Versorgung von Menschen mit chronischen Krankheiten Wer mach was mit wem?

Transkript

1 Versorgung von Menschen mit chronischen Krankheiten Wer mach was mit wem? Prof. Dr. Dr. Thomas Roseman Institut für Hausarzutmedizin, Universität Zürich

2 Agenda Versorgung chronisch Kranker - wo stehen wir? Wer macht was - wie ist die Evidenz? Woher nehmen eine Ressourcenfrage? Ausblick

3 Diabetics who received recommended preventive care services Base: Adults with diabetes Percent received all four diabetes services* AUS CAN FR GER NETH NZ UK US * Hemoglobin A1c checked in past six months; feet examined for sores or irritations in past year; eye exam for diabetes in past year; and cholesterol checked in past year. Data collection: Harris Interactive, Inc Commonwealth Fund International Health Policy Survey of Sicker Adults.

4 Blood Pressure Under Control Last Time Checked Has Heart Disease, Hypertension, and/or Diabetes Percent yes, under control CAN NOR US NZ SWE FR AUS GER NETH SWIZ UK Base: Has heart disease, hypertension, and/or diabetes and blood pressure checked in past year. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

5 Chronic Care-Model (CCM) Gemeinwesen Ressourcen, Entscheidungsstrukturen und Prozesse Unterstützung des Selbst-Managements Stärkung der Eigenverantwortung ( Empowerment ) Gesundheitssystem Organisation der Gesundheitsversorgung Gestaltung der Leistungserbringung Aufgabenteilung im Praxisteam, strukturierter Ansatz regelm. Monitoring Entscheidungsunterstützung EbM-Leitlinien für Arzt + Patient, Kooperation Fachspezialisten klin. Informationssysteme Patientenregister, Recall, individueller Therapieplan, el. Patientenakte informierter aktivierter Patient produktive Interaktionen vorbereitetes pro-aktives Versorgungs- / Praxisteam Wagner et al verbesserte Ergebnisse 5

6 Support for Doctors Working in Teams and Groups to Improve Patient Care Percent reporting it is very important/important for improving patient care Important Very important Doctors and nurses working closely as teams, with expanded role for nurses 30 Doctors practicing with other doctors in groups, rather than on their own Note: Subgroups may not sum to total because of rounding. Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2011.

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8 Evidenz substitution of GPs by nurses 1966 to 2002: articles were screened of which 25 articles, relating to 16 studies. many studies had methodological limitations, and patient follow-up was generally 12 months or less. Doctors' workload may remain unchanged either because nurses are deployed to meet previously unmet patient need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors. Cochrane Database Syst Rev Apr 18;(2):CD

9 Einschlusskriterien: Vergleich Pflegekräfte mit Hausärzten, Pädiatern oder Geriatern Tätigkeit der Pflegekraft entspricht der des Arztes (kein zusätzlicher Sevice) Management der Patienten deligiert oder in Eigenverantwortung Alle Altersgruppen und soziale Schichten Jede Art von Kontakt, (Erstkontakt und/oder kontinuierliche Versorgung) Jede Art von Behandlungsanlass/Erkrankung Auswahl der Studien Beschränkt auf primary care, keine Spitalambulanz, Poliklinik, etc.

10 Included Eligibility Screening Identification Records identified per database searched: COCHRANE (n=362) MEDLINE (n=1348) EMBASE (n=1204) CINAHL (n=1429) Total records identified through database searching (n = 4343) Records after duplicates removed (n = 4133) Records screened (n = 3960) Potentially relevant and eligible for detailed evaluation (n = 480) Full-text examination (n = 263) Potentially relevant studies for appraisal examination 44 publications Studies included in quantitative analyses: 26 reported in 32 publications Records identified by hand searching reference lists of included studies and key reviews (n=440) Records excluded (n = 3480) Excluded with reasons (n = 217) Excluded with reasons (n = 218) Excluded at data appraisal (n = 12)

11 Herkunft der Studien

12 Patientenzufriedenheit

13 Patientenzufriedenheit 13

14 Lebensqualität 14

15 Mortalität 15

16 Study or subgroup Nurses Physicians SMD (95% CI) N Mean(SD) N Mean(SD) IV, Fixed direct costs - all patients 1 Dierick-van Daele, (36.29) (49.94) (-0.3 to -0.08) 2 Dierick-van Daele, (53.18) (67.15) (-0.13 to 0.08) Kosten direct costs - patients <65 years 3 Dierick-van Daele, (33.98) (46.58) (-0.33 to -0.12) 4 Dierick-van Daele, (33.98) (46.58) (-0.29 to -0.08) 5 Dierick-van Daele, (33.98) (46.58) (-0.32 to -0.11) direct costs - total costs of clinicians 6 Venning, (25.23) (29.62) (-0.2 to 0.02) 7 Venning, (33.41) (33.41) (-0.2 to 0.02) 8 Venning, (33.43) (33.43) (-0.19 to 0.03) 9 Venning, (25.18) (29.63) -0.1 (-0.21 to 0.01) costs per patient for drug treatment at 6 months follow up 10 Chan, (48.8) (63.1) (-0.94 to -0.34) cost per Quality of Life Years 11 Campbell, (0.69) (0.69) 0.19 (0.08 to 0.3) direct cost: study practices vs a external reference 12 Dierick-van Daele, (40.37) (40.48) (-0.14 to 0.01) 13 ierick-van Daele, (60.07) (63.03) 0.06 (-0.01 to 0.14) 14 Dierick-van Daele, (43.35) (42.99) (-0.15 to -0.01) Nurses cheaper Physicians cheaper

17 Methodische Qualität

18 Wer Nurse oder MPA? Studie Effekt PraxArt: Chronic care for osteroarthritis patients + Arthritis Rheum Dec 15;57(8): PRoMPT: Primary care Monitoring for depressive Patients Trial + Ann Intern Med Sep 15;151(6): CARAT: + Cardiovasc Diabetol Jun 15;9:23. (protocol) CAMON: Case management in oncology rehabilitation - Trials Apr 28;12:103. CHARMED: Chronic care for age-related macular degeneration? Trials Oct 11;12:221. Chronic Care for chronic obstructive lung disease CAROL Teammitglied: MPA Pflegekraft

19 Woher nehmen? Careum Working paper 1, Obsan, Schweizerisches, Gesundheitsobservatorium, Neuchâtel

20 Percent Blood Pressure Under Control Last Time Checked, by Medical Home Has Heart Disease, Hypertension, and/or Diabetes Medical home No medical home AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US Base: Has heart disease, hypertension, and/or diabetes and blood pressure checked in past year. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

21 Patient Engagement in Care Management for Chronic Condition, by Medical Home 100 Percent reporting positive patient engagement in managing chronic condition* Medical home No medical home AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US * Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care. Base: Has chronic condition. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

22 Wer macht was mit wem? Die Evidenz im Hinblick auf einen optimalen skillmix ist unzureichend quantitativ wie qualitativ Valide ökonomische Evaluationen fehlen Dennoch: es gibt Hinweise auf positive Effekte des Skillmix. Wahrscheinlich sind mehr Qualität aber keine Kostenersparnis Daher braucht es methodisch gute Studien im Schweizer Setting Für die erfolgreiche Implementierung braucht es eine adäquate Strategie