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Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?

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Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different? Barbara Starfield, MD, MPH Bellagio, Italy April 2008 08 Bellagio chronic care ... – PowerPoint PPT presentation

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Title: Chronic Care, Chronic Disease Care, and Primary Care: One and the Same, or Different?


1
Chronic Care, Chronic Disease Care, and Primary
Care One and the Same, or Different?
  • Barbara Starfield, MD, MPH
  • Bellagio, Italy
  • April 2008

2
The purpose of this presentation is to explore
the concepts of disease and chronic disease
and to show why a more appropriate focus is on a
continuum of care (primary care) for all people
and populations rather than on care for targeted
diseases.
Starfield 03/08 D 3978
3
The IOM report, Crossing the Quality Chasm, urges
selecting priority conditions for attention to
the quality of care. The list from which they
should be chosen includes cancer, diabetes,
emphysema, high cholesterol, HIV/AIDS,
hypertension, ischemic heart disease, stroke, and
perhaps also arthritis, asthma, gall bladder
disease, stomach ulcers, back problems,
Alzheimers, depression, anxiety disorders.
Why arent undernutrition, occupational diseases,
osteoporosis, low birth weight and prematurity,
or virtually any childhood disorder (except
asthma) considered high priority? Who should
decide what a priority disease is? The disease
experts?
Starfield 02/08 D 3948
4
Diseases
  • are professional constructs
  • can be and are artificially created to suit
    special interests the sum of deaths attributed
    to diseases exceeds the number of deaths
  • do not exist in isolation from other diseases and
    are, therefore, not an independent representation
    of illness
  • are but one manifestation of ill health

Sources Chin. The AIDS Pandemic the Collision
of Epidemiology with Political Correctness.
Radcliffe Publishing, 2007. De Maeseneer et al.
Primary Health Care as a Strategy for Achieving
Equitable Care a Literature Review Commissioned
by the Health Systems Knowledge Network. WHO
Health Systems Knowledge Network, 2007. Available
at http//www.wits.ac.za/chp/kn/De20Maeseneer20
200720PHC20as20strategy.pdf. Mangin et al, BMJ
2007 335285-7. Murray et al, BMJ 2004
3291096-1100. Tinetti Fried, Am J Med 2004
116179-85. Walker et al, Lancet 2007 369956-63.
Starfield 08/07 D 3831
5
Are diseases really discrete categorizations of
pathology?
Starfield 03/08 D 3979
6
There appear to be many disorders included under
the rubric of diabetes insulin secretion
insulin transport zinc-binding to insulin and
pancreatic islet beta cell development.
IS DIABETES A DISEASE? DOES IT MAKE SENSE TO
ASSUME THAT GUIDELINES FOR THE IDENTIFICATION AND
MANAGEMENT OF DIABETES APPLY TO ALL DIABETICS?
Starfield 03/08 D 3980
Source Topol et al, JAMA 2007 298218-21.
7
In a relatively small-scale study, diabetics who
have weight loss are five times more likely to
have their diabetes disappear than diabetics who
have standard diabetes care.
Questions  Is diabetes a chronic disease? Is
it a disease?
Starfield 02/08 D 3940
Source Dixon et al, JAMA 2008 299316-23.
8
If the association between obesity and diabetes
is absent in people with low concentrations of
persistent organic pollutants, and the
association becomes stronger as the concentration
of these pollutants rises, is obesity a risk
factor for diabetes? Is diabetes a single
disease?
Starfield 02/08 D 3944
Source Jones et al, Lancet 2008 371287-8.
9
If three diabetics per one thousand per year die
from the implementation of supposedly
evidence-based treatment, is diabetes a single
disease?
Source Kolata G. Diabetes study partially halted
after deaths. Seattle, WA University of
Washington press release, February 2, 2008.
Starfield 02/08 D 3946
10
There is broad variation in breast cancer risk
among carriers of BRCA1 and BRCA2 mutations.
Question Is BRCA1 and BRCA2-related breast
cancer a disease?
Source Begg CB, Haile RW, Borg A et al.
Variation of breast cancer risk among BRCA1/2
carriers. JAMA 2008 299(2)194-201.
Starfield 02/08 D 3939
11
If a 90-year-old woman dies two months following
hip fracture, did she die from an acute disease
or a chronic disease?
What is the cause of death likely to be coded
as?
Starfield 02/08 D 3943
12
If oral contraceptives are protective on
epithelial and non-epithelial cervical cancer but
not on mucinous cervical cancer, is cervical
cancer a single disease?
Starfield 02/08 D 3945
Source Franco Duarte-Franco, Lancet 2008
371277-8.
13
COPD is a chronic systemic inflammatory syndrome
with complex chronic co-morbidities. Patients
with COPD mainly die of non-respiratory disorders
such as cardiovascular disease or cancer.
  • COPD is a heterogeneous disease process.

