Dr Anthony Cummins

Chronic disease management

Senior Cycle 1 General Practice

With grateful acknowledgements to Professor David Whitford RCSI Bahrain & Professor Susan Smith RCSI Dublin

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2Format of module

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1 Chronic disease management

2 Format

3 Initial questions

4 Ageing, chronic disease & polypharmacy

5 Frailty & concerns of chronic disease patients

6 What are the chronic diseases?

7 Diseases likely to be chronic

8 Models of development of chronic disease

9 Life course model

10 Common factors in chronic diseases

11 Why do we need chronic disease management?

12 Disease burden

13 Premature mortality

14 Population projections

15 What is multimorbidity?

16 Multimorbidity worldwide

17 Is multimorbidity “the new thing”?

18 Challenges to multimorbidity

19 Multimorbidity in Ireland

20 Impact of multimorbidity

21 Treatment burden

22 What should chronic disease management include?

Requirements of a chronic disease management programme 23

Where should they be managed and by whom 1? 24

Where should they be managed and by whom 2? 25

Collaborative care: the patient’s & the GP’s perspectives 26

The patient-professional relationship 27

Outcome impact of collaborative care for depression 28

Chronic disease: the patient’s perspective 1 29

Chronic disease: the patient’s perspective 2 30

Chronic disease: the doctor’s perspective 31

What are expert patients & expert patient programmes? 32

Expert patients 33

Expert patient programmes 34

Expert patient programmes UK 35

Effective chronic disease self-management 36

Chronic disease programmes planned for Ireland 37

“Tackling chronic disease” HSE policy framework 38

HSE/ ICGP “Primary Care Clinical Care Programme” 39

Is chronic disease management more effective than current practice? 40

Impact of UK coronary disease projects 41

A systematic review of chronic disease management 42-43

Improving attendance at chronic disease management clinics 44

Key points & references 45-46

3Initial questions

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What is chronic disease management?Which are the chronic diseases we need to manage?What characterises chronic diseases from other, acute, diseases?Why do we need chronic disease management systems?What is multimorbidity?What should a chronic disease management programme include?Where & who should manage chronic diseases?Collaborative care: what are the patient’s and the doctor’s perspectives?What are “expert patients” and “expert patient programmes”?Which chronic disease management programmes are planned in Ireland?Do chronic disease management systems work better than current practice?

4Ageing, chronic disease & polypharmacy

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5Frailty and concerns of chronic disease patients

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What are the common chronic diseases?

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7Diseases that are likely to be chronic in duration

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Parkinson’s

DepressionAnxiety

Epilepsy

COPD

IBD

Chronic psychoses

Dementia

OA

Diabetes

AF

Stroke

Hypertension

RA

Asthma

Heart Failure

IHD

Thyroid

Psoriasis

Obesity

RA: rheumatoid arthritisOA: osteoarthritis

IBD: inflammatory bowel diseaseAF: atrial fibrillation

COPD: chronic obstructive pulmonary disease

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Models of development/ risk of development of chronic diseases

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9A life course approach

A life course approach to chronic disease is the study of long-term effects on chronic disease risk of certain factors e.g. physical & social exposures during gestation, childhood, adolescence, young adulthood and later adult life to influence the development of chronic diseases. The example here is of COPD but it can be applied to many chronic diseases.

Ben-Shlomo Y , Kuh D Int. J. Epidemiol. 2002;31:285-293

10Common factors in chronic diseases

Time

Doesn’t resolve

Living with a chronic disease affects

i. Individualii. Familyiii. Societyiv. Tax payer

Amenable to further intervention

Psychological impact

Multimorbidity

Benefit from team approach rather than individual approach

Identification of important co-morbidity

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Burden

Direct impact

Quality of Life

(Identified) co-morbidities

Adverse drug events

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Why do we need chronic disease management systems?

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12The worldwide burden of chronic disease

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*DALY: Disability Adjusted Life Year

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It has been estimated that non-communicable diseases account for almost 40% of deaths in developing countries and 75% in industrialised countries. Strong evidence that the expertise of patients could be harnessed to play a part in addressing the challenge of this shifting burden of disease came from Professor Kate Lorig and her colleagues at Stanford University, California. She started to develop and evaluate programmes for people with arthritis and side stepped the traditional model of professionals educating patients. By means of a more radical and innovative solution, using trained lay leaders as educators, she equipped people with arthritis and other chronic diseases with the skills to manage their own condition. She found that, compared with other patients, “expert” patients could improve their self-rated health status, cope better with fatigue and other generic features of chronic disease such as role limitation, and reduce disability and their dependence on hospital care.

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What is multimorbidity?

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16Multimorbidity worldwide

Multimorbidity is commonly defined as the co-existence of two or more chronic conditions in an individual. It is a highly prevalent phenomenon in old age and of growing public health impact in ageing societies. Multimorbidity is common and nowadays represents the norm in clinical practice.

Providing care to patients with multiple chronic conditions is complex and poses a significant challenge to clinicians and healthcare planners.

It is strongly linked to ageing and deprivation.

A UK study sampled 99,997 people aged 18 years or over registered with 182 general practices and found a prevalence rate of 58%.

Multimorbidity patients accounted for 78% of all GP consultations.

65% of > 1 million Medicare beneficiaries had multiple chronic conditions.

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17Is multimorbidity the “new thing”?

