Integrated approaches to prevention and control of chronic conditions

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Integrated approaches to prevention and control
of chronic conditions

• JoAnne Epping-Jordan, PhD
• Coordinator
• Health Care for Chronic Conditions
• World Health Organization
• Geneva, Switzerland

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WHO at a Glance

• Objective
• The attainment by all peoples of the highest
  possible level of health.

• United Nations specialized agency for health
• Governed by 192 Member States
• Headquarters in Geneva
• Six regional offices and numerous country offices

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Chronic Conditions The health care challenge of
the 21st century

• Cover a broad category of what appear
  biomedically as disparate health concerns
• noncommunicable conditions
• persistent communicable conditions
• long-term or recurrent mental disorders
• ongoing physical impairments and disabilities

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WORLD Deaths, by broad cause group, 2001
Total deaths 56,554,000
Noncommunicable conditions (33.1 million)
Communicable diseases, maternal and perinatal
conditions and nutritional deficiencies (18.4
million)
Injuries (5.1 million)
Source World Health Report 2002
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World Deaths, 2000, by selected leading risk
factors (000s)
Source World Health Report 2002
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• Tobacco 4.2 million deaths/year
• Diet/nutrition (insufficient fruit/vegetables) 4
  million deaths/year
• Physical activity 1.6 million deaths/year
• Alcohol 2 million deaths/year

Source World Health Report 2002
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Global determinants driving this increase

• Public health successes ? people are living
  longer
• Rapid economic development ? changes in health
  behaviour
• Aggressive marketing of health risks (tobacco,
  alcohol, fast food)

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Poland "Camel. He grew up to be kind." 2000
Philippines Calendar 2001
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Smoking prevalence in mega countries
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The risk factors of today are the diseases of
tomorrow
Theme of the World Health Report 2002 Measuring,
communicating, and reducing risks to health
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A conceptual model of the progress of a disease
Relationship between diabetes, hypertension and
renal disease
Risk Factors
Early Disease
Confirmed Disease
Complications
Healthy Population
No diabetes
Pre diabetes
Diabetes onset
Diabetes no complications
Diabetes with complications
Source Healthcare Decision Making in the Western
Pacific Region Diabetes and the Care Continuum.
Carol Beaver. 2001
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Interactive model for chronic disease
Hypertension
Diabetes
Renal Disease
Source Healthcare Decision Making in the Western
Pacific Region Diabetes and the Care Continuum.
Carol Beaver. 2001
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No longer is each risk factor and chronic
illness being considered in isolation. Awareness
is increasing that similar strategies can be
equally effective in treating many different
conditions.
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TYPICAL CARE
The Radar Syndrome

• Patient appears
• Patient is treated find it and fix it
  
• Patient is discharged
• then disappears from radar screen

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Radar logic inappropriate care for chronic
conditions

• System oriented to acute illness
• Patients role not emphasized
• Follow-up sporadic
• Prevention overlooked

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Missed opportunities for clinical prevention
What is the impact?

• Tobacco smokers have 18 higher medical charges
  than non-smokers
• A one-unit increase in BMI raises medical charges
  by 1.9
• Each additional day of physical activity per week
  reduces medical charges by 4.7
• Study conclusions
• Health plans that do not systematically support
  members efforts to improve health-related
  behaviors may be incurring significant short-term
  health care charges that may be at least partly
  preventable.

JAMA 1999 282 2235-9
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Health Care Experiences in Five Countries

• 3,849 sicker patients across 5 countries
• Despite differences in health systems, large
  proportions of patients report errors, poor
  communication, faulty care coordination
• Focusing on high utilizers has the potential to
  both control costs and improve care

Blendon et al., Health Affairs 2003 22(3)106-21
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Across the five countries
My regular doctor or health professional DOES
NOT

• make clear specific treatment goals (20-38)
• help me understand what needs to be done for my
  health (12-26)
• ask for my ideas or opinions about treatment
  (47-67)
• keep me motivated (28-43)
• provide advice on weight, nutrition, exercise,
  smoking, drinking (33-49)
• discuss the emotional burden of the condition
  (51-66)

Blendon et al., Health Affairs 2003 22(3)106-21
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World wide, effective prevention and management
of chronic conditions requires an evolution of
health care . from radar care to innovative
care
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Cochrane Review of Interventions to Improve
Diabetes Care in Primary Care

• 40 randomized trials
• Interventions classified as provider-oriented,
  organizational, information systems, or
  patient-oriented
• Combined interventions more potent than
  individual ones, especially those that included
  organizational change
• Patient outcomes (e.g., HbA1c, BP, LDL) improved
  only if patient-oriented interventions included

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Patients and families are the ultimate providers
of health care for chronic conditions
95 or more of the many health decisions a
diabetic patient must make daily are made without
health care professionals even knowing them.
Diabetes Care 1995 18 412-25
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Sample Results Clinica Campesina
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Sample results Premier Health Partners
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Sample results High Plains Community Center
Improved rate results after 7 months
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Other Examples of Innovative Programmes

• Diabetes quadruples foot exam rates (18 - 82)
• Asthma reduces hospital admission costs from
  18,488 to 1,538 per patient
• Coronary artery disease reduces deaths by 41
• Congestive heart failure reduces hospital
  admissions by 56
• Nicotine dependence produces 70 cessation
• Rural South Africa nurse-led PHC programme that
  used registries, self-management support,
  protocols and follow-up, resulted in good
  outcomes for hypertension, diabetes, asthma and
  epilepsy with minimal physician support

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Improving the system of hypertension care in Tula
Oblast, Russian Federation (1998-2000)

• Number of patients managed at the primary care
  level increased by 7.6 times
• BP stabilization achieved in 69.4 of patients
• Hypertension related hospitalizations decreased
  by 85
• Hypertensive crises decreased by 60

University Research Corporation, USA
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Summary

• The disease burden has changed towards chronic
  conditions world wide. The health system hasnt.
• Effective interventions exist for most major risk
  factors and chronic conditions, yet patients do
  not receive them.
• Effective prevention and management of chronic
  conditions requires an evolution of health care,
  away from a model that is focused on acute
  symptoms towards a coordinated, proactive system
  of care.
• Evidence shows that integrated approaches result
  in improved efficiency and better outcomes.

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Trying harder will not work. Changing systems
of care will. Crossing the Quality Chasm,
Institute of Medicine, 2001
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For more information
Contact Dr J. Epping-Jordan Coordinator Health
Care for Chronic Conditions World Health
Organization Tel [phone] Fax 41 22
791 4259 email eppingj_at_who.int www.who.int/chro
nic_conditions/en