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Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different? Barbara Starfield, MD, MPH Bellagio, Italy April 2008.

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Presentation on theme: "Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different? Barbara Starfield, MD, MPH Bellagio, Italy April 2008."— Presentation transcript:

1 Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different? Barbara Starfield, MD, MPH Bellagio, Italy April 2008

2 The purpose of this presentation is to explore the concepts of “disease” and “chronic disease” and to show why a more appropriate focus is on a continuum of care (“primary care”) for all people and populations rather than on care for targeted diseases. Starfield 03/08 D 3978

3 The IOM report, Crossing the Quality Chasm, urges selecting priority conditions for attention to the quality of care. The list from which they should be chosen includes cancer, diabetes, emphysema, high cholesterol, HIV/AIDS, hypertension, ischemic heart disease, stroke, and perhaps also arthritis, asthma, gall bladder disease, stomach ulcers, back problems, Alzheimers, depression, anxiety disorders. Starfield 02/08 D 3948 Why aren’t undernutrition, occupational diseases, osteoporosis, low birth weight and prematurity, or virtually any childhood disorder (except asthma) considered high priority? Who should decide what a priority disease is? The disease experts?

4 Diseases are professional constructs can be and are artificially created to suit special interests; the sum of deaths attributed to diseases exceeds the number of deaths do not exist in isolation from other diseases and are, therefore, not an independent representation of illness are but one manifestation of ill health Starfield 08/07 D 3831 Sources: Chin. The AIDS Pandemic: the Collision of Epidemiology with Political Correctness. Radcliffe Publishing, De Maeseneer et al. Primary Health Care as a Strategy for Achieving Equitable Care: a Literature Review Commissioned by the Health Systems Knowledge Network. WHO Health Systems Knowledge Network, Available at: Mangin et al, BMJ 2007; 335: Murray et al, BMJ 2004; 329: Tinetti & Fried, Am J Med 2004; 116: Walker et al, Lancet 2007; 369:

5 Are diseases really discrete categorizations of pathology? Starfield 03/08 D 3979

6 There appear to be many disorders included under the rubric of diabetes: insulin secretion; insulin transport; zinc-binding to insulin; and pancreatic islet beta cell development. Starfield 03/08 D 3980 IS DIABETES A DISEASE? DOES IT MAKE SENSE TO ASSUME THAT GUIDELINES FOR THE IDENTIFICATION AND MANAGEMENT OF DIABETES APPLY TO ALL “DIABETICS”? Source: Topol et al, JAMA 2007; 298:

7 In a relatively small-scale study, diabetics who have weight loss are five times more likely to have their diabetes disappear than diabetics who have standard diabetes care. Starfield 02/08 D 3940 Source: Dixon et al, JAMA 2008; 299: Questions: Is diabetes a “chronic disease”? Is it a disease?

8 If the association between obesity and diabetes is absent in people with low concentrations of persistent organic pollutants, and the association becomes stronger as the concentration of these pollutants rises, is obesity a risk factor for diabetes? Is diabetes a single disease? Starfield 02/08 D 3944 Source: Jones et al, Lancet 2008; 371:287-8.

9 If three diabetics per one thousand per year die from the implementation of supposedly evidence-based treatment, is diabetes a single disease? Starfield 02/08 D 3946 Source: Kolata G. Diabetes study partially halted after deaths. Seattle, WA: University of Washington press release, February 2, 2008.

10 There is broad variation in breast cancer risk among carriers of BRCA1 and BRCA2 mutations. Starfield 02/08 D 3939 Source: Begg CB, Haile RW, Borg A et al. Variation of breast cancer risk among BRCA1/2 carriers. JAMA 2008; 299(2): Question: Is BRCA1 and BRCA2-related breast cancer a disease?

11 If a 90-year-old woman dies two months following hip fracture, did she die from an acute disease or a chronic disease? Starfield 02/08 D 3943 What is the “cause of death” likely to be coded as?

