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Improving Chronic Disease Care John Riley PA-C, MS MEDEX Northwest/University of Alaska Anchorage February Improving Chronic Disease Care John Riley PA-C, MS MEDEX Northwest/University of Alaska Anchorage February 27, 2006 Adapted from Ed Wagner MD, MPH Mac. Coll Institute for Healthcare Innovation

Obesity* Trends Among U. S. Adults BRFSS, 1991 (*BMI 30, or ~ 30 lbs 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 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 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 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) Source: Prevalence of Inadequate Nutrition by Age and Sex in Alaska 1999 -2001 (Combined) Source: AK BRFSS

Prevalence of Physical Inactivity by Age and Sex in Alaska 1999 -2001 (Combined) Source: Prevalence of Physical Inactivity by Age and Sex in Alaska 1999 -2001 (Combined) Source: AK BRFSS

Mrs. Johnson • • • Secretary early fifties Thirsty, losing weight, tired Labs misfiled 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 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 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. Mc. Glynn 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 • 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 Mc. Glynn EA, Asch SM, Adams J, et al. N Engl J Med 2003; 348(26): 2635 -2645

Hwy 61 Hwy 61

The IOM Quality report: A New Health system for the 21 st Century The IOM Quality report: A New Health system for the 21 st Century

What people like Mrs. Johnson with chronic diseases need • Information and ongoing support 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 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 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 Mc. Diabetes Care in the U. S. Harris. Diab Care 2000; 23: 754 -8 Mc. Glynn et al. NEJM 2003; 348: 2635

What’s Responsible for the Quality Chasm? • Is it ignorant health professionals? ? 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. 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 • 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 Change in Hb. A 1 c Changes in Diabetes Outcome Measures in Intervention Group Change in Hb. A 1 c -0. 2% Change in BP 0. 8/-1. 8 Meigs et al. Diabetes Care 2003; 26: 750.

Conclusions • Baseline levels of diabetes care quality about the same or worse than 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 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 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! It’s like having a Dementor in the exam room!

Disease Management Contains • Population Identification process (Registry) • Evidence-based practice guidelines (Chosen and 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 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. , Hb. A 1 c, 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 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 Nurse Case Management RCT-Aubert et al. Change in Treatment and Glycemic Control Between Baseline and 12 Months

Meigs et al. • used guidelines and registry • increased pt. info and decision 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 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 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 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 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 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 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 Hb. A 1 c Levels across 31 RCTs Norris Effects of Self-management Education on Hb. A 1 c Levels across 31 RCTs 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 , 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 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 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 1 and 2 involving 180 Community Health Centers and 38, 000 BPHC Diabetes Collaboratives 1 and 2 involving 180 Community Health Centers and 38, 000 diabetic persons Average Hb. A 1 c Values

Results for All Asthma Teams Treatment with Maintenance Anti-Inflammatory Medications Results for All Asthma Teams Treatment with Maintenance Anti-Inflammatory Medications

Premier Health Partners • Dayton, Ohio • 100 physicians in 36 practices • Change 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 • A 1 c < 7% was 42% in 1999 and 70% in 2001

Disease Management Contains • Population Identification process (Registry) • Evidence-based practice guidelines (Chosen and 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

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