Parkinson's Elevated: improving healthspan

Abstract

As Parkinson's disease (PD) progresses, relatively mild symptoms advance to a major disorder that affects every organ system in the body. Current care for people with PD (PwP) reacts to rising disability. There is a missed opportunity to keep PwP as healthy as possible. In this perspective, we spell out our vision for a proactive, value-based health care model built around a patient-centered integrated practice unit (IPU) for PD. The IPU will provide integrated interdisciplinary care overseen by a specialized Parkinson's primary care physician working closely with a movement disorders neurologist. The IPU will implement an evidence-based exercise program for people early in the disease. The focus of this intervention is a heart rate driven high-intensity aerobic exercise program, which is the only treatment with evidence that it can slow disease progression. It will also include resistance exercises, flexibility exercise and balance exercise. For people whose disease is moderate or severe, the IPU will provide care curated through a network of rehabilitation providers with expertise in PD all of whom understand the exercise prescription. By integrating care, slowing disease progression, and incorporating specialized rehabilitation we anticipate improving healthspan. In creating the IPU as a fully capitated (shared-risk) model in which the IPU and the insurance company assume joint accountability for quality and cost of care we anticipate demonstrating financial sustainability of implementing the exercise prescription and providing integrated care.

Keywords: Parkinson's disease; healthspan; high-intensity aerobic exercise; integrated practice unit; proactive care.

Figure 1

Ideal journey of a person with Parkinson’s disease. The ideal journey will accelerate diagnosis, extend the healthspan, and make the endgame shorter and more meaningful.

Figure 2

Hypothetical clinical and cost trajectories. (A) This figure depicts the hypothetical healthspan of typical Americans without PD or other neurodegenerative illness. A typical unhealthy American does little to promote health and may develop metabolic syndrome which increases risk of type II diabetes, heart disease, and/or stroke. These unhealthy Americans likely experience a “marginal decade” (75) or more at the end of their life in which they are alive, but have poor health and poor quality of life. In contrast, by early middle age at the latest, a typical healthy American engages in multi-modal exercise, healthy eating, quality-sleep, and care for their mental health. As long as these healthy Americans do not develop a disease out of their control such as cancer or a neurodegenerative illness, they maintain a high healthspan until their time of death. (B) This figure depicts the hypothetical healthspan of 3 PwP all diagnosed at age 60, but treated under different care scenarios. The person with PD treated in the Parkinson's Elevated IPU with the PD ExRx maintains the highest healthspan. The person with PD who receives good neurologic and family support, but is treated in the traditional reactive care model has more disability in their later decades than the person in the IPU. The third person with PD is someone without support who is diagnosed over a decade into their decline and thus starts at a much lower level of health at time of diagnosis. This person continues a precipitous decline due to continued lack of support. (C) This figure overlays the hypothetical typical healthy American and the hypothetical person with PD treated in the Parkinson's Elevated IPU model. While the healthspan of the person with PD is lower than that of the healthy person without PD, it is not that much lower. (D) This figure compares the hypothetical total cost of healthcare for PwP in different care scenarios. The lifetime cost is denoted by the area under each curve. Note that for a person with PD with late diagnosis and little support the cost of care is hypothesized to rise even before diagnosis. For a person with PD in the Parkinson's Elevated IPU, cost is hypothesized to rise at diagnosis when resources are invested in proactive care, but over time the cost curve falls below that of a person with PD treated in the traditional reactive-only care model. We anticipate that the Parkinson's Elevated IPU will reduce long-term costs through steering patients toward a more benign trajectory for both their PD and non-PD comorbidities (because exercise and care coordination help far more than just PD). In a more benign trajectory, less reactive care is needed. When reactive care is needed however, there will be reduced spend by bringing most of the care into the unit. Finally, transition to hospice at the right time will save high-but-futile spending in the last few months of life. Note that the IPU curve is the only one without steep rise in cost at end of life due to the team being able to proactively transition PwP to hospice. Abbreviations: PD, Parkinson's disease; PwP, people with Parkinson's disease; IPU, integrated practice unit.