Chronic disease management
The background
Bob Lewin
Professor of Rehabilitation
Presentations at - www.yorkconference.org
CARE AND EDUCATION RESEARCH GROUP
At the Department of Health someone had noticed
a problem. The number of people with a chronic
condition has almost doubled in 30 years…….
All people reporting a chronic condition
35%
36
35
35
34
33
33
32
32
31
Percent
30
32
31
30
29
28
26
24
21%
 
24
60% of adults
22
21
20
1972
1975
1981
1985
1991
1995
Year
1996
1998
1998
2000
2001
(note: data from 1998 is weighted)
2002
…around 50% of all bed use is for chronic disease….
Cumulative bed day use by ICD
code
60,000,000
Bed days used
50,000,000
40,000,000
30,000,000
20,000,000
50% of admissions
are accounted for
by 3% of diseases
10,000,000
-
Cause of admission
…and it is going to get worse!
Ageing population - greater chronicity & fewer to pay.
low levels of activity
Change in ethnic
mix
Increasing number of people
surviving fatal events. or
disease or congenital
conditions
obesity
smoking
drink?
****
CMO Liam Donaldson
!
Luckily some other people had been thinking
about it …the Chronic Care Model by Ed Wagner.
www.improvingchroniccare.org
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.
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”
Percentage of those admitted as inpatients by cumulative days
spent as inpatients
Cumulative percentage of inpatient
days
1.00
0.90
0.80
0.70
0.60
0.50
0.40
5% of patients
account for 42% of
bed use
10% of patients
account for 55% of
bed use
0.30
0.20
0.10
0.00
0.00
0.10
0.20
0.30
0.40
0.50
0.60
Percentage of inpatients
0.70
0.80
0.90
1.00
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
Supported – “self care” for everyone with a chronic disease
17,000,000
people
have a
long-term
condition
3
2
1
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 longterm chronic
conditions".
By 2008 everybody
with a chronic
disease who wants an
"expert patient" (sic)
will have one, he
promised.
I’m your fairy
godmother from
the USA and I can
solve all your
problems
Prof Kate Lorig.
Who are
you?
Level 2 – “disease management”
3,500,000?
“high risk”
15-25%
2
Case management
3000 Community Matrons in post by March 2007
Castlefields Health Centre
3
15%  in admissions
31%  in length of stay
41% in total bed use
Improved referrals across the patch
The NHS version of the Wagner Model
biomedical understanding of disability
Implicit belief - because impairment often causes disability
correcting the impairment will correct
the disability
I
IMPAIRMENT = LESION,
(% blockage of arteries,
size of infarct, ejection
fraction, etc.)
M
P
A
I
R
M
E
N
T
D IS A B ILIT Y
DISABILITY= DIFFERENCE FROM WELL
PEERS (functional ability, angina, anxiety,
depression, work status etc.)
impairment = the lesion
disability = difference from age adjusted normal
handicap = the additional imposition of society
Impairment does NOT relate to disability: e.g heart failure
Or in Angina
the frequency of angina
% occlusion
r = 0.03 NS
anger
anxiety
r = 0.5
r = 0.5
p< 0.01
p< 0.05
Smith, 1984, Brit. J Med Psychol
Anxious
depressed (31%)
angio score
poor LVF
sub. Disability
exercise to pain
Non Distressed
12.7
6
61
4.5 min
Channer, K. 1988, J Royal Soc Med
12.2
11
34
7.5
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
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
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
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
Self Management - The Angina Plan
142 randomised to treatment
Angina Plan
68
education
session 74
90% at 6 month follow-up
63
67
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
anxiety & depression
9
8
7
6
5
4
3
2
1
0
-1
-2
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
Anxiety
physical activity: SAQ
Depression
angina and use of GTN
40% reduction
1.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
-3.0
-3.5
-4.0
-4.5
Angina
Lewin RJP, British Journal of General Practice, 2002, 52, 194-201
GTN
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 GP / specialist
(psychologist, dietician
etc)
Refer to hospital based
programme
Community facilitator visit at 6 months to reassess
Annual GP checks
Adjusted % of MI, CABG, PTCA patients receiving CR by
region
More rehabilitation programmes
350
380*
300
250
285
200
272
150
100
161
99
50
0
1988
1992
1996
2004
NSF
Estimated shortfall 330,000 patients a year
Specialist liaison nurses
3
2
1
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
THE END
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.
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 selfmanagement 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.
New GMS and PMS:
rewards good CDM
PMS+ and enhanced services to
build capacity for new chronic
disease services
Set of tools in each
health community to
create a health and
social care system to
support people with a
chronic problem
Software systems for Registration,
Recall, and Review.
At risk patient can be identified by
NUMBER OF MEDS OR
ADMISSIONS
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
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!
Use of the Angina
7000*
Plan
5132
2764
2002 2003
2004
* Estimate from uptake per month to Aug 2004
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
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
new test to qualify for free bus pass
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
The Angina
Plan
home based programme, a patient held manual & trained
facilitator
142 randomised to treatment
Angina Plan
68
education
session 74
30-60 minutes introduction session
and 4, 10-15 minute phone calls / home /clinic visits, to set
further goals, praise progress, encourage adherence
90% at 6 month follow-up
63
67
9
8
7
6
5
4
3
2
1
0
-1
-2
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
Anxiety
treatment - explanation of misconceptions - goal setting and
pacing - daily walking - relaxation tape - instruction on using
relaxation on chest tightness.
Depression
1.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
-3.0
-3.5
-4.0
-4.5
physical activity: SAQ
Lewin RJP, British Journal of General Practice, 2002, 52, 194-201
40% reduction
Angina
GTN
Cardiac CDM
Approx 2 million people living with symptomatic heart disease
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
28.0%
16.8%
13.5%
11.2%
8.9% 8.5% 8.2% 7.9%
5.1% 4.0% 3.5%