Innovative practices for complex chronic disease

management: prevention and health promotion

Richard SmithDirector, UnitedHealth Chronic

Disease InitiativeGranada Form, June 2010

Agenda

• UnitedHealth/NHLBI centres of excellence to counter chronic disease

• Grand Challenges in Chronic Disease• Conceptual difficulties in prevention and

health promotion in complex chronic disease

• Three stages of prevention• Examples of innovation at each level• Conclusions

Deaths from chronic disease are displacing deaths from infectious disease even in rural Bangladesh

11 UnitedHealth and NHLBI Collaborating Centres of Excellence to counter chronic disease

National Heart, Lung, and Blood Institute

• Part of the National Institutes of Health, the largest funders of health research in the world

• NIH mission :Acquire new knowledge that will lead to better health for everyone

– Support research

– Train young investigators

– Communicate research results to the medical community and the public

• NHLBI mission: Conducts and supports basic research, clinical investigations and trials, observational studies, demonstration and education projects related to the causes, prevention, diagnosis, and treatment of heart, blood vessel, lung, and blood diseases; and sleep disorders.

• Annual budget: Over $3 billion

NHLBI Global Health Initiative

• Has created an Office of Global Health

• Is guiding the Global Alliance for Chronic Disease

• Commissioned an Institute of Medicine report on global cardiovascular disease

• Has committed $35m in cash to its nine centres. Much of it funding complex interventions (mostly RCTs)

• Now making more funds available

• Other institutes at NIH may follow; Fogarty already does a lot

UnitedHealth Group• UnitedHealth Group (UHG) is a health and wellbeing company with

a wide range of competencies, including co-ordination of health care and information technology

• $90 billion revenue; buys health care for 70m people; 70 000 staff; operates in 40 countries—but mostly US

• A third of the business is organising health care for governments—mostly Medicare and Medicaid programmes in the US; also working with the NHS in Britain

• Has committed $15m in cash and kind to the creation of the centres

• Wants not simply to fund centres but to work in partnership withthem

Patients with five or more chronic conditions account for two thirds of Medicare spending

Multiple chronic conditions leads to an increase in unnecessary admissions to hospital

What do we hope to achieve?• Raise the importance of chronic disease control and prevention

globally and regionally

• Eventually reduce morbidity and premature mortality from chronicdisease

• Increase the number of individuals, institutions, and communities equipped to counter chronic disease

• Develop and spread equitable programmes for preventing and countering chronic disease

• Create, develop, and sustain a global network for research into countering chronic disease

• Build constructive partnerships and avoid reinventing the wheel

• Ensure that the whole is more than the sum of the parts

What are the centres doing?• A very wide range of activities, including:

– Surveillance

– Community interventions through schools, workplaces, health services, government, and the media

– Develop tools for estimating risk in low income countries

– Guidelines for use by non-doctors

– Programmes with community health workers

– Primary prevention strategies in primary care, including using the polypill

– Secondary prevention studies

– Disease management

– Policy development

– Advocacy

– Training and education

Goals of the Grand Challenges

• A. Raise public awareness• B. Enhance economic, legal, and

environmental policies• C. Modify risk factors• D. Engage businesses and community• E. Mitigate health impacts of poverty and

urbanisation• F. Reorientate health systems

Conceptual difficulties in prevention and health promotion in complex chronic disease

• Little evidence specifically on prevention in those with complex chronic disease

• Programmes should be patient not disease centred and driven by the values of the patient—for example, does it make sense to encourage a patient near the end of life to stop smoking?

• Prevention and “disease management” merge in those with complex chronic disease

Four levels of prevention• Primordial prevention--creating economic, environmental and

social conditions that are conducive to health and that minimise the likelihood of developing disease.

• Primary prevention-- addressing specific causal factors, like tobacco use, poor diet and physical inactivity in the case of chronic disease, in order to reduce the chances of people developing disease.

• Secondary prevention--targeting people with a disease which is established but usually at an early stage in order to limit the exacerbation of the disease and the development of complications.

• Tertiary prevention— working with patients with well-established disease to minimise suffering and complications.

Causes of chronic diseases

What should be the priorities?

• Social determinants• Risk factors, particularly tobacco control

and hypertension (salt reduction)• Improve health systems

Framework Convention on Tobacco Control

• Only treaty negotiated by WHO• Comprehensive strategy

– Price and tax strategies to reduce demand– Non-price strategies to reduce demand– Strategies to reduce supply

• Most countries have signed• Could we have something similar for other

risk factors?

Primary prevention of chronic disease in individuals

Polypill concept• Five pills in one (statin, three anti-hypertensives

at half dose, folate acid, NOT ASPIRIN)• Everybody takes from age 55• Reduce heart attacks and stroke by 50-80%• Costs $1 a month; several pills available in India• Evidence that pill will reduce lipids and blood

pressure• No primary care RCT; one about to begin in

India

A “disruptive” technology: objections

• Says medical model of “diagnose and treat” doesn’t work: “tailoring” of drugs better than

• May encourage unhealthy lifestyles• Destroys lucrative drug markets• Medicalisation

Why remote patient management transforms chronic care

Early intervention – constant monitoring

• Integration of care – exchange of data and communication across multiple co-morbidities, multiple providers, and complex disease states

• Coaching – techniques to encourage patient behavioral change and self-care

• Trust

• Workforce – shift to lower levels of healthcare workers, including medical assistants, community health workers and social workers for much of the interaction with the patient

• Productivity – more effective use of provider time at each level of worker

BUT……• None of these can be accomplished by merely connecting a sensing

device in the home.

• All of them require substantial reorganization of systems of care, and financing that rewards discontinuous leaps forward in performance.

• That’s why these innovations take some 17 years on average to

implement

Conclusions• Most of the work (and cost) of health systems is now

related to chronic disease, particularly complex chronic disease

• The world has mostly not woken up this new reality• It needs to wake up, and many changes will be needed,

including a real shift towards prevention of chronic disease and health promotion

• There are innovative ideas at all levels of prevention of complex chronic disease

• Health systems are usually very slow to implement these ideas—but they need to do so, particularly with the increasing unsustainability of current systems