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Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different? Barbara Starfield, MD, MPH Bellagio, Italy April 2008
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Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

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Page 1: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Chronic Care, Chronic Disease Care, and Primary Care: One and the Same,

or Different?

Barbara Starfield, MD, MPH

Bellagio, ItalyApril 2008

Page 2: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

The purpose of this presentation is to explore the concepts of “disease” and “chronic disease” and to show why a more appropriate focus is on a continuum of care (“primary care”) for all people and populations rather than on care for targeted diseases.

Starfield 03/08D 3978

Page 3: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

The IOM report, Crossing the Quality Chasm, urges selecting priority conditions for attention to the quality of care. The list from which they should be chosen includes cancer, diabetes, emphysema, high cholesterol, HIV/AIDS, hypertension, ischemic heart disease, stroke, and perhaps also arthritis, asthma, gall bladder disease, stomach ulcers, back problems, Alzheimers, depression, anxiety disorders.

Starfield 02/08D 3948

Why aren’t undernutrition, occupational diseases, osteoporosis, low birth weight and prematurity, or virtually any childhood disorder (except asthma) considered high priority? Who should decide what a priority disease is? The disease experts?

Page 4: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Diseases

• are professional constructs• can be and are artificially created to suit

special interests; the sum of deaths attributed to diseases exceeds the number of deaths

• do not exist in isolation from other diseases and are, therefore, not an independent representation of illness

• are but one manifestation of ill health

Starfield 08/07D 3831

Sources: Chin. The AIDS Pandemic: the Collision of Epidemiology with Political Correctness. Radcliffe Publishing, 2007. De Maeseneer et al. Primary Health Care as a Strategy for Achieving Equitable Care: a Literature Review Commissioned by the Health Systems Knowledge Network. WHO Health Systems Knowledge Network, 2007. Available at: http://www.wits.ac.za/chp/kn/De%20Maeseneer%202007%20PHC%20as%20strategy.pdf. Mangin et al, BMJ 2007; 335:285-7. Murray et al, BMJ 2004; 329:1096-1100. Tinetti & Fried, Am J Med 2004; 116:179-85. Walker et al, Lancet 2007; 369:956-63.

Page 5: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Are diseases really discrete categorizations of pathology?

Starfield 03/08D 3979

Page 6: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

There appear to be many disorders included under the rubric of diabetes: insulin secretion; insulin transport; zinc-binding to insulin; and pancreatic islet beta cell development.

Starfield 03/08D 3980

IS DIABETES A DISEASE? DOES IT MAKE SENSE TO ASSUME THAT GUIDELINES FOR THE IDENTIFICATION AND MANAGEMENT OF DIABETES APPLY TO ALL “DIABETICS”?

Source: Topol et al, JAMA 2007; 298:218-21.

Page 7: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

In a relatively small-scale study, diabetics who have weight loss are five times more likely to have their diabetes disappear than diabetics who have standard diabetes care.

Starfield 02/08D 3940Source: Dixon et al, JAMA 2008; 299:316-23.

Questions:  Is diabetes a “chronic disease”? Is it a disease?

Page 8: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

If the association between obesity and diabetes is absent in people with low concentrations of persistent organic pollutants, and the association becomes stronger as the concentration of these pollutants rises, is obesity a risk factor for diabetes? Is diabetes a single disease?

Starfield 02/08D 3944Source: Jones et al, Lancet 2008; 371:287-8.

Page 9: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

If three diabetics per one thousand per year die from the implementation of supposedly evidence-based treatment, is diabetes a single disease?

Starfield 02/08D 3946

Source: Kolata G. Diabetes study partially halted after deaths. Seattle, WA: University of Washington press release, February 2, 2008.

Page 10: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

There is broad variation in breast cancer risk among carriers of BRCA1 and BRCA2 mutations.

Starfield 02/08D 3939

Source: Begg CB, Haile RW, Borg A et al. Variation of breast cancer risk among BRCA1/2 carriers. JAMA 2008; 299(2):194-201.

