Transcript The Patient`s Role In Chronic Illness Care

Improving Chronic
Disease Care
John Riley PA-C, MS
MEDEX Northwest/University of
Alaska Anchorage
February 27, 2006
Adapted from Ed Wagner MD, MPH
MacColl Institute for Healthcare Innovation
Obesity* Trends Among U.S. Adults
BRFSS, 1991
(*BMI  30, or ~ 30 lbs overweight for 5’4” person)
No Data
<10%
10%-14%
Source: Mokdad A H, et al. JAMA 2001;286:10
15-19%
20%
Obesity* Trends Among U.S. Adults
BRFSS, 1995
(*BMI  30, or ~ 30 lbs overweight for 5’4” person)
No Data
<10%
10%-14%
Source: Mokdad A H, et al. JAMA 2001;286:10
15-19%
20%
Obesity* Trends Among U.S. Adults
BRFSS, 2000
(*BMI  30, or ~ 30 lbs overweight for 5’4” person)
No Data
<10%
10%-14%
Source: Mokdad A H, et al. JAMA 2001;286:10
15-19%
20%
Obesity* Trends Among U.S. Adults
BRFSS, 1991, 1995 and 2000
1991
1995
2000
No Data
<10%
10%-14%
15-19%
20%
Prevalence of Inadequate
Nutrition by Age and Sex in
Alaska 1999-2001 (Combined)
Men
Women
% eat <5 fruits and
vegetables/day
100
80
75 78
81
75
79 75
83
77
71 72
77
63
60
40
20
0
18-24
Source: AK BRFSS
25-34
35-44
45-54
55-64
65+
% no leisure time physical activity
Prevalence of Physical Inactivity by
Age and Sex in Alaska 1999-2001
(Combined)
50
38
40
30
27
22
19 20
20
16
15
28
Men
Women
24
22
18
12
10
0
18-24
25-34
Source: AK BRFSS
35-44
45-54
55-64
65+
Mrs. Johnson
•
•
•
•
•
•
Secretary early fifties
Thirsty, losing weight, tired
Labs misfiled
Diabetes registry not utilized
Screenings tests not done
Co morbid Mental health
issues not addressed
• Referral info not coordinated
• Not instructed in glucometer
use
• Confusion about what to do
What Mrs. Johnson Experienced?
• Fragmented, discontinuous care
• Deficits in her clinical care
• Quality not “embedded” in clinical delivery
system
• Inadequate self-management contributing to
suboptimal disease control
• Care across providers and settings not
communicated, much less coordinated
Is Mrs. Johnson a Rare Case?
• Generally, less than 50% of folks with
major chronic illnesses receive accepted
treatments.
• Less than 50% have satisfactory levels of
disease control.
• Majority of Americans don’t feel that the
chronically ill get good care.
McGlynn EA, Asch SM, Adams J, et al. N Engl J Med
2003; 348(26):2635-2645
What people with chronic disease get
• 27% of hypertensives are adequately treated
• 25% of eligible patients with atrial fibrillation
receive recommended care
• 58% of people with depression are receiving
adequate treatment
• 64% of CHF patients are receiving
recommended care
Hyman DJ, Pavlik DN. N Engl J Med 2001; 345:479-486
McGlynn EA, Asch SM, Adams J, et al. N Engl J Med
2003; 348(26):2635-2645
Hwy 61
The IOM Quality report:
A New Health system for the 21st
Century
What people like Mrs. Johnson with
chronic diseases need
• Information and ongoing
support for self-management
• Continuous, integrated care
delivered by an
interdisciplinary team
• Evidence-based clinical
management
• Care following clinical
improvement methods
• Care using informatics
What’s Responsible for the Quality Chasm?
• Is it patients like
Mrs. Johnson
who lack
knowledge and
motivation, and
fail to comply
with their
doctors’
instructions?
The Evidence:
1. Motivation and adherence are not
genetically determined
2. Behavioral interventions are consistently
successful in raising adherence
3. Noncompliance is not a patient problem;
it is a system failure
paraphrased from Dr. Paul Farmer reflecting
his experience in Haiti
Diabetes Care in the U.S.
Harris. Diab Care 2000; 23:754-8
McGlynn et al. NEJM 2003; 348:2635
100%
80%
60%
40%
20%
0%
R
e
D
ca
di
In
30
am
Ex
AN
Ey
1
L<
8
90
0/
<
1c
14
P<
bA
LD
B
H
rs
to
What’s Responsible for the Quality
Chasm?
