OCC3052 – ENABLING OCCUPATION II:
PERFORMANCE CHALLENGES IN POPULATION
HEALTH
WEEK 8: CHRONIC CONDITIONS
S2, 2019
LEARNING OBJECTIVES
▪ Understand and describe chronic conditions, their impact and
their cost.
▪ Identify and examine the factors that influence the incidence
and prevalence of chronic conditions.
▪ Explore how the Australian health systems respond to the
demands created by chronic conditions.
▪ Reflect on what this means for OT practice.
WHAT, HOW MANY & WHY?
LIFE EXPECTANCY
▪ Australians are living longer.
▪ Life expectancy in Australia for a boy born
in 2012 was 79.9 years, and for a girl, 84.3 years.
▪ Men who had survived to the age of 65 in 2012 can expect
to live, on average, an additional 19.1 years (to 84.1 years),
and women an additional 22.0 years (to 87.0 years).
▪ Life expectancy in Australia has risen by more than 30 years
since the late 1800s.
▪ A boy born in 1890 had a life expectancy of 47.2 years;
for girls it was 50.8 years.
LIFE EXPECTANCY
LIFE EXPECTANCY
Males
Females
New South Wales
79.9
84.2
Victoria
80.5
84.5
Queensland
79.5
84.0
South Australia
79.8
84.2
Western Australia
80.1
84.8
Tasmania
78.7
82.6
Northern Territory
74.7
80.0
Australian Capital Territory
81.2
85.1
State or Territory
In 2011, Australia was ranked 6th among OECD countries for
life expectancy at birth for males, and 7th for females
DEATHS IN AUSTRALIA
▪ There were 146,932 deaths in Australia in 2011. The
leading underlying cause of death was coronary heart
disease, accounting for 11,733 male deaths and 9,780
female deaths.
▪ For males the next most common causes of death were lung
cancer (4,959 deaths) and cerebrovascular diseases (which
include stroke) (4,427 deaths).
▪ For females the next most common causes
of death were cerebrovascular diseases
(6,824 deaths), and dementia and Alzheimer
disease (6,596 deaths).
CAUSES OF DEATH OVER TIME
▪
For both males and females, the five leading causes of
death were the same in 2001 and 2011. The leading
cause of death in both years was coronary heart disease,
accounting for 20% of deaths in 2001 and 15% in 2011.
▪
For males, the largest changes in leading causes of death from 2001
to 2011 were the rise of dementia and Alzheimer disease from 13th to
6th place, and the fall of land transport accidents from 9th to 17th
place. For males, two leading external causes of death (land transport
accidents and suicides) fell in rank over this period while many cancer
causes of death rose in rank (lung, prostate and pancreatic cancers,
and cancers with unknown or ill-defined site).
▪
For females, cancer-related causes of death (breast, colorectal,
pancreatic and ovarian) fell in rank over this period. Meanwhile, lung
cancer deaths rose in rank, from 5th in 2001 to 4th in 2011.
CAUSES OF DEATH OVER TIME
▪ For males, the largest changes in leading causes of
death from 2001 to 2011 were the rise of dementia
and Alzheimer disease from 13th to 6th place, and
the fall of land transport accidents from 9th to 17th place.
▪ For males, two leading external causes of death (land transport
accidents and suicides) fell in rank over this period while many
cancer causes of death rose in rank (lung, prostate and pancreatic
cancers, and cancers with unknown or ill-defined site).
▪ Although the number of new cancer cases each
year is rising, largely due to population ageing,
the number of new cases per 100,000 population
is steady and death rates are continuing to fall.
HEALTH & DEATH OVER TIME
There has been a long and continuing decline in death rates in Australia.
Between 1907 and 2012, the age-standardised death rate fell by more than 70%,
from 2,054 to 550 deaths per 100,000 population.
CHRONIC CONDITIONS AS CAUSES OF
DEATH
▪ Coronary heart disease (CHD) was an associated cause of death
for 51% of deaths due to diabetes, 28% of deaths due to chronic
and unspecified kidney failure and 19% of deaths due to chronic
obstructive pulmonary disease (COPD).
