Beverley Rowbotham - AMA - Using Pathology Testing to Control the Chronic Disease Epidemic
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Beverley Rowbotham - AMA - Using Pathology Testing to Control the Chronic Disease Epidemic

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Beverley Rowbotham, Director of Haematology Sullivan Nicolaides Pathology Brisbane, Clinical Lead Pathology, National eHealth Transition Authority, Federal Councillor AMA, Past President Royal......

Beverley Rowbotham, Director of Haematology Sullivan Nicolaides Pathology Brisbane, Clinical Lead Pathology, National eHealth Transition Authority, Federal Councillor AMA, Past President Royal College of Pathologists of Australasia presented "Using Pathology Testing to Control the Chronic Disease Epidemic" at the National Pathology Forum 2013.

This annual conference provides a platform for the public and private sectors to come together and discuss all the latest issues affecting the pathology sector in Australia. For more information, please visit the conference website: http://www.informa.com.au/pathologyforum

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  • 1. Using pathology testing to control the chronic disease epidemic Beverley Rowbotham
  • 2. “At the present time, one person is dying of diabetes every seven seconds, but the news can only talk about victims of hurricanes with house flying through the air.” Nassin Taleb “ Antifragile:things that gain from disaster” 2012 Global type 2 diabetes market $28B. This is expected to double by 2022.
  • 3. G Anderson and E Chu NEJM 2007:356:209-211
  • 4. Life expectancy at birth in top 20 OECD countries: 2005 Japan Switzerland Iceland Australia Spain Sweden Italy France Canada2 Norway New Zealand Austria Ireland Netherlands Greece Luxembourg Germany United Kingdom Finland Belgium Korea 82.1 81.3 81.2 80.9 80.7 80.6 80.4 80.3 80.2 80.1 79.6 79.5 However Indigenous Australians have an 79.4 average life expectancy of 79.4 59.4 for men and 64.8 for 79.3 women1 79.3 79.0 For more on Indigenous health and 79.0 disadvantage, see The Future of Indigenous Australia 78.9 78.7 78.5 0 2 76 78 80 82 Life expectancy at birth (years) 1. 2001 data 2. 2004 data Note: Ireland, Italy and Luxembourg excluded from 2004 OECD life expectancy data Source: OECD, Health Data 2005; Productivity Commission, Overcoming Indigenous Disadvantage (2007) "Strategic Areas For Action"
  • 5. Annual national burden of disease for top 10 disease groups in Australia: 2003 Mental illness is a significant issue Cancers1 Cardiovascular disease • In 2004-5, 11% of persons selfreported a current long-term mental health or behavioural problem. This is a reported increase of 5.9% since 20014 Mental illness Nervous system • A 1997 survey into the mental health and wellbeing of Australian adults found that 18% of all people suffered some degree of mental disorder in the previous 12 months Chronic respiratory Injuries2 Diabetes • Of persons with a mental-health related disability, 45% report severe core-activity limitations, 29% moderate limitations, and 59% work or schooling restrictions Musculoskeletal Genitourinary Digestive system 0 Years of life lost (YLL) Years lost to disability (YLD) 100,000 200,000 300,000 400,000 500,000 Burden of disease (DALYs3) 1. Includes malignant and other neoplasms 2. Includes intentional and unintentional injuries 3. Disease Adjusted Life Years (years lost through death by disease, and years lost to disability by disease) 4. Mental health data is complex. Increased self-reporting rates may be due to greater willingness to report, rather than increased prevalence Source: AIHW, The Burden of Disease and Injury in Australia 2003 (2007); ABS 4824.0.55.001, Mental Health in Australia: A Snapshot 2004-5 (2006)
