the community and duke: changing health care delivery

THE COMMUNITY AND DUKE:

J. Lloyd Michener, MD

Professor and Chair

Department of Community and Family Medicine

Director, Duke Center for Community Research

Duke University Health System

American Association of Colleges of Osteopathic Medicine (AACOM)

April 9, 2010

DURHAM HEALTH INNOVATIONS Changing Health Care Delivery Systems –

Implications for Medical Education

How do you start to fix the foundational issue around why our healthcare system is so expensive and yet so broken??

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United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Average spending on healthper capita ($US PPP)

Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data

Problem 1. Cost

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88 84 89 8999 97

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109 106116 115 113

130 134128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

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1997/98 2002/03

Countries’ age-standardized death rates, list of conditions considered amenable to health care Source: E. Nolte and C. M. McKee, Measuring the Health of Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1):58–71

USA worse/1937th by WHO

Problem 2. Quality

We are trying to provide care through a system designed for acute care

When Most Illness is Chronic

*Source: Paez KA, Zhao L, Hwang W. Rising out of pocket spending for chronic conditions: A ten year trend. Health Affairs, Vol 28, Number 1, pp 15-23.

MEPS Survey 2005

16.5

19.9

24

20.214.8

3.78.4

16.7

21.5

20.2

1.2 4.4

22.4

45.354.2

10.813.1

36.9

67.678.6

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0-19 20-44 45-64 65-79 80+

None One Two Three or more

Most Causes of Illness are Related to Health Behaviors

Source: IFTF; Centers for Disease Control and Prevention.

Genetics(20%)

Access to care(10%)

Health Behaviors(50%)

Environment(20%)

1998

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2007(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)

2007

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: CDC Behavioral Risk Factor Surveillance System

Green LA, Fryer GE Jr, Yawn BP, Lanier D, and Dovey SM. Ecology of Medical Care Revisited. NEJM 344:2021-205. June 28, 2001.

Most illness and care occurs in the community

Source: The Quality of Medical Care in the United States: A Report on the Medicare Program. The Dartmouth Atlas ofHealth Care 1999. The Center for the Evaluative Clinical Sciences Dartmouth Medical School

Disease Burden/Practice Patterns Vary

Percent African American (quantiles)

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0.1% - 14.9%

15% - 38.5%

38.6% - 81.5%

81.6% - 100%

Hypertension Patients06-07

Patterns of illness vary locally too

Presenter

Presentation Notes

Now we take a subset of the data from the first set of slides. We focus on a particular health endpoint by selecting only those patients who had a HTN diagnosis. Note still simulated data. Left map still percent African-American. Right map now patients from same time period with HTN diagnosis. Note that while this map matches up with the population density of the county, it is more aligned with the % AA map. Middle map distinguishes between those patients with a HTN diagnosis who were seen in clinic (yellow dots) versus those seen through the ED (blue dots). Note that the pattern of blue dots is very closely aligned with the % AA map. It’s not enough to understand what’s happening at the county or zip code level. When we apply a highly resolved geographic scale, we see important differences across neighborhoods. We should be using technologies like this to shape our strategic planning around how to deliver health care more effectively.

Source: American Association of Family Physicians (AAFP), March 2010

Interest in Primary Care

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Positions Offered Positions Filled

Family MedicinePositions Offered & Filled

It’s (partially) the money...

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Pediatrics

Family Medicine

Internal Medicine

Family Medicine w OB

Nurse Anesthetist

Cardiology

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And also time...

Type of Visit Hours/Day

AcuteChronicPreventiveTotal or mean

3.710.67.4

21.7

Time Required to Meet Clinical Guideline Recommendations

Data obtained from National Ambulatory Medical Care Survey, 2006

Source: Yarnall KSH, Ostbye T, Krause KM, Pollak KI, Gradison M, Michener JL. Family physicians as team leaders: “time” to share the care. Prev Chronic Dis 2009;6(2).

Yes...we can

Can We do Better?

What will this require?Practice what we teach; teach what we practice; research how to do better

University• Coordinated placement/pipeline program

Professional Schools• Training and practice in teamwork

• Primary care leadership

PA, NP, PT

• Expansion of program size; teamwork

Residency

• Restructure around improving population health

• Clinical Leadership

Faculty and Staff• Classes, Grand Rounds, online training in community engagement

• Shift practice and research to improving community outcomes

the community and duke: changing health care delivery

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