On Workforces, Pounds, On Workforces, Pounds, Stress, Diseases, and Stress, Diseases, and

Outcomes Outcomes

Dr. Michael EvansDr. Michael EvansDirector, Knowledge Innovation and Patient SelfDirector, Knowledge Innovation and Patient Self--ManagementManagementCentre for Effective Practice Centre for Effective Practice Director, Health Media Design Lab, Li Kai Director, Health Media Design Lab, Li Kai ShingShing Knowledge InstituteKnowledge InstituteStaff Physician and Associate Professor, Family & Community MedStaff Physician and Associate Professor, Family & Community MedicineicineUniversity of TorontoUniversity of Toronto

FormatFormat

Panel reflects broad range of talentPanel reflects broad range of talentIntroductionsIntroductionsI have reviewed papers and highlighted in I have reviewed papers and highlighted in a presentationa presentationAdded some of my thoughtsAdded some of my thoughtsAsk the panelists to reflect and augment Ask the panelists to reflect and augment (while sitting)(while sitting)All panelists were more interested in All panelists were more interested in questionsquestions

““In the perspective of every person lies a In the perspective of every person lies a lens through which we may better lens through which we may better

understand ourselvesunderstand ourselves.”.” E Langer

Ed WagnerEd Wagner: Chronic Disease : Chronic Disease Management,InnovationManagement,InnovationAlan Maynard (Bob Elliot)Alan Maynard (Bob Elliot): P4P: P4P-- the UK experiment and the UK experiment and outcomesoutcomesIan Ian BowmerBowmer: Big picture, policy, workforce: Big picture, policy, workforceRobert WellsRobert Wells: Australia, policy, workforce, CDM barriers: Australia, policy, workforce, CDM barriersMike EvansMike Evans: KT to primary care, : KT to primary care,

SelfSelf--management/Selfmanagement/Self--care, mediacare, mediaSummarized their reports (?!) Summarized their reports (?!)

and added my own biasand added my own biasThey will correct my inaccuraciesThey will correct my inaccuracies

and illuminate my highlightsand illuminate my highlights

Themes and SubThemes and Sub--ThemesThemes

Chronic DiseaseManagement

CaregiversPatient Self-Management

E-HealthEHR & KMDr. Google

InterprofessionalSystem Change

Knowledge•Why•What to do

Desire•Why bother•Priority

Skills•How to do•Personal strategy

IndividualReality•Resources•Self-efficacy•Habits

What we rarely do

What we do now in a limited way

Where we need to be

From Ed Wagner see www.improvingchroniccare.org

Two major responses to improving Two major responses to improving longitudinal coordinated care in USlongitudinal coordinated care in US

1.1. Disease ManagementDisease Managementstratifies the population by risk and then links high stratifies the population by risk and then links high risk patients with case or care managers, generally risk patients with case or care managers, generally nurses, who provide education, selfnurses, who provide education, self--management management support, and variably involve themselves in clinical support, and variably involve themselves in clinical management. Relationships with physicians are management. Relationships with physicians are generally distantgenerally distant

2.2. Ambulatory practices redesign deliveryAmbulatory practices redesign deliveryemphasize the importance of nonemphasize the importance of non--physician team physician team members in care, and the importance of members in care, and the importance of collaborative selfcollaborative self--management support. management support.

From Ed Wagner Paper

Workforce ChallengesWorkforce ChallengesDM model:DM model:The rapid growth of this industry and strategy The rapid growth of this industry and strategy has contributed to nursing shortages in clinical practice.has contributed to nursing shortages in clinical practice.Redesign Ambulatory care Delivery:Redesign Ambulatory care Delivery: Expansion of Expansion of clinical roles for medical assistants and related staff to clinical roles for medical assistants and related staff to take on responsibilities such as selftake on responsibilities such as self--management management support. Training of existing staff to competently perform support. Training of existing staff to competently perform these tasks is an urgent need not currently well these tasks is an urgent need not currently well addressed.addressed.“Regardless of response type, the “Regardless of response type, the dramatic decline in dramatic decline in primary care residents is the major American human primary care residents is the major American human resource issue regarding chronic care in the U.Sresource issue regarding chronic care in the U.S. If . If current trends continue, basic chronic illness care will of current trends continue, basic chronic illness care will of necessity gravitate to the specialty sector”necessity gravitate to the specialty sector”

From Ed Wagner Paper

Berg AO, Norris TE, Ann Fam Med 2006;4(Suppl 1):S40-S44.

Inserting Chronic Care Skills into Inserting Chronic Care Skills into TrainingTraining

Learning Learning collaborativescollaboratives involving teaching practices involving teaching practices within 31 different US medical schools. within 31 different US medical schools.