  • 6. By 2036, it is projected that one quarter of Australians will be over 65 Acute care expenditure rises sharply from 60 onwards Australian population by age bracket: 1976-2036 Hospital expenditure per capita by age group: 2002/3 Population by age bracket (#) 30,000,000 Hospital expenditure per capita ($) 6,000 % population by age bracket 1976 2006 2036 25,000,000 20,000,000 <25 25-44 44 27 33 29 27 25 45-64 65+ 20 9 25 13 25 24 5,000 65+ One major contributor to high cost of treatment in older years is the use of expensive technology 4,000 45-64 15,000,000 3,000 25-44 10,000,000 5,000,000 Males Females 2,000 1,000 <25 85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 2036 5-9 0 2006 0-4 0 1976 Note: Population projections based on Series B growth assumptions Source: ABS 3222.0, Population Projections, Australia, 2004-2101 (2006); ABS 3201.0, Population by Age and Sex, Australian States and Territories (2006); Productivity Commission, Economic Implications of an Ageing Australia (2005)
  • 7. National health expenditure, by area of expenditure – Australia: 2005/6 ($ per capita) 261 121 93 4,224 315 259 148 Non-government 754 694 Public/community health represents just over 6% of total expenditure 1,579 Government Hospitals Pharmaceuticals, aids and appliances Medical services Dental services Other health Capital Public and practitioners expenditure/ community tax health Admin Research Total 1. Includes Commonwealth, State and local governments 2. Includes private health insurance funds, injury compensation insurers, and private individuals 3. Includes public and private hospitals and patient transportation Source: AIHW, National health expenditure 2005-6 (AIHW data cube)
  • 8.    Australia: AIHW Chronic disease key indicators database and reports WHO 2012: Target 25% reduction in premature mortality from non communicable disease by 2025. Global Alliance for Chronic Disease (includes Australia): Research target for 2014: type 2 diabetes in low and middle income countries, vulnerable populations in high income countries and indigenous populations in Canada and Australia.
  • 9.  Traditional: diagnosis, monitoring, treatment selection, prognostics  Novel uses  Disruptive health solution.
  • 10. Pathology testing in Australia In 2010 – 2011, just over half of Australians had a pathology test This is the second most common medical consultation ( 85% of Australians will see a GP in a year) Almost half of MBS pathology claims were made by 7% of Australians 14% of Australians made MBS claims for more than 10 pathology tests Source: Australian Government Department of Health and Aging
  • 11. BEACH 2009-2010
  • 12. The rise of cholesterol testing: how much is unnecessary? Doll et all BJGP 2011
  • 13. Medicare Payments - An Index of Medicare Benefits Paid From January 2000 to December 2010 (3 month moving averages) & percentage growth over this period All benefits include EMSN payments, GP benefits also include bulk billing incentive payments 3.000 All others 172% Medical Cost Inflation ! 2.500 GPs 141% DI 112% 2.000 Path 94% AWE 66% 1.500 CPI 40% 1.000 Jan-00 Ed Wilson Jan-01 Jan-02 Jan-03 Jan-04 Jan-05 Jan-06 Jan-07 Jan-08 Jan-09 Jan-10 Ed Wilson EW Consulting P/L EW Consulting P/L
  • 14. Medicare Payments - An Index of Benefits per Service From January 2000 to December 2010 & percentage growth over this period All benefits include EMSN payments, GP benefits also include bulk billing incentive payments 2.00 1.90 GPs 92% 1.80 AWE 66% 1.70 1.60 All others 62% 1.50 CPI 40% 1.40 1.30 DI 33% 1.20 1.10 Path 4% 1.00 0.90 Jan-00 Jan-01 Jan-02 Jan-03 Jan-04 Jan-05 Jan-06 Jan-07 Jan-08 Jan-09 Jan-10 Ed Wilson EW Consulting P/L
  • 15. Item 65070 65090 66536 66500-15 66551 66560 66593 66650 69475 71075 71097 71106 Description FBE/FBC blood grouping HDL simple chemistries HbA1c microalbumin ferritin tumour markers Hep. X1 IGE ANAs Rheumatoid Factor Percentage coned out 45 to 55 55 to 75 70 to 80 10 to 40 40 to 65 10 to 25 25 to 45 20 to 50 20 to 45 25 to 50 25 to 40 75 to 90 percent percent percent percent percent percent percent percent percent percent percent percent
  • 16. Pathology as a percentage of Medicare Outlays January 2000 to date three month moving average 18% 17% 16% 15% 14% 13% 12% 11% 10% Patholgy: Currently 12.8% of Medicare outlays
