The Prospects of Success for Chronic Disease Management

1
The Prospects of Success for Chronic Disease
Management

• Hugh Walker, Ph.D.
• Professor of Health Economics, Queens Medical
  School
• Rural Health Sciences Network
• Chronic Disease Management Charette
• Kingston, Ontario --- December 8th, 2006

2
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!!

6
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
Best Candidate Diseases for Chronic Disease
Management (B.C. Family Physicians)
Diabetes Mellitus Hypertension Congestive Heart Failure Asthma Chronic Lung Disease Chronic Depression Chronic Renal Failure
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11
Stages of a Chronic Disease
12
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
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Refer to Large Handout with Hastings Prince
Edward statistics

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Prevalence of Chronic Conditions, (population
12, heart disease 30)
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Number of Chronic Conditions, by Age
Number of Chronic Conditions   Age 20-39 Age 40-59 Age 60-79 Age 80
       
0 62 44 20 12
1 27 30 25 24
2 8 14 24 22
gt 2 3 12 31 42
17
Use of Health Care Resources by 20-30 Age Group
by Numbers of Chronic Conditions per Patient
18
Use of Health Care Resources by 40-59 Age Group
by Numbers of Chronic Conditions per Patient
19
Use of Health Care Resources by 60-79 Age Group
by Numbers of Chronic Conditions per Patient
20
Use of Health Care Resources by 80 Age Group
by Numbers of Chronic Conditions per Patient
21
Cost Pressures
22
Alberta HW Funding Rates by Age and Gender
2005-06
23
Estimated Economic Burden of Illness by Cost
Component in Canada, 2005
Cost Component 2005 Cost in 000s 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
25
Estimated Drug Costs for Eight Weeks of Treatment
for Metastatic Colorectal Cancer
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

• 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

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

• Number of new patients requiring chemotherapy
  increasing at 7 per year
• Chemotherapy drugs are predicted to at least
  double in price in the next 10 years
• Chemotherapy visits increasing by 25 per year
• Cancer drug expenditures are increasing at 22
  per year.

28
Summary of Cancer Drug Approval and Public
Funding Status
Approved and Funded Limited 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
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Risk Factors for Chronic Disease

30
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?

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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

37
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

43
U.S., West Virginia Medicaid
44
United Kingdom
45
France
46
British Columbia
47
Calgary Health Region

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Ontario
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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

52
Appendix 1 Examples

53
U.S., West Virginia Medicaid

54
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
West Virginia Medicaid (3)

• Were in an Appalachian culture where theres a
  fatalism many people dont go in for checkups or
  preventive services, a state official said
• the state has some of the countrys 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
West Virginia Medicaid (4)

• 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
West Virginia Medicaid (5)

• 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.

60
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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UK The Expert Patient (3)

• 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.

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UK The Expert Patient (4)

• 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.

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UK The Expert Patient (5)

• 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.

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UK The Expert Patient (6)

• 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.

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France

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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 CRIs 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

70
British Columbia

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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.

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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.

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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.

74
Calgary Health Region

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Calgary Health Region CDM (1)

• The Regions 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

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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

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Calgary Health Region CDM (3)

• 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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Calgary Health Region CDM (4)

• 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

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Ontario

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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