Although exacerbations of COPD, especially those
defined as being infectious, are quite frequent,
the number of randomized placebo-controlled
trials of antibiotics is surprisingly small.
Starfield 10/07 D 3907
Sources Fabbri Rabe, Lancet 2007 370797-9.
Calverley Rennard, Lancet 2007 370774-85.
14
When occurring in the same individual, BMI
greater than 30, systolic blood pressure greater
than 140, and blood cholesterol greater that 250
mg/dL are associated with a six-fold increased
odds of Alzheimers disease.
What type of disease is Alzheimers? What is the
disease?
Starfield 03/08 D 3981
Source Michel et al, JAMA 2008 299688-90.
15
Hypothyroidism is three times more likely in
women with rheumatoid arthritis than in the
general population. Women with both conditions
have a fourfold higher risk of cardiovascular
disease than euthyroid women with arthritis,
independent of conventional risk factors.
Inflammation and autoimmunity are implicated in
vulnerability to a wide variety of chronic
diseases and they may well be acute.
Starfield 03/08 D 3982
Source Raterman et al, Ann Rheum Dis 2008
67229-32.
16
What Is a Chronic Disease?
Generally defined as persistence or recurrence,
usually beyond one year
Starfield 10/06 D 3459
17
Chronic Disease Expanded Definition
  • Incurable
  • Complex causation
  • Multiple risk factors
  • Long latency
  • Prolonged course
  • Associated with functional impairment or
    disability

Starfield 05/07 D 3710
Source Australian Institute of Health and
Welfare. Indicators for Chronic Diseases and
Their Determinants, 2008. Canberra, Australia
AIHW, 2008.
18
How chronic are chronic diseases?
Starfield 10/07 D 3888
19
Persistence of Diagnoses
per 1000, not adjusted for age
Starfield 04/02 02-067
Starfield 09/07 D 3860 n
20
Persistence of Diagnoses
per 1000, not adjusted for age
Starfield 04/02 02-066
Starfield 09/07 D 3861 n
21
Persistence of Diagnoses
per 1000, not adjusted for age
Starfield 04/02 02-065
Starfield 09/07 D 3862 n
22
Not all chronic diseases are manifested year to
year.
Acute diseases sometimes behave as if they were
chronic, recurring year to year. Only a minority
of common chronic diseases or conditions are
currently candidates for the vast majority of
chronic disease management programs. Acute and
chronic conditions share a characteristic
inflammation.
Starfield 08/06 D 3435
23
People and populations differ in their overall
vulnerability and resistance to threats to
health. Some have more than their share of
illness, and some have less. Morbidity mix
(sometimes called case-mix) describes this
clustering of ill health in patients and
populations.
Starfield 03/06 CM 3372
24
Influences on the Health of Individuals
PHYSIOLOGICAL STATE MATERIAL RESOURCES SOCI
AL RESOURCES BEHAVIORS CHRONIC STRESS HEA
LTH SERVICES RECEIVED
OCCUPATIONAL ENVIRONMENTAL EXPOSURES
SOCIODEMOGRAPHIC CHARACTERISTICS
DEVELOPMENTAL HEALTH DISADVANTAGE
WEALTH LEVEL DISTRIBUTION
POLITICAL AND POLICY CONTEXT
HEALTH
POWER RELATIONSHIPS
BEHAVIORAL CULTURAL CHARACTERISTICS
GENETIC BIOLOGICAL CHARACTERISTICS
HEALTH SYSTEM CHARACTERISTICS
Health has two aspects occurrence
(incidence) and intensity (severity).
Including income inequality
For influences at the community level, there is a
spectrum from those that are aggregations from
individual-level data to those that are
ecological in nature.
Starfield 04/07 IH 3637
Source Starfield, Soc Sci Med 2007 641355-62.
25
Influences on Health Equity
ENVIRONMENTAL CHARACTERISTICS
OCCUPATIONAL ENVIRONMENTAL POLICY
WEALTH LEVEL DISTRIBUTION
HISTORICAL HEALTH DISADVANTAGE
SOCIAL POLICY ECONOMIC POLICY
POWER RELATIONSHIPS
POLITICAL CONTEXT
BEHAVIORAL CULTURAL CHARACTERISTICS
HEALTH POLICY
DEMOGRAPHIC STRUCTURE
HEALTH SYSTEM CHARACTERISTICS
Dashed lines indicate the existence of pathways
through individual-level characteristics that
most proximally influence health. For influences
at the community level, there is a spectrum from
those that are aggregations from individual-level
data to those that are ecological in nature.
Health has two aspects occurrence
(incidence) and intensity (severity).
Including income inequality
Starfield 04/07 IH 3638
Including social cohesion
Source Starfield, Soc Sci Med 2007 641355-62.
26
IH 3789 n
Starfield 07/07 IH 3789 n
27
Etiologic Heterogeneity
of different conventional risk factors
Starfield 03/08 IH 3983
Source Australian Institute of Health and
Welfare. Indicators for Chronic Diseases and
Their Determinants, 2008. Canberra, Australia
AIHW, 2008.
28
Pleiotropism
of specific diseases associated with selected
risk factors
Starfield 03/08 IH 3984
Source Australian Institute of Health and
Welfare. Indicators for Chronic Diseases and
Their Determinants, 2008. Canberra, Australia
AIHW, 2008.
29
There is more variability in disease
manifestations and persistence within diseases
than across diseases because
  • diseases are not necessarily unique
    pathophysiological entities
  • variability in diagnostic styles and practices
  • presence of co-morbidity

