medicine has been demonstrated by the women's health movement, the value for men's health has not been fully realized, as evidenced by the insidious increase in morbidity and mortality in the male population.2

Complicating the morbidity and mortality issues is the male perception of a lower risk for health problems compared with their female counterparts, perceptions which further promote unhealthy behaviors.3 Additionally, male socialization often requires a projection of strength, autonomy, and stoicism that rejects showing weakness and vulnerability.1 Functionally, the lack of knowledge regarding risk factors of serious health conditions, the inability to leave the workforce, and the lack of insurance3-5 also contribute to the poorer health of men. These factors may play a critical role in why men allow diseases to progress longer before seeking medical care and participate in fewer health screenings compared with women.6 Sex-specific studies also highlight a trend of delayed help-seeking when men become ill7 and show that men look for help with specific, acute problems rather than for more general, preventative health concerns.8 Moreover, healthcare providers typically spend less time with men than women, provide fewer services, and offer less education on ways to change behavior to improve health.1-3 The end result of these issues is that men access healthcare services less frequently than women, have increased health risks,1 and die approximately 2 years earlier than women.9

As the aging population continues to expand, the male burden to the current healthcare system will substantially increase. Those persons =65 years of age comprised 12.3% of the population in 2003, and this number is predicted to increase to 20% of the population by the year 2030.10 As such, delays in diagnosing and treating men's health problems can have serious clinical and economic consequences,3 because opportunities for early treatment and interventions for long-term conditions will be missed, leading to unnecessary pain, suffering, and healthcare resource consumption.4 A crucial step towards the goal of improving the focus on men's healthcare is to identify those diseases and/or conditions that are the most prevalent in this population. As such, the purpose of this study was to determine the 10 most prevalent diagnosed diseases in a representative population of men =50 years of age, with additional focus on men eligible for Medicare, in hopes of identifying target areas for future prevention and medical management.

METHODS

This is a retrospective analysis of medical and pharmacy claims obtained from the Integrated Health Care Information Solutions (IHCIS) database and medical claims obtained from the Centers for Medicare & Medicaid Services (CMS) during the 2003 calendar year. The IHCIS database is a large national managed care database that represents a total of 30 health plans and covers more than 25 million lives; the CMS data represent a 5% random sample of Medicare-eligible patients. The Medicare data contain all inpatient and outpatient (Parts A and B, respectively) fee-for-service claims for male beneficiaries =65 years of age enrolled for the year 2003. This analysis included all men =50 years of age from the IHCIS database and all Medicare-eligible men from the CMS data. The objective of the study was to identify the most prevalent diagnosed diseases in this population of men =50 years of age, with a focus on Medicare-eligible men.

International Classification

of Diseases, Ninth Revision

Thomson Medstat Disease Staging coding criteria were used to identify disease diagnosis. This method is based on electronic screening and identification of a comprehensive map of diagnosis codes for various disease states. The proprietary coding criteria, developed by physicians and medical records professionals employed by Thomson Medstat, have been widely used as a classification system for diagnostic categories, being 1 of 4 systems selected to disseminate with the Healthcare Cost and Utilization Project (HCUP) nationwide inpatient sample. With these coding criteria, all potential diseases for the population selected were identified using the inpatient and outpatient claims. After identification, the diagnoses were ranked according to frequency of occurrence within each database. The 10 most prevalent long-term diseases were then identified. The results of the analysis were further stratified by age groups: (1) 50 to 59 years; (2) 60 to 69 years; (3) 70 to 79 years; and (4) =80 years.

Although patients were identified in 2003, patients were not required to be eligible for medical services for the entire 2003 calendar year. As such, the time period of assessment may vary for each patient. To account for varying time periods, a prevalence rate was calculated by dividing the number of diagnosed cases of a disease by the total person- time observations (numbers of diagnosed cases/total person-time). For example, assume 3 patients had a total follow-up time of 2 years, 1 full year of follow-up for 1 patient and 6 months of follow-up for the other 2 patients. If 2 of these patients were diagnosed with hypertension during their follow-up, the diagnosed prevalence of hypertension would be 2 diagnosed patients per 2 person-years. As with any prevalence measure, the numerator is the number of diagnosed cases. In a person-time calculation, the denominator is the sum of each individual's time observed in the database.11 In the example given above, the persontime prevalence rate would be 1.0 (100%), meaning that over a 1-year period of time, all patients would be expected to be diagnosed with the disorder of interest. For the purposes of this study, a calculation of the number of patients experiencing a medical condition per 100 patient-years was calculated and reported as the person-time prevalence rate.

RESULTS

Sample Characteristics

The IHCIS data included 1 134 491 men =50 years of age, constituting 963 452 total years of follow-up, an average of approximately 310 days per patient. The average age was 59.3 years, with 58.5% in their 50s, 30.7% in their 60s, and 10.8% in their 70s. There were no men =80 years of age. Patients averaged 7 diagnosed disease states per individual patient while receiving their healthcare from preferred provider organizations (45.4%), health maintenance organizations (32.7%), and other types of insurance coverage (21.9%).

