Chronic Conditions The need for a comprehensive public health - - PowerPoint PPT Presentation

Chronic Conditions

The need for a comprehensive public health approach

Olga McDaid

PhD Scholar HRB PhD Programme for Health Services Research, Trinity College Dublin

Supervisors

• Prof. Charles Normand, Dr.Alan Kelly, Dr.Susan Smith

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Chronic condition burden in Ireland

Population prevalence projections for selection of chronic conditions 2010-2020

Estimated increase in the number of adults aged 18+ who self-report a doctor-diagnosed condition in the previous 12 months. SLAN 2007 (ref study). Diabetes CHD HBP Stroke CAO N increase % increase 30,000 28% 24,000 31% 103,000 24% 6,000 27% 19,000 23%

Changing demographics

 Growing population  Ageing population – proportion of older people in Ireland expected to double by 2050

Chronic condition burden – 40% increase by 2020

Multimorbidity – defined as 2 or more co-occurring

conditions in an individual

‘the norm, not the exception’ (Fortin et al, 2005)

Public/population health perspective

Comorbidity OR Multimorbidity?

Multimorbidity - an overarching global term referring to all conceptualisations of co-occurring conditions within an individual.

Multimorbidity Implications

QoL, SRH, physical functioning, & premature mortality

Healthcare utilisation, complexity, polypharmacy & costs

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25 CHRONIC CONDITIONS IN TILDA 2010 (50yrs +, n = 8,162)

High Blood Pressure 32.4 % Heart murmur 4.6% Arthritis 27.6 % Anxiety 4.6% High cholesterol 24.7 % Stroke/TIA 3.6 % Falls/fracture 17.7 % Varicose Ulcer 3.5 % Chronic respiratory disease 12.2 % Hearing impairment 2.7 % Osteoporosis 9.3 % Other mental health conditions 2.4% Incontinence 9.2 % Vision impairment 2.1 % Angina/heart attack 8.5 % Alcohol or substance abuse 1.6 % Diabetes 8.0% Heart failure 1.1% Stomach ulcer 7.2% Memory disorders 0.7 % Abnormal heart rhythm 7.1 % Parkinson's 0.5 % Cancer 6.1 % Liver disease 0.5% Depression 5.2%

MULTIMORBIDITY MEASURE IN TILDA

Chronic conditions -

physical diseases, mental health, geriatric syndromes and impairments

Inclusion criteria

 Chronicity, prevalence, and inclusion in other measures.  Produce consequences, or sequelae

Self-rated health

‘fair or poor’

Quality

• f

Life

CASP 19

Physical function

ADL or IADL

Multimorbidity prevalence

➟ Threshold multimorbidity (2+) – 53.8% ➟ Physical-mental health multimorbidity – 7.5% ➟ Mental health multimorbidity – 3.3% ➟ Concurrent condition counts

2 conditions = 21.0% (95% CI’s 20.0-21.9%, n=1,731) 3 conditions = 14.1% (95% CI’s 13.3-14.9%, n=1,151) 4 conditions = 8.8% (95% CI’s 8.1-9.5%, n=697) 5 conditions = 4.7% (95% CI’s 4.2-5.2, n=378) 6+ conditions = 5.1% (95% CI’s 4.6-5.6%, n=399)

Population prevalence of all type multimorbidity (50 yrs+)

Mean number of conditions by sex and age sex and age (TILDA 2010)

4 3 2 1 1 2 3 4

50 years 51 years 52 years 53 years 54 years 55 years 56 years 57 years 58 years 59 years 60 years 61 years 62 years 63 years 64 years 65 years 66 years 67 years 68 years 69 years 70 years 71 years 72 years 73 years 74 years 75 years 76 years 77 years 78 years 79 years 80 years 81 years 82 years 83 years 84 years 85 years 86 years 87 years 88 years 89 years 90 years

Male Female

Prevalence of concurrent multimorbidity by deprivation

(SAHRU deprivation deciles 1=most affluent, 10=most deprived)

5 10 15 20 25 30

None One Two Three Four Five Six +

Percentage % Number of conditions

1 & 2 3 & 4 5 & 6 7 & 8 9 & 10

Multimorbidity Prevalence

Threshold multimorbidity (2+)

• Rural areas
• Living alone
• Permanently sick and disabled

Physical-mental health multimorbidity

• Permanently sick and disabled
• Separated or divorced
• Employment (self-employment) protective

Cluster analysis

Dendrogram Legend

C1 Angina C2 Heart attack C3 Heart failure C4 Stroke C5 Trans ischaemic attack C6 A heart murmur C7 An abnormal heart rhythm C8 Diabetes C9 High blood pressure C10 High cholesterol C11 Falls C12 Fractures C13 Incontinence C14 Vision impairment C15 Hearing impairment C16 Chronic lung disease C17 Asthma C18 Osteoarthritis C19 Rheumatoid arthritis C20 Unclassified arthritis C21 Osteoporosis C22 Cancer C23 Stomach ulcers C24 Varicose ulcers C25 Alcohol or substance abuse C26 Anxiety C27 Depression C28 Other mental health conditions

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Effect of Multimorbidity on healthcare services

Healthcare services

• GP visits
• Outpatient visits
• Emergency Department
• Hospital Stays
• Polypharmacy

Two-part modeling process controlled for range of covariates Findings:

• Substantial burden of care
• Multimorbidity is a significant driver of healthcare in Ireland, across all

healthcare outcomes examined, even after controlling for age effects and other need factors such as disability and frailty.

• In general, appears to be a cascade effect of increasing levels of multimorbidity
• n HCU, however the independent effect on propensity of service use and

intensity of use varies according to type of healthcare services

Predicted probability of propensity to visit a GP by increasing levels of multimorbidity

Predicted probability of intensity of GP use by increasing levels of multimorbidity

10/10/2013

• Focus on ‘silo’s of conditions or broader outcome constructs
• Parity of mental and physical health conditions
• Need to design effective programmes to prevent/delay the onset of complex health status

in later life

• Accurate estimates of population prevalence and incidence as well as condition patterns
• r “clusters” – provide a more informed approach to chronic condition burden and

prevention at a population level

• Design an appropriate healthcare system to adapt to increasing population health demand

and projected complexity – informed by a population health approach to chronic condition

High burden of multimorbidity at a population level in Ireland - associated with negative impacts on individuals and society.

The need for a comprehensive public health approach

LIMITATIONS AND NEXT STEPS…

 Data are self-reported  Severity of conditions  Economic data is limited

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Predictors of multimorbidity – longitudinal data

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Mental & physical health – parity

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Social patterning of multimorbidity

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Comparative population level data

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Patient intervention

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Clinical and policy guidelines

10/10/2013

Acknowledgements TILDA - Funded by - Department of Health (ROI), The Atlantic Philanthropies, Irish Life. Thanks to:  Brendan Whelan (TILDA) Howard Johnston (Health Atlas) & Davida de la Harpe (HSE) Alan Kelly & Conor Teljeur (SAHRU) This work was funded by the Health Research Board in Ireland under Grant No. PHD/2007/16.

Thank you for listening…

Contact: mcdaido@tcd.ie

Clinical perspective

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• Management of complex patients
• Increased prescribing
• Treatment regimes based on RCTs that have excluded

complex patients

• Healthcare systems adopt a vertical approach
• Fragmentation of care
• Investigations driven by a focus on co-morbidity