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

Level 2 – “disease management”Level 2 – “disease management”

15-25%

3,500,000? “high risk” 2

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

The NHS version of the Wagner ModelThe NHS version of the Wagner Model

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

THE END

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