Challenges in Acute & Chronic Care

Learning Objectives
• Are acute care needs being adequately
addressed?
• Is the US prepared for the increasing
number of people with chronic conditions?
• How could the health care system be
changed to better meet the needs of the
growing numbers of people with chronic
medical conditions?
 Changing Burden of Disease
• There are many different ways to measure
burden of disease (level of health in
population)
– Deaths
– Premature deaths (% who die before age 70)
– Disabilities
– DALYs (combine of deaths and disabilities)

• The measurement can affect which

diseases have the highest burden of
disease
– E.g. depression kills few people but impairs many
 Measuring burden of disease
1. Death
2. Premature death (less than 70)
3. DALYs that include disabilities and
restricted abilities
Changing Burden of Disease

–1900-1950 Infectious Diseases

–1950-2000 Acute Care
–2000-2050 Chronic Care
Where should the US focus its efforts?

1. Infectious diseases (AIDS, TB, etc)

2. Acute illnesses ( heart attacks, trauma)
3. Chronic diseases (diabetes, COPD)
 Where should the world focus its efforts?

1. Infectious diseases (AIDS, TB, etc)

2. Acute illnesses ( heart attacks, trauma)
3. Chronic diseases (diabetes, COPD)
 Acute Care System
• There are three major policy concerns with
the current system which remains focused
on acute care
– Cost
– Access
– Quality
 Committee of Five
• The AMA established a committee in 1926 designed to
“investigate and attempt to solve the organizational
problems leading to the rising level of spending for medical
care”.
• Two of the five members were from Hopkins
• If only they had solved the problem!

Winford H. Smith Lewellys F. Barker

Director of Johns Hopkins Johns Hopkins Medical
Hospital School
Johns Hopkins Hospital: Cost per Day

Fiscal Average Cost Per

Year Adjusted Patient Day
1930 7
1940 12
1950 16
1960 40
1970 114
1980 342
1990 911
2000 2,059
2010 3,482
 Who has reasonable access to
medical care?
1. All people living in the US
2. All American citizens
3. Only those with health insurance
4. Only those with health insurance living in
affluent areas
5. No one
 Some of the factors associated with
reasonable access to necessary care
– Adequate insurance coverage
– Income
– Transportation
– Availability of health professionals in the area
– Literacy about health needs
– Discrimination
– Quality of the health care provider
 Access - Survey of Girls in Grades 9- 12
Why didn’t they seek medical care?

• 41% - did not want to tell parents

• 36% - cost too much
• 25% - no time
• 11% - no transportation
 Percent of girls grades 9-12
too embarrassed to discuss certain
medical problems with their doctor

• 35% - all girls

• 51% - girls with depression
• 55% - girls with physical or sexual abuse
 Quality of Care
• Inadequate care following a heart attack
leads to 18,000 unnecessary deaths each
year
• Over half of all adults over age 50 do not
get the recommended tests for colorectal
cancer
• Only about half the time do patients get
the recommended care
 Improving Patient Safety and
Quality of Care
• There are a series of initiatives to make
people safer when they enter the hospital
– check list
• There are a series of initiatives to make
sure that people get the recommended
care
 What needs to be done to
improve quality of care
1. Pay for performance (paying doctors
more if they meet certain targets)
2. More NIH practice guidelines(helping
doctors determine what needs to be
done)
3. Checklists (having physicians go through
a procedure before undertaking a
procedure)
4. More incentives for patients to comply
The UN General Assembly had a summit in
September 2011 addressing chronic
conditions

“Cancer, diabetes, and heart

diseases are no longer the
diseases of the wealthy. Today,
they hamper the people and the
economies of the poorest
populations even more than
infectious diseases. This
represents a public health
emergency in slow motion.”

- UN Secretary Ban Ki-Moon

 Defining Chronic Conditions

• Lasts - or is expected to last - a year

or longer
• Limits what one can do
• Requires ongoing care
 Projected global deaths, selected causes

Source: http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf
 Leading causes of burden of
disease, 2004 and 2030

Source: http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf
 In US the number of people with chronic
conditions is increasing rapidly
• In 2000, 125 million Americans had Number of People With Chronic Conditions (in millions)

one or more chronic conditions.

• This number is projected to increase
by more than one percent each year
through 2030.
• Between 2000 and 2030 the number
of Americans with chronic conditions
will increase by 37 percent, an
increase of 46 million people.

Source: Wu, Shin-Yi and Green, Anthony. Projection of Chronic Illness

Prevalence and Cost Inflation. RAND Corporation, October 2000.
 In US, more than 60% of health care spending is on
behalf of people with multiple chronic conditions
Percentage of Health Care Total Spending by Number of
Half of the population with no Chronic Conditions
chronic conditions represent
only 16 percent of health care
spending.

