Chronic disease management The background Bob Lewin Professor of Rehabilitation

1. CAREAND EDUCATION RESEARCH GROUP Chronic disease management The background Bob Lewin Professor of Rehabilitation Presentations at - www.yorkconference.org

2. 35% 60% of adults 21% €€€€ €€€€€€ At the Department of Health someone had noticed a problem. The number of people with a chronic condition has almost doubled in 30 years…….

3. …around 50% of all bed use is for chronic disease…. 50% of admissions are accounted for by 3% of diseases

4. ! * * * * CMO Liam Donaldson …and it is going to get worse! Ageing population - greater chronicity & fewer to pay. Change in ethnic mix low levels of activity obesity smoking drink? Increasing number of people surviving fatal events. or disease or congenital conditions increasing burden of chronic disease

5. Luckily some other people had been thinking about it …the Chronic Care Model by Ed Wagner. www.improvingchroniccare.org

6. The intention is to start rebuilding healthcare around chronic rather than acute illness PCTs need to work with Acute Care Trusts to develop integrated approaches. A key issue is the sharing of incentives to promote high quality care. strategic partnerships local authorities community and voluntary organisations Software to support care planning, risk stratification, and monitoring quality The Expert Patient programme NHS Direct Digital TV multidisciplinary team in primary care. risk stratification modern matrons and case management Evidence based guidelines incorporated in IT systems NSFs, elderly, mental health, CHD, etc.

7. 5% of patients account for 42% of bed use 10% of patients account for 55% of bed use Can better CDM be cost effective? 5% of patients use 42% of bed days. 80% of bed days in hospitals are currently used by emergency beds Some patients are trapped in the “revolving door”

8. The Kaiser Permanente Triangle – matching the level of CDM provided to the extent of use of acute services 3. 5% (42%) case management 2. 15-25% disease management 1. 70-80% self-management

9. I’m your fairy godmother from the USA and I can solve all your problems Who are you? 3 2 1 Prof Kate Lorig. Supported – “self care” for everyone with a chronic disease 11 June 2004 At a recent Big Conversation event the Health Secretary, John Reid said "The government intends to roll out its "expert patient" pilots across the country. These involve training lay people to support patients with long-term chronic conditions". By 2008 everybody with a chronic disease who wants an "expert patient" (sic) will have one, he promised. 17,000,000 people have a long-term condition

10. Level 2 – “disease management” 3,500,000? “high risk” 2 15-25%

11. 3 Case management 3000 Community Matrons in post by March 2007 Castlefields Health Centre 15%  in admissions 31%  in length of stay 41% in total bed use Improved referrals across the patch

12. The NHS version of the Wagner Model

13. impairment = the lesion disability = difference from age adjusted normal handicap = the additional imposition of society biomedical understanding of disability Implicit belief - because impairment often causes disability correcting the impairment will correct the disability IMPAIRMENT = LESION, (% blockage of arteries, size of infarct, ejection fraction, etc.) DISABILITY= DIFFERENCE FROM WELL PEERS (functional ability, angina, anxiety, depression, work status etc.)

14. Impairment does NOT relate to disability: e.g heart failure

15. Or in Angina the frequency of angina % occlusion r = 0.03 NS anger r = 0.5 p< 0.01 anxiety r = 0.5 p< 0.05 Smith, 1984, Brit. J Med Psychol Anxious depressed (31%) Non Distressed angio score 12.7 12.2 poor LVF 6 11 sub. Disability 61 34 exercise to pain 4.5 min 7.5 Channer, K. 1988, J Royal Soc Med

16. A biopsychosocial understanding of disability impairment on its own cannot explain disability including work status the extent of the symptoms reported the success or failure of medical treatment or surgery the number of acute medical events and readmissions medical costs to predict all of these you also need to include • aspects of personality • anxiety & depression • disease specific health beliefs • patients’ own attempts to cope (coping actions) Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462

