19th COCHRANE COLLOQUIUM

Sustainable Evidence-Based Health Care in Times of Crisis

Madrid October 19-22 . 2011

Rafael Bengoa | Regional Minister for Health and Consumer AffairsBasque Government. Spain

2

1992 1997 2002 2007

Evolution of diabetes and cardiovascular disease in the Basque Country%

This challenge of this epidemic is going much faster than our reaction to it.

4,5 - 6,0 6,1 - 7,5 7,5 - 9,0 9,1 - 10,5 10,6 - 12,0

3Massive Demand…

0

2

4

6

8

10

Gre Sue Por Fin UK Pb Ita Lux Irl Aus Fra Ale Din Bel Esp

5.95.9

2.52.5

9.59.5

European Countries

Ecosalud. OCDE 2005.

Medical consultations/capita. Europe. 2003

4Fragmentation

5THIS IS THE RESULT ACROSS THE CONTINUUM !

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Primary Prevention

Primary Prevention

Early Management

Early Management

AcuteManagement

AcuteManagement

Rehabilitation& secondary

prevention

Rehabilitation& secondary

prevention

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“ Having everything under the same

roof does not guarantee clinical

integration nor a tidy operation across the disease continuum” R. Bengoa

Primary Prevention

Primary Prevention

Early Management

Early Management

AcuteManagement

AcuteManagement

Rehabilitation& secondary

prevention

Rehabilitation& secondary

prevention

CEO

U1 U2 U3

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Primary Prevention

Primary Prevention

Early Management

Early Management

AcuteManagement

AcuteManagement

Rehabilitation& secondary

prevention

Rehabilitation& secondary

prevention

“ Both downstream and upstream interventions are vital for the final population outcome in the control of a disease. It is sterile to continue opposing these two approaches. They are two sides of the same coin. What we need is an integrated approach across the continuum balancing public health interventions and health service interventions and the local organization to operationalise this as a system on the ground “ R. Bengoa

Downstream Upstream

9MESSAGE IS CLEAR :

Most countries are improving in each of the boxes of the continuum but not using the potential of an integrated approach across the continuum.

One of the reasons for this is that we do not have a “system” operating at the local level

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THAT FRAGMENTATION

CANNOT PROVIDE

A SUSTAINIBLE HEALTH SYSTEM

11Tools for Integration Help to move towards a “System” Perspective

risk stratification…

case nurses…

routine clinical reminders…

continuum of care…

activated patient…

regular telemonitoring……

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13

¿WHAT ARE WE TRYING TO DO ?

TRYING TO FIT IN SOME OF THOSE

MANAGEMENT PROCESSES IN ….

14Using frameworks/models

15Some sort of structured patient education: both direct and remote

REMOTE PATIENT EDUCATION

PATIENT EDUCATION

16With some sort of case manager

• Nurses who act a case managers for patients with complex conditions.

• Their function will be to evaluate their physical and social needs and coordinate their care.

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Diabetic retinopathy

Telecare /Telemedicine ++++

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What results are some

organizations getting?

Is the Evidence Growing?

19Community Care North Carolina (CCNC)

Health programme for:

– Low-income adults and their children and dishabilities (880.000 habitants)

– 3000 physicians

Objective:

– Improve the quality, cost, accesibility and utilisation of services for Medicaid recipients

Source: http://www.communitycarenc.org/our-results/

Methods to promote integration:– Locally adapted clinical guidelines

– Case management services

– Financial incentives

– Data review and analysis

– Feedback on clinical practice

20Integrated cardiovascular care…

...is leading to reductions in heart attacks and strokes.

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1,0

1,1

1,2

1,3

1,4

1,5

1,6

1,7

1,8

1,9

2,0

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Stoke-related Hospitalization Rates in No. Cal.

1998-2007

ST Elevated MIs in No. Cal.1998-2007

0,4

0,6

0,8

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1998

1999

2000

2001

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2003

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2006

2007

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KP Northern California ALL program, PHASE, results.

21VA Continues to Exceed HEDIS in 2008

INDICATOR VA 2008 VA 2007 Commercial

2007 Medicare

2007 Medicaid

2007

Breast cancer screening 87% 86% 69% 67% 50%

Cervical cancer screening 92% 91% 82% n/a 65%

Colorectal cancer screening 79% 78% 56% 50% n/a

LDL Cholesterol < 100 after AMI, PTCA, CABG 66% 62% 59% 56% 38%

Diabetes: DM control HbA1c < 9.0% 84% 84% 71% 71% 52%

Diabetes: LDL-C<100 68% 64% 44% 47% 31%

Diabetes: Eye Exam 86% 85% 55% 63% 50%

Diabetes: Renal Exam 93% 91% 81% 86% 74%

Diabetes: BP < 140/90 78% 77% 64% 59% 56%

Hypertension: BP < 140/90 75% 76% 62% 58% 53%

Smoking Cessation Counseling (3) 89% 83% 76% n/a 70%

Smoking : Medications offered(3) 84% n/a 51% n/a 39%

Smoking: Referral/strategies (3) 92% n/a 48% n/a 39%

Immunizations: influenza 84% 72% 49% 72%  

Immunizations: pneumococcal 94% 90% n/a 67%  

22Why ? Because the Evidence is Increasing

• Estimated $3.7 million net savings for a ROI of > 2 to 1

Geisinger Proven Health Navigator Model

• 30% decrease in hospitalizations for asthma and 11% lower ER visits

UK Tornbay

• 29% reduction in ER visits; 11% reduction in ambulatory care sensitive admissions versus control sites

Puget Sound

• 10% relative reduction in hospitalizations and even greater among those with chronic illnesses.

