chronic disease management the background bob lewin professor of rehabilitation presentations at - ...
TRANSCRIPT
Chronic disease management
The background
Bob LewinProfessor of Rehabilitation
Presentations at - www.yorkconference.org
CARE AND EDUCATION RESEARCH GROUP
At the Department of Health someone had noticed At the Department of Health someone had noticed a problem. The number of people with a chronic a problem. The number of people with a chronic condition has almost doubled in 30 years…….condition has almost doubled in 30 years…….
All people reporting a chronic condition
21
24
2930
31 31
35
33 3332 32
35
20
22
24
26
28
30
32
34
36
1972 1975 1981 1985 1991 1995 1996 1998 1998 2000 2001 2002
Year (note: data from 1998 is weighted)
Pe
rce
nt
35%
21%21% €€€€€€€€€€€€ €€€€€€€€60% of adults
……around 50% of all bed use is for chronic disease….around 50% of all bed use is for chronic disease….
Cumulative bed day use by ICD code
-
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
Cause of admission
Be
d d
ays u
se
d
50% of admissions 50% of admissions are accounted for are accounted for by 3% of diseasesby 3% of diseases
* * * * !
CMO Liam Donaldson
……and it is going to get worse!and it is going to get worse!
Change in ethnic Change in ethnic mixmix
Ageing population - greater chronicity & fewer to pay.Ageing population - greater chronicity & fewer to pay.
low levels of activitylow levels of activity
obesityobesity
smokingsmoking
drink? drink?
Increasing number of people Increasing number of people surviving fatal events. or surviving fatal events. or disease or congenital disease or congenital conditionsconditions
Luckily some other people had been thinking Luckily some other people had been thinking about it …the Chronic Care Model by Ed Wagner.about it …the Chronic Care Model by Ed Wagner.
www.improvingchroniccare.orgwww.improvingchroniccare.org
PCTs need to work with Acute Care Trusts to develop integrated approaches. A key issue is the sharing of incentives to promote high quality care.
The Expert Patient programmeNHS Direct Digital TV
Evidence based guidelines incorporated in IT systemsNSFs, elderly, mental health, CHD, etc.
multidisciplinary team in primary care. risk stratification modern matrons and case management
strategic partnerships local authorities community and voluntary organisations
Software to support care planning, risk stratification, and monitoring quality
The intention is to start rebuilding healthcare The intention is to start rebuilding healthcare around chronic rather than acute illnessaround chronic rather than acute illness
5% of patients use 42% of bed days.
80% of bed days in hospitals are currently used by emergency beds
Some patients are trapped in the “revolving door”
Percentage of those admitted as inpatients by cumulative days spent as inpatients
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00
Percentage of inpatients
Cu
mu
lati
ve
pe
rce
nta
ge
of
inp
ati
en
t d
ay
s
10% of patients account for 55% of bed use
5% of patients account for 42% of bed use
Can better CDM be cost effective? Can better CDM be cost effective?
The Kaiser Permanente Triangle – matching the level of The Kaiser Permanente Triangle – matching the level of CDM provided to the extent of use of acute services CDM provided to the extent of use of acute services
3. 5% (42%)
case management
2. 15-25%
disease management
1. 70-80% self-management
Prof Kate Lorig.
11 June 2004
At a recent Big Conversation event the Health Secretary, John Reid said
"The government intends to roll out its "expert patient" pilots across the country. These involve training lay people to support patients with long-term chronic conditions".
By 2008 everybody with a chronic disease who wants an "expert patient" (sic) will have one, he promised.
Who are you?
I’m your fairy godmother from the USA and I can solve all your problems
Supported – “self care” for everyone with a chronic diseaseSupported – “self care” for everyone with a chronic disease
17,000,000 people have a long-term condition
2
1
3
3
Case managementCase management
Castlefields Health CentreCastlefields Health Centre
15% 15% in admissions in admissions
31% 31% in length of stay in length of stay
41%41% in total bed use in total bed use
Improved referrals across the patchImproved referrals across the patch
3000 Community Matrons in post by March 2007
biomedical understanding of disability biomedical understanding of disability
IMPAIRMENTIMPAIRMENT = LESION, = LESION, (% blockage of arteries, (% blockage of arteries, size of infarct, ejection size of infarct, ejection fraction, etc.)fraction, etc.)
