Disease oriented programs and programs focussing on patients with multimorbid conditions in Germany.
Prof. Joachim Szecsenyi, MD, MScDpt. General Practice and Health Services ResearchUniversity of Heidelberg Hospitalwww.allgemeinmedizin.uni-hd.de
Integrated Care Conference, Berlin, April 11th, 2013
Overview
The challenge
Summary
Programms for single chronic diseases
and formultimorbidity
Population Germany 2005/2025
Abteilung Allgemeinmedizin und Versorgungsforschung3
Vaupel et al. Nature 2010
Germany: Society of longevity
Life expectancy at age of 60:
– women: 24,9 years– men: 21,3 years
Increasing no. of patients with chronic diseases,above and below 60 years of age
Increasing no. of patients with more than one chronic condition, co- and multimorbidity
“Low fertility, low immigration and long lives”Christensen K, Doblhammer G, Rau R, Vaupel JW: Ageing populations: the challenges ahead. The Lancet 2009, 374: 1196 – 1208
4
Disease Management – the ideal
Activated patient
Good cooperation primary/
secondary care
Pro-active team, evidence-based care
Active sick funds, professional
organisations /feed-back
trans-sectoral / integrated
DMPs in Germany
2002/2003 introduction in social code book (SGB V)
Core contents are compulsory for contracts between insurers and providers
Defined by national expert groups at the level of the federal joint committee – Evidence based clinical guidelines– Basic data set– Quality indicators, provision of feedback– Transfer between different levels of care– Quality criteria for patient education
Some small differences in renumeration, type of feedback etc. by region/contract
Larger regional differences in CME, quality circles
DMPs in Germany
Patients and doctors have to enrol General practitioners play a leading role Cooperation with specialists (ambulatory and hospital
outpatient) Insurers have some co-steering role for the patient Financial incentives for sick-funds from the national
risk compensation scheme Financial incentives for participating practices
DMPs in Germany
Currently 6 diseases – Cardiovascular disease; module on heart failure)– diabetes mellitus, type 1 and 2 – breast cancer – asthma – COPD
Participants– > 7 million. patients (thereof > 3.6 million with diabetes 2)– More than 40.000 providers
What do doctors say?– in the beginning much resistance– „Cookbook medicine“– „Old fashioned drugs“– „buerocracy“– …
– Now: more positive
„DMPs are recognized by patients as care that is more structured and that reflects the core elements of the Chronic Care Model and evidence-based counselling to a larger extend than usual care.“
Szecsenyi et al. Diabetes Care 2008
Morbidity adjusted survival of elderly
patients with
Diabetes mellitus 2
Miksch A, Laux G, Ose D, Joos S, Campbell S, Riens B, Szecsenyi J. Is there a survival benefit within a German primary-care based disease management program? Am J Manag Care 2010; 16(1):49-54.
Ose D, Wensing M, Szecsenyi J, Joos S, Hermann K, Miksch A , Diabetes Care. 2009
Quality of life and multimorbidity
More findings (for different DMPs)
Reduced mortality and costs for medication and hospitalisation (Stock et al. 2010)
National evaluation programme shows positive effect on non-smoking and blood pressure control
Reduction of unplannend hospitalisations (Lindner et al. 2011) Better control of Asthma (Schneider et al. 2012)
Due to different evaluation approaches also some inconsistent findings when programs are compared
DMPs have extensively contributed to establish new roles and to improve competencies of medical assistants in primary care practices: human and structural investments in primary care
Improved use of pathways of care between different providers and levels of care
Multimorbidity
In primary care the rule, not the exception (Fortin et al. 2006), depression and pain often co-morbidity (Freund et al. 2012)
Limited applicability of disease specific guidelines (Boyd et al. 2005)
Limited applicability of DMPs for multimorbid patients at high risk
Priorisation important
Risk adjusted, individual approach necessary (i.e. case-management)
The next steps ahead..
Case management (CM) including telefone-monitoring in general practice
Trained medical assistants Monitoring lists Better use of family and
community resources Aims:
– Improving chronic care management
– Involving patients and families– Continuous monitoring and
prevention of decompensation
Foto : BMBF/PT DLR Gesundheitsforschung
(Arzthelferin mit ArtMol Monitoring-Liste)
Practice based CM trials in Germany
DEPRESSIONPromPT trial(Gensichen et al 2009)
ARTHRITISPraxArt trial(Rosemann et al. 2007)
CHRONIC HEART FAILUREHicMan trial(Peters-Klimm et al. 2011, 2012)
MUlTIMORBIDITY PracMan trial
Foto : BMBF/PT DLR Gesundheitsforschung
(Arzthelferin mit ArtMol Monitoring-Liste)
Color-coded algorithm
Emergency- immediate GP contact
GP visit within 24h/GP report
Normal
PraCMan study design
Cluster-randomized trial in Baden-Württemberg (Germany)115 practices including 132 teams (approx.2.100 patients),funded by AOK
Intervention: GP-centered care + CMControl: GP-centred care
Population: Patients with DM Typ II, COPD, CHFas tracer conditions≥ 75. percentile likelihood of hospitalization (predictive modelling plus assessment by GP
Endpoint: Rate of all-cause hospitalizations in 12 months
(Freund et al. Trials 2011)
Secondary outcomes
Mortality Direct and indirect costs Quality of life (SF12 and EQ5D) Quality of care (PACIC) Health-related behavior (smoking status, PE) Medication adherence (MARS) Clinical Endpoints:
– DM Type 2: HbA1c, fasting glucose, Hypoglycemia– COPD: Dyspnea, FEV1, exacerbations– CHF: NYHA, decompensations
Results available summer 2013
DMPs in Germany:
Care is more oriented according to the Chronic Care Model
Practices are more pro-active Patients are more activated Care is more coordinated Positive effects on QoL and survival Smaller effects on prescribing,
hospitalisation and costs
Summary
Further development of DMPs to adress multimorbidity
Development of primary carepractice-based case managementfor multimorbid conditions
PraCMan trial helps to understandhow to select the right patients forthe right type and intensityof intervention
Long term investment in primary care teams necessary
Summary
Thank you!