Integrated approaches to prevention and control of chronic conditions

… … committed to health care improvementcommitted to health care improvement

Integrated approaches to prevention and control of chronic conditions JoAnne Epping-Jordan, PhD

CoordinatorHealth Care for Chronic

ConditionsWorld Health Organization

Geneva, Switzerland


WHO at a

WHO at a

GlanceGlance

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


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


32.5%

58.5%

9.0%

Injuries(5.1 million)

Noncommunicableconditions(33.1 million)

WORLDDeaths, by broad cause group, 2001

Communicable diseases, maternal and perinatal

conditions and nutritional deficiencies

(18.4 million)

Total deaths: 56,554,000

Source: World Health Report 2002


0 1000 2000 3000 4000 5000 6000 7000 8000

Occupational risk factors for injury Unsafe health care injections

Vitamin A deficiency Zinc deficiency

Urban air pollution Iron deficiency

Indoor smoke from solid fuels Unsafe water, sanitation, and hygiene

Alcohol Physical inactiv ity

High BMILow fruit and vegetable intake

Unsafe sex Underweight

High cholesterol Tobacco

High blood pressure

WorldDeaths, 2000, by selected leading risk

factors (000s)



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



Public health successes people are living longer

Rapid economic development changes in health behaviour

Aggressive marketing of health risks (tobacco, alcohol, fast food)

Global determinants Global determinants driving this increasedriving this increase


Poland:Poland:

"Camel. He "Camel. He grew up to be grew up to be kind." 2000kind." 2000

PhilippinesPhilippines::

Calendar Calendar 20012001


0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

%

Ban

gla

des

h

Bra

zil

Ch

ina

Ind

ia

Ind

on

esia

Jap

an

Mex

ico

Nig

eria

Pak

ista

n

Ru

ssia

US

A

Men Women

Smoking prevalence in mega Smoking prevalence in mega countriescountries


The risk factors of today The risk factors of today are the diseases of are the diseases of

tomorrowtomorrowTheme of the World Health Report 2002

‘Measuring, communicating, and reducing risks to health’


A conceptual model of the progress of a disease

Relationship between diabetes, hypertension and

renal disease

Source: Healthcare Decision Making in the Western Pacific Region: Diabetes and the Care Continuum. Carol Beaver. 2001

Risk Factors

Risk Factors

Early Disease

Early Disease

Confirmed Disease

Confirmed Disease ComplicationsComplicationsHealthy

PopulationHealthy

Population

No diabetes

Pre diabetes

Diabetes onset

Diabetes no complications

Diabetes with complications


Interactive model for chronic disease

Source: Healthcare Decision Making in the Western Pacific Region: Diabetes and the Care Continuum. Carol Beaver. 2001

Healthy

Population

Risk

Factors Early

Disease

Confirmed

Disease

Complicatio

ns

Hypertension

Healthy

Population

Risk

Factors Early

Disease

Confirmed

Disease

Complicatio

ns

Healthy

Population

Risk

Factors Early

Disease

Confirmed

Disease

Complicatio

ns

Diabetes

Renal Disease


No longer is each risk factor and chronic illness being considered

in isolation. Awareness is increasing that similar strategies

can be equally effective in treating many different

conditions.


The Radar SyndromeThe Radar Syndrome Patient appears Patient is treated

“find it and fix it”

Patient is discharged

… then disappears from radar screen

TYPICAL CARETYPICAL CARE


Radar logic = inappropriate Radar logic = inappropriate care for chronic conditionscare for chronic conditions

System oriented to acute illness Patient’s role not emphasized Follow-up sporadic Prevention overlooked


JAMA 1999; 282: 2235-9

Missed opportunities for Missed opportunities for clinical prevention: What is clinical prevention: What is the impact?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.”


-

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


-

Across the five countries

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%)

“My regular doctor or health professional DOES NOT …”“My regular doctor or health professional DOES NOT …”

Blendon et al., Health Affairs 2003; 22(3):106-21


World wide, effective World wide, effective prevention prevention

and management of and management of chronic conditions requires chronic conditions requires

an evolution an evolution of health care ….of health care ….

from “radar care” to from “radar care” to “innovative care”“innovative care”



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


“95% or more of the many health decisions a diabetic

patient must make daily are made without health care

professionals even knowing them.”

“95% or more of the many health decisions a diabetic

patient must make daily are made without health care

professionals even knowing them.”

Patients and families are the ultimate providers of health care for chronic conditions

Diabetes Care 1995; 18: 412-25


Sample Results: Clinica Sample Results: Clinica CampesinaCampesina

Measure Initial rate Improved rate

Average HbA1c 10.5% 8.7%

At least 2HbA1c/year

15% 45%

Eye exams 7% 27%

Foot exams 15% 56%

Collaborative self-managementgoal

0% 46%


Sample results: Premier Sample results: Premier Health PartnersHealth Partners


HbA1c < 7% 42% 70%

At least 2HbA1c/year

67% 90%

Foot exams 61% 78%

Annual urineprotein

52% 78%

ACE inhibitorswith positiveurine protein

38% 80%


Sample results: High Plains Sample results: High Plains Community CenterCommunity Center


BP < 140/90 35% 62%

At least 2 BPchecks/year

47% 87%

Documented self-management goal

34% 59%

Hyperlipidemiascreening

70% 82%

Improved rate = results after 7 months


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

Other Examples of Innovative Programmes


Improving the system of Improving the system of hypertension care in Tula Oblast, hypertension care in Tula Oblast, Russian Federation (1998-2000)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


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.

SummarySummary



“Trying harder will not work. Changing systems of care will.”

Crossing the Quality Chasm, Institute of Medicine, 2001


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: [email protected]

www.who.int/chronic_conditions/en

For more informationFor more information

Documents

Integrated approaches to prevention and control of chronic conditions