Managing chronic illness: an overview of the DISMEVAL project and (some) findings

1. Managing chronic illness: an overview of the DISMEVAL project and (some) findings Ellen Nolte on behalf of the DISMEVAL Consortium Belgian Presidency of the European Council ‘Innovative approaches for chronic illness in public health and healthcare systems’ Brussels, 20 October 2010

2. Outline • Background • About DISMEVAL and progress to date • (Some) findings • Concluding remarks

3. Background (1) • Growing proportion of people with chronic illness • ~20% to over 40% of population in EU aged 15 years and over report a long standing health problem • People with chronic diseases are more likely to utilise health care • Individual chronic diseases (e.g. diabetes) account for 2-15% of national health expenditure in some European countries • Health care tends to be built around an acute, episodic model of care that is not well-equipped to meet the requirements of effective chronic illness care • Fragmentation of services acting as barrier to coordination of services along the continuum of care • Sub-optimal quality of care for those with chronic health problems

4. Providing chronic care among primary care physicians in 11 countries Source: Schoen et al. 2009 Source: Schoen et al. 2009

5. Background (2) Disease management interventions/approaches proposed as a means to improve the quality and reduce the cost of care, and to improve health outcomes for the chronically ill Accumulating evidence of effectiveness of (some) individual DM components (at least short-term) however: frequent focus on single conditions, eg diabetes focus on immediate/short-term outcomes based on small-scale studies of high-risk patients, frequently in research/academic settings no universally accepted methods to measuring and reporting programme performance Need to learn about effects of large, population-based approaches using universally accepted evaluation methods that are scientifically sound and are also practicable in routine settings

6. Objectives to review current approaches to chronic care implemented by EU Member States at national and regional level and to examine whether and how these interventions are being evaluated to enhance our understanding of how macro-level health system features interact with interventions to improve chronic illness care through exploring the policy context for chronic disease management in European countries to develop and validate disease management evaluation methods using data from existing programmes and approaches through employing a range of evaluation designs and assess the sensitivity of findings to selected methods to formulate recommendations for scientifically sound yet operationally feasible evaluation approaches for chronic disease management that are relevant to planned and ongoing policies at the EU and the wider European level as well as internationally

7. Australia: Nicholas Glasgow, Nicholas Zwar, Mark Harris, IqbalHasan, TanishaJowsey Canada: IzzatJiwani, Carl-Ardy Dubois Denmark: Michaela Schiøtz, Allan Krasnik, Anne Frølich England: Debbie Singh, Daragh Fahey France: Isabelle Durand-Zaleski, Olivier Obrecht Germany: Ulrich Siering The Netherlands: Eveline Klein-Lankhorst, CorSpreeuwenberg Sweden: Ingvar Karlberg http://www.euro.who.int/en/home/projects/observatory/publications/studies

8. How the project works (1) Brings together multi-disciplinary team from a variety of key disciplines including evaluation science, chronic care, disease management design and operations, epidemiology, economics, and health policy 10 partners in 7 countries:

9. How the project works (2) Project comprises 14 work packages over 36 months Research Phase 1: Review of approaches to chronic care and DM evaluation methods in Europe (WPs 2-4) Phase 2: Testing and validation of methods and metrics for disease management evaluation (WPs 5-10) Phase 3: Developing recommendations for methods & metrics for disease management evaluation (WP11) Dissemination, management & quality assurance

10. Phase 1: Approaches to chronic disease management in Europe Review of approaches in place in 13 countries 7 partner countries: Austria, Denmark, England, France, Germany, Netherlands, Spain 6 additional countries: Estonia, Hungary, Italy, Latvia, Lithuania, Switzerland Methods Use of a common template for data collection on approaches to chronic disease management and on methods and metrics used to evaluate these approaches (13 countries) Interviews with key stakeholders (government/regulator; payer; provider; other (advisory, academic, etc.); patients) in 6 countries Data collection completed, analysis ongoing

11. Phase 2: Testing and validating methods & metrics for DM evaluation Utilisation of data from existing disease management programmes/equivalent in partner countries Austria (WP5), Denmark (WP6), Germany (WP7), France (WP8), the Netherlands (WP9), and Spain (WP10) Overview of methods and metrics to be tested Investigating selection bias in recruitment into structured care approaches in Germany and France Exploring approaches to cost-effectiveness of disease management in Austria and Denmark Advancing existing approaches to evaluation: experiences from the Netherlands and Spain

12. Healthcare delivery (1) Implementing new roles and competencies in primary care Nurse-led strategies common in systems with tradition in multidisciplinary team working (UK, Netherlands) Challenging in systems where primary care traditionally provided by doctors in solo-practice and few support staff (Austria, Denmark, France, Germany) Strengthening coordination through structured (disease-specific) approaches Structured disease management (programmes) (Austria, Denmark, Germany, France, Netherlands) Primary care physician remains principal provider/’care coordinator’ (exception: care chains in the Netherlands)