Intermountain Health Care

SUSTAINIBILITY ?

23 Building some sort of Local Health “System”

BETTER CARE FOR INDIVIDUALS ( IOM )

BETTER POPULATION HEALTH

LOWER GROWTH IN EXPENDITURE BY ELIMINATING INEFFICIENCIES.

TACTICAL APPROACH

make the link between clinical behaviour and financial consequences for clinical decisions

Incentive if savings made

Pathways as a tool to make that link

Aim : LINK several lines of work which tend to operate separately

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DIFFERENT COUNTRIES/SYSTEMS MOVING IN THE SAME DIRECTION

FOCUSING ON TRANSFORMATION OF DELIVERY

CONTEXT : SOME PROMOTING COMPETITION ; OTHERS NOT.

SHIFTING FROM VOLUME AND INPUTS TO VALUE

LEANING ON MODELS: KP AND CCM AND OTHERS

MANY BUILDING SOME SORT OF LOCAL HEALTH “SYSTEM”

Mid-term policy perspective/ trend

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USA. Section 3022 of the Affordable Care Act (ACA) establishes the Medicare Shared Savings Program for Accountable Care Organizations .

England: The White Paper ‘Equity and Excellence:

Liberating the NHS’

New Public Health Law . Basque Country . Spain.

Wales , New Zealand…..

Trend Taking Shape In Normative Policy Interventions

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How are we moving forward in the

Basque Country ?

27Objective:Simultaneously Managing Crisis &

Transformative Change

Short term strategy

Crisis management

Drugs: Brand to Generic

Human Resources: Salaries

Tecnologies: Desinvestment…

Long term strategy

Reforming DeliveryC

hronic Diseases Agenda

Integrated Care

SUSTAINIBILITY?

28Create a narrative/ a common language ….

PROVIDE A NARRATIVE THAT GOES BEYOND “COST CONTAINMENT”

A NARRATIVE WICH PROVIDE A VISION AND STRUCTURE

PROVIDES DIRECTION AND STABILITY IN A CRISIS ENVIROMENT

THE HARDER THE EXTERNAL ENVIROMENT IS, THE GREATER THE COHESION CAN THE COMMON VISION PROVIDE

R. Bengoa

IN THE BASQUE COUNTRY = THE MAIN

NARRATIVE IS “CHRONIC DISEASES”

AND CLINICAL INTEGRATION

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Competencias Avanzadas

Enfermería

Formar a 300 enfermeras

en los nuevos roles hasta

2013

Financiación y Contratación

Implantación plena de un

sistema de asignación

financiera

territorial ajustada

por riesgo

Colaboración sociosanitaria

4 municipios con

funcionamiento integrado, 1

hospital con plan de altas con

prevención de dependencia, 1

unidad de ortogeriatría

Innovación desde los

profesionales Generación de

15-25 proyectos de innovación

al año y extensión de los que

demuestren resultados (~90%)

Centro Servicios Multicanal

Despliegue en Euskadi de

todos los servicios para

mediados de 2013

Prevención y Promoción

Prevención de aparición y

desarrollo de

enfermedades crónicas

(De_Plan, prevención

tabáquica)

Estratificación

Estratificación operativa

de la población vasca de

forma sistematizada y

periódica desde 2011

Autocuidado

Experiencias en las

principales enfermedades

crónicas, potenciando la

adherencia y el uso

apropiado de los recursos

Historia Clínica

unificada

Implantación

universal a finales

de 2011

Atención clínica

integrada

Un tercio de las

organizaciones a 2013,

con procesos integrados

Receta electrónica

Implantación efectiva del

sistema de receta electrónica

en todo Euskadi en 2012 –

2013

Experiencias de

telemonitorización

Monitorización a distancia del

1% de enfermos crónicos

severos (~22.500)

Modelo hospitales subagudos

Implantación del modelo en

hospitales de media estancia y

creación de nuevo hospital de

crónicos en Álava

Centro Investigación

Cronicidad

Ser un referente internacional

en el conocimiento sobre

enfermedades crónicas

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1011

8

12

137

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Launch interventions in a coherent package:Many levers simultaneously

R. Bengoa

30Examples: bottom up Organizational Innovation

Osi Bidasoa

BasurtoSta. Marina

•384.000 habitants •24 primary care centers•1 acute hospital•1 medium and long term hospital

H. Basurto- C-Bilbao-H. Santa marina

•85.000 habitants •First integrated organizational structure (hospital and primary care center)

Integrated organizational

structure

Non Integrated organizational

structure

DIFFERENT MODELS OF INTEGRATED CARE ORGANISATIONS (systems)

31This Should Look Better At The Next LSN Meeting!!!!

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Evidence increasing around a few things…

• Different diseases , similar needs and similar solutions

• Much of the evidence sends clear signals in favor of integrated care

• To pull this off you need patients and staff on board.

• It is therefore less about structural moves than about staff engagement

• Evidence growing but scalability still an issue

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THE PROCESS WILL NOT DEVELOP IN A TIDY SEQUENCE OF LINEAR STEPS. INSTEAD IT WILL PROLIFERATE VIA GROUPS OF INNOVATIVE IDEAS BY

DIFFERENT ORGANIZATIONAL UNITS. Van de Ven 1999

THOSE INNOVATIVE IDEAS BY DIFFERENT ORGANIZATIONAL UNITS MUST BE SUBJECTED TO THE EVIDENCE TEST

SCALABILITY…

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Thank you