Taking action on comorbidities

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Taking action on comorbiditiesNHS Expo 2014

Dr Amina Aitsi-Selmi Dr Junaid Bajwa

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Taking action on comorbidities:

A framework of principles

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• Specialist Adviser in Public Health at the Department of Health

• Senior Research Associate, Institute of Health Equity, UCL

Current roles

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Comorbidities: scope

• What?– Combinations of the five big killers and other common long term

conditions including diabetes and mental illness

• Who?– Adult population– The most vulnerable in our communities– People with serious mental illness– People from certain minority backgrounds (such as BME groups)

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Comorbidities: Our current understanding • Comorbidity is expected to;

– grow in prevalence in England (1.9 to 2.9 million 2008-2018)

– grow in cost (currently £8-13billion/year in England)

• Because of;– an ageing population– historically deteriorating health behaviours– increasing health inequalities and reduced access to

health resources

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Comorbidities: What we know

There is a prevention paradox: while health in the general population improves illness clustering among the socially deprived has got worse

Other views are that we haven’t got the basics right in single disease areas yet, so we should sort this out first

At the moment, research, policies, guidance, delivery of health care and clinical professions reflect the single disease model

We need to know more about the combinations of specific diseases that make up co-morbidities

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2) What’s the way forward?

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Are there two types of people with comorbidities?

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Are there killer combinations?

Mental + physical illness

• The coexistence of mental and physical illness increases mortality and death occurs sooner

• The mentally ill population die of the five big killers and their risk factors mostly

• Socially deprived groups are more likely to have mental illness as a comorbidity

• We’ve made least progress in improving outcomes for people with mental illness

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People with mental illness die of the same causes as the general population but sooner

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Other killer combinations?

1. Diabetes + hypertension? (very common)

2. Chronic kidney disease + heart disease? (big gender differences; worse for women)

3. Coronary heart disease + COPD/Type 2 diabetes in men? (again big gender differences; worse for men)

4. Social deprivation + CHD/COPD? (the prevention paradox and inverse care law)

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Are there any interventions?

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1) Prevention and wellbeing promotion• Primary and secondary prevention; wellbeing

2) Places and the wider determinants• Housing, education, employment, the environment

3) Population needs• Using robust data to identify ‘killer combinations’ and risk stratify

4) Promotion of research and guideline development and use

• Working across organisations and professional bodies

5) People and patient participation• Working with patients and encouraging self-management where possible

6) Parity of esteem • Mental illness and physical illness are on a par as long term conditions

7) Putting coordinated systems in place and payment reform

• Payment systems; technology; workforce skills

Principles of action on co-morbidities

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Are we beginning to address the problem?

The House of Care

Making Every Contact Count (MECC)

Health Checks

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An example: the Lester UK Adaptation tool

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Opportunities and challenges in the health and care (and social) system

NHS (‘treatment’)Public Health (‘prevention’)

Population science (wellbeing!)

Social careDH/other government departments

3rd sector

Health and wellbeing boards

LAs; CCGs

NHS (‘treatment’)

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What else is there that can help?

What are the barriers?

What are the levers?

What are the incentives?

Where can you get data and how can you use it to

specify the problem locally and take action?

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Thank you

[email protected] or

[email protected]

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Taking action on comorbidities:Using data to improve outcomes

NHS ExpoMarch 2014

Dr Junaid Bajwa

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About me

• GP, CCG Board Member NHS Greenwich• Primary Care Transformation Board Member, NHSEL• Associate in Public Health, NHS Greenwich• Council Member of the Clinical Senate, London

• GP Appraiser NHSE• Programme Director, Greenwich VTS

• Prepare to Lead alumni, NHS London• Value Based Healthcare Alumni, Harvard Business School

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1. The majority of >65s have 2+conditions, & the majority of >75s have 3+ conditions 2. More people have 2 or more conditions than only have 1

Multimorbidity: LTC

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The working lunch…..