13. Healthcare delivery (2) Delivery system re-design Managing the primary/secondary care and/or secondary care/rehabilitation interface Provider networks (France) Integrated care contracting (Germany) ‘SIKS’ project (Copenhagen, Denmark) (some) Integrated Care Pilots (England) (some) Reform pool projects (Austria) Managing the health and social care interface (some) Integrated Care Pilots (England)

14. Approaches to chronic care: Germany (1) Nationwide introduction of DMPs from 2003 “an organisational approach to medical care that involves the coordinated treatment and care of patients with chronic disease across boundaries between individual providers and on the basis of scientific and up-to-date evidence” (BVA 2007) DMPs breast cancer; type I and II diabetes; coronary heart disease; asthma; COPD introduced between 2003 and 2006 Anchored in legislation, with G-BA responsible for developing content and Federal Insurance Office (BVA) for licensing and oversight Financial incentive for SHI funds to offer DMPs (linked to risk structure compensation scheme, RSA); reduced from 2009 5.5 million DMP-patients by mid 2009; >13,300 DMPs across country Source: Fullerton, Erler et al,

15. Approaches to chronic care: Germany (2) Integrated care contracts SHI funds permitted to designate 1% of income to selective contracts with individual providers/networks until end of 2008 > 6,000 contracts concluded by end 2008; wide variation in nature and scope, mostly focusing on hospital/rehabilitation interface GP-centred care Voluntary scheme, family doctor designated first contact of care All SHI funds have to offer GP-centred care Low uptake of ~20% of those covered by SHI ‘Policlinics’ (MVZ) Aim to enhance coordination by bringing together different specialities with teams typically comprising at least one GP Low take up (~ 1,000 centres vs 80,000 family physician practices) Source: Fullerton, Erler et al.

16. Approaches to chronic care: Netherlands Care groups (zorggroepen) Legal entity that brings together providers in primary care Contract with health insurers on basis of bundled payment (‘chain-DBC’) for the treatment of a given condition according to nationally defined care standard Care groups most evolved in the area of diabetes; chain DBC for diabetes refers to package of care for those with diabetes but without major complications Ten ‘experimental’ diabetes care groups established in 2006/07 supported by ZonMW and evaluated by the RIVM Government decision of nationwide roll-out care group principle for diabetes, COPD and vascular risk Source: Elissen, Vriejhoef et al.

17. Approaches to chronic care: Austria Reform pool Combines funds from SHI and regional governments to finance projects that coordinate healthcare delivery across sectors Projects include disease management programmes, forms of case management, integrated care arrangements for stroke patients and others Uptake of funds uneven across federal states Structured disease management (DMPs) Diabetes DMP (Therapieaktiv) implemented in six out of nine federal states (from 2007) with similar programmes introduced in Burgenland and Upper Austria DMPs for other conditions (coronary heart disease, asthma, type I diabetes) under discussion Total of ~17,000 of diabetic patients enrolled in DMP (estimated total of people with diabetes 400,000) Source: Flamm, Soennichsen et al.

18. Impact of chronic care approaches and policies (1) Germany Statutory evaluation of DMPs finds improved quality of care for diabetes patients; limited evidence from (few) controlled studies point to improved outcomes (QoL; mortality) Methodological challenges () DMPs are disease-oriented; complex patients difficult to accommodate Lack of evidence of impact of other approaches Netherlands Evaluation of ten ‘experimental’ diabetes care groups finds wide variation in number and types of participants Content of care package Price (between €250 and €470) Impact on cost uncertain; governance issues Source: Fullerton et al, under review; Struijs et al. 2009

19. Impact of chronic care approaches and policies (2) Austria DMPs RCT of TherapieAktiv in Salzburg finds significant improvement in selected clinical outcomes (blood sugar, blood pressure) and process measures (regular check up) Evidence of costs savings inconclusive Reform pool activities projects slow to take off: lack of financial incentives for physicians to take part; requirement of additional funding as disincentive at Pool level Limited federal oversight: duplication of efforts Uneven uptake over ‘space’ and time: highest uptake in 2007 but dropping off thereafter; only 16% of available funding has been used (>30% in Styria to 1.5% in Tyrol) Source: Hofmarcher 2007; Czypionka and Röhrling 2009

20. Observations for chronic care policies in Europe Countries are developing new models of health care delivery to achieve better coordination of services across the entire continuum of care Systems with a tradition of patient choice of any provider, little/no enrolment of patients and using fee-for-service as main payment method in primary care face greatest challenges in implementing system-wide strategies to provide care for patients with chronic illness European health care systems are diverse: there are no universal solutions to the challenges of chronic disease

21. Concluding observations for European research European countries vary widely in their approaches to what can be broadly subsumed under the heading of ‘chronic disease management’ Differences in the importance attached to robust evaluation research in different settings Diversity of partners from different countries productive environment for mutual learning and cross-fertilisation of ideas which has stimulated the development of analytic approaches to disease management evaluation that are unlikely to have developed in isolation