WORKSHOP
Regional strategies to improve efficacy and equity while
guaranteeing economic sustainability
Proactive strategies in primary care:
the Tuscan Experience
Pisa, 13 June 2011
[email protected]
[email protected]
Direzione Generale
1
Diritti di cittadinanza e Coesione sociale
a)
Primary Health Care and the CCM-based
program in Tuscan Region
b)
Impact on quality of care and health care
costs: preliminary results for diabetes
c)
Future perspectives
Direzione Generale
2
Diritto alla Salute e Politiche di Solidarietà
a) Primary Health Care and the CCM-based
program in Tuscan Region
Direzione Generale
3
Diritto alla Salute e Politiche di Solidarietà
The Tuscan Healthcare System: some data
• 3,7 millions inhabitants
• 6.300 millions € for healthcare spending in 2009:
5% prevention
43% hospitals services
52% primary care
• 17 Public Health Authorities:
12 Local Health Authorities and 5 Teaching Hospitals
organized in three Network “Area Vasta”:
• North West Area Vasta: 2 T.H. and 5 L.H.A.
• Center Area Vasta: 2 T.H. and 4 L.H.A.
• South East Area Vasta: 1 T.H. and 3 L.H.A.
• 51.000 employees
• 2.940 GPs
• 14.000 public and private hospital beds
(3,8 per 1.000 inhabitants)
[2009]
Direzione Generale
4
Diritto alla Salute e Politiche di Solidarietà
The Aging Population
Population >64 years
- Tuscany 23,3%
- Italy 19,9%
Tuscany Population Pyramid
2005
Epidemiology of Chronic Diseases
in Tuscany
Number of diagnosed cases for each of the 5
“CCM chronic diseases” per 1,000 residents
16 + according to administrative data;
hypertension limited to exempted cases
(MaCro system)
70
60
50
Men
30
Women
20
10
Fa
ilu
re
He
ar
th
ns
io
n
Hy
pe
r te
St
ro
ke
PD
CO
be
te
s
0
Di
a
2025
40
Direzione Generale
5
Diritto alla Salute e Politiche di Solidarietà
Chronic diseases
From the last quarter of the 20°
century: fourth stage of
epidemiological transition
Aging population and
reduction of the
mortality due to CV
acute event
Increase of the chronic
diseases prevalence
The management of the increasing chronic diseases
prevalence is one of the most important healthcare
problems to deal with.
(Tuscany Strategic Health Plan PSR 2008-2010, p. 34)
Direzione Generale
6
Diritto alla Salute e Politiche di Solidarietà
Where Tuscany wants to invest?
From traditional healthcare to proactive healthcare
Traditional healthcare:
Proactive healthcare:
The healthcare system acts only
when the chronic patient worsens
becoming acute.
The patient’s needs are taken into
account before the disease
worsening and possibly before
disease onset, getting better health
conditions for the population,
addressing equity issue too.
Chronic diseases are not well
treated and prevention as well
as risk factors are not taken
into account. Health inequities
are not taken into account
The healthcare system is able
to manage chronic diseases
and to be effective in facing
the acute diseases onset.
