Titolo della Presentazione: 32pt Arial, Grassetto, Nero Lunghezza massima consigliata: 2 linee...

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Direzione Generale

Diritti di cittadinanza e Coesione sociale

• Nome dell’Autore e/o collaborazioni: 18pt Arial,

Grigio R150 | G150 | B150 Lunghezza massima : 1 line

Pisa, 13 June 2011

WORKSHOPRegional strategies to improve efficacy and equity while

guaranteeing economic sustainability

Proactive strategies in primary care: the Tuscan Experience

[email protected]@ars.toscana.it

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• Titolo della Slide:28pt Arial, Grassetto,

Rossso R 240 | G0 | B0 Lunghezza massima consigliata: 2 linee

• Corpo della slide:20pt Arial, Nero

• Punti elenco: Quadrato, color Rosso

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Si consigliano non più di 7 punti in elenco

Direzione Generale

Diritto alla Salute e Politiche di Solidarietà

a) Primary Health Care and the CCM-based program in Tuscan Region

b) Impact on quality of care and health care costs: preliminary results for diabetes

c) Future perspectives

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Direzione Generale


a) Primary Health Care and the CCM-based program in Tuscan Region

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The Tuscan Healthcare System: some data

• 3,7 millions inhabitants

• 6.300 millions € for healthcare spending in 2009:5% prevention43% hospitals services52% primary care

• 17 Public Health Authorities: 12 Local Health Authorities and 5 Teaching Hospitals organized in three Network “Area Vasta”:

• North West Area Vasta: 2 T.H. and 5 L.H.A.• Center Area Vasta: 2 T.H. and 4 L.H.A.• South East Area Vasta: 1 T.H. and 3 L.H.A.

• 51.000 employees• 2.940 GPs• 14.000 public and private hospital beds (3,8 per 1.000 inhabitants)

[2009]

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Epidemiology of Chronic Diseases in Tuscany

0

10

20

30

40

50

60

70

Men

Women

Number of diagnosed cases for each of the 5 “CCM chronic diseases” per 1,000 residents 16 + according to administrative data; hypertension limited to exempted cases (MaCro system)

The Aging Population

2025

2005

Population >64 years

- Tuscany 23,3%

- Italy 19,9%

Tuscany Population Pyramid

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Direzione Generale


Chronic diseases

From the last quarter of the 20° century: fourth stage of epidemiological transition

Aging population and reduction of the

mortality due to CV acute event

Increase of the chronic diseases

prevalence

The management of the increasing chronic diseases prevalence is one of the most important healthcare problems to deal with.

(Tuscany Strategic Health Plan PSR 2008-2010, p. 34)

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From traditional healthcare to proactive healthcare

Traditional healthcare:

The healthcare system acts only when the chronic patient worsens becoming acute.

Proactive healthcare:

The patient’s needs are taken into account before the disease worsening and possibly before disease onset, getting better

health conditions for the population, addressing equity

issue too.

Chronic diseases are not well treated and prevention as well as risk factors are not taken into account.

Health inequities are not taken into account

The healthcare system is able to manage chronic

diseases and to be effective in facing the acute diseases onset.

Where Tuscany wants to invest?

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Which model to drive the change: the Expanded Chronic Care Model (CCM)

Expanded Chronic Care Model: main strategy of the Regional Health

Plan new delivery System design focused

on multi-professional care team new role of nurses in self

management support; decision support through shared

clinical pathways; investment on integrated information

system community resources exploitation Focus on prevention and health

determinants (community oriented primary care)

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Quality indicators for GPs Incentives based contract - Diabetes

Indicators Target

Records

The practice produce a register of patients winth type 2 diabetes (target prevalence)

>4%

Ongoing Management

The percentage of patients with diabetes who have a record

of HbA1c in the previous 12 months>70%

The percentage of patients with diabetes whose notes record

waistline in the previous 24 months>70%

The percentage of patients with diabetes who are involved

with self management support programs >70%

The percentage of patients with diabetes who have been trained for self monitoring of blood glucose concentrations

>50%

The percentage of patients with diabetes in whom HbA1c is <7 and they don’t assume antidiabetic drugs

>20%

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GPs and other health professionals operators (nurses, medical assistant …) organized in practice (6-16 GPs) to care for chronic patients with a proactive approach (Chronic Care Model)

Pilot phaseJanuary 2010

11 Healthcare• 56 practice• 497 GPs•112 Nurses• 618.969 Patients

MITO project– 1 Healthcare• 4 policlinics• 166 GPs• 175.000 Patients

Extention phaseOctober 2010

Other groups are expected to be involved • 31 practice• 301 GPs• 62 Nurses• 337.213 Patients

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Clinical register

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Diabetes prevalence rate at practice level

0,0%

1,0%

2,0%

3,0%

4,0%

5,0%

6,0%

7,0%

8,0%

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Regional Prevalence

4,9%

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Direzione Generale


b) Impact on quality of care and health care costs: preliminary results for diabetes

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Study objectives

To evaluate the effect of the CCM-based program being implemented in Tuscany on

a) quality of care in terms of process indicators

b) per capita health care costs

in patients with diabetes (and hearth failure)

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Study design

A pre-post comparison-group study

Groups and observation periods (data available up to end 2010):

