La gestión de los cuidados a enfermos crónicos: experiencias en EEUU Caring for people with chronic illness: lessons from the United States Thomas Bodenheimer, MD Professor, Department of Family & Community Medicine University of California, San Francisco, USA
% of People in US with a Chronic Illness 45% 57% 1 Chronic Illness 43% 2 or more chronic illnesses Hoffman et al, JAMA 1996;276:1473 56 million people Spain: 47 million
Per capita health expenditures, 2008 OECD, 2010 9% of GDP 16% of GDP
Average per capita spending by number of chronic conditions (2004) Anderson, “Chronic conditions” Johns Hopkins, 2007
If the US is spending so much, we must be doing a great job
27% of discharged CHF patients are readmitted within 30 days [Jencks et al. NEJM 2009;360:1418]
35% of eligible atrial fibrillation patients failed to receive warfarin [Piccini et al. Am J Coll Cardiol 2009;54:1280]
Only 15% of smokers are offered assistance to quit [Unrod et al. JGIM 2007;22:478]
Adult primary care shortage: 40,000 physicians by 2020
Average primary care panel: 2300
Primary care physician with panel of 2500 average patients would spend 7.4 hours per day doing recommended preventive care [Yarnall,Am J Pub Health 2003;93:635]
Primary care physician with panel of 2500 average patients would spend 10.6 hours per day doing recommended chronic care [Ostbye et al. Annals of Fam Med 2005;3:209]
Primary care with US panel sizes is an impossible job
Yet great energy and dedication to save and improve primary care
Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model
Registries: lists of patients your practice is responsible for
Includes clinical information
Date of last A1c, LDL, blood pressure, eye exam, foot exam, microalbumin,
Results of A1c, LDL, blood pressure, etc.
What patient education was done?
Does patient have a goal and plan to achieve that goal?
Cochrane review of 5 trials: registries that identify diabetic patients at risk and bring those patients into care demonstrate reduced HbA1c levels compared with usual care. [Griffin, Kinmouth. Cochrane Library, Issue 3, 2003]
Teamlets with trained medical assistant health coaches paired with family physicians significantly improved smoking and BMI (body mass index) documentation, more behavior-change action plans done, and more LDL testing compared with comparison group
Teamlet patients had better A1c, LDL, blood pressure vs. comparison group but not quite statistically significant