Dr Anthony Cummins

Chronic disease management

Senior Cycle 1 General Practice
With grateful acknowledgements to Professor David Whitford RCSI Bahrain & Professor Susan Smith RCSI Dublin
1
2 Format of module





2
1 Chronic disease management
2 Format
3 Initial questions
4 Ageing, chronic disease & polypharmacy
5 Frailty & concerns of chronic disease patients
6 What are the chronic diseases?
7 Diseases likely to be chronic
8 Models of development of chronic disease
9 Life course model
10 Common factors in chronic diseases
11 Why do we need chronic disease management?
12 Disease burden
13 Premature mortality
14 Population projections
15 What is multimorbidity?
16 Multimorbidity worldwide
17 Is multimorbidity the new thing?
18 Challenges to multimorbidity
19 Multimorbidity in Ireland
20 Impact of multimorbidity
21 Treatment burden
22 What should chronic disease management include?
Requirements of a chronic disease management programme 23
Where should they be managed and by whom 1? 24
Where should they be managed and by whom 2? 25
Collaborative care: the patients & the GPs perspectives 26
The patient-professional relationship 27
Outcome impact of collaborative care for depression 28
Chronic disease: the patients perspective 1 29
Chronic disease: the patients perspective 2 30
Chronic disease: the doctors perspective 31
What are expert patients & expert patient programmes? 32
Expert patients 33
Expert patient programmes 34
Expert patient programmes UK 35
Effective chronic disease self-management 36
Chronic disease programmes planned for Ireland 37
Tackling chronic disease HSE policy framework 38
HSE/ ICGP Primary Care Clinical Care Programme 39
Is chronic disease management more effective than current practice? 40
Impact of UK coronary disease projects 41
A systematic review of chronic disease management 42-43
Improving attendance at chronic disease management clinics 44
Key points & references 45-46
3 Initial questions





3
What is chronic disease management?
Which are the chronic diseases we need to manage?
What characterises chronic diseases from other, acute, diseases?
Why do we need chronic disease management systems?
What is multimorbidity?
What should a chronic disease management programme include?
Where & who should manage chronic diseases?
Collaborative care: what are the patients and the doctors perspectives?
What are expert patients and expert patient programmes?
Which chronic disease management programmes are planned in Ireland?
Do chronic disease management systems work better than current practice?
4 Ageing, chronic disease & polypharmacy
4
5 Frailty and concerns of chronic disease patients
6




What are the common chronic diseases?
6
7 Diseases that are likely to be chronic in duration
7
RA: rheumatoid arthritis
OA: osteoarthritis
IBD: inflammatory bowel disease
AF: atrial fibrillation
COPD: chronic obstructive
pulmonary disease
8




Models of development/ risk of development of
chronic diseases
8
9 A life course approach
A life course
approach to chronic
disease is the study
of long-term effects
on chronic disease
risk of certain
factors e.g. physical
& social exposures
during gestation,
childhood,
adolescence, young
adulthood and later
adult life to
influence the
development of
chronic diseases.
The example here is
of COPD but it can
be applied to many
chronic diseases.
Ben-Shlomo Y , Kuh D Int. J. Epidemiol. 2002;31:285-293
10 Common factors in chronic diseases
Time

Doesnt resolve

Living with a chronic disease affects

i. Individual
ii. Family
iii. Society
iv. Tax payer

Amenable to further intervention

Psychological impact

Multimorbidity

Benefit from team approach rather than individual approach

Identification of important co-morbidity
10
Burden
Direct impact
Quality of Life
(Identified) co-morbidities
Adverse drug
events
11




Why do we need chronic disease management
systems?
11
12 The worldwide burden of chronic disease
12
*DALY: Disability Adjusted Life Year
12
It has been estimated that non-
communicable diseases account for
almost 40% of deaths in developing
countries and 75% in industrialised
countries. Strong evidence that the
expertise of patients could be harnessed
to play a part in addressing the challenge
of this shifting burden of disease came
from Professor Kate Lorig and her
colleagues at Stanford University,
California. She started to develop and
evaluate programmes for people with
arthritis and side stepped the traditional
model of professionals educating patients.
By means of a more radical and innovative
solution, using trained lay leaders as
educators, she equipped people with
arthritis and other chronic diseases with
the skills to manage their own condition.
She found that, compared with other
patients, expert patients could improve
their self-rated health status, cope better
with fatigue and other generic features of
chronic disease such as role limitation, and
reduce disability and their dependence on
hospital care.
13
13 13
14
14 14
15





What is multimorbidity?
15
16 Multimorbidity worldwide
Multimorbidity is commonly defined as the co-existence of two or more chronic
conditions in an individual. It is a highly prevalent phenomenon in old age and of
growing public health impact in ageing societies. Multimorbidity is common and
nowadays represents the norm in clinical practice.

Providing care to patients with multiple chronic conditions is complex and poses a
significant challenge to clinicians and healthcare planners.

It is strongly linked to ageing and deprivation.

A UK study sampled 99,997 people aged 18 years or over registered with 182 general
practices and found a prevalence rate of 58%.

Multimorbidity patients accounted for 78% of all GP consultations.

