19th COCHRANE COLLOQUIUM
Sustainable Evidence-Based Health
Care in Times of Crisis
Madrid October 19-22 . 2011
Rafael Bengoa | Regional Minister for Health and Consumer Affairs
Basque Government. Spain
Evolution of diabetes and cardiovascular disease in
the Basque Country%
This challenge of this epidemic is going much faster
than our reaction to it.
1992
2002
1997
4,5 - 6,0
6,1 - 7,5
7,5 - 9,0
9,1 - 10,5
2007
10,6 - 12,0
2
Massive Demand…
Medical consultations/capita. Europe. 2003
3
9.5
10
8
5.9
6
4
2.5
2
0
Gre Sue Por Fin UK
Pb Ita Lux Irl Aus Fra Ale Din Bel Esp
European Countries
Ecosalud. OCDE 2005.
Fragmentation
4
THIS IS THE RESULT ACROSS THE CONTINUUM ! 5
6
Primary
Prevention
Early
Management
Acute
Management
Rehabilitati
on
&
secondary
prevention
7
“ Having everything under the same
roof does not guarantee clinical
integration nor a tidy operation
across the disease continuum” R. Bengoa
Primary
Prevention
Early
Management
CEO
U1
Acute
Management
U2
U3
Rehabilitati
on
&
secondary
prevention
8
Primary
Prevention
Downstream
Early
Management
Acute
Management
Rehabilitati
on
&
secondary
prevention
Upstream
“ Both downstream and upstream interventions are vital for the final population
outcome in the control of a disease. It is sterile to continue opposing these two
approaches. They are two sides of the same coin.
What we need is an integrated approach across the continuum balancing public
health interventions and health service interventions and the local organization to
operationalise this as a system on the ground “ R. Bengoa
MESSAGE IS CLEAR :
Most countries are improving in each of the boxes of
the continuum but not using the potential of an
integrated approach across the continuum.
One of the reasons for this is that we do not have a
“system” operating at the local level
9
10
THAT FRAGMENTATION
CANNOT PROVIDE
A SUSTAINIBLE HEALTH SYSTEM
Tools for Integration Help to move towards a
“System” Perspective
risk stratification…
case nurses…
routine clinical reminders…
continuum of care…
activated patient…
regular telemonitoring……
11
12
13
¿WHAT ARE WE TRYING TO DO ?
TRYING TO FIT IN SOME OF THOSE
MANAGEMENT PROCESSES IN ….
Using frameworks/models
14
Some sort of structured patient education:
both direct and remote
PATIENT EDUCATION
REMOTE PATIENT
EDUCATION
15
With some sort of case manager
• Nurses who act a case
managers for patients with
complex conditions.
• Their function will be to
evaluate their physical and
social needs and coordinate
their care.
16
Telecare /Telemedicine ++++
Diabetic retinopathy
17
18
What results are some
organizations getting?
Is the Evidence Growing?
Community Care North Carolina (CCNC)
Health programme for:
– Low-income adults and their children and dishabilities (880.000 habitants)
– 3000 physicians
Objective:
– Improve the quality, cost, accesibility and utilisation of services for Medicaid recipients
Methods to promote integration:
–
–
–
–
–
Locally adapted clinical guidelines
Case management services
Financial incentives
Data review and analysis
Feedback on clinical practice
Source: http://www.communitycarenc.org/our-results/
19
Integrated cardiovascular care…
20
...is leading to reductions in heart attacks and strokes.
Stoke-related Hospitalization
Rates in No. Cal.
ST Elevated MIs in No. Cal.
1998-2007
2,0
1,8
Age and sex adjusted rate per 1,000
1,9
Age and sex adjusted rate per 1,000
1998-2007
2,0
1,8
1,7
1,6
1,5
1,4
1,3
1,2
1,1
1,0
98
19
99
19
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
1,6
1,4
1,2
1,0
0,8
0,6
0,4
98
19
99
19
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
KP Northern California ALL program, PHASE, results.
17
21
VA Continues to Exceed HEDIS in 2008
INDICATOR
Commercial
2007
Medicare
2007
Medicaid
2007
VA 2008
VA 2007
Breast cancer screening
87%
86%
69%
67%
50%
Cervical cancer screening
92%
91%
82%
n/a
65%
Colorectal cancer screening
79%
78%
56%
50%
n/a
LDL Cholesterol < 100 after AMI, PTCA, CABG
66%
62%
59%
56%
38%
Diabetes: DM control HbA1c < 9.0%
84%
84%
71%
71%
52%
Diabetes: LDL-C<100
68%
64%
44%
47%
31%
Diabetes: Eye Exam
86%
85%
55%
63%
50%
Diabetes: Renal Exam
93%
91%
81%
86%
74%
Diabetes: BP < 140/90
78%
77%
64%
59%
56%
Hypertension: BP < 140/90
75%
76%
62%
58%
53%
Smoking Cessation Counseling (3)
89%
83%
76%
n/a
70%
Smoking : Medications offered(3)
84%
n/a
51%
n/a
39%
Smoking: Referral/strategies (3)
92%
n/a
48%
n/a
39%
Immunizations: influenza
84%
72%
49%
72%
Immunizations: pneumococcal
94%
90%
n/a
67%
Why ? Because the Evidence is Increasing
•
Estimated $3.7 million net savings for a ROI of > 2 to 1
Geisinger Proven Health Navigator Model
•
30% decrease in hospitalizations for asthma and 11% lower ER visits
UK Tornbay
•
29% reduction in ER visits; 11% reduction in ambulatory care sensitive admissions versus
control sites
Puget Sound
•
10% relative reduction in hospitalizations and even greater among those with chronic
illnesses.
Intermountain Health Care
SUSTAINIBILITY ?
22
Building some sort of Local Health “System”
Aim : LINK several lines of work which tend to operate separately

