Programme de disease management et organisation des soins - - PowerPoint PPT Presentation

▶
programme de disease management et organisation des soins
SMART_READER_LITE
LIVE PREVIEW

Programme de disease management et organisation des soins - - PowerPoint PPT Presentation

Feb 17, 2024 225 likes •516 views

Programme de disease management et organisation des soins ambulatoires en Allmagne Prof. Joachim Szecsenyi, MD, MSc Dpt. General Practice and Health Services Research University of Heidelberg Hospital www.allgemeinmedizin.uni-hd.de Colloque

slide-1
SLIDE 1

Programme de disease management et

  • rganisation des soins ambulatoires en Allmagne
  • Prof. Joachim Szecsenyi, MD, MSc
  • Dpt. General Practice and Health Services Research

University of Heidelberg Hospital www.allgemeinmedizin.uni-hd.de Colloque IRDES, PRosPERE, drees, Paris, 21 oct. 2009

slide-2
SLIDE 2
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Overview

Disease Management Programmes

(DMPs – The German way) Concept Implementation

Summary Results / Evaluation Processes and outcomes Patients perspectives

slide-3
SLIDE 3
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Germany

  • Population: approx. 80 million
  • Doctors in ambulatory care: 135.000

– General practitioners (GPs)/gen.internists:55.0005.000

  • 90% of population insured by statutory sick funds

(„assurance maladies“) with a comprehensive health baske for patients

  • In some regions gate-keeping models (GP centred care)
  • Ageing population, increase of chronic diseases
  • 2002/2003: introduction of disease-management

programmes for chronically ill patients nationwide

slide-4
SLIDE 4
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Disease Management – the ideal

Activated patient Good cooperation primary/ secondary care Pro-active team, evidence-based care Active sick funds, professional

  • rganisations /

Feed-back

trans-sectoral / integrated

slide-5
SLIDE 5
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

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 differences in CME, quality circles
slide-6
SLIDE 6
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

DMPs in Germany

  • Patients and practitioners have to enrol
  • General practitioners play a leading role
  • Cooperation with specialists (ambulatory and hospital
  • utpatient)
  • Insurers have some steering role for the patient
  • Substantial financial incentives for sick-funds

(national risk compensation scheme) until 2008, now

  • nly € 180/per year per patient
  • Financial incentives for practices (approx. € 100 per

year per patient on top of fees)

slide-7
SLIDE 7
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

  • Currently 6 diseases

– CVD (new: module on heart failure) – diabetes mellitus, type I and II – breast cancer – asthma – COPD

  • Participants

– 5.773.000 patients (April 2009) – Approx. 6.8% of all insurants – More than 60.000 providers (GPs, specialists)

slide-8
SLIDE 8
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

DMP – some elements

slide-9
SLIDE 9
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

  • Guidelines/clinical

pathways for referrals to specialists

– Diabetologist – Opthamologist – Foot specialist/surgeon – etc-

slide-10
SLIDE 10
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

  • What do doctors say?

– in the beginning much resistance – „Cookbook medicine“ – „Old fashioned drugs“ – „burocracy“ – … – Now: more positive

slide-11
SLIDE 11
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Evaluation

  • Nationwide obligatory statutory evaluation
  • No control group
  • Patients incompletely followed over time
  • More sophisticated evaluation in some

projects

  • I will present to you some examples
slide-12
SLIDE 12
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Systolic blood pressure, CVD patients

  • Systolic blood pressure since enrolment in

DMP

Gesetzliche Evaluation, Bundesauswertung zu den Zwischenberichten der AOK-Programme für Patienten mit KHK, 2008

slide-13
SLIDE 13
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Stop smoking, CVD patients

  • % smoking of those who were smokers at enrolment

Gesetzliche Evaluation, Bundesauswertung zu den Zwischenberichten der AOK-Programme für Patienten mit KHK, 2008

slide-14
SLIDE 14
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

  • QoL

– % of patients without episodes of pain in the breast

Patients in the DMP for CVD

Statutory nationwide evaluation for AOK patients, 2008

slide-15
SLIDE 15
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Cardiac events

  • New events, patients in the DMP for CVD

heart attack Acute Coronary syndrome

Statutory nationwide evaluation for AOK patients, 2008

slide-16
SLIDE 16
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

ELSID study on DMP diabetes m. Type II

  • Comparative longitudinal study
  • 2 regions
  • More than 20.000 patients
  • More than 500 practices
  • Routine claims data
  • For subsets of patients