12 If oral contraceptives are protective on epithelial and non- epithelial cervical cancer but not on mucinous cervical cancer, is cervical cancer a single disease? Starfield 02/08 D 3945 Source: Franco & Duarte-Franco, Lancet 2008; 371:277-8.

13 COPD is a chronic systemic inflammatory syndrome with complex chronic co- morbidities. Patients with COPD mainly die of non-respiratory disorders such as cardiovascular disease or cancer. COPD is a heterogeneous disease process. Although exacerbations of COPD, especially those defined as being infectious, are quite frequent, the number of randomized placebo-controlled trials of antibiotics is surprisingly small. Sources: Fabbri & Rabe, Lancet 2007; 370: Calverley & Rennard, Lancet 2007; 370: Starfield 10/07 D 3907

14 When occurring in the same individual, BMI greater than 30, systolic blood pressure greater than 140, and blood cholesterol greater that 250 mg/dL are associated with a six-fold increased odds of Alzheimers disease. What type of disease is Alzheimers? What is the disease? Source: Michel et al, JAMA 2008; 299: Starfield 03/08 D 3981

15 Hypothyroidism is three times more likely in women with rheumatoid arthritis than in the general population. Women with both conditions have a fourfold higher risk of cardiovascular disease than euthyroid women with arthritis, independent of conventional risk factors. Inflammation and autoimmunity are implicated in vulnerability to a wide variety of “chronic” diseases – and they may well be “acute”. Source: Raterman et al, Ann Rheum Dis 2008; 67: Starfield 03/08 D 3982

16 What Is a Chronic Disease? Starfield 10/06 D 3459 Generally defined as persistence or recurrence, usually beyond one year

17 Chronic Disease: Expanded Definition Incurable Complex “causation” Multiple risk factors Long latency Prolonged course Associated with functional impairment or disability Starfield 05/07 D 3710 Source: Australian Institute of Health and Welfare. Indicators for Chronic Diseases and Their Determinants, Canberra, Australia: AIHW, 2008.

18 How “chronic” are chronic diseases? Starfield 10/07 D 3888

19 Persistence of Diagnoses* Overall prevalence time 2 Prevalence among those having diagnosis in time 1 Obesity69539(x 7.8) Asthma70628(x 9.0) Autoimmune disorder18641(x 35.6) Seizures10670(x 67.0) *per 1000, not adjusted for age Starfield 04/ Starfield 09/07 D 3860 n

20 Persistence of Diagnoses* Overall prevalence time 2 Prevalence among those having diagnosis in time 1 UTI87350(x 4.0) Hypertension213879(x 4.1) Headache102455(x 4.5) Lipoid disorders144720(x 5.0) *per 1000, not adjusted for age Starfield 04/ Starfield 09/07 D 3861 n

21 Persistence of Diagnoses* Overall prevalence time 2 Prevalence among those having diagnosis in time 1 URI357585(x 1.6) Pneumonia, non-bacterial186378(x 2.0) Sinusitis231525(x 2.3) Musculoskeletal s/s190461(x 2.4) Dermatitis, eczema109302(x 2.8) Abdominal pain116326(x 2.8) Otitis media136452(x 3.3) *per 1000, not adjusted for age Starfield 04/ Starfield 09/07 D 3862 n

22 Not all chronic diseases are manifested year to year. Acute diseases sometimes behave as if they were chronic, recurring year to year. Only a minority of common chronic diseases or conditions are currently candidates for the vast majority of chronic disease management programs. Acute and chronic conditions share a characteristic: inflammation. Starfield 08/06 D 3435

23 People and populations differ in their overall vulnerability and resistance to threats to health. Some have more than their share of illness, and some have less. Morbidity mix (sometimes called case-mix) describes this clustering of ill health in patients and populations. Starfield 03/06 CM 3372