The Medicare data included 479 190 men =65 years of age, constituting 479 190 total years of follow-up, because all patients were continuously eligible for 1 year. The average age was 74.2 years, with 29.3% in their 60s, 48.6% in their 70s, and 22.1% =80 years of age. Patients had significant comorbidities averaging 14 diagnosed disease states per individual patient.

Prevalent Diagnosed Diseases

The most common diseases diagnosed in men =50 years of age from the IHCIS data were coronary artery disease (CAD)/hyperlipidemia, followed by hypertension, type 2 diabetes, enlarged prostate, and osteoarthritis, respectively (Table 1). The rates of diagnosed CAD/hyperlipidemia and hypertension were more than 2.5 times that of the third- and fourth-place diseases. Enlarged prostate and osteoarthritis, at fourth and fifth place, had almost identical rates of diagnoses, and the remaining 5 diseases on the list of 10 most prevalent diseases had a diagnosis rate of 7.8% to 8.8%.

When the IHCIS results were stratified by age category, CAD/hyperlipidemia and hypertension remained the most diagnosed diseases, whereas the rank of type 2 diabetes and osteoarthritis fell with increasing age, with only diabetes remaining in the 5 most prevalent diseases. The rank of enlarged prostate remained constant over the age cohorts (Figure). In the oldest age group (=70 years), cataracts became the third most diagnosed disease. The prevalence for each of the 10 most diagnosed diseases increased with age (Table 1).

These trends were validated in the Medicare data, with 3 of the 4 most diagnosed diseases remaining the same (Table 2). CAD/hyperlipidemia was the most common disease (89.9%), followed by hypertension (63.3%), cataracts (31.1%), and enlarged prostate (27.8%). As patients aged, the rank of CAD/hyperlipidemia, hypertension, and enlarged prostate remained constant (Table 2).

DISCUSSION

The purpose of this study was to determine the 10 most prevalent diagnosed diseases in men =50 years of age, with additional focus on Medicare-eligible men in hopes of identifying target areas for future prevention and medical management. The results indicated that cardiovascular (CAD, hypertension, and arrhythmias), urological (enlarged prostate and prostate cancer), and musculoskeletal disorders (osteoarthritis and bursitis) comprise 70% of the 10 leading diseases. CAD and hypertension were the most common diagnosed diseases for this male population, with a prevalence rate of 51% and 45%, respectively, in men older than 50, and 89% and 63%, respectively, in Medicare-eligible men. This finding is supported by previous work evaluating the prevalence of these disorders, where 60% of patients had dyslipidemia or hypertension.12 Regardless of age, CAD/hyperlipidemia and hypertension remained the first and second most ranked diseases. These disorders may be responsible for more than 600 000 strokes each year.13

Urological and musculoskeletal disorders were identified as being the second most common classifications of diseases. Enlarged prostate, which constituted the majority of urological disorders in this study, had a prevalence rate of 13.5% in men older than 50 and 27.8% in Medicare-eligible men. Estimates suggest that 50% of men older than 6514 are affected by enlarged prostate; however, the diagnosed prevalence appears to be much lower. Because enlarged prostate was diagnosed more frequently than osteoarthritis, which ranked fifth, enlarged prostate may be the most prevalent symptomatic disease identified in the 5 leading disorders and includes a host of symptoms, which can include nocturia, incomplete emptying, urinary hesitancy, weak stream, and the development of acute urinary retention (AUR).15 Although other conditions may coexist and may cause or exacerbate these voiding symptoms, in general, benign prostatic hyperplasia remains the most likely underlying etiology. It is important for all patients with voiding symptoms to undergo a thorough evaluation to exclude such coexisting conditions. Enlarged prostate has been recognized as an underresearched and poorly understood16 disease and is likely to be less prioritized for medical management in elderly men. The current focus with treatment for enlarged prostate is primarily symptomatic relief, because alpha blockers are used in 85% of patients initiating treatment. Although alpha blockers provide symptom relief in patients with enlarged prostate, they do not treat the underlying disease process, and, therefore, do not reduce the likelihood of future sequelae, such as AUR or surgery. On the other hand, 5-alpha reductase inhibitors (ie, dutaseride and finasteride) provide similar symptomatic relief by specifically treating the underlying disease process. Despite this fundamental difference in favor of 5-alpha reductase inhibitors, the utilization of this class of medication currently trails a distant second behind alpha blockers. This highlights the need to educate patients and providers about the clinical and economic implications of enlarged prostate.17 Prostate cancer, a separate medical condition from enlarged prostate (although both may coexist), is the second most common cause of cancer-related deaths in men, and, in 2005, prostate cancer was the most common newly diagnosed cancer for men.18

Osteoarthritis and bursitis were the 2 musculoskeletal disorders identified in the list of the 10 most prevalent diseases. Osteoarthritis has been recognized as one of the most common joint disorders in the elderly, which increases in prevalence with age.19,20 Although the rank of osteoarthritis in this study fell when the disorders were assessed in older groups, the actual prevalence of osteoarthritis increased with age (11.4% to 19.5% in men older than 50 and to 26.8% in Medicare-eligible men), supporting previous literature. Women are at higher risk of developing osteoarthritis than elderly men, but based on the findings of this study, osteoarthritis is still a significant health problem for the elderly male population.20,21 Similar to enlarged prostate, treatment for osteoarthritis is primarily symptomatic and does not affect disease progression.

