State-of-the-Art Conference on Complex Chronic Care: The Research Agenda Fran Weaver, PhD Acting...
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Transcript of State-of-the-Art Conference on Complex Chronic Care: The Research Agenda Fran Weaver, PhD Acting...
State-of-the-Art Conference State-of-the-Art Conference on Complex Chronic Care: on Complex Chronic Care:
The Research AgendaThe Research Agenda
Fran Weaver, PhDFran Weaver, PhD Acting Center PIActing Center PI
Todd Lee, PharmD, PhDTodd Lee, PharmD, PhDActing Center co-PIActing Center co-PI
Center for Management of Complex Chronic CareCenter for Management of Complex Chronic CareHines VA HospitalHines VA Hospital
Prevalence and Impact Prevalence and Impact of Complex Chronic Conditions of Complex Chronic Conditions
in the Department of in the Department of Veterans Affairs (VA)Veterans Affairs (VA)
Todd A. Lee, PharmD, PhDTodd A. Lee, PharmD, PhD
Acting Center co-PIActing Center co-PI Center for Management of Complex Chronic CareCenter for Management of Complex Chronic Care
Hines VA Hospital Hines VA Hospital
Research Assistant ProfessorResearch Assistant ProfessorNorthwestern UniversityNorthwestern University
Multiple Chronic ConditionsMultiple Chronic Conditions
Diseases often described and studied in Diseases often described and studied in isolationisolation
Many individuals have multiple chronic Many individuals have multiple chronic conditionsconditions
Increasing appreciation of complexity and Increasing appreciation of complexity and interrelatedness of diseases and their interrelatedness of diseases and their managementmanagement
Implications of Implications of Multiple Chronic ConditionsMultiple Chronic Conditions
Conflicting recommendations from clinical Conflicting recommendations from clinical practice guidelinespractice guidelines
Drug-drug interactions; drug-disease Drug-drug interactions; drug-disease interactionsinteractions
Co-occurring conditions can lead to Co-occurring conditions can lead to unexpected consequencesunexpected consequences
Increased disabilityIncreased disability
Lead to deficiencies in careLead to deficiencies in care
Prevalence of Prevalence of Multiple Chronic Conditions in VAMultiple Chronic Conditions in VA
Majority of patients Majority of patients using VA healthcare using VA healthcare services have 2+ services have 2+ chronic conditionschronic conditions
More conditions More conditions associated with associated with higher average higher average annual healthcare annual healthcare costscosts
3+ Conditions
35%
No Conditions
28%
1 Condition
20%
2 Conditions
17%
# # ConditionsConditions
Avg Avg Annual Annual CostCost
% Total % Total System System CostsCosts
00 $648$648 44
11 $1,995$1,995 99
22 $3,366$3,366 1313
3+3+ $9,277$9,277 7373From Yu et al. Med Care Res Rev 2003
Mortality by Number of ConditionsMortality by Number of Conditions
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
None of the SelectedConditions
1 Condition 2 Conditions 3 Conditions 4+ Conditions
Number of Conditions
% D
ied
Clusters of Disease in VAClusters of Disease in VA National VHA data used to identify cohort aged 55 to 64 National VHA data used to identify cohort aged 55 to 64
years in 2000 (N=741,847)years in 2000 (N=741,847)
ICD-9 codes used to identify presence of 11 chronic ICD-9 codes used to identify presence of 11 chronic conditions and mutually exclusive clusters createdconditions and mutually exclusive clusters created
ConditionCondition NN (%)(%) 5-Year 5-Year Mortality %Mortality %
Hypertension + DiabetesHypertension + Diabetes 47,56847,568 (6.4)(6.4) 6.36.3
IHD + HypertensionIHD + Hypertension 28,15428,154 (3.8)(3.8) 6.36.3
Hypertension + OsteoarthritisHypertension + Osteoarthritis 23,69223,692 (3.2)(3.2) 2.92.9
IHD + Hypertension + DiabetesIHD + Hypertension + Diabetes 19,16119,161 (2.6)(2.6) 11.111.1
Hypertension + COPDHypertension + COPD 11,88311,883 (1.6)(1.6) 12.212.2
Hypertension + Diabetes + OsteoarthritisHypertension + Diabetes + Osteoarthritis 9,1369,136 (1.2)(1.2) 5.35.3
3 Disease Clusters3 Disease Clusters
COPD or Cancer part of cluster
Incremental co-morbid effect of COPD and osteoarthritis on five-Incremental co-morbid effect of COPD and osteoarthritis on five-year crude mortality rates in veterans aged 55 to 64 yearsyear crude mortality rates in veterans aged 55 to 64 years
Referent condition + Referent condition + COPDCOPD
Referent condition + Referent condition + OsteoarthritisOsteoarthritis
Referent condition(s)Referent condition(s) RRRR 95% CI95% CI RRRR 95% CI95% CI
None of the selected None of the selected conditionsconditions
2.992.99 2.86, 3.122.86, 3.12 0.620.62 0.58, 0.670.58, 0.67
HypertensionHypertension 3.213.21 3.03, 3.403.03, 3.40 0.770.77 0.71, 0.830.71, 0.83
Diabetes & HypertensionDiabetes & Hypertension 2.432.43 2.24, 2.652.24, 2.65 0.850.85 0.77, 0.930.77, 0.93