Direzione Generale
7
Diritto alla Salute e Politiche di Solidarietà
Which model to drive the change:
the Expanded Chronic Care Model (CCM)
Expanded Chronic Care Model:
 main strategy of the Regional
Health Plan
 new delivery System design
focused on multi-professional care
team
 new role of nurses in self
management support;
 decision support through shared
clinical pathways;
 investment on integrated
information system
 community resources exploitation
 Focus on prevention and health
determinants (community oriented
primary care)
Direzione Generale
8
Diritto alla Salute e Politiche di Solidarietà
Quality indicators for GPs
Incentives based contract - Diabetes
Indicators
Target
Records
The practice produce a register of patients winth type 2 diabetes
(target prevalence)
>4%
Ongoing Management
The percentage of patients with diabetes who have a record
of HbA1c in the previous 12 months
>70%
The percentage of patients with diabetes whose notes record
waistline in the previous 24 months
>70%
The percentage of patients with diabetes who are involved
with self management support programs
>70%
The percentage of patients with diabetes who have been
trained for self monitoring of blood glucose concentrations
>50%
The percentage of patients with diabetes in whom HbA1c is
<7 and they don’t assume antidiabetic drugs
>20%
9
Direzione Generale
Diritto alla Salute e Politiche di Solidarietà
GPs and other health professionals operators (nurses,
medical assistant …) organized in practice (6-16 GPs) to
care for chronic patients with a proactive approach
(Chronic Care Model)
Pilot phase
January 2010
Extention phase
October 2010
11 Healthcare
• 56 practice
• 497 GPs
•112 Nurses
• 618.969 Patients
MITO project– 1 Healthcare
• 4 policlinics
• 166 GPs
• 175.000 Patients
Other groups are expected to be involved
• 31 practice
• 301 GPs
• 62 Nurses
• 337.213 Patients
10
Direzione Generale
10
Diritto alla Salute e Politiche di Solidarietà
Clinical register
11
Direzione Generale
11
Diritto alla Salute e Politiche di Solidarietà
0,0%
12
12versilia_viareggio
11empolese_cerreto
9grossetana_grossetocollina
9amiatagrossetana_amiata
9colmetallifere_follonica
8aretina_arezzo
8casentino_rassina
6,0%
8valtiberina_sansepolcro
7,0%
7valdelsa_poggibonsi
8,0%
7valdichiana_sarteano
6elba_elbaoccidentale
6bassavalcecina_colline
5altavalcecina_pomarance
5valdera_pontedera
5pisana_serchio
4pratese_pratoferrucci
3pistoiese_pistoiaadua
3valdinievole_cintolese
2valle_castelnuovo
2piana_altopascio
2piana_borgonuovo
2piana_ponte
1massa_mito
Diabetes prevalence rate at practice level
Regional
Prevalence
4,9%
5,0%
4,0%
3,0%
2,0%
1,0%
Direzione Generale
Diritto alla Salute e Politiche di Solidarietà
b) Impact on quality of care and health care
costs: preliminary results for diabetes
Direzione Generale
13
Diritto alla Salute e Politiche di Solidarietà
Study objectives
To evaluate the effect of the CCM-based program being implemented in
Tuscany on
a) quality of care in terms of process indicators
b) per capita health care costs
in patients with diabetes (and hearth failure)
Direzione Generale
14
Diritto alla Salute e Politiche di Solidarietà
Study design
A pre-post comparison-group study
Groups and observation periods (data available up to
end 2010):
1/1/2009
1/7/2009
31/12/2009
Start of
program
1/7/2010
31/12/2010
process indicators
(one year)
&
care cost per capita
for selected services
(one semester)
Patients of
CCM – GPs
Patients of
No CCM - GPs
Prevalent
at 1.1.09
Prevalent
at 1.1.10
15
Direzione Generale
Diritto alla Salute e Politiche di Solidarietà
Data sources
Data sources:
the Tuscan longitudinal record-linkage system “MaCro” (Chronic
Diseases) of inhabitants registry, exemptions, specialist care, drug
dispensing and hospital discharge records (administrative data)
through which:
a) cohorts of residents with specific diseases can be identified and
b) levels of adherence to clinical recommendations can be
calculated
Direzione Generale
16
Diritto alla Salute e Politiche di Solidarietà
Study area and populations

Prevalent at 1.1.2009:
A total of 139,267 patients 16+ with diabetes
of which:
26,276 enrolled with the 394 GPs
implementing CCM (intervention group)
112,991 enrolled with the 1,875 GPs not
implementing CCM (control group)

Prevalent at 1.1.2010:
A total of 142,489 patients 16+ with diabetes
of which:
27,149 enrolled with the 394 GPs
implementing CCM (intervention group)
121,110 enrolled with the 1,875 GPs not
implementing CCM (control group)

Age (68% over 65) and sex distributions
(50% women) of the four groups were quite
similar
Direzione Generale
17
Diritto alla Salute e Politiche di Solidarietà
Principal outcomes
a)
Process Indicators
 % of patients with at least one assessment of HbA1c