Source: Medical Expenditure Panel Survey, 2006

 Generally Children Have
a Single Chronic Condition

Upper Respiratory Disease 64 31 5

Asthma 60 34 5

Preadult Disorders 65 26 7

Eye disorders 70 19 8

Disorders of Teeth and Jaw 65 31 4

Single Condition
0% 20% 40% 60% 80% 100%
Condition+1

Condition+2

Partnership for Solutions

 Most Adults Have Multiple
Chronic Conditions

Hypertension 30 29 18 11 13

Upper Respiratory Disease 46 26 14 7 8

Mental Conditions 30 30 16 11 13

Chronic Respiratory Infection 42 28 14 8 7

Arthritis 26 25 20 13 16
Single Condition

0% 20% 40% 60% 80% 100%

Condition+1
Condition+2
Condition+3
Condition+4+

Partnership for Solutions

 Only a Few Seniors Have
One Chronic Condition
Hypertension 17 24 23 20 16

Arthritis 11 22 23 22 21

Heart Disease 10 21 25 24 19

Eye Disorders 9 23 25 22 19

Diabetes Mellitus 8 22 21 21 27

Single Condition 0% 20% 40% 60% 80% 100%

Condition+1
Condition+2
Condition+3
Condition+4+

Partnership for Solutions

Reforms Necessary To Improve Care
For People With Chronic Conditions

Biomedical Medical
Research Education
Health System
Changes

Financing
and Quality
Delivery Metrics
Systems

Partnership for Solutions

 Begins With Creating an
Evidence Base
• Often physicians will pick up a journal with
the results from a clinical trial that could be
useful to their patient and then see that
their patient would have been excluded
from the clinical trial?

• What should the physician do?

 What would you do?
Assume you read something in a clinical journal
that showed a better way to treat a patient but
your patient would have been excluded from the
clinical trial
1. I would ignore the results because the patient
would have been excluded from the study
2. I would follow the recommendation because it is
new and good science
3. I would follow the recommendation under certain
circumstances
 Creating an evidence base for people with multiple
chronic conditions
• Most research on chronic disease
focuses on individual chronic diseases Among the elderly
and not people with multiple chronic population only 4
conditions. percent of type 2
• Researchers are often encouraged to diabetics only have
focus on a single disease such as diabetes
AIDS or breast cancer.
• However, few people with a chronic
disease have only one chronic
disease.
 Problem - Randomized clinical trials often
exclude people with multiple chronic conditions

• Most randomized clinical trials (RCTs) often exclude the elderly and
people with multiple chronic conditions from participating

81% RCTs 39% RCTs 54% RCTs

exclude exclude exclude
people with older adults people
common taking other
conditions medication

LEADS TO A LACK OF EVIDENCE BASE FOR

PEOPLE WITH MULTIPLE CHRONIC CONDITIONS
 Physician Concerns

% physicians who feel well prepared to treat people with multiple

chronic conditions

AUS AUS AUS AUS AUS AUS AUS

AUS
69%
CAN
69%
GER
69%
NL
69%
NZ
69%
UK
69%
US
69%
69% 55% 93% 75% 67% 76% 68%

Source: Schoen et al Health Affairs, 2006

 Medical education continues to have a single
disease approach

• Most clinical instruction is

carried out by teacher-
researchers with expertise in
one particular disease
• Medical education tends to
have a “body part by body
part” orientation instead of an
integrated approach.

 Educational systems should make sure that they are focused on

better care for people with multiple chronic conditions.
Medical Education
• “It is much more important to know
what sort of patient has a disease
than what sort of disease a patient
has”
William Osler, founder of Johns
Hopkins medical and public health
schools
Number of Unique Doctors Increases with the
Number of Chronic Conditions the Patient Has
15.0

13.0
Amount of Services Utilized

10.0

7.8

6.0
4.8
5.0
3.7

1.6

0.0
0.0 1.0 2.0 3.0 4.0 5+
Number of Chronic Conditions
 Greater Focus on Care Coordination

Nursing Home
Home Care

Specialist Inter- Hospital

disciplinary
Team

Lab/X- Patient
Ray Primary
Care
 Components of Person Centered Care

• Needs assessment
• Interdisciplinary team to
consider social and medical
aspects of persons needs
including psychological,
mental and physical factors
Payment systems are being updated to reflect the
needs of people with chronic conditions

• A payment system oriented around acute illness tends to pay

providers using fee-for-service.
• Each activity receives a separate payment.
• Shift should be to payment based on outcomes not inputs – focus on
multiple chronic conditions
• Challenge for pay for performance systems is that most outcome
measures are single disease focused
 Some Proposed Delivery
System Solutions
• Patient centered medical home
• Pay for care coordination
• Quality measures that emphasize care
coordination
• Electronic medical records
 What To Do
• What changes are needed over the next
10 years to make health care more
responsive to the needs of people with
chronic conditions?