IHD & HypertensionIHD & Hypertension 2.632.63 2.43, 2.852.43, 2.85 0.830.83 0.73, 0.940.73, 0.94
DiabetesDiabetes 2.352.35 2.10, 2.642.10, 2.64 0.690.69 0.59, 0.800.59, 0.80
IHD & Diabetes & IHD & Diabetes & HypertensionHypertension
2.012.01 1.86, 2.171.86, 2.17 0.840.84 0.76, 0.940.76, 0.94
IHDIHD 2.522.52 2.28, 2.792.28, 2.79 0.630.63 0.52, 0.760.52, 0.76
DepressionDepression 2.532.53 2.12, 3.022.12, 3.02 0.650.65 0.50, 0.840.50, 0.84
CancerCancer 1.791.79 1.68, 1.911.68, 1.91 0.550.55 0.48, 0.640.48, 0.64
Cancer & HypertensionCancer & Hypertension 2.282.28 2.08, 2.502.08, 2.50 0.640.64 0.54, 0.750.54, 0.75
Hypertension & Hypertension & DepressionDepression
2.152.15 1.75, 2.651.75, 2.65 0.750.75 0.59, 0.960.59, 0.96
Diabetes & IHDDiabetes & IHD 2.162.16 1.78, 2.621.78, 2.62 0.750.75 0.57, 0.990.57, 0.99Abbreviations: RR = Rate Ratio; IHD = Ischemic Heart DiseaseAbbreviations: RR = Rate Ratio; IHD = Ischemic Heart Disease
Mortality Rate Mortality
Rate
Categories of Death Categories of Death in Patients with COPDin Patients with COPD
Category of causes of death in cohort of Category of causes of death in cohort of 25,297 patients with COPD25,297 patients with COPD
CategoriesCategories %%
Circulatory SystemCirculatory System 33.433.4
CancersCancers 27.727.7
Respiratory systemRespiratory system 20.520.5
Digestive systemDigestive system 3.43.4
Endocrine, nutritional and metabolic diseasesEndocrine, nutritional and metabolic diseases 2.82.8
Genitourinary systemGenitourinary system 2.22.2
OtherOther 8.98.9
Cause of Death Cause of Death in Patients with COPDin Patients with COPD
Top 7 underlying causes of death in Top 7 underlying causes of death in cohort of 25,297 patients with COPDcohort of 25,297 patients with COPD
CauseCause %%
Lung cancer Lung cancer 15.415.4
COPDCOPD 13.113.1
Chronic ischemic heart diseaseChronic ischemic heart disease 12.912.9
Acute myocardial infarctionAcute myocardial infarction 7.57.5
Heart failureHeart failure 2.52.5
Pneumonia, organism unspecifiedPneumonia, organism unspecified 2.02.0
EmphysemaEmphysema 1.81.8
Clusters of Disease Clusters of Disease and Depressionand Depression
Identified cohort with depression in VHA in Identified cohort with depression in VHA in FY2003 (N=335,979)FY2003 (N=335,979)
Created mutually exclusive clusters of Created mutually exclusive clusters of disease based on top 30 most prevalent disease based on top 30 most prevalent chronic conditions (excluding depression) chronic conditions (excluding depression) in VHA (Yu et al., 2003) in VHA (Yu et al., 2003)
Number of Chronic Conditions Number of Chronic Conditions with Depressionwith Depression
Depression Alone*5.5%
Depression + 1 Chronic
Condition11.6%
Depression + 2 Chronic
Conditions16.8%
Depression + 3 Chronic
Conditions19.1%
Depression + >3 Chronic
Conditions47.1%
* Depression Alone is depression without any of the 30 other conditions included when creating clusters
Top 5 Clusters of Depression Top 5 Clusters of Depression and Chronic Physical Conditionsand Chronic Physical Conditions
ConditionCondition NN (%)(%)
Depression + HypertensionDepression + Hypertension 11,94811,948 (13.5)(13.5)
Depression + Hypertension + DiabetesDepression + Hypertension + Diabetes 5,2225,222 (5.9)(5.9)
Depression + Hypertension + IHDDepression + Hypertension + IHD 4,8504,850 (5.5)(5.5)
Depression + Hypertension + ArthritisDepression + Hypertension + Arthritis 4,1254,125 (4.7)(4.7)
Depression + ArthritisDepression + Arthritis 3,6843,684 (4.2)(4.2)
Other Factors Increase ComplexityOther Factors Increase Complexity Not simply number of conditions that lead to Not simply number of conditions that lead to
complex patientscomplex patients
Patient factorsPatient factors
Health literacy, social support, Health literacy, social support, socioeconomic statussocioeconomic status
Health system factorsHealth system factors
Dual healthcare benefit and coordinating Dual healthcare benefit and coordinating care under two benefitscare under two benefits
Moving ForwardMoving Forward
OUTCOMES
Traditionally
Use VA Information Resources to ID patients
Earlier Intervention; Tailored Guidelines;
Increased Resources
Management of “Whole Patient”
Improved Model for Complex Chronic Care Patients
IMPROVED OUTCOMES
Diabetes case management
Depression Rx
SummarySummary
Patients with complex chronic conditions Patients with complex chronic conditions are the rule rather than the exception in are the rule rather than the exception in VAVA
Need better understanding of these Need better understanding of these patients, best management strategies patients, best management strategies and their outcomesand their outcomes
VA presents unique opportunity to begin VA presents unique opportunity to begin to build evidence for appropriately to build evidence for appropriately managing complex chronic care patientsmanaging complex chronic care patients
Complex Chronic Care AgendaComplex Chronic Care Agenda