DISABILITYDISABILITY= DIFFERENCE FROM WELL = DIFFERENCE FROM WELL PEERS (functional ability, angina, anxiety, PEERS (functional ability, angina, anxiety, depression, work status etc.)depression, work status etc.)
DISABILITY
IMPAIRMENT
Implicit belief - because impairment often causes disability correcting the impairment will correctthe disability
impairmentimpairment = the lesion
disabilitydisability = difference from age adjusted normal
handicaphandicap = the additional imposition of society
Impairment does NOT relate to disability: e.g heart failureImpairment does NOT relate to disability: e.g heart failure
Or in AnginaOr in Angina
the frequency of angina
anger r = 0.5 p< 0.01anxiety r = 0.5 p< 0.05
Smith, 1984, Brit. J Med Psychol
% occlusion r = 0.03 NS
Channer, K. 1988, J Royal Soc Med
AnxiousAnxious depressed (31%) Non Distresseddepressed (31%) Non Distressed
angio score 12.7 12.2poor LVF 6 11sub. Disability 61 34exercise to pain 4.5 min 7.5
disability including work status
the extent of the symptoms reported
the success or failure of medical treatment or surgery
the number of acute medical events and readmissions
medical costs
Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462
aspects of personalityanxiety & depression disease specific health beliefspatients’ own attempts to cope (coping actions)
A biopsychosocial understanding of disabilityA biopsychosocial understanding of disability
impairment on its own cannot explainimpairment on its own cannot explain
to predict all of these you also need to includeto predict all of these you also need to include
The original CDM for CHD Cardiac rehabilitationThe original CDM for CHD Cardiac rehabilitation
36 randomised trials meta-analysis shows a 20% all cause and 26% reduction in cardiac mortality at 2-5 years.
Contrast this with 2% overall improvement in survival from surgery and 0% from PCTA
Recent trials show same benefits as early trials despite the introduction of statins thus more than good medical management.
Next to Aspirin the most cost effective intervention by a long distance.
Menu basedAssessment of chronic disease management needsDiscuss different options to achieve goals Offering choice of venuereassess results and try again
6 week, home based post MI programme
A work book, diaries, record sheets and information
2 audio tapes, advice for family, a stress management course on tape
A specially trained ‘Facilitator’
Exercise programme – walking. Secondary prevention – written advice
Cognitive behavioural intervention
change patients beliefs and attributions
self recording
self help for psychological problems
relaxation and stress management
face-to-face session, phone calls or home/clinic visits at week 1, 4, 6 after discharge.
Lewin, Lancet, 1992; 339:1036-1040
Self management programme the Heart ManualSelf management programme the Heart Manual
Results of the trial show that in Heart Manual rehabilitation patients (n=88) 6 were readmitted to hospital in the first six months, whilst in control patients (n=88) 18 were readmitted to hospital in the first six months and all patients in this group had 1.8 more GP consultations per person than those in the Heart Manual rehabilitation group.