Starfield 10/01 D 3887
30
Co- and Multi-morbidity (Morbidity Burden)
Starfield 09/07 CM 3864 n
31
Co-morbidity is the concurrent existence of one
or more unrelated conditions in an individual
with any given condition. Multi-morbidity is the
co-occurrence of biologically unrelated illnesses.
For convenience and by common terminology, we use
co-morbidity to represent both co- and
multi-morbidity.
Starfield 03/06 CM 3375
32
Distribution of Morbidity in a Non-Elderly
Insured Population 1 Year Experience (US)
Starfield 09/00 00-058
Starfield 09/07 CM 3865 n
Source HMO health plan with 500K members.
33
Morbidity Burdens of Socially Disadvantaged and
Socially Advantaged People
Starfield 09/07 CM 3866 n
34
The high frequency of
Co-morbidity Multi-morbidity Morbidity
burden makes it inappropriate to focus on single
diseases
Starfield 03/08 CM 3985
35
Co-morbidity, Inpatient Hospitalization,
Avoidable Events, and Costs
Source Wolff et al, Arch Intern Med 2002
1622269-76.
Starfield 11/06 CM 3503 n
ages 65, chronic conditions only
36
The greater the morbidity burden, the greater the
persistence of any given diagnosis.
That is, with high co-morbidity, even acute
diseases are more likely to persist.
Starfield 08/06 CM 3439
37
Odds Ratios and Confidence Intervals for
Persistence by Degree of Co-morbidity Urinary
Tract Infection
Starfield 10/03 03-346
Starfield 09/07 D 3863 n
C Statistic .633
controlled for age and sex
38
Expected Resource Use (Relative to Adult
Population Average) by Level of Co-Morbidity,
British Columbia, 1997-98
Thus, it is co-morbidity, rather than presence or
impact of chronic conditions, that generates
resource use.
Starfield 09/07 CM 3867 n
Source Broemeling et al. Chronic Conditions and
Co-morbidity among Residents of British Columbia.
Vancouver, BC University of British Columbia,
2005.
39
Increase in Treated Prevalence Selected
Conditions, US, People with Private Insurance,
1987-2002
  • Treated Prevalence
  • Percentage Change, 1987-2002
  • Hyperlipidemia 437
  • (Heart disease 9)
  • Bone disorders 227
  • Upper GI problems 169
  • Cerebrovascular disease 161
  • Mental problems 136
  • Diabetes 64
  • Endocrine disorders 24
  • Hypertension 17
  • Bronchitis 13

Starfield 09/06 D 3858
Source Thorp et al, Health Affairs 2005
W5317-25, 2005.
40
As thresholds for diagnosing disease are lowered
over time, the variability within diseases will
increase even further, as will the prevalence of
multiple simultaneous or sequential diseases.
Starfield 03/08 D 3986
41
What is needed is person-focused care over time,
NOT disease-focused care.
Starfield 10/06 PC 3462
42
Top Ten Health Conditions and Impact on Costs
Starfield 03/08 D 3994
Source Loeppke et al, J Occup Environ Med 2007
49712-21.
43
When people (not diseases) are the focus of
attention
  • Outcomes are better
  • Side effects are fewer
  • Costs are lower
  • Population health is greater