BETTER CARE FOR INDIVIDUALS ( IOM )

BETTER POPULATION HEALTH

LOWER GROWTH IN EXPENDITURE BY ELIMINATING INEFFICIENCIES.
TACTICAL APPROACH

make the link between clinical behaviour and financial consequences for clinical
decisions

Incentive if savings made
 Pathways as a tool to make that link
23
Mid-term policy perspective/ trend
DIFFERENT COUNTRIES/SYSTEMS MOVING IN THE SAME DIRECTION
 FOCUSING ON TRANSFORMATION OF DELIVERY
 CONTEXT : SOME PROMOTING COMPETITION ; OTHERS NOT.
 SHIFTING FROM VOLUME AND INPUTS TO VALUE
 LEANING ON MODELS: KP AND CCM AND OTHERS
 MANY BUILDING SOME SORT OF LOCAL HEALTH “SYSTEM”
24
Trend Taking Shape In Normative Policy Interventions

USA. Section 3022 of the Affordable Care Act (ACA) establishes
the Medicare Shared Savings Program for Accountable Care
Organizations .

England: The White Paper ‘Equity and Excellence:
Liberating the NHS’

New Public Health Law . Basque Country . Spain.

Wales , New Zealand…..
25
26
How are we moving forward in the
Basque Country ?
Objective:
Simultaneously Managing Crisis &
Transformative Change
27
Short term strategy
Long term strategy
Crisis management
Reforming Delivery
Drugs: Brand to Generic
Human Resources: Salaries
Chronic Diseases Agenda
Tecnologies: Desinvestment…
Integrated Care
SUSTAINIBILITY?
Create a narrative/ a common language ….
28
 PROVIDE A NARRATIVE THAT GOES BEYOND “COST CONTAINMENT”
 A NARRATIVE WICH PROVIDE A VISION AND STRUCTURE
 PROVIDES DIRECTION AND STABILITY
IN A CRISIS ENVIROMENT
 THE HARDER THE EXTERNAL ENVIROMENT IS, THE GREATER THE
COHESION CAN THE COMMON VISION PROVIDE
IN THE BASQUE COUNTRY = THE MAIN
NARRATIVE IS “CHRONIC DISEASES”
AND CLINICAL INTEGRATION
R. Bengoa
Launch interventions in a coherent package:
29
Many levers simultaneously
2
1
Estratificación
Estratificación operativa
de la población vasca de
forma sistematizada y
periódica desde 2011
Prevención y Promoción
Prevención de aparición y
desarrollo de
enfermedades crónicas
(De_Plan, prevención
tabáquica)
3
Autocuidado
Experiencias en las
principales enfermedades
crónicas, potenciando la
adherencia y el uso
apropiado de los recursos
4
Historia Clínica
unificada
Implantación
universal a finales
de 2011
Atención clínica
integrada
Un tercio de las
organizaciones a 2013,
con procesos integrados
5
14
Innovación desde los
profesionales Generación de
15-25 proyectos de innovación al
año y extensión de los que
demuestren resultados (~90%)
6 Competencias Avanzadas
Enfermería
Formar a 300 enfermeras en
los nuevos roles hasta 2013
13
Centro Investigación
Cronicidad
Ser un referente internacional
en el conocimiento sobre
enfermedades crónicas
7 Colaboración sociosanitaria
4 municipios con
funcionamiento integrado, 1
hospital con plan de altas con
prevención de dependencia, 1
unidad de ortogeriatría
12 Modelo hospitales subagudos
Implantación del modelo en
hospitales de media estancia y
creación de nuevo hospital de
crónicos en Álava
11 Experiencias de
telemonitorización
Monitorización a distancia del 1%
de enfermos crónicos severos
(~22.500)
8
10 Receta electrónica
Implantación efectiva del
sistema de receta electrónica
en todo Euskadi en 2012 –
2013
9
Centro Servicios Multicanal
Despliegue en Euskadi de
todos los servicios para
mediados de 2013
Financiación y Contratación
Implantación plena de un
sistema de asignación
financiera
territorial ajustada
por riesgo
R. Bengoa
Examples: bottom up Organizational Innovation
30
DIFFERENT MODELS OF INTEGRATED CARE ORGANISATIONS (systems)
Integrated organizational structure
Osi Bidasoa
Non Integrated organizational
structure
H. Basurto- C-Bilbao-H. Santa marina
Basurto
Sta. Marina
•85.000 habitants
•First integrated organizational
structure (hospital and primary care
center)
•384.000 habitants
•24 primary care centers
•1 acute hospital
•1 medium and long term hospital
This Should Look Better At The Next LSN Meeting!!!!
31
32
Evidence increasing around a few things…
• Different diseases , similar needs and similar solutions
• Much of the evidence sends clear signals in favor of integrated care
• To pull this off you need patients and staff on board.
• It is therefore less about structural moves than about staff
engagement
• Evidence growing but scalability still an issue
SCALABILITY…
33
THE PROCESS WILL NOT DEVELOP IN A TIDY
SEQUENCE OF LINEAR STEPS.
INSTEAD IT WILL PROLIFERATE VIA GROUPS
OF INNOVATIVE IDEAS BY DIFFERENT
ORGANIZATIONAL UNITS.
Van de Ven 1999
THOSE INNOVATIVE IDEAS BY DIFFERENT ORGANIZATIONAL
UNITS MUST BE SUBJECTED TO THE EVIDENCE TEST
34
Thank you
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Diapositiva 1 - Cochrane Collaboration