Author of Lecture:
Armstrong, Bruce (Prof.)
Title of Lecture:
The Challenge of Chronic Disease
COMMONWEALTH OF AUSTRALIA
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Lifting the last straw
The challenge of chronic disease
Bruce Armstrong
School of Public Health
The University of Sydney
Acknowledgements
• Mr Chris Goumas and Dr Anne Kricker
for analysis of Australian hospitalisation
and mortality data
• Australian Institute of Health and
Welfare as the source of the
hospitalisation data:
http://www.aihw.gov.au/hospitals/datacubes/index.cfm
Hospitals in crisis!
Medical Journal of Australia 2008; 189: 220-21
Questions
• Is there an ever increasing demand for
hospital services?
• Are patients ever sicker?
• Is the back of the hospital camel about
to break?
• Is growth in chronic disease the cause?
• What can we do about it?
Crude hospital use rates Australia
19923/94 to 2006/07
Separations per 10,000; Bed days per 1,000
4,500
4,000
3,500
3,000
M-Separations
F-Separations
M-Bed days
F-Bed days
2,500
2,000
1,500
1,000
500
06
20
05
20
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
19
93
0
Questions
• Is there an ever increasing demand for
hospital services?
– Yes
• Are patients ever sicker?
• Is the back of the hospital camel about
to break?
• Is growth in chronic disease the cause?
• What can we do about it?
Trends in self-assessed health of
Australians 1995 to 2004-05
60
50
1995
2001
2004-5
%
40
30
20
10
0
Fair/Poor
Good
Very good/Excellent
2004–05 National health survey: summary of results, Australia. ABS cat. no. 4364.0. Canberra: ABS, 2006.
Crude all cause mortality rates Australia
1987-2007
900
700
600
500
400
M-Mortality
F-Mortality
300
200
100
Deaths Australia (various years to 2006). ABS cat. no. 3302.0. Canberra: ABS, 2007.
06
20
05
20
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
89
19
88
19
87
0
19
Mortality per 100,000
800
Questions
• Is there an ever increasing demand for
hospital services?
– Yes
• Are patients ever sicker?
– It seems unlikely
• Is the back of the hospital camel about
to break?
• Is growth in chronic disease the cause?
• What can we do about it?
Intensity of hospital bed use
1996/97 to 2006/07
100
90
80
70
60
50
40
Separations per bed per year
30
20
Apparent bed occupancy (%)
10
–0
7
20
06
–0
6
20
05
–0
5
20
04
–0
4
20
03
–0
3
20
02
-0
2
01
20
20
00
–0
0
19
99
–9
9
19
98
–9
8
19
97
–9
7
96
19
–0
1
0
But hospital funding has more-orless kept pace
140
120
100
80
60
Separations per bed per year
40
Apparent bed occupancy (%)
20
Expenditure ($/10) per bed day
Health expenditure Australia 2005-06. Canberra, Australian Institute of Health and Welfare 2007
–0
7
20
06
–0
6
20
05
–0
5
20
04
–0
4
20
03
–0
3
20
02
-0
2
01
20
–0
1
20
00
–0
0
19
99
–9
9
19
98
–9
8
97
19
19
96
–9
7
0
Perhaps private hospitals are
getting more of the cake
Increase in private hospital separations as a % of
total in major disease categories 1995/96 to 2006/07
15
38%
10
5
Health expenditure Australia 2005-06. Canberra, Australian Institute of Health and Welfare 2007
ta
l
To
ar
y
m
pt
om
s
In
ju
ry
C
ar
e
et
c.
Sy
ito
G
en
cu
M
us
ur
in
ta
l
in
lo
s
ke
le
Sk
st
iv
e
ig
e
D
ira
to
ry
or
y
R
es
p
la
t
e
Ey
irc
u
C
ou
s
er
v
ta
l
N
M
en
m
cr
in
e
et
c.
