The Prospects of Success for Chronic Disease Management Hugh Walker, Ph.D. Professor of Health Economics, Queen’s Medical School Rural Health Sciences.

The Prospects of Success for Chronic Disease Management

Hugh Walker, Ph.D.Professor of Health Economics, Queen’s Medical School

Rural Health Sciences Network

Chronic Disease Management CharetteKingston, Ontario --- December 8th, 2006

Setting the Stage

3

Pressures on the Health System

• aging

• growing incidence of chronic diseases

• shortages of health professionals

• costs, costs, costs

4

Health System Opportunities

• better management of chronic diseases

• improved population health

• slowing progress of chronic illness

• better quality of life for many people

• grass roots opportunities to make a health difference

5

Glucose Monitoring with A1C Test

A1C Test – a one % point reduction can reduce by:• 43% - risk of amputation• 37% - microvascular complications• 21% - risk of death related to diabetes• 21% - risk of diabetes complications• 14% - myocardial infarction• 12% - risk of stroke

• and you feel better!!

Overview of Chronic Disease Burden

7

Chronic Disease in the Industrialized World

• Across the industrialized world chronic disease accounts for the vast majority of all reported deaths.

• Africa is the only continent where chronic disease is not the leading cause of death.

8

WHO: Chronic Disease in Canada

• 89% of deaths in Canada• over next 10 years, deaths from diabetes

(“the global epidemic of the 21st century”) will increase by 44%• overweight and obesity is a major risk

factor for Chronic Disease • 70% of men and 73% of women over 30

are overweight/obese• overweight/obesity is expected to increase

9

1. Diabetes Mellitus

2. Hypertension

3. Congestive Heart Failure

4. Asthma

5. Chronic Lung Disease

6. Chronic Depression

7. Chronic Renal Failure

Best “Candidate” Diseases for Chronic Disease Management

(B.C. Family Physicians)

10

11

Stages of a Chronic Disease

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Estimate of Chronic Disease Prevalence in Hastings and Prince Edward Health Unit

Disease Cases Disease Prevalence

Hypertension 22,924 15%

Asthma 12,307 8%

Osteoarthritis 9,501 6%

Diabetes 8,159 5%

COPD 2,820 2%

Congestive Heart Failure 2,685 2%

Rheumatoid Arthritis 1,433 1%

13

Refer to Large Handout with Hastings – Prince Edward

statistics

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17.5

14.7

8.3

4.6

2.7

7.2

23.3

16.6

8.5

5.6

3

10.1

0 5 10 15 20 25 30

Arthritis/Rheumatism

High Blood Pressure

Asthma

Diabetes

Chronic Bronchitis

Heart Disease

%

South East LIHN

Ontario

Prevalence of Chronic Conditions, (population 12+, heart disease 30+)

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Number of Chronic Conditions

Age 20-39

Age 40-59

Age60-79

Age80+

0 62% 44% 20% 12%

1 27% 30% 25% 24%

2 8% 14% 24% 22%

> 2 3% 12% 31% 42%

Number of Chronic Conditions, by Age

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Use of Health Care Resources by 20-30 Age Group

by Numbers of Chronic Conditions per Patient

62

27

83

47

32

129

38 36

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0

10

20

30

40

50

60

70

0 1 2 >2Number of Chronic Conditions

% o

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Gro

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% of Pop

% of MD Consults

% Total Hosp Days

18



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14

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22

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16

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20

Use of Health Care Resources by 80+ Age Group


12

24 22

42

8

1623

53

7

1520

58

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10

20

30

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50

60

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Cost Pressures

22

Alberta H&W Funding Rates by Age and Gender 2005-06

0

5,000

10,000

15,000

20,000

25,000

30,000

Age Group

$

FemaleMale

23

Estimated Economic Burden of Illness by Cost Component in Canada, 2005

Cost Component 2005 Cost in $000’s % of Total

Direct Costs

Hospital Care Expenditure $42,390 16%

Drug Expenditure $24,775 9%

Physician Care Expenditure $18,154 7%

Expenditure for Care in Other Institutions

$13,257 5%

Additional Direct Health Expenditures

$43,393 16%

Subtotal $141,969 53%

Indirect Costs

Pre-Mature Mortality Costs $56,616 21%

Morbidity Costs due to long term disability

$54,415 20%

Morbidity Costs due to short term disability

$16,604 6%

Subtotal $127,635 47%

Total Cost of Illness $269,604 100%

24

Total Health Expenditure as a % of Provincial GDP

0

2

4

6

8

10

12

14

16

Year

% o

f P

rovi

nci

al G

DP

NovaScotiaOntario

Alberta

25

Estimated Drug Costs for Eight Weeks of Treatment for Metastatic Colorectal Cancer

