1 the chronic disease crisis robert l. kane, md university of minnesota school of public health
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The Chronic Disease CrisisRobert L. Kane, MD
University of Minnesota
School of Public Health
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Paradox:
We are still practicing acute care medicine in a world of chronic disease
19th century models at the dawn of the 21st century
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Some Ideas are Just Wrong
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No Chronic Conditions
55%
One or MoreChronic
Conditions45%
People with One or More Chronic Conditions Use:
72% of All Physician Visits
76% of All Hospital Admissions
80% of Total Hospital Days
88% of All Prescriptions
96% of All Home Care Visits
Chronic Care:A Universal 21st Century Challenge
WHO has developed a plan for worldwide attention to chronic care
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Productive Interactions
Informed, Activated
Patient and Caregiver
Prepared, Proactive
Practice Team
Health SystemHealth Care Organization
Self-Management Support
Delivery System Design
Decision Support
Clinical Information Systems
Community
Resources and Policies
Improved OutcomesImproved OutcomesWagner, 1996
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Components of Chronic Disease Care
• Patient experience of care• Care delivery teams• Organizations within which
delivery teams and patients interact
• Regulatory and payment environment
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Some Ideas Need More Thought
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Characteristics of Chronic Disease:
• Last a lifetime• Accumulate with age• Generally progressive• Life-shaping • Different meaning in different cultures
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Goals of Chronic Disease Care
1. Manage the disease to reduce exacerbations.2. Prevent the transition from impairment to disability, and
from disability to handicap.3. Encourage patient to play an active role in managing
his/her disease but avoid allowing the disease to dominate the person’s life.
4. Provide care in a culturally sensitive manner.5. Integrate medical care with other aspects of life without
medicalizing those aspects.
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What is involved
• New definitions– Prevention– Patients’ roles– Time– Place
• New approaches– Professional roles– Expectations– Information technology– Management
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A Lot Depends on Interpretation
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Definitions: Prevention
• Prevent exacerbations
• Reduce expensive utilization
• Prevent dysfunction
• Avoid iatrogenic effects
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Definitions: Patients’ Roles
• 365/24/7– Shared responsibility– Shared risk
• Ongoing communication
• Shared decision making– Need better information– Need time
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Definitions: Time
• Episode vs. Encounter• Pay-off horizon
– Up-front investment recovered over time
• Manage by change, not routine– Scheduling appointments– Length of appointments
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Definitions: Place
• Chronic care occurs across locations• The same care can be provided in different settings
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New Approaches: Professional Roles
• Downward delegation– non-physicians– non-professionals
• Primary care– simple cases– complex cases
• New teams– specialists & ANPs
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New Approaches: Expectations
• Cure vs. Management
• Measuring success– actual vs. expected
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ObservedObserved
ExpectedExpected
OutcomeOutcome
TimeTime
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New Approaches: Management
Case Management Variations• Eligibility management• Care coordination• Utilization management• Disease management
– Often independent– Targeted
• Chronic care management
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New Approaches: Management
• Patient self-care (Lorig; J Fries)– Education– Motivation– Attitudinal change
• Doctor-patient partnerships– Information based– Patient empowering
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New Approaches: Information Technology
Problems with too much as well as too little information.Need to focus provider & patient attention on salient data
• Just in time information
• Structured information– Clinical glidepaths
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Need Relevant Information
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Clinical Glidepath• A Clinical Glidepath is a way to observe one or more parameters of a
patient’s condition on a regular basis to be able to compare the observed state with the expected state.
• It is a tool to improve communication between patients and primary care providers.
• If the patients stays within the expected course, nothing need be done.
• But if the patient’s clinical course deviates, this change should trigger immediate closer attention to ward off a problem while it is early.
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o
o
o
X
Clinical Glidepath
Expected Course
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Strategies for Improving Chronic Disease Care
• Interdisciplinary team care– Data elements v data collection
• Group care• Information systems
– Electronic medical record– Computerized physician order entry– Clinical tracking systems
• Mobile computing
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Evidence of Success
• Some encouraging signs but no clear trend• Increased clinic visits and reorganization associated with
fewer hospitalizations and urgent care visits in VA COPD DiabetesPneumonia Chronic renal failureCHF DepressionAngina
Ashton, NEJM, 2003
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Quality care related to better survival among vulnerable older patients
Higashi, Ann Int Med, 2005
Self-management programs for diabetes and hypertension improve outcomes
Chodosh, Ann Int Med, 2005
Medication adherence reduces hospitalizations for diabetes, hypertension, hypercholesterolemia and CHF
Sokol, Med. Care, 2005
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Disease Management Observations
• Multiple definitions• Small number of well designed studies
– Variable content, setting, duration and intensity of intervention
• Evidence weak– Better for process than outcomes– Utilization effects in both directions
• Not clear which DM elements work
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“The prevailing evidence appears to be that while disease management programs improve adherence to practice guidelines and lead to better control of the disease, their net effects on health care costs are not clear.”
CBO, 2004
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Paying for Good Chronic Care
• FFS does not fit chronic care philosophy– No ability to invest– Every item must become billable
• Managed care seemed to offer the ideal setting for chronic care principles, BUT it did not work as well as many had hoped
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Managed Care Strategies
• Favorable case mix selection• Substitution• Primary care investment
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Payment Issues• Providers expect to be paid for what they do• Who will invest in primary care• Medicare as an HMO
– Expand coverage to include new services• Monitoring• Counseling
– Share savings from decreased inpatient/ER utilization– Pay more per visit for fewer visits– Pay for episodes instead of incidents– Pay for outcomes
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Conclusions
• Chronic disease is here to stay• More must be done to bring the health care system into
alignment• There is good scientific evidence to show better care is
possible• Managed care does not seem to be the magic carpet
– If managed care is to have any success, need better case mix payment system
• Changing the payment system is necessary but not sufficient
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How You Implement Is Important
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It Shouldn’t Be This Way: The Failure of Long-Term
Care
Robert L. KaneJoan West
Vanderbilt University Press, 2005
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Our mission is to draw upon the unique credentials of health care professionals as both care recipients (either directly or indirectly) and subject matter experts to promote the changes needed for aligning our medical system better with chronic illness care. Our message to policymakers and health system leaders—If professionals working within the health care system are having serious problems with getting care for themselves and their families, then the system is failing in a major way.
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Meeting the Challenge of Chronic Illness
Robert L. KaneReinhard Priester
Annette Totten
Johns Hopkins University Press, 2005