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Chronic Disease in Primary Care

Chronic Disease in Primary Care. It is complex Martin Dawes. Be Active.

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Chronic Disease in Primary Care

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  1. Chronic Disease in Primary Care It is complex Martin Dawes

  2. Be Active • Participation in regular physical activity, United States, 1990–99*The definition of moderate physical activity was changed in 1997.Sources:  Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System. 1991–97.  Centers for Disease Control and Prevention, National Center for Health Statistics. National Health Interview Survey. 1990–99.

  3. Don’t eat too much

  4. I don’t have an “epidemiology” of patients “Standards that define quality of patient care…by placing emphasis on high rates of adherence to guidelines and targets rather than weighing the burden, risks and benefits of complex therapies in shared decision making could ultimately undermine quality of care.” Boyd et al JAMA 2005; 294:716-24

  5. Starfield CMAJ 2009 “Models of care based on the diagnosis and management of a small set of specific chronic diseases are not likely to have much impact on overall population health or equity in health. Nor is adherence to guidelines for treating such conditions. The evidence on which most such models is based is flawed  and not generalizable to populations in primary care. In contrast, patient-focused primary care has been shown to be beneficial.” Starfield, CMAJ • May 26, 2009; 180 (11). Toward international primary care reform

  6. Intensive glucose controlAccord - 3.5 years - 6.4% vs 7.5% A1c - 10,251, 62 y/o, diab 10 years, 35% CVDAdvance - 5 years - 6.5% vs 7.3% A1c - 11,140, 66 y/o, diab 8 years, 32%CVD * microvascular data not yet reported for ACCORD ** development of macroalbuminuria ↓ by 1.2% - NSS in doubling of creatinine or dialysis serious adverse event data not reported N Engl J Med 2008;358:2560-72 AND 2545-59

  7. The paradox of primary care.Kurt C. Stange 2009 The paradox is that compared with specialty care primary care is associated with : (1) apparently poorer quality care for individual diseases, yet (2) similar functional health status at lower cost for people with chronic disease, and (3) better quality, better health, greater equity, and lower cost for whole people and populations.

  8. Aspects of Care That Distinguish Conventional Health Care from People-Centred Primary Care Starfield 05/09 PC 4187 n Source: World Health Organization. The World Health Report 2008: Primary Health Care – Now More than Ever. Geneva, Switzerland, 2008.

  9. What happens to people with back pain? • Aus inception cohort of 973 consecutive patients presenting to primary care with acute low back pain (<2 weeks' duration). • 406 whose pain persisted for three months = inception cohort of patients with chronic LBP. • follow-up was 97% for all outcomes. The cumulative probability of being pain-free 42% at 12/12. BMJ. 2009 Oct 6;339:

  10. Prognosis • The prognosis is less favourable for those who have taken previous sick leave for low back pain, have high disability levels or high pain intensity at onset of chronic low back pain, have lower education, perceive themselves as having a high risk of persistent pain, and were born outside Australia.

  11. Real populations In primary care 40% of new presentations never fit criteria for any known diagnosis In primary care 40% of patients have multiple comorbid conditions About half of people over 65 years old have at least 3 coexisting chronic conditions About one in five have 5 or more

  12. Hypothetical >70 year old woman COPD Type 2 diabetes Hypertension Osteoarthritis Osteoporosis Boyd et al JAMA 2005; 294:716-24

  13. We need a guideline for each patient – not each problem 19 doses of 12 different medications Taken at five times during the day 14 non pharmacological activities 10 different possibilities for significant medicine interactions either with other medicines or other diseases

  14. It is not just about drugs • People are older • More Chronic Disease • What is the aim of primary care? • We don’t know the targets, we don’t have the evidence • BP committees discussing < or <= to 130 • BP systolic SD is 20 mmHg

  15. Prognosis & Tx • Who is going to get sick? • 1785 patients with new angina (mean age early 60’s) • Within 5 years 10% died – 5% from IHD (Buckley BMJ 2009) • What can I do to stop that – in primary care?

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