– Surveys (i.e. PACIC – Patient Assessment of Chronic Illness Care) – Clinical data, mortality data

  • Observational arm (DMP vs. Routine care)
  • Controlled arm (DMP vs. optimized DMP,

restructered organisation within the practice)

slide-17
SLIDE 17
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

„In the last 6 months …

… I was involved in planning care for my illness.“ n=1.312 p=0,04

Gestaltung des Behandlungsplans

25,2 21 56,3 30 18,5 49 10 20 30 40 50 60 So gut wie nie/meistens nicht Gelegentlich Meistens/fast immer Antworten PACIC Prozent DMP Nicht-DMP

slide-18
SLIDE 18
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

„In the last 6 months…

… I got support in setting goals for my diet and my physical activities n=1.302 p<0,001

Konkrete Ziele

23,2 23,2 53,6 34,6 23,6 41,8 10 20 30 40 50 60 So gut wie nie/meistens nicht Gelegentlich Meistens/fast immer Antworten PACIC Prozent DMP Nicht-DMP

slide-19
SLIDE 19
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

  • In all Items of the PACIC and in the sum score there

a more coordinated care according to the Chronic Care Model was shown for diabetic patients in the DMP vs. routine care

  • Motivational counselling according to the 5A concept

was better in the DMP vs. routine care

  • „DMPs are recognized by patients as care that is

more structured and that reflects the core elements

  • f the Chronic Care Model and evidence-based

counselling to a larger extend than usual care.“

  • Szecsenyi J et al. Diabetes Care 2008
slide-20
SLIDE 20
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Ose D, Wensing M, Szecsenyi J, Joos S, Hermann K, Miksch A , Diabetes Care. 2009

DMP as a „safeguard“ for patients with co-morbidity ?

slide-21
SLIDE 21
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

  • Matched pairs comparison of patients with

diabetes mellitus type II (DMP vs. routine care) N=1.927 matched-pairs Matching criteria Age: mean=70,7 years Sex: 60,3% woman Insurance status: penioneer (yes/no) Morbidity (Pharmacy Cost Groups, Diagnostik Cost groups) Is there a Survival benefit ?

slide-22
SLIDE 22
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

  • A matched-pairs comparison of more than

1.000 patients showed a significant (and relevant) survival benefits for older patients with diabetes mellitus in the DMP vs. non- DMP

  • Results submitted and therefore not

displayed here

slide-23
SLIDE 23
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Do DMPs save money?

  • Evaluations of some sick funds show

moderate cost reduction DMP vs. Non-DMP, especially for diabetes patients with higher morbidity

  • ELSID study shows overall cost reduction for

DMP diabetes mellitus type II vs. routine care due to lower costs for hospitalisation (but there are higher costs for prescribing)

slide-24
SLIDE 24
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

The next steps we are taking..

  • Telefone-monitoring in

general practice

  • Trained practice

assistants/nurses

  • Monitoring lists
  • Better use of family and

community resources

  • Aims:

– Improving primary care practices – Involving patients and families – Continuous monitoring and prevention of decompensation

Foto : BMBF/PT DLR Gesundheitsforschung (Arzthelferin mit ArtMol Monitoring-Liste)

slide-25
SLIDE 25
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Example Heart Failure Early detection of decompensation

slide-26
SLIDE 26
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

Very promising results from cluster randomized controlled trials Positive effects on patient related

  • utcomes and quality of care

DEPRESSION PromPT trial (Gensichen et al, Ann Int Med 2009) ARTHRITIS PraxArt trial (Rosemann et al. Arthr Rheum2007) CHRONIC HEART FAILURE HicMan trial (Peters-Klimm et al. (in review) MUTIMORBIDITY PracMan trial started Sept. 2009

Foto : BMBF/PT DLR Gesundheitsforschung (Arzthelferin mit ArtMol Monitoring-Liste)

slide-27
SLIDE 27
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

  • Advantages of disease management in

primary care/general practice:

  • 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

slide-28
SLIDE 28
  • Prof. J. Szecsenyi, Dpt. General Practice & HSR, Heidelberg University Hospital

Paris, 21 octobre 2009

  • General practice is the right place for

managing DMPs,

– Addresses target population – Equity, no „cherry picking“ – Trusted by patients – Enhanced role for practice assistants/nurses – Cooperation with specialists – Partnering with sick funds and professional

  • rganisations
  • Long term investment in primary care

necessary

Summary