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