Integrated approaches to prevention and control of chronic conditions

1. Integrated approaches to prevention and control of chronic conditions JoAnne Epping-Jordan, PhD Coordinator Health Care for Chronic Conditions World Health Organization Geneva, Switzerland

2. WHO at a Glance Objective: ‘The attainment by all peoples of the highest possible level of health.’ • United Nations specialized agency for health • Governed by 192 Member States • Headquarters in Geneva • Six regional offices and numerous country offices

3. Chronic Conditions: The health care challenge of the 21st century Cover a broad category of what appear biomedically as disparate health concerns • noncommunicable conditions • persistent communicable conditions • long-term or recurrent mental disorders • ongoing physical impairments and disabilities

4. WORLD Deaths, by broad cause group, 2001 Total deaths: 56,554,000 Noncommunicable conditions (33.1 million) Communicable diseases, maternal and perinatal conditions and nutritional deficiencies (18.4 million) Injuries (5.1 million) Source: World Health Report 2002

5. World Deaths, 2000, by selected leading risk factors (000s) Source: World Health Report 2002

6. Tobacco: 4.2 million deaths/year • Diet/nutrition (insufficient fruit/vegetables): 4 million deaths/year • Physical activity: 1.6 million deaths/year • Alcohol: 2 million deaths/year Source: World Health Report 2002

7. Global determinants driving this increase • Public health successes  people are living longer • Rapid economic development  changes in health behaviour • Aggressive marketing of health risks (tobacco, alcohol, fast food)

8. Poland: "Camel. He grew up to be kind." 2000 Philippines: Calendar 2001

9. Smoking prevalence in mega countries

10. The risk factors of today are the diseases of tomorrow Theme of the World Health Report 2002 ‘Measuring, communicating, and reducing risks to health’

11. A conceptual model of the progress of a diseaseRelationship between diabetes, hypertension and renal disease Healthy Population Risk Factors Early Disease Confirmed Disease Complications No diabetes Pre diabetes Diabetes onset Diabetes no complications Diabetes with complications Source: Healthcare Decision Making in the Western Pacific Region: Diabetes and the Care Continuum. Carol Beaver. 2001

12. Confirmed Disease Confirmed Disease Confirmed Disease Early Disease Early Disease Early Disease Healthy Population Healthy Population Healthy Population Risk Factors Risk Factors Risk Factors Complications Complications Complications Interactive model for chronic disease Hypertension Diabetes Renal Disease Source: Healthcare Decision Making in the Western Pacific Region: Diabetes and the Care Continuum. Carol Beaver. 2001

13. No longer is each risk factor and chronic illness being considered in isolation. Awareness is increasingthat similar strategies can be equally effective in treating manydifferent conditions.

14. TYPICAL CARE The Radar Syndrome • Patient appears • Patient is treated “find it and fix it” • Patient is discharged … then disappears from radar screen

15. Radar logic = inappropriate care for chronic conditions • System oriented to acute illness • Patient’s role not emphasized • Follow-up sporadic • Prevention overlooked

16. Missed opportunities for clinical prevention: What is the impact? • Tobacco smokers have 18% higher medical charges than non-smokers • A one-unit increase in BMI raises medical charges by 1.9% • Each additional day of physical activity per week reduces medical charges by 4.7% Study conclusions: “Health plans that do not systematically support members’ efforts to improve health-related behaviors may be incurring significant short-term health care charges that may be at least partly preventable.” JAMA 1999; 282: 2235-9

17. - Health Care Experiences in Five Countries • 3,849 “sicker patients” across 5 countries • Despite differences in health systems, large proportions of patients report errors, poor communication, faulty care coordination • Focusing on high utilizers has the potential to both control costs and improve care Blendon et al., Health Affairs 2003; 22(3):106-21

18. - Across the five countries “My regular doctor or health professional DOES NOT …” • make clear specific treatment goals (20-38%) • help me understand what needs to be done for my health (12-26%) • ask for my ideas or opinions about treatment (47-67%) • keep me motivated (28-43%) • provide advice on weight, nutrition, exercise, smoking, drinking (33-49%) • discuss the emotional burden of the condition (51-66%) Blendon et al., Health Affairs 2003; 22(3):106-21

19. World wide, effective prevention and management of chronic conditions requires an evolution of health care …. from “radar care” to “innovative care”

21. Cochrane Review of Interventions to Improve Diabetes Care in Primary Care • 40 randomized trials • Interventions classified as provider-oriented, organizational, information systems, or patient-oriented • Combined interventions more potent than individual ones, especially those that included organizational change • Patient outcomes (e.g., HbA1c, BP, LDL) improved only if patient-oriented interventions included

22. Patients and families are the ultimate providers of health care for chronic conditions “95% or more of the many health decisions a diabetic patient must make daily are made without health care professionals even knowing them.” Diabetes Care 1995; 18: 412-25

23. Sample Results: Clinica Campesina

24. Sample results: Premier Health Partners

25. Sample results: High Plains Community Center Improved rate = results after 7 months

26. Other Examples of Innovative Programmes • Diabetes: quadruples foot exam rates (18% - 82%) • Asthma: reduces hospital admission costs from $18,488 to $1,538 per patient • Coronary artery disease: reduces deaths by 41% • Congestive heart failure: reduces hospital admissions by 56% • Nicotine dependence: produces 70% cessation • Rural South Africa: nurse-led PHC programme that used registries, self-management support, protocols and follow-up, resulted in good outcomes for hypertension, diabetes, asthma and epilepsy with minimal physician support

27. Improving the system of hypertension care in Tula Oblast, Russian Federation (1998-2000) • Number of patients managed at the primary care level increased by 7.6 times • BP stabilization achieved in 69.4% of patients • Hypertension related hospitalizations decreased by 85% • Hypertensive crises decreased by 60% University Research Corporation, USA

28. Summary • The disease burden has changed towards chronic conditions world wide. The health system hasn’t. • Effective interventions exist for most major risk factors and chronic conditions, yet patients do not receive them. • Effective prevention and management of chronic conditions requires an evolution of health care, away from a model that is focused on acute symptoms towards a coordinated, proactive system of care. • Evidence shows that integrated approaches result in improved efficiency and better outcomes.

30. “Trying harder will not work. Changing systems of care will.”Crossing the Quality Chasm, Institute of Medicine, 2001

31. For more information Contact: Dr J. Epping-Jordan Coordinator Health Care for Chronic Conditions World Health Organization Tel: +41 22 791 4646 Fax: +41 22 791 4259 email: eppingj@who.int www.who.int/chronic_conditions/en