B
lo
od
la
s
En
do
eo
p
N
ec
t
io
n
s
0
In
f
Increase in % private
20
Proportion of total health expenditure on public and
private hospitals 1995/96 to 2005/06
Public
Private
45
40
35
30
25
20
15
10
5
Health expenditure Australia 2005-06. Canberra, Australian Institute of Health and Welfare 2007
–0
6
20
05
–0
5
20
04
–0
4
20
03
–0
3
20
02
–0
2
20
01
–0
1
20
00
–0
0
19
99
–9
9
19
98
–9
8
19
97
–9
7
96
19
95
–9
6
0
19
% total health expenditure
50
Questions
• Is there an ever increasing demand for hospital
services?
– Yes
– [Population ageing contributes a small part to it]
• Are patients ever sicker?
– It seems unlikely
• Is the back of the hospital camel about to
break?
– Maybe
• Is growth in chronic disease the cause?
• What can we do about it?
ec
tio
En
C
do an n
cr ce
in r
e
D etc
ia
be .
O
te
rg
s
M
an e
ic nta
m l
e
N nta
e
A rv l
lz
he ous
C ime
irc r
ul 's
at
or
y
IH
D
Fl Re Str
u
s o
& p i ke
pn rat
eu o r
m y
on
i
C a
O
D
ig PD
es
tiv
G
e
en
ito Liv
R ur er
e
i
S y n a n ar
l
y
m f
Ex pt ailu
te om re
r
s
In nal et
te
c
nt cau .
se se
lf s
A ha
ll
r
ca m
us
es
In
f
Change in rate per 100,000
Change in crude mortality rates for selected
causes 1997-06
40
20
0
-20
-40
-60
-80
-100
-120
-140
-160
Deaths Australia (various years to 2006). ABS cat. no. 3302.0. Canberra: ABS, 2007.
ec
t
io
En
n
C
do an s
cr ce
in r
e
D etc
ia
be .
te
B s
lo
o
M d
e
N nta
er
vo l
us
C
irc Ey
ul e
at
or
y
O IH
th D
er
H
R St D
es ro
p i ke
ra
to
r
C y
O
O D i PD
r a ge
lc s
av tiv
e
G ity
Ib e
t
G
en lee c.
d
ito in
ur g
in
M
ar
us
y
cu
lo Sk
sk in
Sy ele
m ta
pt l
om
In s
C jur y
ar
e
C
he Di etc
m aly
ot s
he is
ra
py
In
f
Change in rate per 10,000
Change in crude separation rates for selected
causes 1993-07
550
500
450
400
350
300
250
200
150
100
50
0
-50
ec
t
io
En
n
C
do an s
cr ce
in r
e
D etc
ia
be .
te
B s
lo
o
M d
e
N nta
er
vo l
us
C
irc E
u l ye
at
or
y
I
O H
th D
er
H
R St D
es ro
p i ke
ra
to
r
C y
O
O D i PD
r a ge
lc s
av tiv
G ity e
I
G ble etc
en e .
ito din
ur g
in
M
ar
us
y
cu
lo Sk
s
in
Sy kele
m ta
pt l
om
O
s
th
er Inj
re ur y
as
o
C
he Di ns
m aly
ot s
he is
ra
py
In
f
Change in rate per 1,000
Change in crude bed day rates for selected
causes 1993-07
120
100
80
60
40
20
0
-20
-40
-60
-80
Major contributors (%) to increasing
Chapter XXI bed use
Factors influencing heath status and health service contact
Sepns Days
Care involving dialysis
57.2
28.8
Other medical care
13.2
6.7
Care involving rehabilitation procedures
8.8
47.1
Adjust and manage implanted device
6.5
3.4
Special screening exam for cancer
4.7
2.4
Procreative management
4.2
2.1
Follow-up after treatment for cancer
3.3
1.7
Problems related to medical facilities and other health care
0.7
8.0
Problems related to care-provider dependency
0.0
1.4
Questions
• Is there an ever increasing demand for hospital
services?
– Yes
– [Population ageing contributes a small part to it]
• Are patients ever sicker?
– It seems unlikely
• Is the back of the hospital camel about to break?
– Maybe
• Is growth in chronic disease the cause?
– No, but doing more for chronic disease probably is
• What can we do about it?
What can we do about it?