Question: Is BRCA1 and BRCA2-related breast cancer a disease?

Page 11: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

If a 90-year-old woman dies two months following hip fracture, did she die from an acute disease or a chronic disease?

Starfield 02/08D 3943

What is the “cause of death” likely to be coded as?

Page 12: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

If oral contraceptives are protective on epithelial and non-epithelial cervical cancer but not on mucinous cervical cancer, is cervical cancer a single disease?

Starfield 02/08D 3945Source: Franco & Duarte-Franco, Lancet 2008; 371:277-8.

Page 13: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

COPD is a chronic systemic inflammatory syndrome with complex chronic co-morbidities. Patients with COPD mainly die of non-respiratory disorders such as cardiovascular disease or cancer.

COPD is a heterogeneous disease process.

Although exacerbations of COPD, especially those defined as being infectious, are quite frequent, the number of randomized placebo-controlled trials of antibiotics is surprisingly small.

Sources: Fabbri & Rabe, Lancet 2007; 370:797-9. Calverley & Rennard, Lancet 2007; 370:774-85.Starfield 10/07D 3907

Page 14: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

When occurring in the same individual, BMI greater than 30, systolic blood pressure greater than 140, and blood cholesterol greater that 250 mg/dL are associated with a six-fold increased odds of Alzheimers disease.

What type of disease is Alzheimers? What is the disease?

Source: Michel et al, JAMA 2008; 299:688-90.Starfield 03/08D 3981

Page 15: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Hypothyroidism is three times more likely in women with rheumatoid arthritis than in the general population. Women with both conditions have a fourfold higher risk of cardiovascular disease than euthyroid women with arthritis, independent of conventional risk factors. Inflammation and autoimmunity are implicated in vulnerability to a wide variety of “chronic” diseases – and they may well be “acute”.

Source: Raterman et al, Ann Rheum Dis 2008; 67:229-32.Starfield 03/08D 3982

Page 16: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

What Is a Chronic Disease?

Starfield 10/06D 3459

Generally defined as persistence or recurrence, usually beyond one year

Page 17: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Chronic Disease: Expanded Definition

• Incurable• Complex “causation”• Multiple risk factors• Long latency• Prolonged course• Associated with functional impairment or

disability

Starfield 05/07D 3710

Source: Australian Institute of Health and Welfare. Indicators for Chronic Diseases and Their Determinants, 2008. Canberra, Australia: AIHW, 2008.

Page 18: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

How “chronic” are chronic diseases?

Starfield 10/07D 3888

Page 19: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Persistence of Diagnoses*

Overall prevalence

time 2Prevalence among those having diagnosis in time 1

Obesity 69 539 (x 7.8)

Asthma 70 628 (x 9.0)

Autoimmune disorder 18 641 (x 35.6)

Seizures 10 670 (x 67.0)

*per 1000, not adjusted for age

Starfield 04/0202-067Starfield 09/07D 3860 n

Page 20: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Persistence of Diagnoses*

Overall prevalence

time 2Prevalence among those having diagnosis in time 1

UTI 87 350 (x 4.0)

Hypertension 213 879 (x 4.1)

Headache 102 455 (x 4.5)

Lipoid disorders 144 720 (x 5.0)

*per 1000, not adjusted for age

Starfield 04/0202-066Starfield 09/07D 3861 n

Page 21: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Persistence of Diagnoses*Overall

prevalence time 2

Prevalence among those having diagnosis in time 1

URI 357 585 (x 1.6)

Pneumonia, non-bacterial 186 378 (x 2.0)

Sinusitis 231 525 (x 2.3)

Musculoskeletal s/s 190 461 (x 2.4)

Dermatitis, eczema 109 302 (x 2.8)

Abdominal pain 116 326 (x 2.8)

Otitis media 136 452 (x 3.3)

*per 1000, not adjusted for ageStarfield 04/0202-065Starfield 09/07D 3862 n

Page 22: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Not all chronic diseases are manifested year to year.