Monday Tues Weds Thurs Fri0800am 0810am 0820am 0830am 0840am 0850am 0900am 0910am 0920am 0930am 0940am 0950am 1000am 1010am 1020am 1030am 1040am 1050am 1100am 1110am 1120am 1130am 1140am 1150am 1200pm 1210pm 1220pm 1230pm

1600pm 1610pm 1620pm 1630pm 1640pm 1650pm 1700pm 1710pm 1720pm 1730pm 1740pm 1750pm 1800pm 1810pm 1820pm 1830pm 1840pm 1850pm 1900pm

What about: QoF/ LES/DES/ CIS/ Additional Services/ Child Protection/ GSF/ Information Governance/ CQC/ PRG/ Practice Meetings/ KPI’s/ Audit: Research/ Reviewing Prescribing/ HR issues/ LMC/ Public Health/ CCG ….(+++++++++++)….Stepping outside the chaos to manage LTC holistically

Proactive, not reactive medicine

• 16 face to face 10 minute appts• Telephone encounters: 5-10• Home visits (2-3)• Referrals: 3 (am)• Review blood tests/Investigations• Post/ Fax/ Email (75-100 letters per day)• 16 face to face 10 minute appts• Referrals: 3 (pm)

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Long Term Conditions Module

Improving the experience of healthcare for those with long term conditions

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Risk Stratification

Consider the System

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Identifying Patients

Low RiskDisease Prevention and Promotion of

Healthy Living

Monitoring and Support for Disease

Self-Management

A&E, Inpatient care, Case Management and Palliative Care

Reduce Admissions

Improve control

Reduce Readmission

Reduce Length of stay

Risk Profile Typical Provision Aim of service

Control Risk Factors

High Risk

High - Moderate Risk

Moderate - Low Risk

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Primary Care: What if we used what we have?

Metrics• HbA1c• Cholesterol• BP• MRC• eGFR*• BMI• Waist circ• Audit C score• PHQ9• Being Housebound• No of repeat• Age >75• Being a smoker

Long Term Conditions• Cancer, • COPD, • Asthma, • Diabetes, • CKD 3,4,5, • Hypertension, • Rh Arthritis, • AF, • HF, • Hypertension, • Mental Health

condition, • LD, • Dementia,

• Parkinsons, • Cirrhosis, • being on the GSF, • Inflammatory

Bowel Disease, • Stroke/TIA, • Osteoporosis

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Metrics• HbA1c• Cholesterol• BP• MRC• eGFR*• BMI• Waist circ• Audit C score• PHQ9• Being Housebound• No of repeat• Being a smoker

Long Term Conditions• Cancer, • COPD, • Asthma, • Diabetes, • CKD 3,4,5, • Hypertension, • Rh Arthritis, • AF, • HF, • Hypertension, • Mental Health

condition, • LD, • Dementia,

• Parkinsons, • Cirrhosis, • being on the GSF, • Inflammatory

Bowel Disease, • Stroke/TIA, • Osteoporosis • Age >75

(Modifiable) (Fixed)

Primary Care: What if we used what we have?

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Within the metric….RAG

Metrics• HbA1c• Cholesterol• BP• MRC• eGFR*• BMI• Waist circ• Audit C score• PHQ9• Being Housebound• No of repeat• Age >75• Being a smoker

RAG: R-2pts / A-1pt / G-0pt• G (6.5-7.5), A (7.5-8.5); R (>8.5)• > 4:2: A: 1 pt if above this ratio• (>150/90; if DM/CKD/CHD >140/90) 1 pt if above• G: 3,A: 4, R: 5• G (CKD2 60-89); A (CKD3 30-59); R (CKD4,5 ie < 29)• A: (Obese**) R (:morbid obesity)• A: 1 pt if above norm• R: (>5)• (last recorded within 3m) R: 15-27; A: 5-14• A: 1 point• Repeat medications (>5): A 1 pt if above• A 1 pt if above 75• A 1pts

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Managing the chaos: Proactive vs Reactive

• Cumulative totals within each of the categories would then allow a 360° review of your registered population

• Could you then establish a set of rules re: appointments; removing the monthly letters for each review/ reduce waste in the system; offer extended appointments with a focus on self management- improving the patient experience

Green Amber Red

Dr appts (?around bday)

2/yr 3/yr 4/yr

Nurse appts 3/yr 4/yr 5/yr

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PDSA: future add ons

• PDSA cycle• Coding: Number of hospital admissions A(2); R(>3); • Quantify length of stay in hospital• QAdmission®• QRISK®2 calculates your risk of cardiovascular disease(R >30%) (A>20)• QDScore® algorithm calculates your risk of Type 2 diabetes.)• QoL score (would be useful to include this metric- we do not currently

assess this in primary care)• Looking at social determinants of health: e.g. personal/ household income,

social housing, postcode, use of carers, social isolation

“Not all that can be counted, counts. And not all that counts can be counted.” -- Albert Einstein

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Personal Health Plan

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Improving the Patient Experience

Health & Medicine

Taking action on comorbidities