The Association of American Medical Colleges (AAMC) partner The Association of American Medical Colleges (AAMC) partner with RWJ/Improving Chronic Illness Carewith RWJ/Improving Chronic Illness Care

Goal is to redesign teaching primary care in accord with Goal is to redesign teaching primary care in accord with the Chronic Care Model;the Chronic Care Model;

Increase resident skills in working with teams, provide selfIncrease resident skills in working with teams, provide self--management support, use registries to organize care, etc. management support, use registries to organize care, etc.

Success measuredSuccess measuredby changes in patient outcomes (e.g.,by changes in patient outcomes (e.g.,↑↑ in the % of diabetic in the % of diabetic patients with HbA1c levels <7% and BP <130/80), patients with HbA1c levels <7% and BP <130/80), ↑↑ in critical processes such as percentage of chronically ill in critical processes such as percentage of chronically ill patients with documented selfpatients with documented self--management goals, and management goals, and improvements in resident involvement in chronic care. improvements in resident involvement in chronic care.

From Ed Wagner Paper

Canadian SnapshotsCanadian Snapshots

1300

1500

1700

1900

2100

2300

2500

198

3

198

5

198

7

198

9

199

1

199

3

199

5

199

7

199

9

200

1

200

3

200

5

200

7

Source: Medical Education Statistics, AFMCNote: Figure for 2005 is estimated

Target of 2500 by 2007

First Year Enrolment in Canadian Medical Schools: First Year Enrolment in Canadian Medical Schools: actual for 1983-2005 and projected for 2006-7

(including 40-50 Visa students)

10% cutCMF report

From Ian Bowmer paper

Migration of Canadian Physicians: 1990Migration of Canadian Physicians: 1990--20042004

-478 -479

-689-635

-777

-674-726

-658-568 -584

-420

-609

-500

-320-262

263 256 259 278 296256

218 227

319 340256

334291

240317

-215 -223

-430-357

-481-418

-508-431

-249 -244-164

-275-209

-80

55

-1000

-800

-600

-400

-200

0

200

400

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Moved abroad Returned Net gain/loss

Source: Supply, Distribution and Migration of Canadian Physicians, CIHI

OutcomesOutcomesIn its soonIn its soon--toto--bebe--published report on health published report on health

outcomes the Health Council of Canada raised a outcomes the Health Council of Canada raised a number of questions:number of questions:Does care match expertDoes care match expert--recommended recommended guidelines?guidelines?Is care efficient and coordinated over time?Is care efficient and coordinated over time?Is care safe?Is care safe?How do people experience care?How do people experience care?How successfully does care prevent avoidable How successfully does care prevent avoidable health problems?health problems?Does care provide good value for money?Does care provide good value for money?

From Ian Bowmer paper

Changing OutcomesChanging OutcomesOutcomes often in silosOften measures of activity, workload, number treated, how long they waited, and surrogate outcomes. We need to answer some rather more fundamental questions such as:

how much good treatment is doing in health terms for patientswhere the greatest health gains are likely to be achievedwhich activities should be expanded and which make such a small contribution at such a high cost that they should be phased out. This is impossible without the routine measurement of patient outcomes.

Alan Maynard wonders why we don’t use Quality of Life (SF 36/12, EQ5D)

Effectiveness of InterventionsEffectiveness of InterventionsBeneficial

15%

Likely to be beneficial

23%

Trade off between benefits and harms

7%Unlikely to be beneficial

5%

Unknown effectiveness

46%

Likely to ineffective or harmful

4%

From Alan Maynard-- Original Source BMJ 2005

“the only message “the only message understood by a doctor has understood by a doctor has

to be written on a cheque”to be written on a cheque”

The Minister of Health The Minister of Health AneurinAneurin Bevan Bevan is alleged to have remarked whilst is alleged to have remarked whilst implementing the NHS in 1948…implementing the NHS in 1948…

yesnoyesyesnopayment per patient for care within a given time period (e.g. a year)

capitation

Yesnoyesyesnopayment per unit of time input (e.g. per month)

salary

Nomaybe*no noyespayment for each medical act

fee-for-service

controls cost of doctor employment

incentive to target the poor

incentive to shift patients’costs to others

incentive to decrease activity

incentive to increase activity

Incentive effectsDefinitionPayment type

From Alan Maynard Paper

Payment of WorkforcePayment of Workforce

Incentives for Best Practice: The Incentives for Best Practice: The UK experimentUK experiment