Acute diseases sometimes behave as if they were chronic, recurring year to year.

Only a minority of common chronic diseases or conditions are currently candidates for the vast majority of chronic disease management programs.

Acute and chronic conditions share a characteristic: inflammation.

Starfield 08/06D 3435

Page 23: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

People and populations differ in their overall vulnerability and resistance to threats to health. Some have more than their share of illness, and some have less. Morbidity mix (sometimes called case-mix) describes this clustering of ill health in patients and populations.

Starfield 03/06CM 3372

Page 24: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Influences on the Health of Individuals

For influences at the community level, there is a spectrum from those that are aggregations from individual-level data to those that are ecological in nature.

*“Health” has two aspects: occurrence (incidence) and intensity (severity).

SOCIODEMOGRAPHICCHARACTERISTICS

GENETIC &BIOLOGICAL

CHARACTERISTICS

DEVELOPMENTALHEALTH

DISADVANTAGE

POLITICALAND

POLICYCONTEXT

WEALTH: LEVEL &DISTRIBUTION**

POWERRELATIONSHIPS

HEALTH SYSTEMCHARACTERISTICS

BEHAVIORAL &CULTURAL

CHARACTERISTICS

OCCUPATIONAL &ENVIRONMENTAL

EXPOSURES

HEALTH*

PHYSIOLOGICAL STATE

MATERIALRESOURCES

SOCIALRESOURCES

BEHAVIORS

CHRONICSTRESS

HEALTH SERVICES RECEIVED

Starfield 04/07IH 3637

**Including income inequality

Source: Starfield, Soc Sci Med 2007; 64:1355-62.

Page 25: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Influences on Health Equity

SOCIALPOLICY

ECONOMICPOLICY

WEALTH: LEVEL &DISTRIBUTION**

POWER RELATIONSHIPS***

HEALTH SYSTEMCHARACTERISTICS

AVERAGE HEALTH*

DEMOGRAPHICSTRUCTURE

BEHAVIORAL &CULTURAL

CHARACTERISTICS

EQUITY IN HEALTH*

Dashed lines indicate the existence of pathways through individual-level characteristics that most proximally influence health.

For influences at the community level, there is a spectrum from those that are aggregations from individual-level data to those that are ecological in nature.

HISTORICAL HEALTH

DISADVANTAGE

POLITICALCONTEXT

*“Health” has two aspects: occurrence (incidence) and intensity (severity).

OCCUPATIONAL &ENVIRONMENTAL

POLICY

HEALTHPOLICY

Starfield 04/07IH 3638

ENVIRONMENTALCHARACTERISTICS

Source: Starfield, Soc Sci Med 2007; 64:1355-62.

**Including income inequality

***Including social cohesion

Page 26: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

IH 3789 n

Etiologic HeterogeneityEtiologic HeterogeneityCause A Cause B Cause C

Dis-ease 1

PleiotropismPleiotropism

Dis-ease 3

Cause A

Dis-ease 1 Dis-ease 2

PenetrancePenetrance

No Dis-ease

Cause A Cause B Cause C

Starfield 07/07IH 3789 n

Page 27: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Starfield 03/08IH 3983

Source: Australian Institute of Health and Welfare. Indicators for Chronic Diseases and Their Determinants, 2008. Canberra, Australia: AIHW, 2008.

Etiologic Heterogeneity# of different conventional risk factors

IHD 9

Stroke 7

Diabetes 6

Kidney disease 5

Arthritis 3

Osteoporosis 4

Lung cancer 1

Colorectal cancer 4

COPD 2

Asthma 2

Depression 5

Oral problems 3

Page 28: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Starfield 03/08IH 3984

Source: Australian Institute of Health and Welfare. Indicators for Chronic Diseases and Their Determinants, 2008. Canberra, Australia: AIHW, 2008.