Fran Weaver, PhDFran Weaver, PhD
Acting Center PIActing Center PICenter for Management of Complex Chronic CareCenter for Management of Complex Chronic Care
Hines VA HospitalHines VA Hospital
Research Associate ProfessorResearch Associate ProfessorNorthwestern UniversityNorthwestern University
SOTA 2006SOTA 2006 VA Research & Development hosted a SOTA in VA Research & Development hosted a SOTA in
Sept. 2006 in Arlington, VASept. 2006 in Arlington, VA
Synthesize what we know about managing Synthesize what we know about managing care for patients with complex chronic care for patients with complex chronic illnessesillnesses
Develop policy recommendations for VA and Develop policy recommendations for VA and larger health community re: improved clinical larger health community re: improved clinical care models and management strategiescare models and management strategies
Develop a research agenda to address gapsDevelop a research agenda to address gaps
WorkgroupsWorkgroups Identifying the patient with complex chronic illnessIdentifying the patient with complex chronic illness
Self-management for patients with complex chronic Self-management for patients with complex chronic illnessillness
Developing the evidence and knowledge base for Developing the evidence and knowledge base for managing patients with complex chronic illnessmanaging patients with complex chronic illness
Improving systems to manage complex chronic careImproving systems to manage complex chronic care
Informatics and complex chronic careInformatics and complex chronic care
Linking system and patient strategies for managing Linking system and patient strategies for managing complexitycomplexity
Identifying the Complex PatientIdentifying the Complex Patient A patient for whom clinical decision making and A patient for whom clinical decision making and
care processes are not standard or routinecare processes are not standard or routine
e.g., conflicting guidelines, exceptions needed e.g., conflicting guidelines, exceptions needed because of homelessness, caregiver supportbecause of homelessness, caregiver support
Need for considering multiple elements of Need for considering multiple elements of complexity: medical, biological, genetic, complexity: medical, biological, genetic, socioeconomic, cultural, behavioral, environmentalsocioeconomic, cultural, behavioral, environmental
Focus on identifying characteristics of high risk Focus on identifying characteristics of high risk cohorts or clusterscohorts or clusters
Self-managementSelf-management
Barriers to self-management may be even greater in Barriers to self-management may be even greater in complex patientscomplex patients
Patient: prioritizing multiple demands, individualized Patient: prioritizing multiple demands, individualized plans, new technologyplans, new technology
Provider: inadequate time & resources, lack of Provider: inadequate time & resources, lack of appropriate treatment guidelinesappropriate treatment guidelines
System: lack of reimbursement for self-management System: lack of reimbursement for self-management support taskssupport tasks
Test new care delivery models – group visits, peer Test new care delivery models – group visits, peer support, telemedicine, MyHealthsupport, telemedicine, MyHealtheeVetVet
Developing an Evidence BaseDeveloping an Evidence Base
Improved research methods (e.g., RCT that Improved research methods (e.g., RCT that include complex patients)include complex patients)
Develop guidelines that address patients with Develop guidelines that address patients with complex conditionscomplex conditions
Educate/train professionals re: complexEducate/train professionals re: complex
Greater use of multidisciplinary teamsGreater use of multidisciplinary teams
Engage patients and caregiversEngage patients and caregivers
Improving SystemsImproving Systems
High quality achieved through maximizing High quality achieved through maximizing functional status, quality of life and patient functional status, quality of life and patient satisfactionsatisfaction
Reduce adverse events, eliminate Reduce adverse events, eliminate unnecessary care, and enhance patient unnecessary care, and enhance patient safetysafety
Patient-centric orientation – foster autonomy Patient-centric orientation – foster autonomy and independence (including decision and independence (including decision making)making)
InformaticsInformatics
Promote communication/information Promote communication/information sharing between providerssharing between providers
Using informatics for patient self-Using informatics for patient self-managementmanagement
Encourage patients to use informatics to Encourage patients to use informatics to share information with providersshare information with providers
Identify and build upon existing systems Identify and build upon existing systems when possiblewhen possible
Linking Patient and SystemLinking Patient and System