24 Influences on the Health of Individuals For influences at the community level, there is a spectrum from those that are aggregations from individual-level data to those that are ecological in nature. *“Health” has two aspects: occurrence (incidence) and intensity (severity). SOCIODEMOGRAPHIC CHARACTERISTICS GENETIC & BIOLOGICAL CHARACTERISTICS DEVELOPMENTAL HEALTH DISADVANTAGE POLITICAL AND POLICY CONTEXT WEALTH: LEVEL & DISTRIBUTION** POWER RELATIONSHIPS HEALTH SYSTEM CHARACTERISTICS BEHAVIORAL & CULTURAL CHARACTERISTICS OCCUPATIONAL & ENVIRONMENTAL EXPOSURES HEALTH* PHYSIOLOGICAL STATE MATERIAL RESOURCES SOCIAL RESOURCES BEHAVIORS CHRONIC STRESS HEALTH SERVICES RECEIVED Starfield 04/07 IH 3637 **Including income inequality Source: Starfield, Soc Sci Med 2007; 64:

25 Influences on Health Equity SOCIAL POLICY ECONOMIC POLICY WEALTH: LEVEL & DISTRIBUTION** POWER RELATIONSHIPS*** HEALTH SYSTEM CHARACTERISTICS AVERAGE HEALTH* DEMOGRAPHIC STRUCTURE BEHAVIORAL & CULTURAL CHARACTERISTICS EQUITY IN HEALTH* Dashed lines indicate the existence of pathways through individual-level characteristics that most proximally influence health. For influences at the community level, there is a spectrum from those that are aggregations from individual-level data to those that are ecological in nature. HISTORICAL HEALTH DISADVANTAGE POLITICAL CONTEXT *“Health” has two aspects: occurrence (incidence) and intensity (severity). OCCUPATIONAL & ENVIRONMENTAL POLICY HEALTH POLICY Starfield 04/07 IH 3638 ENVIRONMENTAL CHARACTERISTICS Source: Starfield, Soc Sci Med 2007; 64: **Including income inequality ***Including social cohesion

26 IH 3789 n Etiologic Heterogeneity Cause A Cause BCause C Dis-ease 1 Pleiotropism Dis-ease 3 Cause A Dis-ease 1 Dis-ease 2Penetrance No Dis-ease Cause A Cause BCause C Starfield 07/07 IH 3789 n

27 Starfield 03/08 IH 3983 Source: Australian Institute of Health and Welfare. Indicators for Chronic Diseases and Their Determinants, Canberra, Australia: AIHW, Etiologic Heterogeneity # of different conventional risk factors IHD9 Stroke7 Diabetes6 Kidney disease5 Arthritis3 Osteoporosis4 Lung cancer1 Colorectal cancer4 COPD2 Asthma2 Depression5 Oral problems3

28 Starfield 03/08 IH 3984 Source: Australian Institute of Health and Welfare. Indicators for Chronic Diseases and Their Determinants, Canberra, Australia: AIHW, Pleiotropism # of specific diseases associated with selected risk factors Smoking9 Physical activity7 Alcohol7 Nutrition7 Obesity7 Hypertension (?)3 Dyslipidemia (?)2 Impaired glucose tolerance (?)1 Proteinuria (?)1

29 There is more variability in disease manifestations and persistence within diseases than across diseases because: diseases are not necessarily unique pathophysiological entities variability in diagnostic styles and practices presence of co-morbidity Starfield 10/01 D 3887

30 Co- and Multi-morbidity (Morbidity Burden) Starfield 09/07 CM 3864 n

31 Co-morbidity is the concurrent existence of one or more unrelated conditions in an individual with any given condition. Multi-morbidity is the co-occurrence of biologically unrelated illnesses. Starfield 03/06 CM 3375 For convenience and by common terminology, we use co-morbidity to represent both co- and multi- morbidity.

32 Distribution of Morbidity in a Non-Elderly Insured Population: 1 Year Experience (US) Source: HMO health plan with 500K members. Starfield 09/ Starfield 09/07 CM 3865 n

33 Morbidity Burdens of Socially Disadvantaged and Socially Advantaged People Starfield 09/07 CM 3866 n

34 The high frequency of Co-morbidity Multi-morbidity Morbidity burden makes it inappropriate to focus on single diseases Starfield 03/08 CM 3985

35 Co-morbidity, Inpatient Hospitalization, Avoidable Events, and Costs* Source: Wolff et al, Arch Intern Med 2002; 162: *ages 65+, chronic conditions only Starfield 11/06 CM 3503 n

36 The greater the morbidity burden, the greater the persistence of any given diagnosis. Starfield 08/06 CM 3439 That is, with high co-morbidity, even acute diseases are more likely to persist.