Pleiotropism# of specific diseases associated

with selected risk factors

Smoking 9

Physical activity 7

Alcohol 7

Nutrition 7

Obesity 7

Hypertension (?) 3

Dyslipidemia (?) 2

Impaired glucose tolerance (?) 1

Proteinuria (?) 1

Page 29: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

There is more variability in disease manifestations and persistence within diseases than across diseases because:

• diseases are not necessarily unique pathophysiological entities

• variability in diagnostic styles and practices

• presence of co-morbidity

Starfield 10/01D 3887

Page 30: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Co- and Multi-morbidity(Morbidity Burden)

Starfield 09/07CM 3864 n

Page 31: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Co-morbidity is the concurrent existence of one or more unrelated conditions in an individual with any given condition. Multi-morbidity is the co-occurrence of biologically unrelated illnesses.

Starfield 03/06CM 3375

For convenience and by common terminology, we use co-morbidity to represent both co- and multi-morbidity.

Page 32: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Distribution of Morbidity in a Non-Elderly Insured Population: 1 Year Experience (US)

0

10

20

30

40

0 1 2 3 4 5 6 7 8 9 10+

Nos. of morbidity types (ADGs)

% o

f p

op

ula

tio

n

Source: HMO health plan with 500K members.Starfield 09/0000-058Starfield 09/07CM 3865 n

Page 33: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Morbidity Burdens of Socially Disadvantaged and Socially Advantaged People

0 5 10 15 20 25 30

10+ Morbidity-Types

6-9 MorbidityTypes

% of Total Population

HMO

CHC (Disadvantaged)

Starfield 09/07CM 3866 n

Page 34: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

The high frequency of

Co-morbidity

Multi-morbidity

Morbidity burden

makes it inappropriate to focus on single diseases

Starfield 03/08CM 3985

Page 35: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Co-morbidity, Inpatient Hospitalization, Avoidable Events, and Costs*

11

362

296

267

216

169

119

74

40

208

17

34

57

86

119

152

182

233

84

211

1154

2394

4701

13,973

0

50

100

150

200

250

300

350

400

0 1 2 3 4 5 6 7 8 9 10+

Number of types of conditions

Ra

te p

er

1000

be

ne

fici

ari

es

0

2000

4000

6000

8000

10000

12000

14000

16000

Co

sts

ACSC Complications Costs

(4 or moreconditions)

Source: Wolff et al, Arch Intern Med 2002; 162:2269-76. *ages 65+, chronic conditions only

Starfield 11/06CM 3503 n

Page 36: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

The greater the morbidity burden, the greater the persistence of any given diagnosis.

Starfield 08/06CM 3439

That is, with high co-morbidity, even acute diseases are more likely to persist.

Page 37: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Odds Ratios and Confidence Intervals for Persistence* by Degree of Co-morbidity: Urinary Tract Infection

*controlled for age and sex C Statistic .633Starfield 10/0303-346

0.225

0.3400.422

0.532 0.5720.513

0.729

0.877

1.1031.1691.166

1.563

1.821

2.283

2.393

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

1 2 3 4 5Low High

Degree of co-morbidity

Starfield 09/07D 3863 n

Page 38: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Expected Resource Use (Relative to Adult Population Average) by Level of Co-Morbidity, British Columbia, 1997-98

Starfield 09/07CM 3867 n

None Low Medium HighVery High

Acute conditions only

0.1 0.4 1.2 3.3 9.5

Chronic condition 0.2 0.5 1.3 3.5 9.8

High impact chronic condition

0.2 0.5 1.3 3.6 9.9

Source: Broemeling et al. Chronic Conditions and Co-morbidity among Residents of British Columbia. Vancouver, BC: University of British Columbia, 2005.

Thus, it is co-morbidity, rather than presence or impact of chronic conditions, that generates resource use.