Continuity of care over timeContinuity of care over time
Coordination of care across settingsCoordination of care across settings
Engagement of patient and familyEngagement of patient and family
Patient-centered assessment and care Patient-centered assessment and care planningplanning
Collaborative team-based approachCollaborative team-based approach
Point-person/liaisionPoint-person/liaision
Journal SupplementJournal Supplement
J of Gen Intern Med 22(Suppl 3) J of Gen Intern Med 22(Suppl 3) Dec 2007Dec 2007
9 articles based on background 9 articles based on background papers and workgroup efforts of papers and workgroup efforts of the SOTAthe SOTA
Research AgendaResearch Agenda
1.1. Advance our understanding of high risk patients Advance our understanding of high risk patients with complex chronic illnesses and social with complex chronic illnesses and social complexities, including impact on health care complexities, including impact on health care servicesservices
Multiple chronic illnesses (physical and/or Multiple chronic illnesses (physical and/or mental), socioeconomic issues (insurance, mental), socioeconomic issues (insurance, homelessness), caregiving responsibilities, homelessness), caregiving responsibilities, multiple system users, cultural & literacy multiple system users, cultural & literacy issues issues
Research Agenda (cont.)Research Agenda (cont.)
2. Support new studies/research that will 2. Support new studies/research that will information guidelines which are adaptive to the information guidelines which are adaptive to the medical and social complexities of patients with medical and social complexities of patients with complex chronic conditionscomplex chronic conditions
Addition of patients to clinical trials who have Addition of patients to clinical trials who have other conditions/problems beyond the other conditions/problems beyond the condition of study (less stringent criteria)condition of study (less stringent criteria)
Research Agenda (cont.)Research Agenda (cont.)
3. Develop and test healthcare system changes 3. Develop and test healthcare system changes that organize care around the medical and that organize care around the medical and social complexities of illness management, social complexities of illness management, including that of the ‘medical home’including that of the ‘medical home’
Every person should have access to a medical home—a Every person should have access to a medical home—a person who serves as a trusted advisor and provider supported person who serves as a trusted advisor and provider supported by a coordinated team with whom they have a continuous by a coordinated team with whom they have a continuous relationship. The medical home promotes prevention; provides relationship. The medical home promotes prevention; provides care for most problems and serves as the point of first-contact care for most problems and serves as the point of first-contact for that care; coordinates care with other providers and for that care; coordinates care with other providers and community resources when necessary; integrates care across community resources when necessary; integrates care across the health system; and provides care and health education in a the health system; and provides care and health education in a culturally competent manner in the context of family and culturally competent manner in the context of family and community. (AAMC position statement on Medical Home, community. (AAMC position statement on Medical Home, March 2008)March 2008)
Research Agenda (cont.)Research Agenda (cont.)
4.4. Support research that examines best Support research that examines best practices in patient-physician practices in patient-physician communication strategies for care communication strategies for care management decisions (e.g., how to management decisions (e.g., how to prioritize care needs, consideration of prioritize care needs, consideration of other factors that affect care – e.g., other factors that affect care – e.g., family/caregiving responsibilities, living family/caregiving responsibilities, living situation/environment, cultural)situation/environment, cultural)
Research Agenda (cont.)Research Agenda (cont.)
5.5. Design and evaluate new informatics strategies Design and evaluate new informatics strategies to support management of complex chronic to support management of complex chronic carecare
MyHealthMyHealtheeVetVet
Telehealth management – web, health Telehealth management – web, health buddies, etc.buddies, etc.
Research Agenda (cont.)Research Agenda (cont.)
6.6. Examine the role of health care Examine the role of health care financing for patients with multiple financing for patients with multiple chronic conditions and other complex chronic conditions and other complex care needscare needs
Issues of dual useIssues of dual use
Gaps in coverageGaps in coverage