Chronic diseasePractice & Policy

Presentation to AHS Health Policy Advisory Group

Tom O’Dowd & Susan Smith

Patients with multiple chronic illnesses :

• Die prematurely

• Longer hospital stays

• More depression

• More medications

• Poorer function

• Poorer access to specialists

• Excluded from trials

Published by AAAS

G. D. Wieland, Sci. Aging Knowl. Environ. 2005, pe29 (2005)

Fig. 1. Impact of multiple morbidity on Medicare expenditures

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

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

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

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

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

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

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

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

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

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

Sneak peek

Reduce admissions

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

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

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

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