chronic disease practice & policy presentation to ahs health policy advisory group tom o’dowd...
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Chronic diseasePractice & Policy
Presentation to AHS Health Policy Advisory Group
Tom O’Dowd & Susan Smith
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Patients with multiple chronic illnesses :
• Die prematurely
• Longer hospital stays
• More depression
• More medications
• Poorer function
• Poorer access to specialists
• Excluded from trials
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Published by AAAS
G. D. Wieland, Sci. Aging Knowl. Environ. 2005, pe29 (2005)
Fig. 1. Impact of multiple morbidity on Medicare expenditures
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Multiple chronic conditions :
• Vast amount of expenditure– 20% of patients cost 80% of budget– evidence based care is cheaper (Boult 2008)
• Inadequate care– not evidence based
• Poor communications– tests not available, dr not aware of history
• Poor adherence– no one to discuss/review medications
• High readmission rates
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Two or more chronic illnesses in the same individual
From primary care in Canada :
18 - 44 years 61%
45 - 64 years 93%
> 65 years 98%
Fortin et al BMJ 2007
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New concept : Multimorbidity
• Existence of 2 or more chronic conditions in the same patient
• Can co-exist like CVD & DM– or not - like arthritis & asthma
• Literature review : most references come from primary care
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Characteristics of study population (n 92)
• Female : 49 (53%)
• Number of chronic conditions : 4
• Number of current medications : 7.5
• GP visit in last 12/12 : 11.7
• P/nurse visit in last 12/12 : 1.0
• Hosp visit in last 12/12 : 3.3
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Prevalence of conditions %
• Lipid disorders 15• Hypertension
12.5• Depression5.5• NIDDM 7.5• COPD 6• Asthma 5• Acute MI 2
• IHD-no angina 1.5• IHD-with angina 3.5• Cardiovascular
disease other 2.5
• Chronic alcohol abuse 3
• Hiatus hernia 1
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Single vs Multimorbidity
Single morbidity
Multimorbidity
Female 20 (48%) 30 (48%)
Mean age 54 56
GP visits 7 13
Current meds 2.3 7.3
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What is being tried
• Community matrons » www.swirl.nhs.uk/resource/42
• Transitional care - to reduce readmissions.
» Naylor 2004, Coleman 2006
• Patient self management» Lorig et al 1999 & 2001
• Guided care model» Leff et al 2009 www.guidedcare.org
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Copyright ©2007 BMJ Publishing Group Ltd.
Gravelle, H. et al. BMJ 2007;334:31
Emergency admission rates for general population aged >=65 in Evercare/Community matrons and control practices. July 2001 to March 2005
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Guided nurse careLeff et al 2009 www.guidedcare.org
Johns Hopkins
• Nurse based in primary care - 50-60 patients, 3-4 physicians. Planned care,education. Monthly visits.
• At 8 months :• 24% fewer hospital stays• 37% fewer skilled nursing facility days• 15% fewer ED visits• 29% fewer home healtcare episodes• 23% lower health insurance costs• 9% more specialist visits
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Sneak peek
Reduce admissions
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Implications for health system
• Common in younger patients• Big workload for practices
– More illnesses more work– Care is GP centred
• Polypharmacy– More illnesses more work
• Socioeconomic effects• We don’t know impact on function
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Categorisation of chronic illness Glauberman 2002, Martin 2005
• Simple problems :– Protocol driven
• Complicated :– Need specialised
expertise
• Complex :– Additionally need
knowledge of locality, social networks
• Chaotic :– Brittle clinical & social
problems
Hypertension
Open heart surgery
Angina + alcohol+DM + family problems
Angina + DM + alc binging + disadvantage
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What we know- Donald Rumsfelt 2008
• Known knowns :
• Known unknowns :
• Unknown unknowns:
• Hospital budgets will be smaller. Bigger role for nurses
• Role of nurses, OTs, pharmacists
• Redeployment of budgets & staff from acute care to chronic care
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Policy questions
• Money is not the place to start - yet– Consider transfer of resources?
• Patient responsibility & accessible information• Current GMS contract is not geared to chronic
illness : should it be put out to tender?• Appropriate care directed by generalists &
provided by nurses?• ‘Good enough’ care : ‘Boston vs Berlin’• Diagnostics unhitched from hospitals including
radiology