Innovative practices for
 complex chronic disease
management: prevention and
     health promotion
             Richard Sm...
Agenda
• UnitedHealth/NHLBI centres of excellence
  to counter chronic disease
• Grand Challenges in Chronic Disease
• Con...
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 fu...
NHLBI Global Health Initiative

• Has created an Office of Global Health
• Is guiding the Global Alliance for Chronic Dise...
UnitedHealth Group
•   UnitedHealth Group (UHG) is a health and wellbeing company with
    a wide range of competencies, i...
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
• E...
What are the centres doing?
•   A very wide range of activities, including:
     – Surveillance
     – Community intervent...
Goals of the Grand Challenges
• A. Raise public awareness
• B. Enhance economic, legal, and
  environmental policies
• C. ...
Conceptual difficulties in prevention and health
   promotion in complex chronic disease

• Little evidence specifically o...
Four levels of prevention
•   Primordial prevention--creating economic, environmental and
    social conditions that are c...
Causes of chronic diseases
What should be the priorities?
• Social determinants
• Risk factors, particularly tobacco control
  and hypertension (salt...
Framework Convention on
        Tobacco Control
• Only treaty negotiated by WHO
• Comprehensive strategy
  – Price and tax...
Primary prevention of chronic
    disease in individuals
Polypill concept
• Five pills in one (statin, three anti-hypertensives
  at half dose, folate acid, NOT ASPIRIN)
• Everybo...
A “disruptive” technology: objections

• Says medical model of “diagnose and
  treat” doesn’t work: “tailoring” of drugs
 ...
Why remote patient management transforms chronic care

  Early intervention – constant monitoring

• Integration of care –...
BUT……
•   None of these can be accomplished by merely connecting a sensing
    device in the home.

•   All of them requir...
Conclusions
• Most of the work (and cost) of health systems is now
  related to chronic disease, particularly complex chro...
Foro calidad OPIMEC Richard Smith
Foro calidad OPIMEC Richard Smith
Foro calidad OPIMEC Richard Smith
Foro calidad OPIMEC Richard Smith
Foro calidad OPIMEC Richard Smith
Foro calidad OPIMEC Richard Smith
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Foro calidad OPIMEC Richard Smith

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Foro calidad OPIMEC Richard Smith

  1. 1. Innovative practices for complex chronic disease management: prevention and health promotion Richard Smith Director, UnitedHealth Chronic Disease Initiative Granada Form, June 2010
  2. 2. 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
  3. 3. Deaths from chronic disease are displacing deaths from infectious disease even in rural Bangladesh
  4. 4. 11 UnitedHealth and NHLBI Collaborating Centres of Excellence to counter chronic disease
  5. 5. 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
  6. 6. 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
  7. 7. 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 with them
  8. 8. Patients with five or more chronic conditions account for two thirds of Medicare spending
  9. 9. Multiple chronic conditions leads to an increase in unnecessary admissions to hospital
  10. 10. 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 chronic disease • 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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.
  15. 15. Causes of chronic diseases
  16. 16. What should be the priorities? • Social determinants • Risk factors, particularly tobacco control and hypertension (salt reduction) • Improve health systems
  17. 17. 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?
  18. 18. Primary prevention of chronic disease in individuals
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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

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