1. Chronic disease Practice & Policy Presentation to AHS Health Policy Advisory Group Tom O’Dowd & Susan Smith

2. Patients with multiple chronic illnesses : Die prematurely Longer hospital stays More depression More medications Poorer function Poorer access to specialists Excluded from trials

3. Published by AAAS G. D. Wieland, Sci. Aging Knowl. Environ. 2005, pe29 (2005) Fig. 1. Impact of multiple morbidity on Medicare expenditures

4. Multiple chronic conditions : Vast amount of expenditure –20% of patients cost 80% of budget –evidence based care is cheaper (Boult 2008) Inadequate care –not evidence based Poor communications –tests not available, dr not aware of history Poor adherence –no one to discuss/review medications High readmission rates

5. Two or more chronic illnesses in the same individual From primary care in Canada : 18 - 44 years61% 45 - 64 years93% > 65 years98% Fortin et al BMJ 2007

6. New concept : Multimorbidity Existence of 2 or more chronic conditions in the same patient Can co-exist like CVD & DM –or not - like arthritis & asthma Literature review : most references come from primary care

9. Characteristics of study population (n 92) Female : 49 (53%) Number of chronic conditions: 4 Number of current medications: 7.5 GP visit in last 12/12: 11.7 P/nurse visit in last 12/12: 1.0 Hosp visit in last 12/12: 3.3

10. Prevalence of conditions % Lipid disorders 15 Hypertension12.5 Depression5.5 NIDDM7.5 COPD6 Asthma5 Acute MI2 IHD-no angina 1.5 IHD-with angina 3.5 Cardiovascular disease other 2.5 Chronic alcohol abuse 3 Hiatus hernia 1

11. Single vs Multimorbidity Single morbidity Multimorbidity Female20 (48%)30 (48%) Mean age5456 GP visits713 Current meds2.37.3

12. What is being tried Community matrons »www.swirl.nhs.uk/resource/42www.swirl.nhs.uk/resource/42 Transitional care - to reduce readmissions. »Naylor 2004, Coleman 2006 Patient self management »Lorig et al 1999 & 2001 Guided care model »Leff et al 2009 www.guidedcare.org www.guidedcare.org

15. Copyright ©2007 BMJ Publishing Group Ltd. Gravelle, H. et al. BMJ 2007;334:31 Emergency admission rates for general population aged >=65 in Evercare/Community matrons and control practices. July 2001 to March 2005

16. Guided nurse care Leff et al 2009 www.guidedcare.org Johns Hopkinswww.guidedcare.org Nurse based in primary care - 50-60 patients, 3-4 physicians. Planned care,education. Monthly visits. At 8 months : 24% fewer hospital stays 37% fewer skilled nursing facility days 15% fewer ED visits 29% fewer home healtcare episodes 23% lower health insurance costs 9% more specialist visits

18. Sneak peek Reduce admissions

19. Implications for health system Common in younger patients Big workload for practices –More illnesses more work –Care is GP centred Polypharmacy –More illnesses more work Socioeconomic effects We don’t know impact on function

20. Categorisation of chronic illness Glauberman 2002, Martin 2005 Simple problems : –Protocol driven Complicated: –Need specialised expertise Complex: –Additionally need knowledge of locality, social networks Chaotic: –Brittle clinical & social problems Hypertension Open heart surgery Angina + alcohol+DM + family problems Angina + DM + alc binging + disadvantage

21. What we know - Donald Rumsfelt 2008 Known knowns : Known unknowns : Unknown unknowns: Hospital budgets will be smaller. Bigger role for nurses Role of nurses, OTs, pharmacists Redeployment of budgets & staff from acute care to chronic care

22. Policy questions Money is not the place to start - yet –Consider transfer of resources? Patient responsibility & accessible information Current GMS contract is not geared to chronic illness : should it be put out to tender? Appropriate care directed by generalists & provided by nurses? ‘Good enough’ care : ‘Boston vs Berlin’ Diagnostics unhitched from hospitals including radiology