In Britain, there have been radical and expensive policy In Britain, there have been radical and expensive policy changes in the way primary care providers are paidchanges in the way primary care providers are paidMany lessons can be learnt internationally from this Many lessons can be learnt internationally from this social experiment. social experiment. The contract for GPs was reformed in 2004 with the The contract for GPs was reformed in 2004 with the implementation of the Quality Outcomes Framework implementation of the Quality Outcomes Framework (QOF). (QOF). The GPThe GP--QOF is a target payment system that rewards QOF is a target payment system that rewards performance of group practices (i.e. multiperformance of group practices (i.e. multi--disciplinary disciplinary teams, “led” by GPs and including practice nurses and teams, “led” by GPs and including practice nurses and administrative staff) in relation to their achievement in administrative staff) in relation to their achievement in relation initially to 10 clinical targets and some service relation initially to 10 clinical targets and some service targets. targets.

From Alan Maynard paper

P4PP4PEach clinical area has a number of specific indicators of Each clinical area has a number of specific indicators of performanceperformance

Total of 146 spread across the ten clinical areas.Total of 146 spread across the ten clinical areas.Each point was initially valued at £75, subsequently Each point was initially valued at £75, subsequently raised to £125. raised to £125. Determining the baseline and targets for practices relied Determining the baseline and targets for practices relied on often incomplete data and trust. on often incomplete data and trust. Rewarded on a sliding scale for their performance on the Rewarded on a sliding scale for their performance on the clinical indicators within a range of performance. clinical indicators within a range of performance. E.g. practices were rewarded for screening asthma E.g. practices were rewarded for screening asthma patients over the period of the last 15 months. patients over the period of the last 15 months.

If a 70 per cent target was hit for this service, the practice wIf a 70 per cent target was hit for this service, the practice was as allocated the maximum 20 points. (20x£75=£1500). allocated the maximum 20 points. (20x£75=£1500). If its performance was above 25 and less than 70 per cent the If its performance was above 25 and less than 70 per cent the point allocation was proportionate to the level of performance.point allocation was proportionate to the level of performance.

From Alan Maynard paper

FindingsFindingsPay for performance (Pay for performance (P4PP4P) is a ) is a powerful incentivepowerful incentive. .

Performance in relation to achievable points has generally Performance in relation to achievable points has generally exceeded ninety per cent with signs of improvement between exceeded ninety per cent with signs of improvement between 2005 and 2006.2005 and 2006.

P4P in the UK NHS was P4P in the UK NHS was expensiveexpensive. . The cost of services provided by 35,000 GPs rose by one third The cost of services provided by 35,000 GPs rose by one third between 2003between 2003--4 and 20064 and 2006--7 and the overspend following the 7 and the overspend following the introduction of the new contract was £250 million.introduction of the new contract was £250 million.

P4P has to be focused on P4P has to be focused on evidence of health gain. evidence of health gain. Continuing debate about the imprecision of the Qualities Continuing debate about the imprecision of the Qualities nadnadOutcomes Framework (QOF)Outcomes Framework (QOF)Twin issues of service opportunity cost (what was given up by Twin issues of service opportunity cost (what was given up by practices in the pursuit of QOF income) and how to relate such practices in the pursuit of QOF income) and how to relate such activity orientated indicators to measures of patient outcome.activity orientated indicators to measures of patient outcome.

From Alan Maynard paper

FindingsFindingsThere are There are alternative ways of improving chronic care alternative ways of improving chronic care management.management.

The results of any evaluation of the use of P4P should be The results of any evaluation of the use of P4P should be compared with the cost effectiveness of other interventions so acompared with the cost effectiveness of other interventions so as s to ensure the identification of the “best buy”. For instance to ensure the identification of the “best buy”. For instance community nurses.community nurses.

The The regulation of P4Pregulation of P4P is likely to involve considerable is likely to involve considerable cost. cost.

Negotiating such “changes in the goal posts” will be complex andNegotiating such “changes in the goal posts” will be complex andcostly but essential as the evidence base improves. costly but essential as the evidence base improves.

It seems fair to conclude that the clinical effectiveness of It seems fair to conclude that the clinical effectiveness of the provision of chronic care may have improved but that the provision of chronic care may have improved but that better planning and implementationbetter planning and implementation could have could have induced change more cost effectively.induced change more cost effectively.

From Alan Maynard paper

Conclusions (mine)Conclusions (mine)

UK should be congratulatedUK should be congratulatedBold changeBold changeMade mistakesMade mistakes

Many frustrations (baseline data, too Many frustrations (baseline data, too expensive, opportunity costs, refine expensive, opportunity costs, refine outcomes, reporting) but the black box is outcomes, reporting) but the black box is beginning to be illuminated.beginning to be illuminated.

