JEJ_Bellagio_03_04

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



                                … committed to health care improvement
   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



                           … committed to health care improvement
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

                          … committed to health care improvement
                      WORLD
        Deaths, by broad cause group, 2001
                       Total deaths: 56,554,000

                                     58.5%       Noncommunicable
                                                 conditions
                                                 (33.1 million)




 Communicable diseases,      32.5%      9.0%
   maternal and perinatal
                                               Injuries
conditions and nutritional
                                               (5.1 million)
             deficiencies
            (18.4 million)
                                                                  Source: World Health Report 2002




                                                    … committed to health care improvement
                                                      World
     Deaths, 2000, by selected leading risk
                factors (000s)
                 High blood pressure
                              Tobacco
                      High cholesterol
                          Underweight
                           Unsafe sex
       Low fruit and vegetable intake
                              High BMI
                     Physical inactivity
                                Alcohol
Unsafe water, sanitation, and hygiene
        Indoor smoke from solid fuels
                        Iron deficiency
                   Urban air pollution
                       Zinc deficiency
                  Vitamin A deficiency
         Unsafe health care injections
   Occupational risk factors for injury

                                           0   1000   2000   3000   4000   5000    6000   7000    8000
                                                                                                 Source: World Health Report 2002




                                                                                  … committed to health care improvement
 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




                        … committed to health care improvement
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)




                             … committed to health care improvement
Poland:           Philippines:
"Camel. He grew   Calendar
up to be kind."   2001
2000




                     … committed to health care improvement
Smoking prevalence in mega countries
         70.0

         60.0

         50.0

         40.0
     %
         30.0

         20.0

         10.0

          0.0
                Bangladesh




                                                      Indonesia




                                                                                             Pakistan
                                                                                   Nigeria
                                                                          Mexico




                                                                                                        Russia

                                                                                                                 USA
                                      China




                                                                  Japan
                                              India
                             Brazil




                                              Men                          Women




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

                       … committed to health care improvement
      A conceptual model of the progress of
                   a disease
        Relationship between diabetes, hypertension and
                         renal disease




 Healthy         Risk            Early                       Confirmed
                                                                                              Complications
Population      Factors         Disease                       Disease



        No         Pre          Diabetes                    Diabetes no                          Diabetes with
     diabetes   diabetes         onset                     complications                         complications


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




                                                                         … committed to health care improvement
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




                                                            … committed to health care improvement
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.




                        … committed to health care improvement
TYPICAL CARE
The Radar Syndrome
            Patient appears
            Patient is treated
            “find it and fix it”
            Patient is
            discharged

            … then disappears
            from radar screen


                 … committed to health care improvement
Radar logic = inappropriate
care for chronic conditions
   System oriented to acute illness
   Patient’s role not emphasized
   Follow-up sporadic
   Prevention overlooked




                         … committed to health care improvement
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




                                 … committed to health care improvement
   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




                         … committed to health care improvement
         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




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



                     … committed to health care improvement
… committed to health care improvement
 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



                             … committed to health care improvement
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




                   … committed to health care improvement
    Sample Results: Clinica
         Campesina
Measure               Initial rate       Improved rate

Average HbA1c         10.5%              8.7%

At least 2            15%                45%
HbA1c/year

Eye exams             7%                 27%

Foot exams            15%                56%

Collaborative self-   0%                 46%
management
goal


                                     … committed to health care improvement
  Sample results: Premier
     Health Partners
Measure          Initial rate        Improved rate

HbA1c < 7%       42%                 70%

At least 2       67%                 90%
HbA1c/year

Foot exams       61%                 78%

Annual urine     52%                 78%
protein

ACE inhibitors   38%                 80%
with positive
urine protein


                                … committed to health care improvement
 Sample results: High Plains
    Community Center
Measure            Initial rate           Improved rate

BP < 140/90        35%                    62%

At least 2 BP      47%                    87%
checks/year

Documented self-   34%                    59%
management goal

Hyperlipidemia     70%                    82%
screening
                         Improved rate = results after 7 months




                                       … committed to health care improvement
    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


                                 … committed to health care improvement
    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




                            … committed to health care improvement
                    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.

                                     … committed to health care improvement
… committed to health care improvement
 “Trying harder will not work.
Changing systems of care will.”

Crossing the Quality Chasm, Institute of
           Medicine, 2001




                             … committed to health care improvement
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


                               … committed to health care improvement

				
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