Starfield 09/07 PC 3868 n
Source Starfield et al, Health Aff 2005
W597-107.
44
What Is the Appropriate Care Model?
  • Primary care that meets primary care (not
    disease-specific) standards
  • Specialty referrals that are appropriate, i.e.,
    evidence-based
  • Specialty care that meets specialty care
    standards

exist do not exist
Starfield 03/06 PC 3377
45
Primary care works because it has defined
functions that include structural and process
features of health services that are known to
improve outcomes of care.
Starfield 03/08 PC 3987
46
The Health Services System
Source Starfield. Primary Care Balancing Health
Needs, Services, and Technology. Oxford U. Press,
1998.
Starfield 1997 97-103
Starfield 1997 HS 1064
47
Primary Care
Starfield 02/08 EVAL 3968
48
Structural and Process Elements of the Essential
Features of Primary Care
Essential Features
Performance
Capacity
First-contact
Utilization Person-focused relationship
Accessibility Eligible population Range of
services Continuity
Longitudinality
Comprehensiveness
Problem recognition
Coordination
Starfield 1997 97-194
Starfield 04/97 EVAL 1108
49
Primary Care Oriented Health Services Systems
Personnel Facilities and equipment Range of
services Organization Management and
amenities Continuity/information
systems Accessibility Financing Population
eligible Governance
CAPACITY
Cultural and behavioral characteristics
Provision of care
Problem recognition Diagnosis Management Reassessm
ent
PERFORMANCE
People/practitioner interface
Receipt of care
Utilization Acceptance and satisfaction Understand
ing Concordance
Social, political, economic, and physical
environments
HEALTH STATUS (outcome)
Longevity Comfort Perceived well-being Morbidity
burden Achievement Risks Resilience
Biologic endowment and prior health
Source Starfield. Primary Care Balancing Health
Needs, Services, and Technology. Oxford U. Press,
1998.
Starfield 10/07 HS 3890
50
There is no formal quality assessment approach
that includes the critical feature of
problem-recognition, despite the evidence that
patients are more likely to improve when they and
their practitioner agree on what their problem is.
Starfield 03/08 Q 3988
Sources Starfield et al, JAMA 1979 242344-46.
Starfield et al, Am J Public Health 1981
71127-31.
51
Is chronic care management the same as or
pursuant to primary care?
  • Person-focused?
  • Contributory to at least one of the four main
    features of primary care?

Starfield 03/08 CM 3989
52
Is CCM part of primary care or separate from it?
  • If the need for it is uncommon (as the data
    suggest), it is a referral function.
  • If the need for it is common, it is a way of
    enhancing some important and heretofore neglected
    element of care, possibly problem recognition.

Question What critical process of care is served
by CCM? Problem recognition? If not, what?
Starfield 03/08 CM 3990
53
Of all global deaths in 2005, 60 were because of
chronic diseases, principally cardiovascular
diseases (32), cancers (13), and chronic
respiratory diseases (7). Data such as these are
used to argue that chronic diseases are of
growing and epidemic importance as causes of
death.
Question What is the appropriate target for the
percentage of deaths in the world that are
attributable to chronic diseases? Isnt there a
case to be made that perhaps ALL deaths should be
due to chronic diseases, with acute illnesses
falling towards zero percentage?
Starfield 02/08 D 3949
Source Beaglehole et al, Lancet 2007
3702152-7.
54
Deaths may be attributed to chronic diseases, but
people still get sick from acute diseases and
acute exacerbations.
Any enhancement of primary care has to deal with
this reality.
Starfield 03/08 D 3991
55
The global imperative is to organize health
systems around strong, patient-centered, i.e.,
Primary Care.
A disease-oriented approach to global health will
almost certainly worsen global inequities. Those
exposed to a variety of interacting influences
are vulnerable to many diseases. Eliminating
diseases one by one will not materially reduce
the chances of another.
Starfield 03/08 GH 3992
56
(No Transcript)
57
It appears that there may be only a few types
of  medical problems, based on most predominant
etiology
  • Infectious
  • External injury
  • Developmental/physical abnormality
  • Mendelian dominant genetic
  • Autoimmune
  • Cellular degradation/degeneration

Question If this is true or even only partly
true, is the International Classification of
Diseases a useful schema for classifying health
problems? Might there be one that lends itself
better to understanding etiology for the purpose
of more effective prevention and treatment?
Starfield 02/08 D 3941
58
The Impact of Seeing Many Different Physicians
Controlling for morbidity burden
  • More DIFFERENT specialists seen higher total
    costs, medical costs, diagnostic tests and
    interventions, and types of medication
  • More DIFFERENT generalists seen higher total
    costs, medical costs, diagnostic tests and
    interventions
  • More generalists seen (LESS CONTINUITY) more
    DIFFERENT specialists seen. The effect is
    independent of the number of generalist visits.

Using the Johns Hopkins Adjusted Clinical Groups
(ACGs) Source Starfield et al, Ambulatory
specialist use by patients in US health plans
correlates and consequences. Submitted 2008.
Starfield 09/07 CMOS 3854
59
There are methods, e.g., the Johns Hopkins
Adjusted Clinical Groups, for categorizing
patients and populations according to their
burden of diagnosed illness.
Starfield 10/06 CM 3460
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