Page 39: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Increase in Treated Prevalence: Selected Conditions, US, People with Private

Insurance, 1987-2002 Treated Prevalence Percentage Change, 1987-2002

Hyperlipidemia 437(Heart disease 9) Bone disorders 227Upper GI problems 169Cerebrovascular disease 161Mental problems 136Diabetes 64Endocrine disorders 24Hypertension 17Bronchitis 13

Source: Thorp et al, Health Affairs 2005; W5:317-25, 2005.Starfield 09/06D 3858

Page 40: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

As thresholds for diagnosing disease are lowered over time, the variability within “diseases” will increase even further, as will the prevalence of multiple simultaneous or sequential diseases.

Starfield 03/08D 3986

Page 41: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

What is needed is person-focused care over time, NOT disease-focused care.

Starfield 10/06PC 3462

Page 42: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Top Ten Health Conditions and Impact on Costs

Starfield 03/08D 3994

Medical and Rx costs Lost productivity costs Total costs

1 Other cancer Fatigue Back/neck pain

2 Back/neck pain Depression Depression

3 Coronary heart disease Back/neck pain Fatigue

4 Other chronic pain Sleeping problem Other chronic pain

5 High cholesterol Other chronic pain Sleeping problem

6 Gastroesophageal reflux disease

Arthritis High cholesterol

7 Diabetes Hypertension Arthritis

8 Sleeping problem Obesity Hypertension

9 Hypertension High cholesterol Obesity

10 Arthritis Anxiety Anxiety

Source: Loeppke et al, J Occup Environ Med 2007; 49:712-21.

Page 43: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

When people (not diseases) are the focus of attention

• Outcomes are better

• Side effects are fewer

• Costs are lower

• Population health is greater

Starfield 09/07PC 3868 nSource: Starfield et al, Health Aff 2005; W5:97-107.

Page 44: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

What Is the Appropriate Care Model?

• Primary care that meets primary care (not disease-specific) standards*

• Specialty referrals that are appropriate, i.e., evidence-based**

• Specialty care that meets specialty care standards**

Starfield 03/06PC 3377

*exist**do not exist

Page 45: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Primary care “works” because it has defined functions that include structural and process features of health services that are known to improve outcomes of care.

Starfield 03/08PC 3987

Page 46: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

The Health Services System

Starfield 199797-103

CAPACITY

PERFORMANCE

HEALTH STATUS(outcome)

Provisionof care

Receiptof care

PersonnelFacilities and equipmentRange of servicesOrganizationManagement and amenitiesContinuity/information systemsAccessibilityFinancingPopulation eligibleGovernance

People/practitioner interface

Cultural andbehavioral

characteristics

Social, political,economic, and

physical environments

Biologic endowmentand prior health

Problem recognitionDiagnosisManagementReassessment

UtilizationAcceptance and satisfactionUnderstandingConcordance

LongevityComfortPerceived well-beingDiseaseAchievementRisksResilienceSource: Starfield. Primary Care:

Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.

Starfield 1997HS 1064

Page 47: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Primary Care

Starfield 02/08EVAL 3968

First Contact • Accessibility• Use by people for each new problem

Longitudinal • Relationship between a facility and its population

• Use by people over time regardless of the type of problem; person-focused character of provider/patient relationship

Comprehensive • Broad range of services• Recognition of situations where services are

needed

Coordination • Mechanism for achieving continuity• Recognition of problems that require follow-up

Page 48: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Structural and Process Elements of the Essential Features of Primary Care

Essential Features Performance

Utilization

Person-focused relationship

Capacity

Accessibility

Eligible population

Range of services

Continuity

First-contact

Longitudinality

Comprehensiveness

Coordination

Problem recognition

Starfield 199797-194

Starfield 04/97EVAL 1108

Page 49: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Primary Care Oriented Health Services Systems

CAPACITY

PERFORMANCE

HEALTH STATUS(outcome)

Provisionof care

Receiptof care

PersonnelFacilities and equipmentRange of servicesOrganizationManagement and amenitiesContinuity/information systemsAccessibilityFinancingPopulation eligibleGovernance

People/practitioner interface

Cultural andbehavioral

characteristics

Social, political,economic, and

physical environments

Biologic endowmentand prior health

Problem recognitionDiagnosisManagementReassessment

UtilizationAcceptance and satisfactionUnderstandingConcordance

LongevityComfortPerceived well-beingMorbidity burdenAchievementRisksResilienceSource: Starfield. Primary Care:

Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.

