Chronic Disease Management

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Chronic Disease Management

• Dr Bob Ward
• 7/6/06

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The Case For

• Problem that wont go away massive issue for
  NHS and worldwide
• Significant impact on quality of life and on the
  family medical and social
• more likely to see their GP (accounting for about
  80 of GP consultations), to be admitted as
  inpatients, and to use more inpatient days
• will be the leading cause of disability by 2020
  and that, if not successfully managed, will
  become the most expensive problem for health care
  systems.

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Incidence

• In GB, 17.5 million adults may be living with a
  chronic disease
• Around 6 in 10 adults in the household population
  report some form of chronic health problem
• It is likely that up to three-quarters of those
  over 75yrs are suffering from chronic disease,
  and this figure continues to rise

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Incidence

• By 2030, the estimate is that the incidence of
  chronic disease in the over 65s will more than
  double
• It is estimated that 45 of those with chronic
  disease suffer from more than one condition
• WHO data indicates that this incidence is
  globally reflected, with 75 of the total
  population having one chronic condition and 50
  having two or more conditions

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What makes for good chronic disease management?

• Use of information systems to access key data on
  individuals and populations
• Identifying patients with chronic disease
• Stratifying patients by risk
• Involving patients in their own care
• Co-ordinating care (using case-managers)
• Using multidisciplinary teams
• Integrating specialist and generalist expertise
• Integrating care across organisational boundaries
• Aiming to minimise unnecessary visits and
  admissions
• Providing care in the least intensive setting

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Put these clinical areas in the right column
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New clinical indicators

• Dementia
• Depression
• Chronic Kidney Disease
• Atrial Fibrillation
• Palliative Care
• Mental Health
• Heart Failure

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Dementia 20 points

• DEM 1 (5 points)
• The practice can produce a register of patients
  diagnosed with dementia
• DEM 2 (15 points)
• The percentage of patients diagnosed with
  dementia whose care has been reviewed in the
  preceding 15 months (25-60 payment stages)

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Depression 33 points

• DEP 1 (8 points)
• The percentage of patients with diabetes and/or
  heart disease for whom case finding for
  depression has been undertaken on one occasion
  during the previous 15 months using the two
  standard screening questions (40-90 payment
  stages)
• DEP 3 (25 points)
• In those patient with a new diagnosis of
  depression, recorded between 1 April and 31st
  March, the percentage of patients who have had an
  assessment of severity at the outset of treatment
  using an assessment tool validated for use in
  primary care (40-90 payment stages)

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Chronic Kidney Disease 27 points

• CKD 1 (6 points)
• The practice can produce a register of patients
  aged 18 years and over with CKD.
• CKD 2 (6 points)
• The percentage of patients on the CKD register
  whose notes have a record of blood pressure in
  the preceding 15 months (40-90 payment stages)

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Chronic Kidney Disease 2

• CKD 3 (11 points)
• The percentage of patients on the CKD register in
  whom the last blood pressure reading, measured in
  the preceding 15 months, is 140/85 or less
  (40-70 payment stages)
• CKD 4 (4 points)
• The percentage of patients on the CKD register
  with hypertension, who are treated with an
  angiotensin converting enzyme inhibitor (ACE-I)
  or angiotensin receptor blocker (ARB)(40-80
  payment stages)

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Atrial Fibrillation 30 points

• AF 1 (5 points)
• The practice can produce a register of patients
  with Atrial Fibrillation
• AF 2 (10 points)
• The percentage of patients with atrial
  fibrillation diagnosed after 1st April 2006 with
  ECG or specialist confirmed diagnosis (40-90
  payment stages)
• AF 3 (15 points)
• The percentage of patients with atrial
  fibrillation who are currently treated with
  anti-coagulant drug therapy or an anti-platelet
  drug therapy (40-90 payment stages)

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Palliative Care 6 points

• PC1 (3 points)
• The practice has a complete register of all
  patients in need of palliative/supportive care.
• PC2 (3 points)
• The practice has regular (at least 3 monthly)
  multidisciplinary case review meetings where all
  patients on the palliative care register are
  discussed.

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Other New Indicators

• Obesity 1 (8 points)
• The practice can produce a register of patients
  aged 16 and over with a BMI greater than or equal
  to 30 in the last 15 months.
• Learning Difficulties (4 points)
• The practice can produce a register of patients
  with learning disabilities.
• Ethnicity (1 point)
• Ethnic origin is recorded for 100 of new
  registrations from 1 April 2006

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Smoking

• Smoking 1 (33 points)
• The percentage of patients with any or any
  combination of the following conditions coronary
  heart disease, stroke or TIA, hypertension,
  diabetes, COPD or asthma whose notes record
  smoking status in the previous 15 months. (Except
  those who have never smoked where smoking status
  need only be recorded once since diagnosis.)
• Smoking 2 (35 points)
• The percentage of patients with any or any
  combination of the following conditions coronary
  heart disease, stroke or TIA, hypertension,
  diabetes, COPD or asthma who smoke whose notes
  contain a record that smoking cessation advice or
  referral to a specialist service, where
  available, has been offered within the previous
  15 months

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Government initiatives/programmes developed to
improve CDM

• NSFs
• nGMS QoF
• IT developments
• Choice?
• GPSI
• EPP