▪ Hypertensive disease was an associated cause of death for 35%
of deaths due to diabetes, 28% of deaths due to cerebrovascular
diseases (which include stroke) and 21% of deaths due to CHD.
▪ Kidney failure was an associated cause of death
for 26% of deaths due to diabetes.
▪ Influenza and pneumonia was also a common associated
cause of death – more specifically, for 31% of deaths due
to asthma, 30% of deaths due to COPD and 29% of
deaths due to dementia and Alzheimer disease.
CHRONIC CONDITIONS AS CAUSES OF
DEATH
Selected chronic diseases as underlying and associated causes of death, 2011 (per cent)
CHRONIC CONDITIONS & DEATH OVER
TIME DEATH
▪
Currently, 9 in 10 deaths have chronic
condition as an underlying cause.
▪
Cardiovascular diseases (coronary
heart disease and stroke), dementia
and Alzheimer disease, lung cancer
and chronic lower respiratory disease
including COPD are the most common
underlying causes, together being
responsible for 40% of all deaths.
CANCER
CANCER
▪ In 2010, 116,580 new cases of cancer were diagnosed in
Australia (excluding basal and squamous cell carcinoma of the
skin – the most common types of non-melanoma skin cancer).
More than half (57%) of these cases were diagnosed in
males.
▪ The risk of being diagnosed with any cancer before the age
of 85 was 1 in 2 for males and 1 in 3 for females.
▪ The most commonly diagnosed cancers in 2010
were prostate in males (19,821), bowel (14,860),
breast cancer in females (14,181), melanoma of
the skin (11,405) and lung (10,296).
CANCER
▪ The number and rate of new cases of cancer
have increased over time. Between 1990 and
2010, the age-standardised incidence rate for
total cancers rose by 16%, from 422 new cases per 100,000
people to 488 per 100,000. This was driven by rises in the
incidence of prostate, breast and bowel cancers, due largely to
improved detection and diagnosis of these cancers.
▪ The number of new cases of cancer diagnosed in Australia is
projected to continue to rise over the next decade and is expected
to reach 150,000 in 2020. This increase in the number of new
cases, due primarily to population growth and ageing, is expected
to be most evident among older populations.
ARTHRITIS & MUSCULOSKELETAL
CONDITIONS
▪
In 2011-12, an estimated 6.1 million people (28% of all Australians) had
arthritis and/or another musculoskeletal condition.
▪
Arthritis was the most common condition, affecting 3.3 million people (15% of
the population), including 8% with osteoarthritis and 2% with rheumatoid
arthritis. Prevalence is higher in females than males (18% compared with 12%)
and increases with age (affecting 52% of people aged 75 or over).
▪
Back problems and disc disorders affect about 2.8 million people (13% of the
population). The rates are highest among people aged 65-74.
▪
An estimated 725,500 people (3% of the population) reported that they had
been diagnosed with osteoporosis or low bone density (osteopenia). Most cases
were reported by women (82%) and people aged 55 and over (83%). As
these conditions have no overt symptoms, the figures may be underestimated.
▪
An estimated 64,200 children aged 0-14 had arthritis or another
musculoskeletal condition. Juvenile arthritis affected less than 1% of Australian
children.
ARTHRITIS & MUSCULOSKELETAL
CONDITIONS
People with arthritis and other musculoskeletal conditions were
more likely to report:
▪ Limitations in performing core activities (particularly self-care
and mobility) than the overall population (44% compared
with 15%).
▪ High or very high psychological distress (17%) than people
without these conditions (9%).
▪ Experiencing mental disorders than those without
these conditions (1.5 times as high).
CORONARY HEART DISEASE
▪
In 2011-12, an estimated 585,900
Australians had CHD, with the
condition being more common in men
(3.3%) than women (2.0%) and
among those aged 70 and over
(15% compared with 2.2% for those
aged 25-69).
▪
In 2011, an estimated 69,900
people aged 25 and over had a
heart attack. There has been a 20%
fall in heart attack rates over the last
5 years (age-standardised rate of
427 per 100,000 people in 2011
compared with 534 in 2007).
