Academia and the Chronically Ill Ed Wagner, MD, MPH MacColl Institute for Healthcare Innovation Center for Health Studies Group Health Cooperative Improving Chronic Illness Care A national program of the Robert Wood Johnson Foundation

Ms. G 67 yo widow who cares for grandchildren 10+ yr history of diabetes and hypertension not well controlled She initiates her visits when she perceives a problem Confused about diet, exercise, drugs Recent onset of SOB leading to hospitalization Greater confusion following discharge Readmitted with CHF

Is Ms. G a Rare Case? Generally, less than 50% of folks with major chronic illnesses receive accepted treatments Less than 50% have satisfactory levels of disease control Majority of Americans don’t feel that the chronically ill get good care Physicians frustrated with chronic illness care

Would Ms. G have received different care in an AMC? Care generally better in AMCs (1), BUT of CHF patients discharged from 7 university hospitals: 72% were discharged on an ACE inhibitor 44% received a recommended ACE inhibitor dose 11% had documented counseling about following daily weights 9% of smokers received documented counseling (2) (1)Ayanian JZ and Weissman JS. Milbank Q 2002; 80:569 (2)Nohria et al. Am Heart J 1999; 137:987

Would Ms. G have received better primary care in a teaching institution? Chronic illness improvement studies in AMCs suggest that baseline performance is little different than in the community “ We …found no relevant studies of ambulatory care [comparing] teaching and non-teaching hospitals, despite its growing importance”* *Ayanian JZ and Weissman JS. Milbank Q 2002; 80:569

What Patients with Chronic Illnesses Need A “continuous (and coordinating) healing relationship” With a care team and practice system organized to meet their needs for: 4Effective Treatment (clinical, behavioral, supportive) 4Information and support for their self-management, and 4Systematic follow-up and assessment tailored to clinical severity

What Americans with Chronic Disease Receive 27% of hypertensives are adequately treated 42% and 66% of diabetics have controlled lipid and blood pressure levels, respectively 35% of eligible patients with atrial fibrillation receive anticoagulation 25% of people with depression are receiving adequate treatment 44 % of discharged CHF patients are readmitted within 120 days

If care were improved to the extent found in the literature—the Quality Chasm Most patients with chronic illness would have regular prevention and be on effective treatments Major risk factors (HbA1c, BP, LDL) would be significantly reduced Recovery rates for major depression would be nearly doubled Children with moderate asthma would be symptom-free two weeks less each year Risk of major diabetic complications would be reduced 20-50% Readmission rates of persons hospitalized with CHF would be reduced by about 50% and quality of life improved

Why are we doing so poorly? The IOM Quality Chasm report says: “The current care systems cannot do the job.” “Trying harder will not work.” “Changing care systems will.”

What’s Responsible for the Quality Chasm? Its neither unmotivatable patients nor hopeless providers

1. Motivation and adherence are not genetically determined – behavioral interventions consistently successful in raising adherence, but most patients don’t receive them. 2. Much of the variation in care is within a practice--i.e., same clinician treating similar persons differently The Evidence:

What’s Responsible for the Quality Chasm? A system that is not working for either patients or health professionals??

What Ms. G Experienced? Deficits in her clinical care Patient initiated contacts oriented to acute problem Focus on symptoms and lab results, not longer term disease control and prevention Care not planned Care dependent on doctor, doctor’s memory, and disorganized written record

What Ms. G Experienced? Ineffective Self-management Support Why is self-management so important? The person makes most of the decisions regarding their health Must have information, skills, confidence Growing evidence that concerted efforts to support self-management improve care and outcomes

What Ms. G Experienced? Lack of Follow-up and Care Coordination No electronic system keeping track of Ms. G Primary care not proactive in assuring regular interactions with Ms. G Communication with other caregivers not a priority

Can the system be changed?