1. Reduce inequity in the distribution of
power, money and access to
resources
36
38
35
29
37
Mortality by SES
Australia
1985-87 & 1998-00
18
12
6
9
8
Australian Institute of Health and Welfare. Health
inequalities in Australia: Mortality. AIHW Cat No. PHE
55. Canberra, 2004
Quoc Ngu Vu and
Ann Harding. Winners
and losers from taxtransfer system and
other changes under
the Howard years.
Presented to: 'A future
for the Australian
welfare state?
Continuity and
Change from Howard
to Rudd', Macquarie
University July 2008
CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of
the Commission on Social Determinants of Health. Geneva, World Health Organization, 2008.
Three overarching recommendations
1. Improve Daily Living Conditions
3. Measure and Understand the Problem and Assess
the Impact of Action
CSDH. Closing the gap in a generation: health equity through action on the social determinants of health. Final
Report of the Commission on Social Determinants of Health. Geneva, World Health Organization, 2008.
Selected actions
CSDH.
Closing the
gap in a
generation:
health equity
through action
on the social
determinants
of health.
Final Report
of the
Commission
on Social
Determinants
of Health.
Geneva,
World Health
Organization,
2008.
What can we do about it?
1. Reduce inequity in the distribution of
power, money and access to
resources
2. Take a whole society approach to
reducing major lifestyle risk factors
What major lifestyle risk factors?
Risk Factors
Smoking
% of total disease
burden (DALYS)
7.8
High body weight
7.5
Physical inactivity
6.6
Alcohol drinking
2.3
Low fruit and vegetable intake
2.1
Begg S et al. The burden of disease and injury in Australia 2003. Canberra, AIHW 2007
Potential impact
Mortality over 24 years: Nurses Health Study
Low risk
Never
smoked
30+
min/day
exercise
High diet
quality
Alcohol 114gm/day
BMI <25
van Dam RM et al. Combined impact of lifestyle factors on mortality: prospective cohort study
in US women. BMJ 2008;337:a1440
What is a whole society
approach?
• Create environments conducive to healthy
lifestyles
• Reduce the appeal of and access to the
means for unhealthy lifestyles
• Increase access to the means for healthy
lifestyles
• Mass media “social marketing” for the
healthy and against the unhealthy lifestyles
Trends in smoking in Australian adults
% current smokers
70
60
58
50
45
45
40
30
20
28
28
30
43
40
40
34
33
29
29
28
Male
30
27
29
29
24
23
27
25
Female
25
21
24
21
10
0
Centre for Behavioural Research on Cancer re-analysis of Roy Morgan, TCCV and NDHS surveys, Tobacco Facts and Issues in press
Trends in overweight and obesity
in Australian adults
Indicators for
chronic
diseases and
their
determinants.
AIHW,
Canberra
2008
What can we do about it?
1. Reduce inequity in the distribution of
power, money and access to
resources
2. Take a whole society approach to
reducing major lifestyle risk factors
3. Engage primary care practitioners in
organised, evidence-based, cost
effective disease risk reduction and
early detection
The US Preventive
Services Task Force,
an activity of the US
Agency for Health
Care Quality and
Research has been
evaluating the
evidence on preventive
services for 23 years.