 % of patients with at least one assessment of micro-albuminuria
 % of patients with at least one assessment of creatininemia
 % of patients with at least one assessment of lipids
 % of patients with at least one assessment by an ophthalmologist
during the twelve-month periods of observation
b) Care cost per capita (selected services)
 per capita cost for diabetes specialist care
 per capita cost for eye specialist care
 per capita cost for specific laboratory diagnostic procedures
during the six-month periods of observation
Direzione Generale
18
Diritto alla Salute e Politiche di Solidarietà
a) process indicators (lab tests)
glycated hemoglobin testing
creatinine
100
90
90
Age-standardized percentage
100
80
70
60
50
40
30
20
10
80
70
60
50
40
30
20
10
Years
Years
microalbuminuria
CCM
100
lipid profile
No CCM
80
70
60
50
40
30
20
10
CCM
100
No CCM
90
Age-standardized percentage
90
2010
2009
2010
0
2009
0
80
70
60
50
40
30
20
10
Years
CCM
2010
2009
2010
0
2009
0
Years
No CCM
19
CCM
No CCM Direzione Generale
Diritto alla Salute e Politiche di Solidarietà
a) process indicators
(eye specialist care)
oculistic visit
90
80
70
60
50
40
30
20
10
2010
0
2009
Age-standardized percentage
100
Years
CCM
No CCM
Direzione Generale
20
Diritto alla Salute e Politiche di Solidarietà
b) per capita cost of selected health
care services – 2° semester (I)
per capita cost of
eye specialist care
per capita cost of
specific lab tests
4,0
29,0
3,5
27,0
3,0
25,0
2,5
23,0
2,0
1,5
21,0
1,0
19,0
0,5
17,0
0,0
15,0
2010
2009
noCCM
2009
CCM
2010
noCCM
CCM
Direzione Generale
21
Diritto alla Salute e Politiche di Solidarietà
b) per capita cost of selected health
services – 2° semester (II)
per capita cost of
diabetes specialist care
8,0
7,0
6,0
5,0
4,0
3,0
2,0
2009
2010
noCCM
CCM
Direzione Generale
22
Diritto alla Salute e Politiche di Solidarietà
Summarizing
In patients with diabetes enrolled with CCM-GPs,
compared with patients with diabetes enrolled
with no-CCM-GPs:
a) quality of care in terms of pure process indicators
has improved
b) per capita cost of eye specialist care and lab
tests have increased
c) per capita cost of diabetes specialist care has
decreased
Direzione Generale
23
Diritto alla Salute e Politiche di Solidarietà
And equity ?
Data from LHA of Arezzo on
1,494 patients with diabetes
enrolled with CCM – GPs,
of whom 90 (6 %) defined as
“deprived”: tenants paying a rent
and/or referring economic
difficulties
HbA1c
100
90
80
%

Deprived
70
Not deprived
60
 Preliminary results
50
40
2009
Micro-albuminuria
100
90
90
80
80
70
Deprived
60
%
%
Lipids
100
70
Not deprived
50
2010
Deprived
60
Not deprived
50
40
40
30
30
20
20
2009
2010
2009
2010
Direzione Generale
24
Diritto alla Salute e Politiche di Solidarietà
c) Future perspectives
Direzione Generale
25
Diritto alla Salute e Politiche di Solidarietà
What next? What we know…
“… Disease-oriented medicine…through a focus on
particular chronic diseases and their management is thus
highly inequitable” (Starfield, The hidden inequity in health
care. IJEqH 2011)
“… it is neither necessary nor desirable to try to introduce
the whole model at once. It is most effective to focus on one
highly important change at a time (Kriendler, Lifting the
burden of chronic disease: What’s worked, what hasn’t, what
next. 2008)
“… High-performing organizations more often used
computerized reminders (clinical information systems),
guidelines supported by clinician education or computer
support (decision support), formal self-management
programs (self-management support), and a registry (clinical
information systems) … smaller practices would have greater
difficulty implementing the CCM and improving outcomes.
(Health Affairs 28, no. 1- 2009: 75–85)
Direzione Generale
26
Diritto alla Salute e Politiche di Solidarietà
What next? What we should do …
Our CCM-based program is intended as a transitional phase towards
person-focused care since it shifts chronic diseases management to
primary health care
 Practice need to be more supported by the clinical
information systems for implementing proactive approach
and promoting clinical and equity audit
 We need to review the clinical pathways, most focusing
on risk (eg. Cardiovascular) and not on specific disease
 We have to introduce formal and more standardized self
management support programs aiming to an actual
proactive patient and focusing attention on individual
determinants of health
 We should change deeply the service delivery design
strenghtening the integration between primary care and
specialsitic services in the community
Direzione Generale
27
Diritto alla Salute e Politiche di Solidarietà
Thanks for your attention
[email protected]
[email protected]
Direzione Generale
28
Diritto alla Salute e Politiche di Solidarietà