Randomized trials of system change interventions: Diabetes Cochrane Collaborative Review and JAMA Re-review About 40 studies, mostly randomized trials Interventions classified as decision support, delivery system design, information systems, or self-management support No single element emerged as essential or superfluous, but 19 of 20 studies which included a self-management component improved care. All 5 studies with interventions in all four domains had positive impacts on patients Renders et al, Diabetes Care, 2001;24:1821 Bodenheimer, Wagner, Grumbach, JAMA 2002; 288:1910

To Change Outcomes Requires Fundamental Practice Change Reviews of interventions in other conditions show that practice changes are similar across conditions Integrated changes with components directed at:  influencing physician behavior,  better use of non-physician team members,  enhancements to information systems,  planned encounters, and  modern self-management support

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Outcomes

Can Busy Practices Change in Accord with the CCM? Chronic Conditions Breakthrough Series Year-long collaborative quality improvement efforts involving multiple delivery systems and faculty Chronic Care Model guides comprehensive system change External evaluation of early efforts by RAND Approximately 1000 different health care organizations and various diseases involved to date HRSA’s Health Disparities Collaboratives- 500 community and migrant health centers

BPHC Diabetes Health Disparities Collaboratives* Improvement in Average HbA1c Levels *200+centers and ~60,000 patients:

RAND ICIC EVALUATION Studied 51 organizations in four different collaboratives 2132 BTS patients, 1837 controls with diabetes, CHF, asthma Controls generally from other practices in organization Data included patient and staff surveys, medical record reviews Preliminary findings generally support effectiveness

High Plains Community Center Lamar, Colorado Serves 11,000 people 29% uninsured 14% monolingual in Spanish 172 diabetics – A1c fell from 9.5% to 8.4% 114 with CVD - % with BP<140/90 rose from 35% to 62%

Premier Health Partners Dayton, Ohio 100 physicians in 36 practices Change began in one practice—spread throughout system ACE-inhibitors for albuminuria was 38% in 1999 and 80% in 2001 A1c < 7% was 42% in 1999 and 70% in 2001

Chronic Illness Care and Academia Few models of high quality chronic illness care Lagging behind the community in many places Some evidence that attitudes and behaviors of residents and attendings during clerkships diminish student perceptions of chronic illness care and career interest Concerns about chronic illness care contributing to reduced interest in generalist careers

Ms. G Receives ambulatory care in an AMC practice redesigned for her needs Has a continuing healing relationship with a practice team Practice involved in continuous QI Lives to see great- grandchildren

Self-management Support Every patient receives effective self- management interventions and ongoing collaborative goal-setting and problem solving by the team. Teaching practices model and teach collaborative self-management support.

Delivery System Design Practice team has defined roles, uses planned visits to support evidence-based care, and assures regular follow-up and care coordination Teaching practices emphasize team care and planned encounters with continuing care nurses playing major role in patient care and teaching.

Decision Support Evidence-based guidelines are integrated into care, and supported by provider education, links with specialty expertise, and reminder and fail-safe systems. Evidence-based guidelines and protocols are routinely integrated into curriculum and practice systems, and not portrayed as second-class cookbook medicine.

Clinical Information System: Registry A database of clinically useful and timely information on all patients provides reminders and feedback and facilitates care planning for individuals or populations. Continuing care teaching practices routinely use electronic databases and functions to monitor and assure quality of care.

Community Resources and Policies Health care organization has linkages with community organizations that can enhance practice capabilities, provide key patient services, or improve care coordination. Teaching practices routinely link patients with resources in the community and assure coordination of care.

Health Care Organization Organization and its leaders encourage and support better care using ongoing quality measurement, improvement & incentives. Teaching practices continuously monitor and improve care quality.

“The university and its medical center must become more actively involved with experimentation on new methods of delivery of community and personal health services of high quality.” “If we are to solve the problem of providing better medical care for all segments of society,...role models [for trainees] must portray individuals who are interested in systems of medical care…” John A. D. Cooper. Institutional Response to Expectations for Health Care. J Med Education 1969; 44:31-35

Is there a business case for CCM based care improvement? 27 RCTs tested the impact of CCM interventions on health care use/cost data for diabetes, heart disease and asthma: 79Diabetes 813Asthma 35CHF Cost/Use Reduction Total Studies Bodenheimer, Wagner, Grumbach. JAMA, 2002; 288:1910