STROKE
▪ In 2009, an estimated 375,800
Australians (205,800 males and
170,000 females) had had a stroke
at some time in their lives. Most (70%) were aged 65 or
over.
▪ The rate of stroke events has fallen by 25% over the last
decade (from an age-standardised rate of 186 to 140 per
100,000 population between 1997 and 2009). But the total
number of Australians experiencing a stroke rose by 6% over
the same period, reflecting the ageing of the population.
▪ In 2009, over one-third (35%) of Australians who
experienced a stroke had a resulting disability; this was an
improvement from 1998 when the rate was 45%.
STROKE
Over the last 3 decades, stroke death rates have fallen by almost 70% (from an agestandardised rate of 103 to 33 deaths per 100,000 population between 1979 and 2011).
MENTAL HEALTH
▪ 2007 data suggests that of the Australian adult
population, an estimated that 45% of Australians
aged 16-85 had experienced a mental disorder
sometime in their lifetime (equating to 7.3 million people), and that
an estimated 1 in 5 (20%) of the population aged 16-85 (equating
to 3.2 million people) had experienced a common mental disorder
in the previous 12 months.
▪ Of these, anxiety disorders (such as social phobia) were the most
common, afflicting 14.4% of the population, followed by affective
disorders (such as depression, 6.2%) and substance-use disorders
(such as alcohol dependence, 5.1%). These 3 groups of common
mental disorders were most prevalent in people aged 16–24 and
decreased as age increased. Prevalence was higher for females
than males in all age groups.
MENTAL HEALTH
▪ From the child and adolescent survey
conducted in 1998, 14% of children and
adolescents aged 4-17 (an estimated 321,181 people in
2013) had a clinically significant mental health problem.
▪ In terms of less common but more severe mental disorders,
estimates from the 2010 National Survey of People Living
with Psychotic Illness indicated that 0.45% of the population
aged 18-64 (almost 64,000 people) were treated annually
by public sector mental health services for a psychotic
disorder, with schizophrenia being the most common disorder.
MENTAL HEALTH
Prevalence of common mental disorders in the Australian population, 1997/1998 and 2007
CHRONIC RESPIRATORY CONDITIONS
▪ In 2011-12, about 3 in 10 Australians (29%) suffered from
1 or more chronic respiratory conditions (6.3 million people).
▪ Hay fever and asthma were the 2 most common conditions,
affecting an estimated 3.7 million (17%) and 2.3 million Australians (10%).
▪ Asthma was one of the most common chronic health conditions among
children, (i.e. estimated 393,000 children aged 0-14 (9%) in 2011-12).
▪ COPD was comparatively rarer (i.e. estimated at 529,000 Australians
(2%)).
▪ Both COPD and asthma were more common in areas of lowest
socioeconomic status than in areas with the highest status (4% compared
with 2% for COPD, and 12% compared with 9% for asthma).
▪ Small fall in the age-standardised prevalence of asthma and COPD from
2001 to 2011-12, from 12% to 10% for asthma and from 4% to 2% for
COPD.
CHRONIC RESPIRATORY CONDITIONS &
DEATH
DIABETES
▪ There are an estimated 1 million people aged 2 or over
with diagnosed diabetes in Australia. However, this is
likely to be an underestimate – as for every 4 adults with
diagnosed diabetes, there is estimated to be 1 with undiagnosed
diabetes.
▪ Of all people with diabetes, around 85% have type 2 diabetes
and 12% have type 1 diabetes. In addition, gestational diabetes
affects about 1 in 20 pregnancies each year.
▪ Diabetes is becoming more common – the rate of self-reported
diabetes more than doubled, from 1.5% to 4.2% of Australians,
between 1989-90 and 2011-12.
▪ In 2011-12, diabetes was more common in men (6%) than women
(4%) and was more common in older age groups – affecting 15%
of those aged 65-74 compared with 5% for those aged 45-54.
DIABETES
▪ In 2011, there were around 2,400 new cases of type 1 diabetes,
with half of these being among people aged 18 or under.
▪ Rates of type 1 diabetes remained stable over 2000-2011, with
age-standardised rates of around 10 to 12 new cases per
100,000 population per year.
