Managing Chronic Diseases in the Slovak Republic: Future Perspectives and Challenges By: Jordan Hicks

Overview Impact of Chronic Illnesses Mortality Rates in the Slovak Republic Population Characteristics Current Long-Term Care Options Place of Death in the Slovak Republic Clinical Guidelines for Chronic Care Chronic Care Model

Impact on Healthcare Chronic diseases are the main reason for poor health and restricted activity Affecting over 1/3 of Europe’s population 70–80% of health care costs are spent on chronic diseases. = €700 billion in the European Union This corresponds to €700 billion in the European Union and Cost expected to increase in coming years nowadays there are more than 350.000 diabetics in Slovakia (7% of the population) (Legido-Quigley ,2013)

Mortality in the Slovak Republic In total, 94.4% of the deaths were caused by the disease and 5.6% of deaths were resulted from the external causes such as injury, accidents, poisoning, homicides, suicides (Loucka, 2014)

Mortality in the Slovak Republic Mortality Rate Diseases of the circulatory system Neoplasms External cause Disease of the respiratory system Disease of the digestive system Other cause Total Males 12845 (46.8%) 6782 (24.7%) 2325 (8.5%) 1846 (6.7%) 1793 (6.5%) 1855 (6.8%) 27446 Females 15420 (60.6%) 5184 (20.4%) 632 (2.5%) 1333 (5.2%) 1158 (4.6%) 1740 25467 The population in Slovakia for the period 2009–2011, mortality rate is the following: Cardiovascular diseases: men  – 46%, women – 60% Cancer: men – 25%, women – 20% Respiratory diseases: men – 7%, women – 6% Since 2000, the number of diabetics has increased by 20% nowadays there are more than 350.000 diabetics in Slovakia (7% of the population) (Loucka, 2014)

Slovak Republic Population In 1993 there were 45 seniors per 100 children, in 2013 it was 88 seniors per 100 children 41% of the population smoke regularly or occasionally The consumption of the alcoholic drinks was 106.3 per inhabitant in the year 2008 Given this information, healthcare professionals are going to have to acknowledge and prepare for the increase in need for chronic care (Kapalla, 2010)

Slovak Republic Population: Median Age 1.3 babies per mother on average The average age in Slovakia has increased to 39.6 years in 2013, which is 5.5 years more than 20 years ago © Statista 2016

Current Situation No nursing homes available to public Care homes for older people or local variations of nursing homes usually do not have a physician on the staff Many GPs do not have enough experience with symptom management at the end of life (Loucka, 2014)

Current Situation: Place of Death Slovak patients with chronic conditions are more likely to die in hospitals than in some other European Union member countries. Place of Death Deaths cause by chronic conditions Total YES NO CZ (N, %) SK (N, %) Home 7672 (15.4%) 6232 (27.5%) 12372 (24.7%) 9333 (31.9%) 35609 (23.5%) Hospital 31824 (63.9%) 14096 (62.2%) 26917 (53.7%) 14355 (49.1%) 87192 (57.4%) Long term health care facility 7811 (15.7%) 719 (3.2%) 4410 (8.8%) 863 (3.0%) 13803 (9.1%) Other 2533 (5.1%) 1610 (7.1%) 6399 (12.8%) 4695 (16.1) 15237 (10.0%) 49840 22657 50098 29246 151841 63% in slovakia compared to In the Netherlands, where only a third of such patients die in hospitals, nursing home care is developed to a very high level and provides care for similar proportion of dying people as hospitals (Loucka, 2014)

Current Situation: Clinical Guidelines According to the World Health Organization: there is currently no official basis for the development of clinical guidelines on chronic conditions in Slovakia Translated European recommendations Guidance produced by the Czech National College of General Practice The Institute of Preventive Medicine, with the support of the Slovakian Ministry of Health guidelines last updated in 2002. (Legido-Quigley, 2013) The Institute of Preventive Medicine, with the support of the Slovakian Ministry of Health, was active in the field of clinical guidelines some years ago, producing the handbooks for diagnostic and therapeutic guidelines, including the most important and frequent chronic conditions. Unfortunately, these were last updated in 2002 and no longer reflect current practice. Chronic NCDs require a long-term perspective to developing the often complex programmes needed to manage them, in which different health professionals intervene both simultaneously and consecutively. This necessitates a systematic and integrated approach.

Challenges to Consider Identifying innovative methods for cost-effective prevention of common risk factors Developing coordinated patient- centered care Stimulating integrated research (Legido-Quigley, 2013)

Future Perspectives: Acute Care Acute Care Beds among the Highest in Europe Active bed reduction plan: 6000 acute beds were eliminated or transformed into chronic care beds 3 acute care hospitals were closed and several others transformed into almost exclusively chronic (long-term) care facilities Need to update technical infrastructure of hospital to account for change in population. (Szalay,2011)

Future Perspectives Re-distribution of the financial resources and the investment into predictive, preventive and personalized medicine Promote home hospice care services and education in palliative care for staff in nursing homes and other end-of-life settings Increase education regarding the role of nutrition and other factors in sustaining health over the life time palliative home care is still not recognized in the health care insurance law and hence the palliative home care services can’t access the governmental health care budget.

Chronic Care Model Organizational support Clinical information systems Delivery system design Decision support Self-management support Community resources he first 4 concepts in the CCM address practice strategies, the final 2 are specifically patient centered foster systemic change and encourage: strong doctor-patient relationships, higher levels of training from chronic disease management, and continuity and coordination of the patient’s journey through the health care system Denmark, Finland, France and Poland are seeing success from putting these types of chronic disease models into place

Conclusion Chronic care management requires a long term perspective Need for clinical guidelines: one overarching agency or main institution playing a coordinating role. Shift focus from acute care to long-term care Enforce the importance of prevention and education regarding lifestyle choices Implement a Chronic Care Model Government, Stakeholder involvement, and integration with IT system could contribute to prompt interventions and an overall improvement in health Collaborative, integrated, and people-centered care provision is a way forward for sustainable and efficient care systems (Nagyova, 2013)

References Kapalla, M., Kapallová, D., & Turecký, L. (2010). An overview of the healthcare system in the Slovak Republic. The EPMA Journal, 1(4), 549–561. http://doi.org/10.1007/s13167- 010-0061-y Legido-Quigley, H., Panteli, D., Car, J., McKee, M., & Busse, R. (n.d.). Clinical guidelines for chronic conditions in the European Union. 2013: World Health Organization. Loucka, M., Payne, S. A., & Brearley, S. G (2014). Place of death in the Czech Republic and Slovakia: a population based comparative study using death certificates data. BMC Palliative Care, 13, 13. http://doi.org/10.1186/1472-684X-13-13 MINARECHOVÁ, R. (2015, April 09). Study highlights Slovakia’s aging population. Retrieved September 13, 2016, from The Slovak Spectator, http://spectator.sme.sk/c/20056850/study-highlights-slovakias-aging-population.html Nagyova, I. (2013). An Optimal Framework for Chronic Condition Management in Europe. Microbial Ecology In Health & Disease, 2413. doi:10.3402/mehd.v24i0.23078 Szalay T, Pažitný P, Szalayová A, Frisová S, Morvay K, Petrovič M and van Ginneken E. Slovakia: Health system review. Health Systems in Transition, 2011; 13(2):1–200.