Using pathology testing to control the chronic disease epidemic

Beverley Rowbotham

“At the present time, one person is dying of diabetes every seven seconds, but the news

can only talk about victims of hurricanes with house flying through the air.”

Nassin Taleb “ Antifragile:things that gain from

disaster”

2012 Global type 2 diabetes market $28B.

This is expected to double by 2022.

G Anderson and E Chu NEJM 2007:356:209-211

1. 2001 data 2. 2004 data Note: Ireland, Italy and Luxembourg excluded from 2004 OECD life expectancy data Source: OECD, Health Data 2005; Productivity Commission, Overcoming Indigenous Disadvantage (2007) "Strategic Areas For Action"

Life expectancy at birth in top 20 OECD countries: 2005

However Indigenous Australians have an

average life expectancy of 59.4 for men and 64.8 for

women1

For more on Indigenous health and disadvantage, see The Future of Indigenous Australia

82

81.3Switzerland

81.2Iceland

80.9Australia

80.7Spain

80.6Sweden

Norway

79.6New Zealand

79.5Austria

79.4Ireland

Italy

79.4Netherlands

79.3Greece

Canada2

Finland

78.7Belgium

78.5Korea

0 76

82.1

78

79.3

80

Japan

Life expectancy at birth (years)

Luxembourg

79.0Germany

79.0United Kingdom

78.9

80.2

France 80.3

80.4

80.1

2

0 100,000 200,000 300,000 400,000 500,000

Cancers1

Cardiovascular

disease

Mental illness

Nervous system

Chronic respiratory

Injuries2

Diabetes

Musculoskeletal

Genitourinary

Digestive system

Burden of disease (DALYs3)

1. Includes malignant and other neoplasms 2. Includes intentional and unintentional injuries 3. Disease Adjusted Life Years (years lost through death by disease, and years lost to disability by disease) 4. Mental health data is complex. Increased self-reporting rates may be due to greater willingness to report, rather than increased prevalence Source: AIHW, The Burden of Disease and Injury in Australia 2003 (2007); ABS 4824.0.55.001, Mental Health in Australia: A Snapshot 2004-5 (2006)

Years lost to disability (YLD)

Years of life lost (YLL)

Annual national burden of disease for top 10 disease groups in Australia: 2003

• In 2004-5, 11% of persons self-reported a current long-term mental health or behavioural problem. This is a reported increase of 5.9% since 20014

• A 1997 survey into the mental health and wellbeing of Australian adults found that 18% of all people suffered some degree of mental disorder in the previous 12 months

• Of persons with a mental-health related disability, 45% report severe core-activity limitations, 29% moderate limitations, and 59% work or schooling restrictions

Mental illness is a significant issue

Note: Population projections based on Series B growth assumptions Source: ABS 3222.0, Population Projections, Australia, 2004-2101 (2006); ABS 3201.0, Population by Age and Sex, Australian States and Territories (2006); Productivity Commission, Economic Implications of an Ageing Australia (2005)

By 2036, it is projected that one quarter of Australians will be over 65

Acute care expenditure rises sharply from 60 onwards

Hospital expenditure per capita by age group: 2002/3 Australian population by age bracket: 1976-2036

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

65+

45-64

25-44

<25

Population by age bracket (#)

1976 2006 2036

13

25

29

33

2006

24965+

252045-64

252725-44

2744<25

20361976

13

25

29

33

2006

24965+

252045-64

252725-44

2744<25

20361976

% population by age bracket

0

1,000

2,000

3,000

4,000

5,000

6,000

0-4

5-9

10

-14

15

-19

20

-24

25

-29

30

-34

35

-39

40

-44

45

-49

50

-54

55

-59

60

-64

65

-69

70

-74

75

-79

80

-84

85

+

Males Females

Hospital expenditure per capita ($)

One major contributor to

high cost of treatment in

older years is the use of

expensive technology

1. Includes Commonwealth, State and local governments 2. Includes private health insurance funds, injury compensation insurers, and private individuals 3. Includes public and private hospitals and patient transportation Source: AIHW, National health expenditure 2005-6 (AIHW data cube)

National health expenditure, by area of expenditure – Australia: 2005/6 ($ per capita)

1,579

Hospitals

694

Pharma-

ceuticals,

aids and

appliances

754

Medical

services

Dental

services

148

Other health

practitioners

315

Capital

expenditure/

tax

261

Public and

community

health

121

Admin

93

Research

4,224

Total

Non-government

Government

259

Public/community health

represents just over 6% of total

expenditure

Australia: AIHW Chronic disease key indicators database and reports

WHO 2012: Target 25% reduction in premature

mortality from non communicable disease by 2025.

Global Alliance for Chronic Disease (includes

Australia): Research target for 2014: type 2 diabetes in low and middle income countries, vulnerable populations in high income countries and indigenous populations in Canada and Australia.

Traditional: diagnosis, monitoring,

treatment selection, prognostics

Novel uses

Disruptive health solution.

Pathology testing in Australia In 2010 – 2011, just over half of Australians had a pathology test

This is the second most

common medical consultation ( 85% of Australians will see a GP

in a year)

Almost half of MBS pathology claims were made by 7% of

Australians

14% of Australians made MBS claims for more than 10

pathology tests

Source: Australian Government Department of Health and Aging

BEACH 2009-2010

The rise of cholesterol testing: how much is unnecessary? Doll et all BJGP 2011

Medicare Payments - An Index of Medicare Benefits PaidFrom January 2000 to December 2010 (3 month moving averages) & percentage growth over this period

All benefits include EMSN payments, GP benefits also include bulk billing incentive payments

1.000

1.500

2.000

2.500

3.000

Jan-00 Jan-01 Jan-02 Jan-03 Jan-04 Jan-05 Jan-06 Jan-07 Jan-08 Jan-09 Jan-10

All

others

GPs

DI

Path

AWE

CPI

94%

112%

40%

172%

66%

141%

Ed Wilson

EW Consulting P/L

Medical Cost Inflation !