▪ In 2011-12, there were around 49,800 new cases of diagnosed
type 2 diabetes among people 10 and over, based on preliminary
findings.
▪ Despite nearly all cases (92%) occurring in those
aged 40 and over, there were around 430 new
cases among children and young people aged
10–24 – even though type 2 diabetes is generally
regarded as a disease of adulthood.
DIABETES & MEDICATION
CHRONIC KIDNEY DISEASE
According to the 2011-12 Australian
Health Survey, 1 in 10 people (or 1.7
million Australians) aged 18 and over
have biomedical signs of CKD.
There were about 2,500 new cases
of KRT-treated-ESKD in 2011
(equating to an age-standardised
rate of 10 people per 100,000
population or 7 new treated-ESKD
cases per day).
Diabetes was the leading cause of
KRT-treated-ESKD in 2011,
accounting for 1 in 3 new cases.
Over-representations are present.
INJURIES
▪
Injury was recorded as a cause of 10,668 deaths in 2009-10 in Australia,
or 7.6% of all deaths.
▪
One-third of male injury deaths and almost two-thirds of female cases
occurred at ages 65 and older. Less than 2% of cases were at ages
younger than 15.
▪
The most common causes of injury deaths in 2009-10 were falls (32.2%),
intentional self-harm (20.8%) and transport accidents (13.9%).
▪
From 1999-00 to 2009-10, injury deaths comprised a fairly constant
proportion of all deaths in Australia, ranging from 7.4% to 8.1%.
INJURIES
▪ Adjusting for age, injury deaths decreased from
55.1 per 100,000 population in 1999-00 to 46.8
in 2004-05, with little change in more recent years.
▪ The injury death rate was 45.4 per 100,000 population in 200910.
▪ For most external causes, rates of injury-related deaths tended to
decline from 1999-00 to 2007-08: 3.8% per year for transport
injury, 3.3% for thermal injury (i.e. exposure to smoke, fire, heat
and hot substances), 5.5% for drowning, 3.2% for suicide and 5.5%
for homicide. Rates of poisoning deaths involving pharmaceuticals
fell sharply to 2001-02, then rose by 2.2% per year to 2007-08.
▪ Rates of fall-related injury deaths have not shown a marked trend.
INJURIES & HOSPITALISATIONS
IN VICTORIA, THE RESULT HAS BEEN…
Projected prevalence of selected chronic diseases in Victoria 2022
Demand for
health services
is changing
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
Planning area
W
es
t
So
ut
h
Co
as
t
So
ut
h
im
m
er
a
W
M
al
ee
an
d
Py
re
ne
es
Ea
st
Ce
Gi
pp
nt
ra
sla
lV
nd
ic
-W
el
lin
gt
Go
on
Ge
ul
bu
el
on
rn
g
Va
an
lle
d
ya
Co
nd
as
t
Lo
w
er
Hu
m
e
Up
pe
r
Hu
m
Ce
e
nt
ra
lG
ip
ps
la
nd
Ce
nt
ra
lH
igh
la
nd
s
0.0%
Ce
nt
ra
la
nd
Hospital
utilisation could
be better
managed
% primary care type presentations to ED
Primary care type presentations to ED
CHRONIC CONDITIONS: IMPACT & COST
CHRONIC CONDITIONS: AN OVERVIEW
▪ Have complex and multiple causes.
▪ Usually have a gradual onset, and are often accompanied by acute
stages, and may also have a sudden onset – especially after injury.
▪ Occurs at all stages cross the life span; more prevalent in older
age.
▪ Can compromise quality of life through physical (and often comorbid mental) health limitation and disability.
▪ Are generally long term and persistent,
leading to a gradual deterioration of health.
▪ Not usually immediately life threatening,
but are a significant cause of premature
death.
CHRONIC CONDITIONS: WHAT & WHY?
▪ Advances in prevention and treatment of diseases and injuries has
increased prevalence and incidence. This is alongside demographic
changes (people living longer and an ageing population).
▪ Impact of lifestyle worldwide: tobacco, alcohol, physical inactivity,
poor diet and nutrition, obesity, high blood pressure.
▪ WHO (2011) indicates a rapid increase in the global burden of
disease due to chronic conditions.