• If all drugs available and active in metastatic colorectal cancer were used in sequence the cost/patient would be ~ $250,000

• NOTE: 7500 people in Ontario get colorectal cancer/year and 3100 die/year

Regimen Drugs and Schedule of Administration

Drug Costs ($)

Flurouracil Weekly – Monthly $63 - $263

Irinotecan Weekly – biweekly $9457 - $11,889

Bevacizumab Weekly – biweekly $21,399 - $30,675

26

Examples of Current Drug Costs/Month – based on 1.7m2 person

• Bortezomib (Velcade) - $6297• Sorafenib (Nexavar) - $5000• Sunitinib (Sutent) - $4631• Rituximab (Rituxan) - $4076• Bevacizumab (Avastin) - $3500• Traztuzumzb (Herceptin) - $3436• Imatinib (Gleevec) - $3241• Temozolomide (Temodol) - $2938• Erlotinib (Tarceva) - $2532

27

The Future of Cancer Costs

1. Number of new patients requiring chemotherapy increasing at 7% per year

2. Chemotherapy drugs are predicted to at least double in price in the next 10 years

3. Chemotherapy visits increasing by 25% per year

4. Cancer drug expenditures are increasing at 22% per year.

28

Summary of Cancer Drug Approval and Public Funding Status

Approved and

FundedLimited Access/Funding

Recommended But Not Funded

Not Approved or Funded

British Columbia 21 1 0 2

Alberta 7 7 6 4

Saskatchewan 12 2 4 6

Manitoba 9 10 0 5

Ontario 6 13 1 4

Quebec 14 8 0 2

New Brunswick 15 4 0 5

Nova Scotia 5 10 2 7

P.E.I 4 6 1 13

NFLD & Lab 9 6 1 8

Risk Factors for Chronic Disease

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Risk Factors

• Smoking

• Overweight & obesity

• Diet

• Physically inactive

• Low income

• Non-compliance

• Lack of knowledge

31

Progress on Risk Factors

• 50% reduction in smoking over 30 years

• Overweight and obesity worsening

• Inactivity --- little improvement

• Low patient expertise

• Availability of monitoring devices

32

We Need Better Information about What We Eat

• How many consumers realize that a venti Caffè Mocha with breve milk and whipped cream at Starbucks punishes them with 770 calories, a third of their daily quota of 2000?

• And how many Burger King customers realize that a single meal consisting of a triple Whopper with cheese, a king-size Coke and a large order of fries rings in at 2,120 calories, their whole daily allowance?

33

What does “super-sizing” cost?

• Paying 67 cents to super-size an order – provides 73 % more calories – for 17 % more money – adds an average of 36 grams of adipose tissue (fat)

• The future medical costs for that bargain would be– $6.64 for an obese man and – $3.46 for an obese woman.

• The hidden financial costs associated with weight gain from upsizing a meal may help convince people it is not a bargain

34

Obesity and lower wages

• a weight increase of 64 pounds above the average for white women

• was associated with 9 percent lower wages

• lower promotion rates

35

Goals for Chronic Disease Mgt

• Reduce morbidity and progress of disease– at a patient level– at a population level

• Increase evidence based management

• Reduce costs and scarce resource use

36

Multiple chronic conditions

• 65% of older patients have multiple chronic conditions

• Multiple conditions – require coordination of care– more monitoring– more support

Growing Interest in CDM

38

World-wide buzz about CDM

• widespread interest and planning

• we can improve care and have better outcomes

• we must improve care and outcomes to manage future costs

39

Chronic Disease Management Programs

• Chronic Disease Management Programs improve quality of care of people with chronic diseases as measured by performance indicators.

• However, there is not much substantial evidence in the research literature available on their impacts on survival, patient quality of life, or on their relative cost-effectiveness.

40

Variability of Chronic Disease Management Programs

The variability of chronic disease management programs, and their dependence on context (both geographic and program specificity) complicate the transferability of findings to other settings.