  • 17. National health expenditure, by area of expenditure – Australia: 2005/6 ($ per capita) 261 121 93 4,224 315 259 148 Non-government 754 694 Public/community health represents just over 6% of total expenditure 1,579 Government Hospitals Pharmaceuticals, aids and appliances Medical services Dental services Other health Capital Public and practitioners expenditure/ community tax health Admin Research Total 1. Includes Commonwealth, State and local governments 2. Includes private health insurance funds, injury compensation insurers, and private individuals 3. Includes public and private hospitals and patient transportation Source: AIHW, National health expenditure 2005-6 (AIHW data cube)
  • 18. Cavian et al, Mckinseys
  • 19.   BEACH 2009-10 Audit of pathology requesting -diagnosis purpose monitoring Primary prevention 40% 40% Patient request 10% 10% - appropriateness guidelines for disease e.g. diabetes(72%) obesity(24%) - adequacy of management Type 2 diabetes HBA1c 43% >7.0% ◦ 78% were taking at least one medication to manage blood glucose ◦ LDL cholesterol 44.3% >2.5 (target<2.0) ◦ 70% were taking a lipid lowering medication
  • 20.       Has the right population been tested ? Has the diagnosis been made? Was the best treatment selected? Did the clinician use the test to guide treatment decisions? Did the clinician recognise a meaningful change in a test result? Did the patient take the medication? “When patients start a new medication for a chronic condition, intentional nonadherers hold beliefs that are significantly different from those of adherers and unintentional nonadherers.” Clifford S et al J Psychosom Res 2008  Heart Foundation estimate of savings from improved prevention/management: $2.6B over 5 years( R Grenfell personal communication)
  • 21. Doll et al BJGP 2011
  • 22. Doll et al BJGP 2011
  • 23. Doll et al BJGP 2011
  • 24. 3 surveys involving 6390 GPs, in 10 EU countries and Australia By permission R Horvath
  • 25. HbA1c ‘True’ CD (RC) value at 80% probability to indicate poorer or better control corresponds to a change of +12% in HbA1c
  • 26. CV for HbA1c 4.4%
  • 27.    Guidelines on intervals between tests Education on meaningful change in test measurement -Reduce harm by reducing testing with no clinical utility Careful design of programs, targets and incentives One third of patients with CAD who have met target LDL levels undergo repeat testing within months without a change in treatment. Virani et al JAMA Int Med2013 cdmNet –web based care management systems improve glycaemic control. Wickramsinghe L et al MJA 2013  Discourage the use of testing as a measure of compliance. R Horne
  • 28. Data base mining: find patients, find insights Find the patients and manage the cases - MBS - 7 % Australians use 50% of the pathology services - Social disadvantage maps Find the insights and change strategies - LIS - Linked databases - Kaggle
  • 29. Donald Woods Foundation South Africa, 5000 people /month Diabetes first, then hypertension, HIV, TB
  • 30. Dr Jeffery Brenner, Camden Coalition of Healthcare Providers
  • 31. Regional Population Health Atlas > Focus on Le Fevre Peninsula. HbA1c by Age ( <7% or >7%) @ Postcode level AND SEIFA context
  • 32. SODIUM RISK n = 23,442 Admissions Mortality Risk 50% 40% 30% 20% 10% 0% 112 120 116 128 124 136 132 144 140 Extreme Sodium mmol/L 152 148 160 156
  • 33.   - Disruptive solutions Christensen Harvard Business School Revolutions in health care: Muir Gray - Public health – Snow and cholera Technology – treatment of AML Citizens, knowledge and the smart phone.
  • 34.    An innovation that simplifies, increases access and affordability A business model innovation Disruptive value network Eg personal computer – from high cost exclusive use to low cost, general use.
  • 35. Find a doctor, pharmacist, dentist Get tests Get prescriptions View claims View personal health records
  • 36.  Stop talking about pathology as a cost centre It is a risk management strategy for health care outcomes including cost.  Get organised Incentivise case finding and appropriate management, including testing protocols   Use the data Patient centred care