• Is it ignorant health
professionals??
The Evidence:
• Much of the variation in care is within a
practice--i.e., same clinician treating
similar persons differently
• Studies consistently show gap between
professional knowledge and performance
• Educational interventions not very
effective
A Controlled Trial of Web-based
Diabetes Disease Management
• Hospital-based internal medicine clinics
• Web tool links timely patient specific information
to evidence-based decision support
• “Annual eye exam by eye care professional
recommended” or “consider starting fluvastatin”
• Web consulted on 42% of visits
• 600 patients with Type II
Meigs et al. Diabetes Care 2003; 26:750.
Changes in Diabetes Outcome
Measures in Intervention Group
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Change in HbA1c -0.2%
Change in BP 0.8/-1.8
Baseline
Follow-up
R
B
a
Ex
85
0/
al
in
et
13
P<
7
30
<
1c
1
L<
bA
LD
H
m
Meigs et al. Diabetes Care 2003; 26:750.
Conclusions
•Baseline levels of diabetes care quality about the
same or worse than national averages
•Elegant cognitive intervention increased use of
statins but not eye exams or glycemic or BP control
•Study conducted at Massachusetts General
Hospital
•Why the poor baseline care, and why the
feeble effect?
What’s Responsible for the Quality
Chasm?
The IOM Quality Chasm report says:
• “The current care systems cannot do the
job.”
• “Trying harder will not work.”
• “Changing care systems will.”
Usual Chronic Illness Care
• Oriented to acute illness
• Focus on symptoms and lab
results
• Patient’s role in management
not emphasized
• Care dependent on
provider’s memory and time
• Interaction often not
productive, and frustrating
for both patient and provider
It’s like having a
Dementor in the exam
room!
Disease Management Contains
• Population Identification process (Registry)
• Evidence-based practice guidelines (Chosen and agreed to by clinicians)
• Collaborative practice model to include physicians and support-service
providers
• Risk identification and matching of interventions with need
• Patient self-management education (may include primary prevention,
behavior modification programs, and compliance/surveillance)
• Process and outcomes measurement, evaluation, and management
• Routine reporting/feedback loop (may include communication with patient,
physician, health plan and ancillary providers, and practice profiling)
• Appropriate use of information technology (may include specialized
software, data registries, automated decision support tools, and call-back
systems)
From Disease Management Association of America, www.dmaa.org
Randomized trials of system change
interventions: Diabetes
Cochrane Collaborative Review
• 41 studies, majority randomized trials
• Interventions classified as provider-oriented,
organizational, information systems, or patientoriented
• Patient outcomes (e.g., HbA1c, BP, LDL) only
improved if patient-oriented interventions included
• All 5 studies with interventions in all four domains
had positive impacts on patients
Renders et al. Diabetes Care 2001;24:1821
Bodenheimer, Wagner, Grumbach. JAMA 2002; 288:1909
Delivery System Design
Practice team has defined roles, uses
planned visits and clinical case
management to support evidence-based
care, and assures regular follow-up and
care coordination
Nurse Case Management RCT-Aubert et al.
Change in Treatment and Glycemic Control
Between Baseline and 12 Months
1.0%
0.5%
0.0%
-0.5%
Intervention
Control
-1.0%
-1.5%
-2.0%
Change in HbA1c
Change in % on
Insulin
Meigs et al.
•used guidelines and
registry
•increased pt. info and
decision support at
acute visit
•No other changes to
system
Aubert et al.
•used guidelines and
registry
•Added nurse case
manager linked to
diabetes specialists
•Nurse conducted planned
visits in primary care,
adjusted therapy by
protocol
•Self-management
emphasized with classes
and nurse education
•Follow-up phone calls
Decision Support
Use of evidence-based guidelines supported
by proven provider education modalities,
integration of specialty expertise, and
reminder and fail-safe systems (e.g.,
standing orders)
Clinical Information System:
Registry
A database of clinically useful and timely
information on all patients provides
reminders and feedback and facilitates
care planning for individuals or
populations
Self-management Support
What is self-management?
“The individual’s ability to manage the symptoms,
treatment, physical and social consequences
and lifestyle changes inherent in living with a
chronic condition.”
Barlow et al, person Educ Couns 2002;48:177
Self - Management
•
•
•
•
•
•
•
•
•
•
•
What it isn’t
Didactic Pt Education
Sage on the Stage
You Should….
