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Chronic disease
Practice & 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
Fig. 1. Impact of multiple morbidity on Medicare expenditures
G. D. Wieland, Sci. Aging Knowl. Environ. 2005, pe29 (2005)
Published by AAAS
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 a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Characteristics of study
population (n 92)
•
•
•
•
•
•
Female : 49 (53%)
Number of chronic conditions
Number of current medications
GP visit in last 12/12
P/nurse visit in last 12/12
Hosp visit in last 12/12
:4
: 7.5
: 11.7
: 1.0
: 3.3
Prevalence of conditions %
•
•
•
•
•
•
•
Lipid disorders 15
Hypertension 12.5
Depression
5.5
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
Multimorbidity
Female
Single
morbidity
20 (48%)
Mean age
54
56
GP visits
7
13
Current meds 2.3
30 (48%)
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
Emergency admission rates for general population aged >=65 in Evercare/Community
matrons and control practices. July 2001 to March 2005
Gravelle, H. et al. BMJ 2007;334:31
Copyright ©2007 BMJ Publishing Group Ltd.
Guided nurse care
Leff 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 :
Hypertension
– Protocol driven
• Complicated
:
Open heart surgery
:
Angina + alcohol+DM +
family problems
– Need specialised
expertise
• Complex
– Additionally need
knowledge of locality,
social networks
• Chaotic
:
– Brittle clinical & social
problems
Angina + DM + alc binging
+ disadvantage
What we know
- Donald Rumsfelt 2008
• Known knowns :
• Hospital budgets will be
smaller. Bigger role for
nurses
• Known unknowns :
• Role of nurses, OTs,
pharmacists
• Unknown
unknowns:
• 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