41

Critical Factors in the Design of Successful CDM Programs (1)

• Suitable Target Condition

• Evidence Based

• Consideration of Barriers to Implementation

• Balance of Economic and Quality of Care Goals

42

Critical Factors in the Design of Successful CDM Programs (2)

• Strategies to Change Attitudes of Stakeholders

• Strategies for Continuous Quality Improvement

• Strategies for Evaluation of Cost-Effectiveness

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U.S., West Virginia Medicaid

44

United Kingdom

45

France

46

British Columbia

47

Calgary Health Region

•

48

Ontario

Can we be successful?

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What is required for success?

• Vision and leadership• CDM plan• LHIN support• Resources: skills, money and people• Population health information• Registries and monitoring capability• Planning and evaluation tools• Marketing and recruitment

51

Excellent Prospects for Success

• Rural Health Sciences Network

• Interest and enthusiasm we see here today

• CDM is a provincial goal

• LHIN

• Academic medicine resources

Appendix 1: Examples

U.S., West Virginia Medicaid

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West Virginia Medicaid (1)

• In a pilot phase starting in three rural counties, many West Virginia Medicaid patients will be asked to sign a pledge

• “to do my best to stay healthy,” • to attend “health improvement programs as

directed,” • to have routine checkups and screenings, to

keep appointments, • to take medicine as prescribed and • to go to emergency rooms only for real

emergencies.

55

West Virginia Medicaid (2)• Those signing and abiding by the agreement will

receive “enhanced benefits” including – mental health counseling, – long-term diabetes management – cardiac rehabilitation, – prescription drugs – home health visits as needed, – antismoking and antiobesity classes.

• Those who do not sign will get federally required basic services, but be limited to four prescriptions a month and will not receive the other enhanced benefits.

56


• “We’re in an Appalachian culture where there’s a fatalism; many people don’t go in for checkups or preventive services,” a state official said

• the state has some of the country’s highest rates of obesity, smoking, heart disease and diabetes.

• “We want to reach people before they get chronic and debilitating diseases that will keep them on Medicaid for the rest of their lives.”

57


• In future years, those who comply fully will get further benefits (“like a Marriott rewards plan,” an official said),

• their nature to be determined but perhaps including orthodontics or other dental services.

58


• The incentive effort, the first of its kind, received quick approval last summer from the Bush administration, which is encouraging states to experiment with “personal responsibility” as a chief principle of their Medicaid programs.

59

West Virginia Medicaid (6)• A stinging editorial in The

New England Journal of Medicine on Aug. 24 said it – could punish patients for factors beyond

their control, like lack of transportation; – would penalize children for errors of parents; – would hold Medicaid patients to standards of

compliance that are often not met by middle-class people;

– put doctors in untenable positions as enforcers.

http://topics.nytimes.com/top/reference/timestopics/organizations/n/new_england_journal_of_medicine/index.html?inline=nyt-org

United Kingdom NHS (1)

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UK: The Expert Patient (2)

• the average diabetes patient spends only 3 hours a year with a physician

• the remaining 8757 hours of the year it is up to the patient to monitor and manage their chronic disease/condition

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• Promote awareness and create an expectation that patient expertise is a central component in the delivery of care to people with chronic disease.

• Establish a program for developing more user-led self-management courses to allow people with chronic diseases to have access to opportunities to develop the confidence, knowledge and skills to manage their conditions better, and thereby gain a greater measure of control and independence to enhance their quality of life.

63


• Identify barriers to mainstreaming user-led self-management in the NHS and address these barriers, in the first instance through existing National Service Frameworks and others that are planned such as that on Long-Term Health Conditions.

• Integrate user-led self-management into existing NHS provision of health care – e.g. into other National Service Frameworks, Healthy Living Centres and NHS Direct.

64


• Ensure that each Primary Care Trust area has arrangements for user-led self-management programs for key chronic conditions to be delivered or commissioned.

• Expand the practical support for user-led programs provided by patients’ organizations in partnership with health and social care professionals.

65


• Build, as part of continuing professional development programs, a core course which would promote health professionals’ knowledge and understanding about the benefits – for them as well as for patients – of user-led self-management programs.

• Establish a National Coordinating and Training Resource to enable health, social services and voluntary sector professionals to keep up to date with developments in the provision of self-management; patients should be part of the process of developing professional education programs.

France

67

The French Model (1)

• France is rated #1 in Health System Performance among all 191 WHO member states

• France spends $2,115 per capita (9.3% of GDP) on health – as compared to $4,358 per capita (12.9% of GDP) in the United States (which rank 31st in Health System Performance)

68

French Model for Chronic Respiratory Insufficiency (2)

• The system of care for patients with severe lung disease in France links critical care centres with step-down respiratory rehabilitation programs in low cost regional hospitals and home ventilator maintenance programs (HVM)

69

The French Model for Chronic Respiratory Insufficiency (3)

• Disease Management of CRI’s in France are arranged around regional population based centers for treatment, in concert with home-based use of HVM programs.

