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Disease oriented programs and programs focussing on patients with multimorbid conditions in Germany. Prof. Joachim Szecsenyi, MD, MSc Dpt. General Practice.

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Presentation on theme: "Disease oriented programs and programs focussing on patients with multimorbid conditions in Germany. Prof. Joachim Szecsenyi, MD, MSc Dpt. General Practice."— Presentation transcript:

1 Disease oriented programs and programs focussing on patients with multimorbid conditions in Germany. Prof. Joachim Szecsenyi, MD, MSc Dpt. General Practice and Health Services Research University of Heidelberg Hospital Integrated Care Conference, Berlin, April 11th, 2013

2 Overview The challenge Summary Programms for single chronic diseases and for multimorbidity

3 Population Germany 2005/2025 Abteilung Allgemeinmedizin und Versorgungsforschung 3 Vaupel et al. Nature 2010

4 Germany: Society of longevity  Life expectancy at age of 60: –women: 24,9 years –men: 21,3 years  Increasing no. of patients with chronic diseases, above and below 60 years of age  Increasing no. of patients with more than one chronic condition, co- and multimorbidity  “Low fertility, low immigration and long lives” Christensen K, Doblhammer G, Rau R, Vaupel JW: Ageing populations: the challenges ahead. The Lancet 2009, 374: 1196 – 1208 4

5 Disease Management – the ideal Activated patient Good cooperation primary/ secondary care Pro-active team, evidence-based care Active sick funds, professional organisations / feed-back trans-sectoral / integrated

6 DMPs in Germany  2002/2003 introduction in social code book (SGB V)  Core contents are compulsory for contracts between insurers and providers  Defined by national expert groups at the level of the federal joint committee –Evidence based clinical guidelines –Basic data set –Quality indicators, provision of feedback –Transfer between different levels of care –Quality criteria for patient education  Some small differences in renumeration, type of feedback etc. by region/contract  Larger regional differences in CME, quality circles

7 DMPs in Germany  Patients and doctors have to enrol  General practitioners play a leading role  Cooperation with specialists (ambulatory and hospital outpatient)  Insurers have some co-steering role for the patient  Financial incentives for sick-funds from the national risk compensation scheme  Financial incentives for participating practices

8 DMPs in Germany  Currently 6 diseases –Cardiovascular disease; module on heart failure) –diabetes mellitus, type 1 and 2 –breast cancer –asthma –COPD  Participants –> 7 million. patients (thereof > 3.6 million with diabetes 2) –More than 40.000 providers

9  What do doctors say? –in the beginning much resistance –„Cookbook medicine“ –„Old fashioned drugs“ –„buerocracy“ –… –Now: more positive

10  „DMPs are recognized by patients as care that is more structured and that reflects the core elements of the Chronic Care Model and evidence-based counselling to a larger extend than usual care.“ Szecsenyi et al. Diabetes Care 2008

11 Morbidity adjusted survival of elderly patients with Diabetes mellitus 2 Miksch A, Laux G, Ose D, Joos S, Campbell S, Riens B, Szecsenyi J. Is there a survival benefit within a German primary-care based disease management program? Am J Manag Care 2010; 16(1):49-54.

12 Ose D, Wensing M, Szecsenyi J, Joos S, Hermann K, Miksch A, Diabetes Care. 2009 Quality of life and multimorbidity

13 More findings (for different DMPs)  Reduced mortality and costs for medication and hospitalisation (Stock et al. 2010)  National evaluation programme shows positive effect on non-smoking and blood pressure control  Reduction of unplannend hospitalisations (Lindner et al. 2011)  Better control of Asthma (Schneider et al. 2012)  Due to different evaluation approaches also some inconsistent findings when programs are compared  DMPs have extensively contributed to establish new roles and to improve competencies of medical assistants in primary care practices: human and structural investments in primary care  Improved use of pathways of care between different providers and levels of care

14 Multimorbidity  In primary care the rule, not the exception (Fortin et al. 2006), depression and pain often co-morbidity (Freund et al. 2012)  Limited applicability of disease specific guidelines (Boyd et al. 2005)  Limited applicability of DMPs for multimorbid patients at high risk  Priorisation important  Risk adjusted, individual approach necessary (i.e. case-management)

15 The next steps ahead..  Case management (CM) including telefone-monitoring in general practice  Trained medical assistants  Monitoring lists  Better use of family and community resources  Aims: –Improving chronic care management –Involving patients and families –Continuous monitoring and prevention of decompensation Foto : BMBF/PT DLR Gesundheitsforschung (Arzthelferin mit ArtMol Monitoring-Liste)

16 Practice based CM trials in Germany DEPRESSION PromPT trial (Gensichen et al 2009) ARTHRITIS PraxArt trial (Rosemann et al. 2007) CHRONIC HEART FAILURE HicMan trial (Peters-Klimm et al. 2011, 2012) MUlTIMORBIDITY PracMan trial Foto : BMBF/PT DLR Gesundheitsforschung (Arzthelferin mit ArtMol Monitoring-Liste)

17 Color-coded algorithm Emergency- immediate GP contact GP visit within 24h/GP report Normal

18 PraCMan study design Cluster-randomized trial in Baden-Württemberg (Germany) 115 practices including 132 teams (approx.2.100 patients), funded by AOK Intervention:GP-centered care + CM Control:GP-centred care Population:Patients with DM Typ II, COPD, CHF as tracer conditions ≥ 75. percentile likelihood of hospitalization (predictive modelling plus assessment by GP Endpoint: Rate of all-cause hospitalizations in 12 months (Freund et al. Trials 2011)

19 Secondary outcomes  Mortality  Direct and indirect costs  Quality of life (SF12 and EQ5D)  Quality of care (PACIC)  Health-related behavior (smoking status, PE)  Medication adherence (MARS)  Clinical Endpoints: –DM Type 2: HbA1c, fasting glucose, Hypoglycemia –COPD: Dyspnea, FEV1, exacerbations –CHF: NYHA, decompensations  Results available summer 2013

20  DMPs in Germany:  Care is more oriented according to the Chronic Care Model  Practices are more pro-active  Patients are more activated  Care is more coordinated  Positive effects on QoL and survival  Smaller effects on prescribing, hospitalisation and costs Summary

21  Further development of DMPs to adress multimorbidity  Development of primary care practice-based case management for multimorbid conditions  PraCMan trial helps to understand how to select the right patients for the right type and intensity of intervention  Long term investment in primary care teams necessary Summary

22  Thank you!

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