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!