20140613 brn symposium

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Implications for the Health Care SystemJoan Escarrabill MD PhDChronic Care Program– Barcelona Esquerra. Hospital Clínic (Barcelona)

Master Plan for Respiratory Diseases (PDMAR) & Home Respiratory Therapies Observatory (ObsTRD). FORES. Ministry of Health (Catalonia)

Implications for the Health Care System

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Sustainability

AccessibilityOutcomes

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Am J Prev Med 2012;42:639–45

Balanced strategies that implement both population and individual-level interventions:

can best maximize health benefıts, minimize harm, avoid unnecessary healthcare costs.

P5 = Population perspective Premature translation

Lost in translation

Harm

Cost

Disparities

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P4 Components Population perspectives

Predictive Ecologic model of Health, integrating multilevel determinants of health

Preventive Principles of population screening

Personalized Principles of evidence based medicine

Participatory Essential public health functions (assessment,policy development and assurance).Information system

Am J Prev Med 2012;42:639–45

Common pratincole

Grey heron

Personalization and Health Care: 5 elements to discuss

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Variability

Individual vs. population

Business model

Results

Dissemination

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The requirements for variation

Copious

Small in extentUndirected

Charles Darwin(1809-1882)

Variations in clinical practice

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Science 1973;182-1102-09 There are wide variations in resource input, utilization of services and expenditures.

Variations indicate that there is a considerable uncercertaunty about the effectiveness of health services

Discharge ratio in surgical procedures

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Source: Methodology of Atlas of Variations in Medical Practice Catalan Agency for Quality and Healthcare Assessment (AQuAS) http://goo.gl/wwI6jh

http://goo.gl/wwI6jh

http://goo.gl/wwI6jh

Long-term Oxygen therapy (LTOT) 2012/13n:

RV:

CSV:

EB:

26805 350 3704 5995 16756

5.44 9.79 25.59 11.10 7.51

0.34 3.18 0.44 0.47 0.41

0.27 0.94 0.31 0.30 0.29

-3

-2

-1

0

1

2

3T

axa

esc

ala

log

arítm

ica

mitj

ana

0

Tots 20-39 anys 40-64 anys 65-74 anys 75+ anysO2 concentrador+liquid

Source: Catalan Agency for Quality and Healthcare Assessment (AQuAS) & Home Respiratory Therapy Observatory (ObsTRD / FORES) 9

Standardized rates LTOT 2012/13

p(14): 120.17

p(86): 367.99

Ciutat de Barcelona

O2 concentrador+liquid 2012

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Source: Catalan Agency for Quality and Healthcare Assessment (AQuAS) & Home Respiratory Therapy Observatory (ObsTRD / FORES)

Home mechanical ventilation by age-groups 2012/13

n:

RV:

CSV:

EB:

3738 200 1138 1049 1351

22.94 6.20 14.35 19.90 62.14

0.37 1.08 0.96 0.54 0.59

0.34 0.72 0.50 0.33 0.47

-3

-2

-1

0

1

2

3

Ta

xa e

sca

la lo

gar

ítmic

a m

itjan

a 0

Tots 20-39 anys 40-64 anys 65-74 anys 75+ anysVent. Mecànica


Home mechanical ventilationStandardized rates 2012/13

p(14): 7.75

p(86): 56.22

Ciutat de Barcelona

Vent. Mecànica 2012

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LTOT HMV

The same accessibilityNo financial issues

Social inequalities

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Ann Intensive Care. 2014;4(1):2. doi: 10.1186/2110-5820-4-2


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Variability


Business model

Results

Dissemination

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Better value through population and personalised medicine.

J A Muir Gray. Lancet 2013;382:200-1

Effectivity

Quality

Safety

Value

Presonalised

Population

medicine

Customize evidence Biomarkers Personal values Clinical situation Context

Responsibilities to the population to be served Avoid inequalities Distribution of resources

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Comparative effectiveness research

• Overall benefits• Majority of patients• Establish population

averages

Personalized medicine

• Subsets of patients• To exploit differences

among subpopulations

Improve health care outcomesRationalize costs

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Even today, countries with more social provision of healthcare and less individualistic attitudes have better health outcomes across all social classes.

How can we balance the role of the individual and the communal in healthcare?


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Variability


Business model

Results

Dissemination

Disruptive business model

Solution shop

Intutive Medicine for unstructured

problems

Hypothesis testing until diagnosis can

be made

Value-added process

Empirical medicine

Standardization

Facilitated network

Patient groups with common needs

Long-term care: adherence

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Personalized medicine

Focus on results

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Precision medicine

Care plan: adherence

Disruptive business model

• Changes in the role of health professionals.

• Implication of new professions

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Lancet 2013;382:923-4

Increase (emergency)

admission

Reduction LOS

Pts > 85 yrsMultimorbidity

Cognitive impairementBalance

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Lancet 2013;382:923-4

Increase (emergency)

admission

Reduction LOS

Pts > 85 yrsMultimorbidity

Cognitive impairementBalance

To identify the optimumcare pathway for adults with medical illnesses

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Future hospital

Hospitals must be designed around the needs of patients

No “one size fits all” : Coordinated mangement of patients with multiple comorbidities

Specialist medical care will not be confined to inside the hospital walls.

Continuity of care

Illnes can occur in any time: 24/7/365.

Reorganisation of ‘front door’

Vulnerable patients.

Patient experience is valued as much as clinical effectiveness

Three elements

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Acute care hub

Clinical coordination

center

“Hub & spoke”

Fast track

Ann Intern Med. 2012;157:448-449.


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Variability


Business model

Results

Dissemination

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Value =Outcomes

Cost

NEJM 2010;363:2477-81

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Int J Epidemiol. 2010;39:97-106

Factors at multiple levels may influence health and disease,

Interrelation among these factors often includes dynamic feedback and changes over time ObesityGenes

Individual behavior

Neighbourhood

School level

Health Policies

food portions, dietary habits,exercise,television-viewing patterns

availability of grocery stores, suitability of the walking environment,advertising of high caloric foods

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Int J Epidemiol. 2010;39:97-106

The impact of investing in good food stores on body mass index (BMI),

Agent’s diet

Availability of good food stores

Her education level,

The diet of her parents and friends

Genetic predispositions

Importance of friend networks

Chronic care related to patients’ needs

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Health Affairs 2013;32:516–525

Identifying the needs of patients

Needs change over time

Social & Health needs

Technical complexity

Cognitive disorders

Multiple nedds (multimorbidity)

Barriers to access

Nursing home / Hospice

Frail patients (“potential risks”)

Post-discharge support

Organ failure


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Variability


Business model

Results

Dissemination

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Alan Williams (1927-2005)

Archie Cochrane (1909-1988)

J Epidemiol & Community Health 1997;51:116-20

Evidence based medicine in not enough

Costs represent health gains that have been denied to others.

All health care activities which meet certain minimum cost effectiveness requirements, when provided for certain specified categories of people, should be provided free within the NHS.

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Lots of it, for a few Not much, to many

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Value for money

JAMA. 2012;307(14):doi:10.1001/jama.2012.362

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To conclude: How many "P" are necessary?

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PredictivePreventivePersonalizedParticipatory

Population perspective

P4

P5

Policy Productivity Precision. People (groups of persons with common needs)Peculiarities Payment. Purpose. Poverty. Palliative Proximity Plurality PlanningProactivity…

P18 ?

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Thank you very much for your attention!!!