www.show.scot.nhs.uk/isdonline/ heart_disease/CHDtables/The%20Heart%20Manual5.doc
Angina PlanAngina Plan 6868
142 randomised to treatment142 randomised to treatment
90% at 6 month follow-up90% at 6 month follow-up
education education sessionsession 7474
6363 6767
-1.2
-1
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
Anxiety Depression
anxiety & depression
-4.5-4.0-3.5-3.0-2.5-2.0-1.5-1.0-0.50.00.51.0
Angina GTN
angina and use of GTN
-2-10123456789
physical activity: SAQ
40% reduction
Lewin RJP, British Journal of General Practice, 2002, 52, 194-201
home based programme, a patient held manual & trained facilitator home based programme, a patient held manual & trained facilitator
30-60 minutes introduction session30-60 minutes introduction session
and 4, 10-15 minute phone calls / home /clinic visits, to set further goals, praise and 4, 10-15 minute phone calls / home /clinic visits, to set further goals, praise progress, encourage adherenceprogress, encourage adherence
Self Management - The Angina PlanSelf Management - The Angina Plan
East riding project - systemEast riding project - system
Confirmed MIConfirmed MI
Hospital based facilitator introduces patient and partner to HMHospital based facilitator introduces patient and partner to HM
Community based Facilitator guides patient through 6 week HM Community based Facilitator guides patient through 6 week HM programme. Home visits week 1,3,6. Final visit gathers assessment programme. Home visits week 1,3,6. Final visit gathers assessment
data.data.
Triage meetingTriage meeting
Discharge to support Discharge to support group and gymgroup and gym
Annual GP checksAnnual GP checks
Refer to GP / specialist Refer to GP / specialist (psychologist, dietician (psychologist, dietician
etc)etc)
Refer to hospital based Refer to hospital based programmeprogramme
Community facilitator visit at 6 months to reassessCommunity facilitator visit at 6 months to reassess
Adjusted % of MI, CABG, PTCA patients receiving CR by Adjusted % of MI, CABG, PTCA patients receiving CR by regionregion
Estimated shortfall 330,000 patients a year
More rehabilitation programmesMore rehabilitation programmes
300
0
50
100
150
200
250
1988 1992 1996
99
161
272
380*
2004
285
350
NSFNSF
2
1
3
Multidisciplinary teams, disease management programmes. Proven efficacy. CR programmes
Home based, cognitive-behavioural self-management programmes – Heart manual, Angina Plan. Cost effective in reduction of readmission.
Assessment method and tracking software - Minimum dataset and CCAD uniting MI, Surgery, Angioplasty and ICD registers.
www.cardiacrehabilitation.org.uk
Specialist liaison nurses
Predictors of treatment costs / successPredictors of treatment costs / success
Psychological factors influence the success of coronary artery surgery. Channer KS. J R Soc Med. 1988.
Anxious and depressed patients accrued 4 x the costs of non-distressed none of which was spent on psychological or psychiatric care
Medical and economic costs of psychological distress in patients with coronary artery disease. Allison TG. Mayo clin proc, 1995.
Predicting completeness of symptom relief after major heart surgery. Jenkins CD. Behav Med., 1996.
Emotional distress before coronary bypass grafting limits the benefits of surgery. Perski A. Am Heart J., 1998.
Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care. 2005 17:141-6. Ouwens M,
The focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals.
CONCLUSION: Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results.
And the evidence is…?And the evidence is…?
The Expert
patient
programme,
NHS Direct,
Digital TV
for p
atients to
better m
anage
their care
Set of tools in each Set of tools in each health community to health community to create a health and create a health and
social care system to social care system to support people with a support people with a
chronic problemchronic problem
Payment by
results: a
means of
releasing funds
from acute care
Incentive scheme to encourage
social services to avoid delayed
transfer of care
Software systems for Registration, Recall, and Review.
At risk patient can be identified by NUMBER OF MEDS OR
ADMISSIONS
New GMS and PMS: rewards good CDM
PMS+ and enhanced services to build capacity for new chronic
disease services
National Service Frameworks:
diabetes, CHD, older people, mental
health, children, renal disease, long term
neurological conditions
disease specific vs generic programmes
over-reliance on educational approach vs cognitive-behavioural behaviour change
clinical guideline based (mortality) vs patient preference (may not be longevity)
CDM provided by need vs CDM provided by consumption
individual change (patient) vs social models of change
Potential tensionsPotential tensions
cost saving to NHS vs improving quality of life
Potential delivery problemsPotential delivery problems
self-management programmes attract the motivated leaving a rump of disenfranchised people
establishing multi-disciplinary community based CDM teams may denude secondary care of staff and motivation
‘market led reforms’ – practice level purchasing, advertising for patients, compulsory use of private sector, Foundation Trusts Status may undermine systematic services
Multi-centred RCT vs. Hospital based rehabilitation in 4 centresequal gain on all measures including gain in fitness (2 METs) HM significantly fewer readmissions to hospital at 12 months Jenny Bell, Andrew CoatsJenny Bell, Andrew Coats
Recommended by: WHO: UK NSF for CHD: Scottish Intercollegiate Guidelines Network Guideline, UNCLE TC et. al.