Guide to Clinical Preventive
Services, 2007. Recommendations
of the U.S. Preventive Services Task
Force. Agency for Healthcare
Research and Quality
http://www.ahrq.gov/clinic/USpstfix.htm
Risk reduction
Screening for alcohol misuse with behavioural
counselling
Adults
B
Treatment with low-dose aspirin for the
primary prevention of cardiovascular events
Adults at high
CVD risk
A
Behavioural counselling to promote a healthy
diet
Adults at high
CVD risk
B
Screening for high blood pressure
Adults
A
Screening for blood lipid disorders
M 35+, F45+
or high risk
A
Screening for obesity with intensive
behavioural counselling intervention
Adults
B
Screening for tobacco use with behavioural
counselling +/- pharmacotherapy
Adults
A
Disease early detection
Screening for abdominal aortic aneurysm
Men 65-75
who smoked
B
Mammographic screening for breast
cancer
Women 40+
A
Women ever
sexually active
B
Adults 50+
A
Adults*
A
Screening for type 2 diabetes mellitus
Adults with HT
or high lipids
B
Screening for osteoporosis
Women 65+ or
60+ if high risk
A
Screening for cervical cancer
Screening for colorectal cancer
Screening for depression
*In clinical practices with systems to assure accurate diagnoses, effective treatment and follow-up
Guidelines for preventive activities in
general practice 2005 – Red Book
• Includes all these but adds:
– Advice on physical activity
– Screening for type 2 diabetes from 55
– Urinalysis every year from 50
– Skin exam for melanoma every year from 13 if high
risk
– Skin exam for NMSC every year from 40 if high risk
– Osteoporosis and fracture risk assessment: women
from 45 and men from 50
Guidelines for preventive activities in general practice (6th Edition). RACGP, Melbourne, 2005
Making it “organised”
• A well-documented evidence-based,
cost-effective schedule of interventions
for specified people at specified
intervals organised into an age-based
sequence of health checks
• Call and recall mechanisms
• Documented follow-up to ensure
appropriate action on findings
• Evaluation of outcomes
What can we do about it?
1. Reduce inequity in the distribution of power,
money and access to resources
2. Take a whole society approach to reducing
major lifestyle risk factors
3. Engage primary care practitioners in
organised, evidence-based, cost effective
risk reduction and disease early detection
4. Institute organised evidence-based
chronic disease care according to an
agreed chronic disease management
model
Aims of Chronic Disease
Management
• Reduce burden of illness and disability
– Treatment
– Prevention
• Reduce hospitalisation
• Lengthen life
Scott IA. Internal Medicine Journal 2008; 38: 427-37
Components of Chronic Disease
Management
• Multidisciplinary care
• Patient self management
– Disease care: Self-monitoring: Lifestyle change
• Coordinated care
– Systems for integrating care across multiple
conditions and providers
• Delivery system redesign
– Hospital: Primary care: Community resources
• Clinical information systems
– Care management: Communication: Evaluation
• Evidence-based decision support and care
Scott IA. Internal Medicine Journal 2008; 38: 427-37
Does it work?
• COPD: ↓ hospitalisation, symptoms; ↑ function
• IHD: ↓ mortality, recurrent heart attack
• Heart failure: ↓ mortality, hospitalisation
• Diabetes: → mortality, hospitalisation,
cardiovascular events; ↑ disease control; ↓
foot ulcers and amputation
Scott IA. Internal Medicine Journal 2008; 38: 427-37
Component effectiveness
Multidisciplinary care
Effective
Patient self-management
Effective
Provider decision support
Case management
Effective/
Uncertain
Uncertain
Clinical information systems
Unevaluated
Health care system redesign
Unevaluated
Access to community resources Unevaluated
Scott IA. Internal Medicine Journal 2008; 38: 427-37
Return on investment
• A positive return from programs for
heart failure and multiple illnesses
• Diabetes programs may save more than
they cost
• Mixed results for asthma programs
• Depression programs cost more than
they save in medical expenses
Goetzel RZ et al. Health Care Financing Review 2005; 26(4): 1-19
Commercial programs
• Commercial programs range from
– Highly integrated services operating in
close collaboration with primary care to
– “Carve out” models that are separate,
condition specific delivery systems.
• Published evidence of the effectiveness
of commercial programs remains scant
Rothman AA et al. Annals of Internal Medicine 2003; 138: 256-61
Organised?
• Australia does not have an organised
approach to chronic disease
management
• We need one badly
Key messages
• While chronic disease is a major contributor
to health service load, its growth is not the
main cause of perceived health system
crises.
• Australia needs a coherent and coordinated
chronic disease control program. It doesn’t
have one now.
• Reducing inequality is an essential
component of chronic disease control and
requires whole of government action.
Key messages
• Effective population-wide disease risk
reduction requires government
planning, legislative and regulatory
action as well as social marketing.
• The disease care system is an essential
component of chronic disease control.
Its actions must be evidence-based,
organised and integrated across health
service levels if it is to be effective and
deliver value for money.