Type 2 diabetes was ranked third in men older than 50 and sixth in the Medicare-eligible population. Studies indicate that the prevalence of type 2 diabetes in men increases with age and peaks at age 75, with approximately 16.5% of the population being affected.22 Results of this analysis support these estimates, with a 17.5% prevalence rate in men older than 50 and a 26.3% prevalence rate in Medicare-eligible men. Similar to hypertension, diabetes is known to have considerable clinical consequences in men, and if untreated or poorly treated, diabetes can result in serious complications and needed interventions. Poorly controlled or untreated diabetes can result in neuropathy, nephropathy, retinopathy, peripheral vascular disease, and CAD.

Most of the diseases identified in this study represent disorders that may have serious clinical and economic implications when they are overlooked or ignored. As such, the need to focus on treating long-term conditions in the early stages, before they become more costly and require more extensive interventions, is imperative to improving overall health4 in men. This is most appropriate when prevention of disease progression can be readily achieved using standard available therapy. The use of healthcare resources is strongly age-dependent and highly correlated to disease progression. Healthcare costs generally rise linearly throughout adult life and then rise exponentially after age 50,23 which may be more indicative of disease progression than aging. By targeting these diseases before progression, healthcare practitioners may minimize excess resource consumption and improve the quality of life of men. For example, patients with enlarged prostate are most likely to receive alpha blocker therapy for the treatment of urinary symptoms. However, alpha blockers do not affect the likelihood of AUR or surgery, although 5-alpha reductase inhibitors (ie, dutasteride and finasteride) have been shown to do so. Therefore, more patients should be considered for 5-alpha reductase inhibitor therapy to improve quality of life, reduce disease progression and sequelae, as well as potentially reduce long-term medical expenditures. However, considerations for initiating treatment must factor in prostate size and prostate-specific antigen levels.

As the aging population continues to expand, awareness and treatment of these diseases will become imperative, especially as the potential burden to the Medicare system continues to grow. Healthcare expenditures in the elderly have outpaced the growth of the gross domestic product over the past few decades, a change largely attributable to the faster growth rate of the elderly population compared with the rest of the population.24 Focusing on treating diseases on the front end before they progress and result in more complications may help to ease the burden on the healthcare system.

Although this study highlights potential disease states for focused targeting, there are some limitations that must be discussed. The use of claims data may not allow for the accurate representation of the prevalence of these disorders, because patients must actively seek medical treatment to be included in the database. Therefore, the results highlight the most prevalent diagnosed disorders that men seek treatment for, not the most prevalent disorders in men. There may be substantial differences in the ranking of diseases if the true prevalence of all diseases could have been captured. Additionally, some disorders, such as depression and anxiety, are generally undercoded in administrative commercial databases, which may cause an underrepresentation of the patients seeking treatment for these disorders.25 Data suggest that depression is ranked fifteenth in terms of diagnosed prevalence; however, earlier studies noted that more than 50% of patients initiating antidepressant therapy did not have a coded diagnosis.26,27 The extent of how such undercoding affected this analysis is not known. Additionally, it is not known to what degree the symptomatic nature of these disorders played in the likelihood of diagnosis or treatment. For example, even though a patient was diagnosed with enlarged prostate, he may not require treatment if he is asymptomatic. The need for treatment may be substantially lower than the diagnosed prevalence across all identified diseases.

Despite these limitations, there is value in identifying the 10 most diagnosed disorders in men =50 years of age. Future research is needed to assess the economic and clinical implications of these disorders, identifying the disorders with the highest likelihood of negative outcomes, whether clinical, economic, or humanistic in nature. The overall objective is to increase the proportion of patients that receive optimal treatment early in the disease process to positively impact patient health and quality of life as well as healthcare systems.

CONCLUSION

Cardiovascular, urological, and musculoskeletal disorders account for 70% of the 10 most prevalent conditions in managed care and Medicare populations, with CAD/hyperlipidemia being the most commonly diagnosed disorder. Of the 5 most diagnosed disorders, enlarged prostate ranked fourth, ahead of osteoarthritis, making it potentially the most prevalent symptomatic disease in men. Most of the diseases identified have the potential to cause significant clinical and economic implications when poorly treated or undertreated. Therefore, there is a need to institute early treatment for these conditions before they progress and require more extensive and costly interventions.

Address correspondence to: Amy L. Grogg, PharmD, Applied Health Outcomes, 4114 Woodlands Parkway, Suite 500, Palm Harbor, FL 34685. E-mail: agrogg@applied-outcomes.com.