18 years ago this paper appeared in the Journal of Clinical Epidemiology

“With the increasing number of elderly people in The Netherlands the prevalence of chronic diseases will rise in the next decades. It is recognized in general practice that many older patients suffer from more than one chronic disease (comorbidity). The aim of this study is to describe the extent of comorbidity for the following diseases: hypertension, chronic ischemic heart disease, diabetes mellitus, chronic nonspecific lung disease, osteoarthritis. In a general practice population of 23,534 persons, 1989 patients have been identified with one or more chronic diseases. Only diseases in agreement with diagnostic criteria were included. In persons of 65 and older 23% suffer from one or more of the chronic diseases under study. Within this group 15% suffer from more than one of the chronic diseases. Osteoarthritis and diabetes mellitus are the diseases with the highest rate of comorbidity. Comorbidity restricts the external validity of results from single-disease intervention studies and complicates the organization of care”

Comorbidity of chronic diseases in general practiceF.G. Schellevis J. van der Velden3, E. van de Lisdonk2, J.Th.M. van Eijk1, C. van Weel2

Journal of Clinical Epidemiology Volume 46, Issue 5, May 1993, Pages 469-473

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18Challenges to multimorbidityDefinition

There is no consensus yet as to which health conditions should be considered and how exactly they should be assessed, summarized and weighted in order to arrive at some overall measure of burden of illness. Apart from quantitative aspects, the type and patterns of concurrent morbidities will matter with respect to treatment options and prognosis.

Measuring the impact of multimorbidity

Many of the health complaints in old age are chronically progressive and interact with each other. Therefore concepts such as 'cure‘, more commonly used with single disease entities, aren’t appropriate. Instead, the focus should be on functional measures, such as critical exhaustion of specific body functions (often termed as 'frailty'), functional disability in daily life, and social participation as well as on subjective measures, such as quality of life (QoL), particularly health-related quality of life (HQoL) and self-determination (autonomy).

Patient complexity

The relationship between multimorbidity and outcomes may be impacted on by a number of factors. These can be divided into internal (health-related knowledge, beliefs, competences, and proactive behaviour ) and external (perceived social support, living conditions, and quality of health care).

18OMAHA study: BMC Health Serv Res. 2011; 11: 47. Published online 2011 February 25. doi: 10.1186/1472-6963-11-47

19Multimorbidity in Ireland

A recent primary care based study examined a sample of 3309 patients aged > 50 yrs.

The prevalence of multimorbidity was 66.2% rising to 81.6% in those > 65.

11% of patients had ≥ 4 chronic conditions.

78% of patients who were eligible for free medical care had multimorbidity

This contrasted with 52% in those not eligible for a medical card.

This emphasises the association between multimorbidity and deprivation.

Further community based research in an Irish setting has identified multimorbidity in 60% of patients with chronic respiratory disease and 91% of opiate misusers in an Irish general practice setting

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20Impact of multimorbidity

Multimorbidity is associated with:

i. Increased psychological distress

ii. Decreased quality of life especially HQoL

iii. Increased number of hospital admissions

iv. Increased length of hospital stay

v. Functional decline (frailty)

vi. Polypharmacy (+ increased adverse drug events & drug interactions)

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21Treatment burden

The concept of treatment burden for patients includes:

i. Adhering to treatments and lifestyle changesii. Learning about treatments and their consequences iii. Engaging with healthcare professionals.

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Multimorbidity is also associated with increased mortality..

This has been demonstrated in two European studies:

A large (n=2285) community-based study involving elderly men in three countries which found significantly increased ten year mortality risk in patients with two or more chronic conditions.

The second, a Dutch study (n=2141) involving community-dwelling people aged between 65 and 85 found an increased three year mortality in the multimorbidity group

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What should chronic disease management include?

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Early diagnosis

Symptom relief

Secondary prevention

Education

Psychological support

Empowerment

Structured care

Chronic disease management programme elements

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Where should chronic disease management programmes occur and who should do provide

them?

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25Where should it occur? Who should provide it?

Primary care

Secondary care

Self-care

Shared care

Tertiary care

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Collaborative care: the patient’s and the GP’s perspectives

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27The patient-professional relationship

Review your module on the consultation showing the Calgary Cambridge model27

28Collaborative care for patients with depression

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29Chronic disease: the patient’s perspective 1

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30Chronic disease: the patient’s perspective 2

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31Chronic disease: the GP’s perspective

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What are expert patients & expert patient programmes?

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33Expert patients

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34Expert patient programmes

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35Expert patient programmes UK

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Which chronic disease programmes are planned here in Ireland?

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38Ireland’s planned programmes

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39Ireland’s planned programmes

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Do chronic disease management systems work better than current practice?

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41Impact of coronary heart disease projects UK

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42Chronic disease management: a systematic review

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43Chronic disease management: a systematic review

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44Chronic disease: how to improve attendances

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Key Points

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46References1 Chronic disease management in primary care: quality & outcomes

Ed. Gill Wakley & Ruth Chambers Radcliffe Publishing 2005

2 Lorig KR, Sobel DS, Stewart AL, et al; Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999 Jan;37(1):5-14.

3 Expert patients http://www.patient.co.uk/doctor/Expert-Patients.htm

4 Quality & Outcomes Framework 1 http://www.nice.org.uk/aboutnice/qof/qof.jsp#What

5 Quality and outcomes framework 2http://www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/QOF/Pages/QualityOutcomesFramework.aspx

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