Finger wagging
Lecturing
Waiting for patients to ask
for help
One time effort
Commercial websites
Remote monitoring
devices
•What it is
• Emphasis on patient
role
• Self-Care Skills
• Self-assessment
• Problem-solving
• Care planning
• Ongoing
• Empowering
Effective Self-management Support
• Patient’s major role in managing her illnesses
and treatment emphasized
• Her knowledge, behaviors and confidence
routinely assessed
• Advice that is based on evidence and
presented as information not scolding
• Clear, collaboratively established goals and
treatment plan for improving self-management
Follow-up Activities in Practice
Essential to Sustain the Effect
•
•
•
•
•
Assessment
Collaborative Goal Setting
Problem-solving
Action Plan
Arrange Follow-up
Effects of Self-management Education
on HbA1c Levels across 31 RCTs
0
-0.1
-0.2
-0.3
Difference in HbA1c
levels between SM
and control groups
-0.4
-0.5
-0.6
-0.7
-0.8
immediate
1-3 months
>4 months
Norris et al, Diabetes Care 2002; 25:1159
IF THIS WERE AN FDA DRUG
PROPOSAL
Generic: SELF-MANAGEMENT/SELF-CARE
(Self-Management , Shared Decision-Making , Patient-Centered Care,
Patient Education , Health Education , Behavioral Medicine ,
Mind/Body Medicine )
Indications and Effectiveness
– Improves functional status and reduces ER and hospital days in
patients with chronic illness
– Decreases arthritis pain and office visits by 43%
– Decreases cardiac events and risk by 75%
– Reduces outpatient utilization by 7-15%
Side Effects
– Improved mood and patient satisfaction
Dosage
– PRN, wide therapeutic range
Source: David Sobel, MD (KP)
The Quality Chasm
Usual Care versus Improved Care
• Readmission rates of patients hospitalized with
CHF reduced by about 50%
• Recovery rates from major depression
increased 50-100%
• Children with moderately severe asthma have
symptoms 14 fewer days/year
• Anticoagulated patients in safe and effective
range twice as frequently
Can Real-world Practices
Change their System of Care?
Chronic Conditions Breakthrough Series
• Year-long collaborative quality improvement
efforts involving multiple delivery systems and
faculty
• Chronic Care Model guides comprehensive
system change
• Three national BTSs with IHI, BPHC Health
Disparities Initiative, and Regional BTSs in a
dozen states
• Involving approximately 1000 different health care
organizations and various diseases
BPHC Diabetes Collaboratives 1and 2
involving 180 Community Health Centers
and 38,000 diabetic persons
10
DC1_Avg
9.19
DC2_Avg
9
8
8.35
8.54
Goal
8.10
7
Average HbA1c Values
Reporting Month
J-04
O-03
J-03
A-03
J-03
O-02
J-02
A-02
J-02
O-01
J-01
A-01
J-01
O-00
J-00
A-00
J-00
O-99
J-99
A-99
6
Results for All Asthma Teams
Treatment with Maintenance Anti-Inflammatory Medications
Treatment with Maintenance Anti-Inflammatory Medications
% of Persistent Patients (severity>1)
100
Weighted average of data from 18 organizations reporting this measure
90
80
70
60
50
40
30
20
10
0
Feb- Mar00
00
Apr- May- Jun00
00
00
Jul00
Aug- Sep- Oct- Nov- Dec- Jan00
00
00
00
00
01
Feb- Mar01
01
Premier Health Partners
• Dayton, Ohio
• 100 physicians in 36
practices
• Change began in one
practice—spread
throughout system
• ACE-inhibitors for
albuminuria was 38% in
1999 and 80% in 2001
• A1c < 7% was 42% in
1999 and 70% in 2001
Disease Management Contains
• Population Identification process (Registry)
• Evidence-based practice guidelines (Chosen and agreed to by clinicians)
• Collaborative practice model to include physician and support-service
providers
• Risk identification and matching of interventions with need
• Patient self-management education (may include primary prevention,
behavior modification programs, and compliance/surveillance)
• Process and outcomes measurement, evaluation, and management
• Routine reporting/feedback loop (may include communication with patient,
physician, health plan and ancillary providers, and practice profiling)
• Appropriate use of information technology (may include specialized
software, data registries, automated decision support tools, and call-back
systems)
From Disease Management Association of America, www.dmaa.org
Thank
you