37 Odds Ratios and Confidence Intervals for Persistence* by Degree of Co-morbidity: Urinary Tract Infection *controlled for age and sex C Statistic.633 Starfield 10/ Degree of co-morbidity Starfield 09/07 D 3863 n

38 Expected Resource Use (Relative to Adult Population Average) by Level of Co- Morbidity, British Columbia, Starfield 09/07 CM 3867 n NoneLowMediumHigh Very High Acute conditions only Chronic condition High impact chronic condition Source: Broemeling et al. Chronic Conditions and Co-morbidity among Residents of British Columbia. Vancouver, BC: University of British Columbia, Thus, it is co-morbidity, rather than presence or impact of chronic conditions, that generates resource use.

39 Increase in Treated Prevalence: Selected Conditions, US, People with Private Insurance, Treated Prevalence Percentage Change, Hyperlipidemia 437 (Heart disease 9) Bone disorders227 Upper GI problems169 Cerebrovascular disease161 Mental problems136 Diabetes 64 Endocrine disorders 24 Hypertension 17 Bronchitis 13 Source: Thorp et al, Health Affairs 2005; W5:317-25, Starfield 09/06 D 3858

40 As thresholds for diagnosing disease are lowered over time, the variability within “diseases” will increase even further, as will the prevalence of multiple simultaneous or sequential diseases. Starfield 03/08 D 3986

41 What is needed is person-focused care over time, NOT disease-focused care. Starfield 10/06 PC 3462

42 Top Ten Health Conditions and Impact on Costs Starfield 03/08 D 3994 Medical and Rx costsLost productivity costsTotal costs 1Other cancerFatigueBack/neck pain 2 Depression 3Coronary heart diseaseBack/neck painFatigue 4Other chronic painSleeping problemOther chronic pain 5High cholesterolOther chronic painSleeping problem 6Gastroesophageal reflux disease ArthritisHigh cholesterol 7DiabetesHypertensionArthritis 8Sleeping problemObesityHypertension 9 High cholesterolObesity 10ArthritisAnxiety Source: Loeppke et al, J Occup Environ Med 2007; 49:

43 When people (not diseases) are the focus of attention Outcomes are better Side effects are fewer Costs are lower Population health is greater Starfield 09/07 PC 3868 n Source: Starfield et al, Health Aff 2005; W5:

44 What Is the Appropriate Care Model? Primary care that meets primary care (not disease-specific) standards* Specialty referrals that are appropriate, i.e., evidence-based** Specialty care that meets specialty care standards** Starfield 03/06 PC 3377 *exist **do not exist

45 Primary care “works” because it has defined functions that include structural and process features of health services that are known to improve outcomes of care. Starfield 03/08 PC 3987

46 The Health Services System Starfield CAPACITY PERFORMANCE HEALTH STATUS (outcome) Provision of care Receipt of care Personnel Facilities and equipment Range of services Organization Management and amenities Continuity/information systems Accessibility Financing Population eligible Governance People/practitioner interface Cultural and behavioral characteristics Social, political, economic, and physical environments Biologic endowment and prior health Problem recognition Diagnosis Management Reassessment Utilization Acceptance and satisfaction Understanding Concordance Longevity Comfort Perceived well-being Disease Achievement Risks Resilience Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, Starfield 1997 HS 1064

47 Primary Care Starfield 02/08 EVAL 3968 First ContactAccessibility Use by people for each new problem LongitudinalRelationship between a facility and its population Use by people over time regardless of the type of problem; person-focused character of provider/patient relationship ComprehensiveBroad range of services Recognition of situations where services are needed CoordinationMechanism for achieving continuity Recognition of problems that require follow-up

