Pisa, 13 June 2011

1. WORKSHOPRegional strategies to improve efficacy and equity while guaranteeing economic sustainabilityProactive strategies in primary care: the Tuscan Experience Pisa, 13 June 2011 lorenzo.roti@regione.toscana.it paolo.francesconi@ars.toscana.it

2. a) Primary Health Care and the CCM-based program in Tuscan Region b) Impact on quality of care and health care costs: preliminary results for diabetes c) Future perspectives

3. a) Primary Health Care and the CCM-based program in Tuscan Region

4. The Tuscan Healthcare System: some data • 3,7 millions inhabitants • 6.300 millions € for healthcare spending in 2009: 5% prevention 43% hospitals services 52% primary care • 17 Public Health Authorities: 12 Local Health Authorities and 5 Teaching Hospitals organized in three Network “Area Vasta”: • North West Area Vasta: 2 T.H. and 5 L.H.A. • Center Area Vasta: 2 T.H. and 4 L.H.A. • South East Area Vasta: 1 T.H. and 3 L.H.A. • 51.000 employees • 2.940 GPs • 14.000 public and private hospital beds (3,8 per 1.000 inhabitants) [2009]

5. The Aging Population Epidemiology of Chronic Diseases in Tuscany Population >64 years - Tuscany 23,3% - Italy 19,9% Number of diagnosed cases for each of the 5 “CCM chronic diseases” per 1,000 residents 16 + according to administrative data; hypertension limited to exempted cases (MaCro system) Tuscany Population Pyramid 2005 2025

6. Chronic diseases From the last quarter of the 20° century: fourth stage of epidemiological transition Aging population and reduction of the mortality due to CV acute event Increase of the chronic diseases prevalence The management of the increasing chronic diseases prevalence is one of the most important healthcare problems to deal with. (Tuscany Strategic Health Plan PSR 2008-2010, p. 34)

7. From traditional healthcare to proactive healthcare Where Tuscany wants to invest? Proactive healthcare: The patient’s needs are taken into account before the disease worsening and possibly before disease onset, getting better health conditions for the population, addressing equity issue too. Traditional healthcare: The healthcare system acts only when the chronic patient worsens becoming acute. Chronic diseases are not well treated and prevention as well as risk factors are not taken into account. Health inequities are not taken into account The healthcare system is able to manage chronic diseases and to be effective in facing the acute diseases onset.

8. Which model to drive the change: the Expanded Chronic Care Model (CCM) ExpandedChronic Care Model: • main strategy of the Regional Health Plan • new delivery System design focused on multi-professional care team • new role of nurses in self management support; • decision support through shared clinical pathways; • investment on integrated information system • community resources exploitation • Focus on prevention and health determinants (community oriented primary care)

9. Quality indicators for GPs Incentives based contract - Diabetes

10. GPs and other health professionals operators (nurses, medical assistant …) organized in practice (6-16 GPs) to care for chronic patients with a proactive approach (Chronic Care Model) 11 Healthcare • 56 practice • 497 GPs • 112 Nurses • 618.969 Patients MITO project– 1 Healthcare • 4 policlinics • 166 GPs • 175.000 Patients Pilot phase January 2010 Other groups are expected to be involved • 31 practice • 301 GPs • 62 Nurses • 337.213 Patients Extention phase October 2010 10

11. Clinical register 11

12. Diabetes prevalence rate at practice level Regional Prevalence 4,9%

13. b) Impact on quality of care and health care costs: preliminary results for diabetes

14. Study objectives To evaluate the effect of the CCM-based program being implemented in Tuscany on a) quality of care in terms of process indicators b) per capita health care costs in patients with diabetes (and hearth failure)

15. Study design A pre-post comparison-group study Groups and observation periods (data available up to end 2010): Start of program 1/7/2010 1/1/2009 1/7/2009 31/12/2010 31/12/2009 process indicators (one year) & care cost per capita for selected services (one semester) Patients of CCM – GPs Patients of No CCM - GPs Prevalent at 1.1.09 Prevalent at 1.1.10

16. Data sources Data sources: the Tuscan longitudinal record-linkage system “MaCro” (Chronic Diseases) of inhabitants registry, exemptions, specialist care, drug dispensing and hospital discharge records (administrative data) through which: a) cohorts of residents with specific diseases can be identified and b) levels of adherence to clinical recommendations can be calculated

17. Study area and populations • Prevalent at 1.1.2009: A total of 139,267 patients 16+ with diabetes of which: • 26,276 enrolled with the 394 GPs implementing CCM (intervention group) • 112,991 enrolled with the 1,875 GPs not implementing CCM (control group) • Prevalent at 1.1.2010: A total of 142,489 patients 16+ with diabetes of which: • 27,149 enrolled with the 394 GPs implementing CCM (intervention group) • 121,110 enrolled with the 1,875 GPs not implementing CCM (control group) • Age (68% over 65) and sex distributions (50% women) of the four groups were quite similar

18. Principal outcomes a) Process Indicators • % of patients with at least one assessment of HbA1c • % of patients with at least one assessment of micro-albuminuria • % of patients with at least one assessment of creatininemia • % of patients with at least one assessment of lipids • % of patients with at least one assessment by an ophthalmologist during the twelve-month periods of observation b) Care cost per capita (selected services) • per capita cost for diabetes specialist care • per capita cost for eye specialist care • per capita cost for specific laboratory diagnostic procedures during the six-month periods of observation

19. a) process indicators (lab tests)

20. a) process indicators (eye specialist care)

21. b) per capita cost of selected health care services – 2° semester (I) per capita cost of eye specialist care per capita cost of specific lab tests

22. b) per capita cost of selected health services – 2° semester (II) per capita cost of diabetes specialist care

23. Summarizing In patients with diabetes enrolled with CCM-GPs, compared with patients with diabetes enrolled with no-CCM-GPs: • quality of care in terms of pure process indicators has improved • per capita cost of eye specialist care and lab tests have increased • per capita cost of diabetes specialist care has decreased

24. And equity ? • Data from LHA of Arezzo on 1,494 patients with diabetes enrolled with CCM – GPs, of whom 90 (6 %) defined as “deprived”: tenants paying a rent and/or referring economic difficulties • Preliminary results

25. c) Future perspectives

26. What next? What we know… • “… Disease-oriented medicine…through a focus on particular chronic diseases and their management is thus highly inequitable” (Starfield, The hidden inequity in health care. IJEqH 2011) • “… it is neither necessary nor desirable to try to introduce the whole model at once. It is most effective to focus on one highly important change at a time (Kriendler, Lifting the burden of chronic disease: What’s worked, what hasn’t, what next. 2008) • “… High-performing organizations more often used computerized reminders (clinical information systems), guidelines supported by clinician education or computer support (decision support), formal self-management programs (self-management support), and a registry (clinical information systems) … smaller practices would have greater difficulty implementing the CCM and improving outcomes. (Health Affairs 28, no. 1- 2009: 75–85)

27. What next? What we should do … Our CCM-based program is intended as a transitional phase towards person-focused care since it shifts chronic diseases management to primary health care • Practice need to be more supported by the clinical information systems for implementing proactive approach and promoting clinical and equity audit • We need to review the clinical pathways, most focusing on risk (eg. Cardiovascular) and not on specific disease • We have to introduce formal and more standardized self management support programs aiming to an actual proactive patient and focusing attention on individual determinants of health • We should change deeply the service delivery design strenghtening the integration between primary care and specialsitic services in the community

28. Thanks for your attention lorenzo.roti@regione.toscana.it paolo.francesconi@ars.toscana.it