EW Consulting P/L Ed Wilson

Medicare Payments - An Index of Benefits per ServiceFrom January 2000 to December 2010 & percentage growth over this period

All benefits include EMSN payments, GP benefits also include bulk billing incentive payments

0.90

1.00

1.10

1.20

1.30

1.40

1.50

1.60

1.70

1.80

1.90

2.00

Jan-00 Jan-01 Jan-02 Jan-03 Jan-04 Jan-05 Jan-06 Jan-07 Jan-08 Jan-09 Jan-10

GPs

AWE

All

others

CPI

DI

Path4%

33%

40%

62%

66%

92%

Ed Wilson

EW Consulting P/L

Item Description65070 FBE/FBC 45 to 55 percent

65090 blood grouping 55 to 75 percent

66536 HDL 70 to 80 percent

66500-15 simple chemistries 10 to 40 percent

66551 HbA1c 40 to 65 percent

66560 microalbumin 10 to 25 percent

66593 ferritin 25 to 45 percent

66650 tumour markers 20 to 50 percent

69475 Hep. X1 20 to 45 percent

71075 IGE 25 to 50 percent

71097 ANAs 25 to 40 percent

71106 Rheumatoid Factor 75 to 90 percent

Percentage coned

out

10%

11%

12%

13%

14%

15%

16%

17%

18%

Pathology as a percentage of Medicare OutlaysJanuary 2000 to date three month moving average

Patholgy: Currently 12.8% of Medicare outlays

1. Includes Commonwealth, State and local governments 2. Includes private health insurance funds, injury compensation insurers, and private individuals 3. Includes public and private hospitals and patient transportation Source: AIHW, National health expenditure 2005-6 (AIHW data cube)

National health expenditure, by area of expenditure – Australia: 2005/6 ($ per capita)

1,579

Hospitals

694

Pharma-

ceuticals,

aids and

appliances

754

Medical

services

Dental

services

148

Other health

practitioners

315

Capital

expenditure/

tax

261

Public and

community

health

121

Admin

93

Research

4,224

Total

Non-government

Government

259

Public/community health

represents just over 6% of total

expenditure

Cavian et al, Mckinseys

BEACH 2009-10

Audit of pathology requesting

- purpose

- appropriateness

guidelines for disease e.g. diabetes(72%) obesity(24%)

- adequacy of management Type 2 diabetes

HBA1c 43% >7.0% ◦ 78% were taking at least one medication to manage blood

glucose

◦ LDL cholesterol 44.3% >2.5 (target<2.0)

◦ 70% were taking a lipid lowering medication

diagnosis monitoring Primary prevention

Patient request

40% 40% 10% 10%

Has the right population been tested ?

Has the diagnosis been made?

Was the best treatment selected?

Did the clinician use the test to guide treatment decisions?

Did the clinician recognise a meaningful change in a test result?

Did the patient take the medication? “When patients start a new medication for a chronic condition, intentional nonadherers hold beliefs that are significantly different from those of adherers and unintentional nonadherers.” Clifford S et al J Psychosom Res 2008

Heart Foundation estimate of savings from improved prevention/management: $2.6B over 5 years( R Grenfell personal communication)

Doll et al BJGP 2011

Doll et al BJGP 2011

Doll et al BJGP 2011

3 surveys involving 6390

GPs, in 10 EU countries

and Australia

By permission R Horvath

HbA1c

‘True’ CD (RC) value at 80% probability to indicate poorer or better control corresponds to a

change of

+12% in HbA1c

CV for HbA1c 4.4%

Guidelines on intervals between tests

Education on meaningful change in test measurement -Reduce harm by reducing testing with no clinical utility

Careful design of programs, targets and incentives

One third of patients with CAD who have met target LDL levels

undergo repeat testing within months without a change in treatment. Virani et al JAMA Int Med2013

cdmNet –web based care management systems improve glycaemic control. Wickramsinghe L et al MJA 2013

Discourage the use of testing as a measure of compliance. R Horne

Data base mining: find patients, find insights Find the patients and manage the cases - MBS - 7 % Australians use 50% of the

pathology services - Social disadvantage maps Find the insights and change strategies - LIS - Linked databases - Kaggle

Donald Woods Foundation South Africa, 5000 people /month Diabetes first, then hypertension, HIV, TB

Dr Jeffery Brenner, Camden Coalition of Healthcare Providers

Regional Population Health Atlas >

Focus on Le Fevre Peninsula.

HbA1c by Age

( <7% or >7%)

@

Postcode level

AND

SEIFA context

112

116

120

124

128

132

136

140

144

148

152

156

160

mmol/L

Extreme Sodium

0%

10%

20%

30%

40%

50%

10%

Mort

alit

y R

isk

SODIUM RISKn = 23,442 Admissions

Disruptive solutions Christensen Harvard Business School

Revolutions in health care: Muir Gray

- Public health – Snow and cholera

- Technology – treatment of AML

- Citizens, knowledge and the smart phone.

An innovation that simplifies, increases access and affordability

A business model innovation

Disruptive value network

Eg personal computer – from high cost exclusive use to low cost, general use.

Find a doctor, pharmacist, dentist Get tests Get prescriptions View claims View personal health records

Stop talking about pathology as a cost centre

It is a risk management strategy for health care outcomes including cost.

Get organised

Incentivise case finding and appropriate management, including testing protocols

Use the data

Patient centred care