48 Structural and Process Elements of the Essential Features of Primary Care Essential FeaturesPerformance Utilization Person-focused relationship Capacity Accessibility Eligible population Range of services Continuity First-contact Longitudinality Comprehensiveness Coordination Problem recognition Starfield Starfield 04/97 EVAL 1108

49 Primary Care Oriented Health Services Systems CAPACITY PERFORMANCE HEALTH STATUS (outcome) Provision of care Receipt of care Personnel Facilities and equipment Range of services Organization Management and amenities Continuity/information systems Accessibility Financing Population eligible Governance People/practitioner interface Cultural and behavioral characteristics Social, political, economic, and physical environments Biologic endowment and prior health Problem recognition Diagnosis Management Reassessment Utilization Acceptance and satisfaction Understanding Concordance Longevity Comfort Perceived well-being Morbidity burden Achievement Risks Resilience Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, Starfield 10/07 HS 3890

50 There is no formal quality assessment approach that includes the critical feature of problem-recognition, despite the evidence that patients are more likely to improve when they and their practitioner agree on what their problem is. Starfield 03/08 Q 3988 Sources: Starfield et al, JAMA 1979; 242: Starfield et al, Am J Public Health 1981; 71:

51 Is chronic care management the same as or pursuant to primary care? Person-focused? Contributory to at least one of the four main features of primary care? Starfield 03/08 CM 3989

52 Is CCM part of primary care or separate from it? If the need for it is uncommon (as the data suggest), it is a referral function. If the need for it is common, it is a way of enhancing some important and heretofore neglected element of care, possibly problem recognition. Starfield 03/08 CM 3990 Question: What critical process of care is served by CCM? Problem recognition? If not, what?

53 Of all global deaths in 2005, 60% were because of chronic diseases, principally cardiovascular diseases (32%), cancers (13%), and chronic respiratory diseases (7%). Data such as these are used to argue that chronic diseases are of growing and epidemic importance as causes of death. Starfield 02/08 D 3949 Source: Beaglehole et al, Lancet 2007; 370: Question: What is the appropriate target for the percentage of deaths in the world that are attributable to chronic diseases? Isn’t there a case to be made that perhaps ALL deaths should be due to chronic diseases, with acute illnesses falling towards zero percentage?

54 Deaths may be attributed to chronic diseases, but people still get sick from acute diseases and acute exacerbations. Any enhancement of primary care has to deal with this reality. Starfield 03/08 D 3991

55 The global imperative is to organize health systems around strong, patient-centered, i.e., Primary Care. A disease-oriented approach to global health will almost certainly worsen global inequities. Those exposed to a variety of interacting influences are vulnerable to many diseases. Eliminating diseases one by one will not materially reduce the chances of another. Starfield 03/08 GH 3992

56

57 It appears that there may be only a few “types” of medical problems, based on most predominant etiology: Infectious External injury Developmental/physical abnormality Mendelian dominant genetic Autoimmune Cellular degradation/degeneration Starfield 02/08 D 3941 Question: If this is true or even only partly true, is the International Classification of Diseases a useful schema for classifying health problems? Might there be one that lends itself better to understanding etiology for the purpose of more effective prevention and treatment?

58 The Impact of Seeing Many Different Physicians More DIFFERENT specialists seen: higher total costs, medical costs, diagnostic tests and interventions, and types of medication More DIFFERENT generalists seen: higher total costs, medical costs, diagnostic tests and interventions More generalists seen (LESS CONTINUITY): more DIFFERENT specialists seen. The effect is independent of the number of generalist visits. Starfield 09/07 CMOS 3854 Controlling for morbidity burden* *Using the Johns Hopkins Adjusted Clinical Groups (ACGs) Source: Starfield et al, Ambulatory specialist use by patients in US health plans: correlates and consequences. Submitted 2008.

59 There are methods, e.g., the Johns Hopkins Adjusted Clinical Groups, for categorizing patients and populations according to their burden of diagnosed illness. Starfield 10/06 CM 3460


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