• Patients who might otherwise be permanent residents of nursing homes in the US are maintained at lower cost in their homes – and with a better quality of life

British Columbia

71

British Columbia (1)

• CDM Secure Website for Practitioners enables BC physicians to obtain a list of their patients who have been diagnosed with diabetes, congestive heart failure, and hypertension, and a report on the extent to which care provided is consistent with evidence-based best practices. Other diseases are being added as well.

72

British Columbia (2)• The CDM Toolkit is an expansion of the CDM

Secure Website for Practitioners, and is especially useful to practices not equipped with an electronic medical record system. The technology makes it possible for practitioners to: – electronically access BC clinical practice guidelines;

complete patient flow sheets; – generate a list of patients who need to be recalled for

an office visit; automatically generate clinical and administrative reports crucial to optimal chronic care provision (e.g., patient profiles, practice profiles, patient education reports);

– and share flow sheets with members of the group practice or practice network, or consultants via secure internet data transfer.

73

British Columbia (3)

• Personal digital assistant (PDA) access to evidence-based clinical practice guidelines: Through a grant from the Ministry of Health Services, the University of BC, Faculty of Medicine, Division of Continuing Medical Education has developed an electronic tool that will enable physician access to clinical guideline information at the point of patient care.

Calgary Health Region

75

Calgary Health Region CDM (1)

• The Region’s strategy for implementing the chronic care model is as follows:

• Support family physicians in their management of people with chronic conditions by partnering them with community care coordinators (nurses). Community Care coordinators assist family physicians in the management of patients with chronic conditions by providing case management, referral to appropriate services and disease management according to clinical practice guidelines

76

Calgary Health Region CDM (2)• Increase the access of family physicians to specialist

expertise and support by having regional staff from acute care specialty clinics see high risk/complex patients and medical specialists provide CMEs and care algorithms for the care teams based on best practice

• Implement an electronic chronic disease management information system to allow all providers across the continuum of care to communicate with each other and monitor care. Embed alerts and reminders into the system so that they are available at point or care

77


• Support patients through the ‘Living well with a Chronic Condition’ program -a community based exercise and education program run by the Region together with community facilities (such as the Talisman center and Ys).

• People with a range of chronic conditions exercise together in community facilities close to where they live and receive education about their specific health condition. The program is staffed with a multidisciplinary team of professionals including exercise specialists, physical therapists, dietitians and social workers

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• Provide self-management support through the Stanford Chronic Disease Self-Management program developed by Stanford University.

• This program is lay led and suitable for people with a range of chronic conditions.

• The intent of the program is to help people make informed choices in their health behaviors and develop strategies to live as fully and productively as they can

Ontario

80

Ontario CDM (1)• Chronic Disease Management: A Checklist

• Develop a process to identify and track patients with chronic illnesses in your patient population

• Understand patient needs and available resources in the community

• Review needs and resources information collected during the strategic planning process

• - Identify gaps in local services and opportunities to make the most of the skills of interdisciplinary providers

• - Collaborate with community partners and implement a mechanism for feedback

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Ontario CDM (2)• Develop CDM programs to meet patient needs and

address gaps in services• Access evidence-based guidelines and adapt them to your

practice setting• Develop protocols to translate guidelines into action.• Use patient flow sheets to organize planned interactions• Communicate roles and responsibilities to interdisciplinary

team members

• Implement protocols and deliver CDM programs• Coordinate services across providers and sites to ensure

seamless delivery of care• Use self help tools and resources to educate patients about

self management

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Ontario CDM (3)• Coordinate CDM programs and arrange systematic follow-

up care

• Schedule regular contact with appropriate providers

• Consider how clinical data can be accessed at the point of care, how care can be monitored and how

• information can be shared among providers

• Monitor and evaluate success in achieving the CDM program objectives

• Select indicators that can be used to monitor progress towards CDM objectives

• Develop mechanisms to collect and review data

• Evaluate data

• Adjust programs and strategies as required

The Prospects of Success for Chronic Disease Management Hugh Walker, Ph.D. Professor of Health Economics, Queen’s Medical School Rural Health Sciences.

Documents

chronic disease slide

patient slide

chronic lung disease

chronic depression

health difference slide

stage slide

numbers of chronic conditions

heart disease