18. The original CDM for CHD Cardiac rehabilitation 36 randomised trials meta-analysis shows a 20% all cause and 26% reduction in cardiac mortality at 2-5 years. Contrast this with 2% overall improvement in survival from surgery and 0% from PCTA Recent trials show same benefits as early trials despite the introduction of statins thus more than good medical management. Next to Aspirin the most cost effective intervention by a long distance. Menu based Assessment of chronic disease management needs Discuss different options to achieve goals Offering choice of venue reassess results and try again

19. Self management programme the Heart Manual 6 week, home based post MI programme A work book, diaries, record sheets and information 2 audio tapes, advice for family, a stress management course on tape A specially trained ‘Facilitator’ Exercise programme – walking. Secondary prevention – written advice Cognitive behavioural intervention change patients beliefs and attributions self recording self help for psychological problems relaxation and stress management face-to-face session, phone calls or home/clinic visits at week 1, 4, 6 after discharge. Lewin, Lancet, 1992; 339:1036-1040

20. Results of the trial show that in Heart Manual rehabilitation patients (n=88) 6 were readmitted to hospital in the first six months, whilst in control patients (n=88) 18 were readmitted to hospital in the first six months and all patients in this group had 1.8 more GP consultations per person than those in the Heart Manual rehabilitation group. www.show.scot.nhs.uk/isdonline/ heart_disease/CHDtables/The%20Heart%20Manual5.doc

21. 142 randomised to treatment Angina Plan 68 education session74 90% at 6 month follow-up 63 67 anxiety & depression physical activity: SAQ angina and use of GTN 40% reduction 9 0.6 1.0 8 0.5 0.4 7 0.0 6 0.2 -0.5 5 0 -1.0 4 -1.5 -0.2 3 -2.0 -0.4 2 -2.5 -3.0 1 -0.6 -3.5 0 -0.8 -4.0 -1 -4.5 -1 -2 Angina GTN -1.2 Anxiety Depression Self Management - The Angina Plan home based programme, a patient held manual & trained facilitator 30-60 minutes introduction session and 4, 10-15 minute phone calls / home /clinic visits, to set further goals, praise progress, encourage adherence Lewin RJP, British Journal of General Practice, 2002, 52, 194-201

22. East riding project - system Confirmed MI Hospital based facilitator introduces patient and partner to HM Community based Facilitator guides patient through 6 week HM programme. Home visits week 1,3,6. Final visit gathers assessment data. Triage meeting Discharge to support group and gym Refer to hospital based programme Refer to GP / specialist (psychologist, dietician etc) Community facilitator visit at 6 months to reassess Annual GP checks

23. 350 More rehabilitation programmes 380* 300 250 285 200 272 150 161 100 99 50 0 1988 1996 1992 2004 NSF Adjusted % of MI, CABG, PTCA patients receiving CR by region Estimated shortfall 330,000 patients a year

24. 3 2 1 Specialist liaison nurses Multidisciplinary teams, disease management programmes. Proven efficacy. CR programmes Home based, cognitive-behavioural self-management programmes – Heart manual, Angina Plan. Cost effective in reduction of readmission. Assessment method and tracking software - Minimum dataset and CCAD uniting MI, Surgery, Angioplasty and ICD registers. www.cardiacrehabilitation.org.uk

25. THE END

26. Predictors of treatment costs / success Anxious and depressed patients accrued 4 x the costs of non-distressed none of which was spent on psychological or psychiatric care Medical and economic costs of psychological distress in patients with coronary artery disease. Allison TG. Mayo clin proc, 1995. Psychological factors influence the success of coronary artery surgery. Channer KS. J R Soc Med. 1988. Predicting completeness of symptom relief after major heart surgery. Jenkins CD. Behav Med., 1996. Emotional distress before coronary bypass grafting limits the benefits of surgery. Perski A. Am Heart J., 1998.

27. And the evidence is…? Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care. 2005 17:141-6. Ouwens M, The focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals. CONCLUSION: Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results.