1/1/2009 1/7/2009 31/12/2009

Start of program1/7/2010 31/12/2010

process indicators (one year)

& care cost per capita for selected services

(one semester)

Prevalent at 1.1.09

Prevalent at 1.1.10

Patients of CCM – GPs

Patients of No CCM - GPs

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Data sources

Data sources: the Tuscan longitudinal record-linkage system “MaCro” (Chronic Diseases) of inhabitants registry, exemptions, specialist care, drug dispensing and hospital discharge records (administrative data)

through which:

a) cohorts of residents with specific diseases can be identified and

b) levels of adherence to clinical recommendations can be calculated

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Study area and populations

Prevalent at 1.1.2009: A total of 139,267 patients 16+ with diabetes of

which:26,276 enrolled with the 394 GPs implementing

CCM (intervention group)112,991 enrolled with the 1,875 GPs not

implementing CCM (control group)

Prevalent at 1.1.2010: A total of 142,489 patients 16+ with diabetes of

which:27,149 enrolled with the 394 GPs implementing

CCM (intervention group)121,110 enrolled with the 1,875 GPs not

implementing CCM (control group)

Age (68% over 65) and sex distributions (50% women) of the four groups were quite similar

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Principal outcomes

a) Process Indicators

% of patients with at least one assessment of HbA1c % of patients with at least one assessment of micro-albuminuria % of patients with at least one assessment of creatininemia % of patients with at least one assessment of lipids % of patients with at least one assessment by an ophthalmologistduring the twelve-month periods of observation

b) Care cost per capita (selected services)

per capita cost for diabetes specialist care per capita cost for eye specialist care per capita cost for specific laboratory diagnostic proceduresduring the six-month periods of observation

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a) process indicators (lab tests)

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40

50

60

70

80

90

100

Ag

e-st

anda

rdiz

ed p

erce

ntag

e

200

9

201

0

Years

CCM No CCM

glycated hemoglobin testing

0

10

20

30

40

50

60

70

80

90

100

Ag

e-st

anda

rdiz

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erce

ntag

e

200

9

201

0

Years

CCM No CCM

creatinine

0

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60

70

80

90

100

Ag

e-st

anda

rdiz

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erce

ntag

e

200

9

201

0

Years

CCM No CCM

microalbuminuria

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50

60

70

80

90

100

Ag

e-st

anda

rdiz

ed p

erce

ntag

e

200

9

201

0

Years

CCM No CCM

lipid profile

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Direzione Generale


a) process indicators (eye specialist care)

0

10

20

30

40

50

60

70

80

90

100A

ge-

stan

dard

ized

per

cent

age

200

9

201

0

Years

CCM No CCM

oculistic visit

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b) per capita cost of selected health care services – 2° semester (I)

per capita cost of eye specialist care

per capita cost of specific lab tests

15,0

17,0

19,0

21,0

23,0

25,0

27,0

29,0

2009 2010

noCCM CCM

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

2009 2010

noCCM CCM

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b) per capita cost of selected health services – 2° semester (II)

per capita cost of diabetes specialist care

2,0

3,0

4,0

5,0

6,0

7,0

8,0

2009 2010

noCCM CCM

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Summarizing

In patients with diabetes enrolled with CCM-GPs, compared with patients with diabetes enrolled with no-CCM-GPs:

a) quality of care in terms of pure process indicators has improved

b) per capita cost of eye specialist care and lab tests have increased

c) per capita cost of diabetes specialist care has decreased

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And equity ?

Data from LHA of Arezzo on 1,494 patients with diabetes enrolled with CCM – GPs, of whom 90 (6 %) defined as “deprived”: tenants paying a rent and/or referring economic difficulties

Preliminary results

HbA1c

40

50

60

70

80

90

100

2009 2010

%

Deprived

Not deprived

Micro-albuminuria

20

30

40

50

60

70

80

90

100

2009 2010

%

Deprived

Not deprived

Lipids

20

30

40

50

60

70

80

90

100

2009 2010

%

Deprived

Not deprived

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c) Future perspectives

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What next? What we know…

“… Disease-oriented medicine…through a focus on particular chronic diseases and their management is thus highly inequitable” (Starfield, The hidden inequity in health care. IJEqH 2011) “… it is neither necessary nor desirable to try to introduce

the whole model at once. It is most effective to focus on one highly important change at a time (Kriendler, Lifting the burden of chronic disease: What’s worked, what hasn’t, what next. 2008) “… High-performing organizations more often used

computerized reminders (clinical information systems), guidelines supported by clinician education or computer support (decision support), formal self-management programs (self-management support), and a registry (clinical information systems) … smaller practices would have greater difficulty implementing the CCM and improving outcomes. (Health Affairs 28, no. 1- 2009: 75–85)

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What next? What we should do …

Practice need to be more supported by the clinical information systems for implementing proactive approach and promoting clinical and equity audit We need to review the clinical pathways, most focusing on risk (eg. Cardiovascular) and not on specific disease We have to introduce formal and more standardized self management support programs aiming to an actual proactive patient and focusing attention on individual determinants of health We should change deeply the service delivery design strenghtening the integration between primary care and specialsitic services in the community

Our CCM-based program is intended as a transitional phase towards person-focused care since it shifts chronic diseases management to primary health care

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Thanks for your attention

[email protected]@ars.toscana.it

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