▪ Predicts that by 2020, chronic
conditions will account for
approximately 75% of all deaths.
▪ In Australia, estimated that chronic conditions are
responsible for over 80% of the burden of disease.
CHRONIC CONDITIONS: COST & IMPACT
Chronic
conditions
Source:
Ratzen (n.d.)
DALYS BY CONDITION
BREAKDOWN OF DALYS BY CONDITION
BURDEN OF DISEASE BY RISK FACTORS
Behavioural:
Smoking
Behavioural:
Inactivity
Behavioural:
Alcohol
Biomedical: Diet
Biomedical:
Obesity
Biomedical:
Hypertension
Biomedical:
Blood fats
Ischaemic heart
disease
Y
Y
N
Y
Y
Y
Y
Stroke
Y
Y
Y
Y
Y
Y
Y
Type 2 diabetes
Y
Y
N
Y
Y
Y
N
Kidney disease
Y
Y
N
Y
Y
Y
N
Arthritis
Y
Y
N
N
Y
N
N
Osteoporosis
Y
Y
Y
Y
N
N
N
Lung cancer
Y
N
N
N
N
N
N
Colorectal
cancer
N
Y
Y
Y
Y
N
N
COPD
Y
N
N
N
N
N
N
Asthma
Y
N
N
N
N
N
N
Depression
N
Y
Y
N
Y
Y
N
Y
Y
N
N
N
N
N
Oral health
SPENDING BY CONDITION
TYPE OF SPENDING BY CONDITION
CHANGE IN ADMISSIONS: 05/06 TO 09/10
CURRENT & FUTURE DIRECTIONS,
Refining Australia’s Health System
CHALLENGES
▪ Changed Commonwealth funding contribution – widening the
fiscal gap
▪ Uncertainty and reduced transparency
▪ National prevention leadership
▪ Health workforce planning – national, public/private
▪ ACSQCHE - across public and private sectors
▪ Co-payment – pressure on primary health care
and public hospitals
Redefining
Commonwealth
– State funding
arrangements
Ensuring that
on-going health
care funding is
sustainable
RATIONALISING ROLES & RESPONSIBILITIES
Particular
emphasis on
education and
health care.
NATIONAL HEALTH PRIORITY AREAS
▪
Arthritis and musculoskeletal conditions
▪
Asthma
▪
Cancer control
▪
Cardiovascular health
▪
Diabetes
▪
Mental health
▪
Injury prevention and control
▪
Obesity
▪
Dementia
PREVENTION
NATIONAL DISABILITY INSURANCE
SCHEME
▪ NDIS will provide support for people with permanent and
significant disabilities, their families and carers.
▪ As a group, people with disability experience significantly poorer
health than those without disability. Almost half (46%) of people
aged 15-64 with severe or profound disability report poor or fair
health compared with 5% for those without disability.
▪ For people aged 15-64 with a specific long-term health condition
or injury, a higher proportion of those with severe or profound
disability than those without disability had: young onset of arthritis
before age 25 (14% compared with 6%); osteoporosis before
age 45 (43% compared with 31%); young onset of
diabetes before age 25 (23% and 7% respectively).
▪ Progressing…sort of.
QUALITY & PERFORMANCE
▪ Enhancing leadership and systems to achieve best use of
people, resources, and evolving knowledge.
▪ Quality Prescribing Initiative, Polypharmacy Initiative, etc.
▪ Clinical leadership programs.
▪ Reporting and review programs – across all areas of service
delivery.
▪ Various states of progress.
OPPORTUNITIES
▪ PCEHR and HealtheNet
▪ Prevention – State leadership
▪ Primary Health Networks – shape agenda for integrated
care
▪ Co-payments – States enter primary care
▪ ABM Portal – smart use of data
▪ Health Productivity and Performance – ensure breadth and
relevance
▪ White papers on the Reform of the Federation and Tax
Reform
NATIONAL STRATEGIC FRAMEWORK FOR
CHRONIC CONDITIONS
NATIONAL STRATEGIC FRAMEWORK
FOR CHRONIC CONDITIONS
Objectives
▪ Focus on prevention for a healthier Australia.