Observations from an outsider/insider…

Are we targeting the right target?Are we targeting the right target?

Stress Stress

Missing the obviousMissing the obvious

0123456789

10

Chest pa

inFati

gue

Dizzine

ssHea

dache

Edema

Back P

ainDys

pnea

Insom

nia

Abdomina

l Pain

Numbness

Organic cause Unexplained cause

3-year incidence of 10 common symptoms in primary care

Katon WJ, Walker EA. Medically Unexplained Symptoms in Primary Care. J Clin Psychiatry 1998;59[suppl 20]:15-21

Physician WellnessPhysician WellnessPhysician Factors

ProfessionalismAltruismPerfectionismNeed to controlNeed to pleaseResponsibilityStoicismDenial IntellectualizationDelayed gratification

Common Problems50% consider leaving medicine46% advanced stages of burn out18% depressed2% think of suicide45% significant marital difficulties25% consider help2% get help

Good Work ExperiencesGood Work Experiences

Control

Responsibility Reward

Variability?Whitehall Study

Tarassoff

•Double-Decker

Caregivers seek help when…Caregivers seek help when…

“The logic of worldly success rests on a fallacy- that our perfection depends on the thoughts and opinions and applause of others. A weird life it is to be living always in somebody else’s imagination, as if that were the only place in which one could become real.”Thomas Merton, The Seven Storey Mountain

Making career decisions..Making career decisions..TTalent: How

can you focus on your

strengths and manage your weaknesses?

Passion: talents develop best in the context of interest

Aristotle: “Where the needs of the world and your talents cross, there lies your vocation.”

Environment: What work environment

best suits your style,

temperament, and values?

Vision: How you see the rest of your

life. How does your

work fit with the rest of your life?

*Richard Leider

*

Would not choosemedicine

Would stay inprimary care

Would become asurgical/diagnosticspecialist

32% 27%

41%

Most Family Physicians Would Not Choose Primary Care Again

Note: Based on a survey of 232 family physicians. Source: Merritt, Hawkins & Associates

Who is the customer and Who is the customer and what do they want?what do they want?

Valuable

Useful

DesirableUsable

Findable

Credible

Accessible

From Peter Morville

JAMA. 2004;292:1711-1716

1. Lower literacy=worse outcomes 2. Intervention makes more of a difference in those with low

literacy

Mixed Message on Literacy

•Didn’t understand his illness •Let others take responsibility•Didn’t ask questions•Didn’t choose from among appropriate treatment options•Didn’t expect his doctor to explain•Didn’t enjoy a satisfying relationship with his doctor

Rourke J, Ann Fam Med 2006;4(Suppl 1):S40-S44.Adapted from WHO

World Health Organization. Towards Unity for Health: Challenges and opportunities for partnership in health development. Geneva: WHO; 2000.

•Provides services to all, addresses priorities•Quality and cost-effectiveness poor•e.g. national health service with ↓ input from consumers and no competition

•consumer-driven, demanding quality•at high cost•neglecting to meet priority health services/equity. •Such a system exists in many industrialized countries where thereis no impetus to meet the needsof society as a whole

•Consumer-driven •Costs constrained by competition •or regulation. •looks after the interests of its “customers” only•minimal attention to health priorities /underserved populations.

•makes good use of resourceswhile providing care for most

•Poor planning to meet priority health needs. •Seen where the health sector fails to take a comprehensive approach •Less than optimal coordinationof numerous inputs to protect and improve health.

ConclusionsConclusionsDisease Management, Redesigning ambulatory Disease Management, Redesigning ambulatory care delivery, Incentives (disincentives), Selfcare delivery, Incentives (disincentives), Self--Management, Interdisciplinary care…. all part of Management, Interdisciplinary care…. all part of a collaborative.a collaborative.Leadership:Leadership:How do we measure success? How do we measure success?

Mostly poor baseline and only through system change Mostly poor baseline and only through system change does the microscope reveal itself.does the microscope reveal itself.Likely now in A1c’s etc. as we look at diseaseLikely now in A1c’s etc. as we look at disease--specificspecificBut need more global measures (QOL, happiness) to But need more global measures (QOL, happiness) to inform change across silosinform change across silos

ConclusionsConclusions“We Suck Less IncorporatedWe Suck Less Incorporated”

Limit fear of Failure, PerfectionismOften the winner is unexpectedImportance of RelationshipsBroken Rocks (self-knowledge, evaluation, compass)

InterdisciplinaryInterdisciplinary (beyond health)“Envision a new way of being as a medical “Envision a new way of being as a medical professional” professional” Sister Elizabeth Davis

Medicine has completely changed and not at allAre you using all your skills?

The End!The End!