- Количество слайдов: 53
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 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) Source: AK BRFSS
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 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. 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 • 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
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 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 Mc. Glynn et al. NEJM 2003; 348: 2635
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 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 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. , 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 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
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 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 , 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 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
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 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