▪ Provide effective and appropriate care to support people with chronic
conditions and optimise quality of life.
▪ Target priority populations.
Strategic Priority Areas
Strategic Priority Areas have been identified under each Objective. These are
the core priority areas where Partners should focus attention to achieve each of
the Objectives. Partners can readily identify, plan and implement their own
policies, strategies, actions and services against the Strategic Priority Areas.
DoH, 2016
NATIONAL STRATEGIC FRAMEWORK FOR
CHRONIC CONDITIONS
Objective 1: Focus on prevention for a healthier Australia
Strategic Priority Area 1.1
Risk reduction
Strategic Priority Area 1.2
Partnerships for health
Strategic Priority Area 1.3
Critical early life stages
Strategic Priority Area 1.4
Timely and appropriate detection
DoH, 2016
NATIONAL STRATEGIC FRAMEWORK FOR
CHRONIC CONDITIONS
Objective 2: Provide effective and appropriate care to support people with
chronic conditions and optimise quality of life
Strategic Priority Area 2.1
Active engagement
Strategic Priority Area 2.2
Continuity of care
Strategic Priority Area 2.3
Accessible health services
Strategic Priority Area 2.4
Information sharing
Strategic Priority Area 2.5
Supportive systems
DoH, 2016
NATIONAL STRATEGIC FRAMEWORK FOR
CHRONIC CONDITIONS
Objective 3: Target priority populations
Strategic Priority Area 3.1
Community and culture
Strategic Priority Area 3.2
Targeted action
DoH, 2016
BUT, IT’S NOT THAT EASY!
CHRONIC CONDITIONS & THEIR RISK
FACTORS
▪ In Australia, as elsewhere, the prevalence of chronic disease
varies across the socioeconomic gradient for a number of
specific diseases, as well as for important disease risk factors
▪ However, the diseases with substantial disparities across the
socioeconomic quintiles are different, for different stages in
the life course.
▪ Any health interventions to address the
impact of chronic disease and associated
risk factors, at a population level, need to
take socioeconomic inequalities into
account.
PREVALENCE OF TYPE 2 DIABETES
Rate ratios (Most/Least disadvantaged) – 2001: 2.39, 2011-12: 2.19
SMOKING RATES
Rate ratios (Most/Least disadvantaged) – 2001: 1.87, 2011-12: 2.33
OBESITY RATES
Rate ratios (Most/Least disadvantaged) – 1995: 1.34, 2007-8: 1.80, 2011-12: 1.63
SO, WHAT DOES THIS ALL MEAN?
IMPLICATIONS FOR OT PRACTICE
OTs are able to play a key role in meeting the challenges and demands of
chronic conditions – be that at the upstream, midstream or downstream levels.
The skills, knowledge and advocacy that OTs are able to bring to their work
makes them an invaluable resource in working with chronic conditions.
“Although more research is needed, evidence indicates that occupational therapy
interventions improve BADLs and IADLs, health, and quality of life for people
with chronic diseases such as RA, COPD, chronic heart failure, and depression.
The evidence suggests that similar occupational therapy interventions are
applicable across a range of diagnoses and may be applicable to diagnoses
beyond the scope of this review. The interventions commonly include goal setting,
energy conservation, joint protection, exercise, assistive devices, and coping
strategies. Occupational therapy practice for people with chronic diseases can
be continued and built on to meet the increasing prevalence and needs of people
with these conditions”
Source:
Hand, Law & McColl (2011)
CONCLUSIONS
fast
▪
Australia’s health care system is complex and changing –
: with chronic
conditions a key driver of demand and cost, and therefore of reform.
▪
As such, responding to health needs requires practitioners to be able to work at
the up, mid and downstream levels.
▪
Good health is more than just getting a service user/client to do what you
suggest. Developing self-confidence and self-agency to manage your health
requires the incorporation of psychological theory and findings, adult learning
principles and health promotion concepts, as well as responding to change.
▪
This in turn requires recognition of political, financial, social and
environmental contexts, enabling service users/clients to address
the multiple barriers to better health and well-being that they face.
▪
There is no simple solution, especially to the challenges posed
by chronic health conditions.