Starfield 10/07HS 3890

Page 50: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

There is no formal quality assessment approach that includes the critical feature of problem-recognition, despite the evidence that patients are more likely to improve when they and their practitioner agree on what their problem is.

Starfield 03/08Q 3988

Sources: Starfield et al, JAMA 1979; 242:344-46. Starfield et al, Am J Public Health 1981; 71:127-31.

Page 51: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Is chronic care management the same as or pursuant to primary care?• Person-focused?

• Contributory to at least one of the four main features of primary care?

Starfield 03/08CM 3989

Page 52: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Is CCM part of primary care or separate from it?

• If the need for it is uncommon (as the data suggest), it is a referral function.

• If the need for it is common, it is a way of enhancing some important and heretofore neglected element of care, possibly problem recognition.

Starfield 03/08CM 3990

Question: What critical process of care is served by CCM? Problem recognition? If not, what?

Page 53: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Of all global deaths in 2005, 60% were because of chronic diseases, principally cardiovascular diseases (32%), cancers (13%), and chronic respiratory diseases (7%). Data such as these are used to argue that chronic diseases are of growing and epidemic importance as causes of death.

Starfield 02/08D 3949Source: Beaglehole et al, Lancet 2007; 370:2152-7.

Question: What is the appropriate target for the percentage of deaths in the world that are attributable to chronic diseases? Isn’t there a case to be made that perhaps ALL deaths should be due to chronic diseases, with acute illnesses falling towards zero percentage?

Page 54: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

Deaths may be attributed to chronic diseases, but people still get sick from acute diseases and acute exacerbations.

Any enhancement of primary care has to deal with this reality.

Starfield 03/08D 3991

Page 55: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

The global imperative is to organize health systems around strong, patient-centered, i.e., Primary Care.

A disease-oriented approach to global health will almost certainly worsen global inequities. Those exposed to a variety of interacting influences are vulnerable to many diseases. Eliminating diseases one by one will not materially reduce the chances of another.

Starfield 03/08GH 3992

Page 56: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?
Page 57: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

It appears that there may be only a few “types” of  medical problems, based on most predominant etiology:

• Infectious• External injury• Developmental/physical abnormality• Mendelian dominant genetic• Autoimmune• Cellular degradation/degeneration

Starfield 02/08D 3941

Question: If this is true or even only partly true, is the International Classification of Diseases a useful schema for classifying health problems? Might there be one that lends itself better to understanding etiology for the purpose of more effective prevention and treatment?

Page 58: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

The Impact of Seeing Many Different Physicians

• More DIFFERENT specialists seen: higher total costs, medical costs, diagnostic tests and interventions, and types of medication

• More DIFFERENT generalists seen: higher total costs, medical costs, diagnostic tests and interventions

• More generalists seen (LESS CONTINUITY): more DIFFERENT specialists seen. The effect is independent of the number of generalist visits.

Starfield 09/07CMOS 3854

Controlling for morbidity burden*

*Using the Johns Hopkins Adjusted Clinical Groups (ACGs)

Source: Starfield et al, Ambulatory specialist use by patients in US health plans: correlates and consequences. Submitted 2008.

Page 59: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

There are methods, e.g., the Johns Hopkins Adjusted Clinical Groups, for categorizing patients and populations according to their burden of diagnosed illness.

Starfield 10/06CM 3460