Initial RCT less anxiety & depression: better quality of life: fewer readmissions to hospital: fewer visits to GP Lewin, Lancet, Lewin, Lancet, 1992; 339:1036-10401992; 339:1036-1040
The Heart Manual: the evidence baseThe Heart Manual: the evidence base
Others - Linden B, 1995: O’Rourke A, 1999: Linden B, 1995: O’Rourke A, 1999: Dalal HM, 2003Dalal HM, 2003
Ps. I have no financial interest in the HM!
2002 2003 2004
2764
5132
7000*
Use of the Angina Use of the Angina PlanPlan
* Estimate from uptake per month to Aug 2004
Australian Royal Commission to investigate failure to return to work following uncomplicated MI:
interview 400 patient medically & psychologically examined
60% of cases no medical justification
38% of these cases directly due to faulty understanding e.g. “angina is a small heart attack”
22% of cases due to anxiety or depression caused by overly cautious prognosis given to the patient or a relative
Return to work following a Heart Attack (MI) Return to work following a Heart Attack (MI)
Wynn, 1967, Med J Australia, 2, 847-851Wynn, 1967, Med J Australia, 2, 847-851
Health PromotionHealth Promotion
Promote better lifestyle to avoid chronic illness – education – develop Promote better lifestyle to avoid chronic illness – education – develop community resources – provide community resources – provide incentivesincentives to encourage people to take to encourage people to take greater greater personal responsibilitypersonal responsibility for their health for their health
new test to qualify for free bus pass
How to meet the shortfall? How to meet the shortfall?
333,000 extra people a year needing cardiac rehabilitation
Potential solutionsPotential solutions
More hospital based group CR programmes
Home Based rehabilitation (e.g. Heart Manual)
Self-management programmes (e.g. Angina Plan)
Lay workers or volunteers (e.g. Bravehart, www.braveheart.uk.net)
Internet
Angina PlanAngina Plan 6868
142 randomised to treatment142 randomised to treatment
90% at 6 month follow-up90% at 6 month follow-up
education education sessionsession 7474
6363 6767
-1.2
-1
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
Anxiety Depression-2-10123456789
physical activity: SAQ
-4.5-4.0-3.5-3.0-2.5-2.0-1.5-1.0-0.50.00.51.0
Angina GTN
40% reduction
Lewin RJP, British Journal of General Practice, 2002, 52, 194-201
The Angina The Angina PlanPlan
home based programme, a patient held manual & trained facilitator
30-60 minutes introduction session
and 4, 10-15 minute phone calls / home /clinic visits, to set further goals, praise progress, encourage adherence
treatment - explanation of misconceptions - goal setting and pacing - daily walking - relaxation tape - instruction on using relaxation on chest tightness.
Cardiac CDMCardiac CDM
28.0%
16.8%16.8%13.5%
11.2%8.9% 8.5% 8.2% 7.9%
5.1% 4.0% 3.5%
0.0%5.0%
10.0%15.0%20.0%25.0%30.0%
Arthrit
is et
c.
Heart
(inc h
igh B
P)
Heart
(inc h
igh B
P)
Respir
ator
ySkin
Men
tal h
ealth
Digesti
ve
Difficu
lty in
hea
ring
Heada
ches
and
m...
Visual
prob
lems
Stroke
Diabet
es
Approx 2 million people living with symptomatic heart disease