65% of > 1 million Medicare beneficiaries had multiple chronic conditions.
16
17 Is multimorbidity the new thing?
18 years ago this paper appeared in the Journal of Clinical Epidemiology

With the increasing number of elderly people in The Netherlands the prevalence of
chronic diseases will rise in the next decades. It is recognized in general practice that
many older patients suffer from more than one chronic disease (comorbidity). The aim
of this study is to describe the extent of comorbidity for the following diseases:
hypertension, chronic ischemic heart disease, diabetes mellitus, chronic nonspecific
lung disease, osteoarthritis. In a general practice population of 23,534 persons, 1989
patients have been identified with one or more chronic diseases. Only diseases in
agreement with diagnostic criteria were included. In persons of 65 and older 23%
suffer from one or more of the chronic diseases under study. Within this group 15%
suffer from more than one of the chronic diseases. Osteoarthritis and diabetes
mellitus are the diseases with the highest rate of comorbidity. Comorbidity restricts
the external validity of results from single-disease intervention studies and
complicates the organization of care
Comorbidity of chronic diseases in general practice
F.G. Schellevis

J. van der Velden
3
, E. van de Lisdonk
2
, J.Th.M. van Eijk
1
, C. van Weel
2

Journal of Clinical Epidemiology Volume 46, Issue 5, May 1993, Pages 469-473
17
18 Challenges to multimorbidity
Definition
There is no consensus yet as to which health conditions should be considered and how exactly
they should be assessed, summarized and weighted in order to arrive at some overall measure
of burden of illness. Apart from quantitative aspects, the type and patterns of concurrent
morbidities will matter with respect to treatment options and prognosis.
Measuring the impact of multimorbidity
Many of the health complaints in old age are chronically progressive and interact with each
other. Therefore concepts such as 'cure, more commonly used with single disease entities,
arent appropriate. Instead, the focus should be on functional measures, such as critical
exhaustion of specific body functions (often termed as 'frailty'), functional disability in daily life,
and social participation as well as on subjective measures, such as quality of life (QoL),
particularly health-related quality of life (HQoL) and self-determination (autonomy).
Patient complexity
The relationship between multimorbidity and outcomes may be impacted on by a number of
factors. These can be divided into internal (health-related knowledge, beliefs, competences, and
proactive behaviour ) and external (perceived social support, living conditions, and quality of
health care).
18
OMAHA study: BMC Health Serv Res. 2011; 11: 47. Published online 2011 February 25. doi: 10.1186/1472-6963-11-47
19 Multimorbidity in Ireland
A recent primary care based study examined a sample of 3309 patients aged > 50 yrs.

The prevalence of multimorbidity was 66.2% rising to 81.6% in those > 65.

11% of patients had 4 chronic conditions.

78% of patients who were eligible for free medical care had multimorbidity

This contrasted with 52% in those not eligible for a medical card.

This emphasises the association between multimorbidity and deprivation.

Further community based research in an Irish setting has identified multimorbidity in
60% of patients with chronic respiratory disease and 91% of opiate misusers in an Irish
general practice setting

19
20 Impact of multimorbidity
Multimorbidity is associated with:

i. Increased psychological distress

ii. Decreased quality of life especially HQoL

iii. Increased number of hospital admissions

iv. Increased length of hospital stay

v. Functional decline (frailty)

vi. Polypharmacy (+ increased adverse drug events & drug interactions)
20
21 Treatment burden
The concept of treatment burden for patients includes:

i. Adhering to treatments and lifestyle changes
ii. Learning about treatments and their consequences
iii. Engaging with healthcare professionals.
21
Multimorbidity is also associated with increased mortality..

This has been demonstrated in two European studies:

A large (n=2285) community-based study involving elderly men in three countries
which found significantly increased ten year mortality risk in patients with two or more
chronic conditions.

The second, a Dutch study (n=2141) involving community-dwelling people aged
between 65 and 85 found an increased three year mortality in the multimorbidity
group
22





What should chronic disease management include?
22
23
23
Early
diagnosis
Symptom
relief
Secondary
prevention
Education
Psychological
support
Empowerment
Structured care
Chronic disease management programme elements
24




Where should chronic disease management
programmes occur and who should do provide
them?
24
25 Where should it occur? Who should provide it?
Primary care
Secondary care
Self-care
Shared care
Tertiary care
25
26





Collaborative care:
the patients and the GPs perspectives
26
27 The patient-professional relationship
Review your module on the consultation showing the Calgary Cambridge model
27
28 Collaborative care for patients with depression
28
29 Chronic disease: the patients perspective 1
29
30 Chronic disease: the patients perspective 2
30
31 Chronic disease: the GPs perspective
31
32





What are expert patients & expert patient
programmes?
32
33 Expert patients
33
34 Expert patient programmes
34
35 Expert patient programmes UK
35
36
36
37





Which chronic disease programmes are planned here
in Ireland?
37
38 Irelands planned programmes
38
39 Irelands planned programmes
39
40




Do chronic disease management systems
work better than current practice?
40
41 Impact of coronary heart disease projects UK
41
42 Chronic disease management: a systematic review
42
43 Chronic disease management: a systematic review
43
44 Chronic disease: how to improve attendances
44
45
Key Points
45
46 References
1 Chronic disease management in primary care: quality & outcomes
Ed. Gill Wakley & Ruth Chambers Radcliffe Publishing 2005
2 Lorig KR, Sobel DS, Stewart AL, et al; Evidence suggesting that a chronic disease self-
management program can improve health status while reducing hospitalization: a
randomized trial. Med Care. 1999 Jan;37(1):5-14.
3 Expert patients http://www.patient.co.uk/doctor/Expert-Patients.htm
4 Quality & Outcomes Framework 1 http://www.nice.org.uk/aboutnice/qof/qof.jsp#What
5 Quality and outcomes framework 2
http://www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/QOF/Pa
ges/QualityOutcomesFramework.aspx
46