28. Payment by results: a means of releasing funds from acute care Incentive scheme to encourage social services to avoid delayed transfer of care Software systems for Registration, Recall, and Review. At risk patient can be identified by NUMBER OF MEDS OR ADMISSIONS Set of tools in each health community to create a health and social care system to support people with a chronic problem New GMS and PMS: rewards good CDM PMS+ and enhanced services to build capacity for new chronic disease services The Expert patient programme, NHS Direct, Digital TV for patients to better manage their care National Service Frameworks: diabetes, CHD, older people, mental health, children, renal disease, long term neurological conditions

29. Potential tensions CDM provided by need vs CDM provided by consumption cost saving to NHS vs improving quality of life clinical guideline based (mortality) vs patient preference (may not be longevity) individual change (patient) vs social models of change Potential delivery problems disease specific vs generic programmes over-reliance on educational approach vs cognitive-behavioural behaviour change self-management programmes attract the motivated leaving a rump of disenfranchised people establishing multi-disciplinary community based CDM teams may denude secondary care of staff and motivation ‘market led reforms’ – practice level purchasing, advertising for patients, compulsory use of private sector, Foundation Trusts Status may undermine systematic services

30. The Heart Manual: the evidence base Initial RCT less anxiety & depression: better quality of life: fewer readmissions to hospital: fewer visits to GP Lewin, Lancet, 1992; 339:1036-1040 Multi-centred RCT vs. Hospital based rehabilitation in 4 centres equal gain on all measures including gain in fitness (2 METs) HM significantly fewer readmissions to hospital at 12 months Jenny Bell, Andrew Coats Others - Linden B, 1995: O’Rourke A, 1999: Dalal HM, 2003 Recommended by: WHO: UK NSF for CHD: Scottish Intercollegiate Guidelines Network Guideline, UNCLE TC et. al. Ps. I have no financial interest in the HM!

31. Use of the Angina Plan 7000* 5132 2764 2002 2004 2003 * Estimate from uptake per month to Aug 2004

32. Return to work following a Heart Attack (MI) Australian Royal Commission to investigate failure to return to work following uncomplicated MI: interview 400 patient medically & psychologically examined 60% of cases no medical justification 38% of these cases directly due to faulty understanding e.g. “angina is a small heart attack” 22% of cases due to anxiety or depression caused by overly cautious prognosis given to the patient or a relative Wynn, 1967, Med J Australia, 2, 847-851

33. new test to qualify for free bus pass Health Promotion Promote better lifestyle to avoid chronic illness – education – develop community resources – provide incentives to encourage people to take greater personal responsibility for their health

34. How to meet the shortfall? 333,000 extra people a year needing cardiac rehabilitation Potential solutions More hospital based group CR programmes Home Based rehabilitation (e.g. Heart Manual) Self-management programmes (e.g. Angina Plan) Lay workers or volunteers (e.g. Bravehart, www.braveheart.uk.net) Internet

35. 142 randomised to treatment Angina Plan 68 education session74 90% at 6 month follow-up 63 67 9 0.6 1.0 8 0.5 0.4 7 0.0 6 0.2 -0.5 5 0 -1.0 4 -1.5 -0.2 3 -2.0 -0.4 2 -2.5 -3.0 1 40% reduction -0.6 -3.5 0 -0.8 -4.0 -1 -4.5 -1 -2 Angina GTN physical activity: SAQ -1.2 Anxiety Depression The Angina Plan home based programme, a patient held manual & trained facilitator 30-60 minutes introduction session and 4, 10-15 minute phone calls / home /clinic visits, to set further goals, praise progress, encourage adherence treatment - explanation of misconceptions - goal setting and pacing - daily walking - relaxation tape - instruction on using relaxation on chest tightness. Lewin RJP, British Journal of General Practice, 2002, 52, 194-201

36. 28.0% 30.0% 25.0% 16.8% 20.0% 13.5% 11.2% 15.0% 8.9% 8.5% 8.2% 7.9% 10.0% 5.1% 4.0% 3.5% 5.0% 0.0% Skin Stroke Diabetes Digestive Respiratory Arthritis etc. Mental health Visual problems Heart (inc high BP) Difficulty in hearing Headaches and m... Cardiac CDM Approx 2 million people living with symptomatic heart disease