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Prof. Joachim Szecsenyi, MD, MSc Dpt . General Practice and Health Services Research

Disease oriented programs and programs focussing on patients with multimorbid conditions in Germany. Prof. Joachim Szecsenyi, MD, MSc Dpt . General Practice and Health Services Research University of Heidelberg Hospital www.allgemeinmedizin.uni-hd.de

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Prof. Joachim Szecsenyi, MD, MSc Dpt . General Practice and Health Services Research

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  1. Disease oriented programs and programs focussing on patients with multimorbid conditions in Germany. Prof. Joachim Szecsenyi, MD, MSc Dpt. General Practice andHealth Services Research University of Heidelberg Hospital www.allgemeinmedizin.uni-hd.de Integrated Care Conference, Berlin, April 11th, 2013

  2. Overview The challenge Programms forsinglechronicdiseases andfor multimorbidity Summary

  3. Population Germany 2005/2025 Vaupel et al. Nature 2010 Abteilung Allgemeinmedizin und Versorgungsforschung

  4. Germany: Society of longevity • Life expectancyatageof 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

  5. Disease Management – the ideal Activated patient Pro-active team, evidence-based care Good cooperation primary/secondary care Active sick funds, professional organisations /feed-back trans-sectoral / integrated

  6. DMPs in Germany • 2002/2003 introduction in socialcodebook (SGB V) • Core contentsarecompulsoryforcontractsbetweeninsurersandproviders • Definedby national expert groupsatthelevelofthefederaljointcommittee • Evidencebasedclinicalguidelines • Basic dataset • Quality indicators, provisionoffeedback • Transfer between different levelsofcare • Quality criteriaforpatienteducation • Somesmalldifferences in renumeration, type offeedback etc. byregion/contract • Larger regional differencesin CME, qualitycircles

  7. DMPs in Germany • Patientsanddoctorshavetoenrol • General practitionersplay a leadingrole • Cooperationwithspecialists (ambulatoryandhospitaloutpatient) • Insurershavesomeco-steeringroleforthepatient • Financial incentivesfor sick-fundsfromthe national riskcompensationscheme • Financial incentivesforparticipatingpractices

  8. DMPs in Germany • Currently 6 diseases • Cardiovasculardisease; moduleon heartfailure) • diabetes mellitus, type 1 and2 • breastcancer • asthma • COPD • Participants • > 7 million. patients(thereof > 3.6 millionwithdiabetes 2) • More than40.000 providers

  9. What do doctorssay? • in thebeginningmuchresistance • „Cookbookmedicine“ • „Old fashioneddrugs“ • „buerocracy“ • … • Now: more positive

  10. „DMPs arerecognizedbypatientsascarethatismorestructuredandthatreflectsthecoreelementsoftheChronic Care Model andevidence-basedcounsellingto a larger extendthanusualcare.“Szecsenyi et al. Diabetes Care 2008

  11. Morbidityadjustedsurvivalofelderlypatientswith Diabetes mellitus 2 Miksch A, Laux G, Ose D, Joos S, Campbell S, Riens B, Szecsenyi J. Is there a survivalbenefitwithin a German primary-carebaseddiseasemanagementprogram? Am J Manag Care 2010; 16(1):49-54.

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

  13. More findings (for different DMPs) • Reducedmortalityandcostsformedicationandhospitalisation(Stock et al. 2010) • National evaluationprogrammeshows positive effect on non-smokingandbloodpressurecontrol • Reductionofunplannendhospitalisations (Lindner et al. 2011) • Bettercontrolof Asthma (Schneider et al. 2012) • Due to different evaluationapproaches also someinconsistentfindingswhenprogramsarecompared • DMPs haveextensivelycontributedtoestablishnewrolesandtoimprovecompetenciesofmedicalassistants in primarycarepractices: human andstructuralinvestments in primarycare • Improveduseofpathwaysofcarebetween different providersandlevelsofcare

  14. Multimorbidity • In primarycaretherule, not theexception (Fortin et al. 2006), depressionandpainoftenco-morbidity (Freund et al. 2012) • Limited applicabilityofdiseasespecificguidelines (Boyd et al. 2005) • Limited applicabilityof DMPs for multimorbid patientsathighrisk • Priorisationimportant • Riskadjusted, individual approachnecessary(i.e. case-management)

  15. The nextstepsahead.. • Case management (CM) includingtelefone-monitoringin generalpractice • Trainedmedicalassistants • Monitoringlists • Betteruseoffamilyandcommunityresources • Aims: • Improvingchroniccaremanagement • Involvingpatientsandfamilies • Continuousmonitoringandpreventionofdecompensation Foto : BMBF/PT DLR Gesundheitsforschung (Arzthelferin mit ArtMol Monitoring-Liste)

  16. Practice based CM trials in Germany DEPRESSION PromPTtrial (Gensichen et al 2009) ARTHRITIS PraxArttrial (Rosemann et al. 2007) CHRONIC HEART FAILURE HicMantrial (Peters-Klimm et al. 2011, 2012) MUlTIMORBIDITY PracMantrial Foto : BMBF/PT DLR Gesundheitsforschung (Arzthelferin mit ArtMol Monitoring-Liste)

  17. Color-coded algorithm Emergency- immediate GP contact GP visit within 24h/GP report Normal

  18. PraCManstudydesign Cluster-randomizedtrial in Baden-Württemberg (Germany) 115 practicesincluding 132 teams(approx.2.100 patients), fundedby AOK Intervention: GP-centeredcare + CM Control: GP-centredcare Population: Patientswith DM Typ II, COPD, CHFastracerconditions ≥ 75. percentilelikelihoodofhospitalization(predictivemodelling plus assessmentby GP Endpoint: Rate of all-causehospitalizations in 12 months (Freund et al. Trials 2011)

  19. Secondary outcomes • Mortality • Directandindirectcosts • Quality oflife (SF12 and EQ5D) • Quality ofcare (PACIC) • Health-relatedbehavior (smokingstatus, PE) • Medicationadherence (MARS) • Clinical Endpoints: • DM Type 2: HbA1c, fastingglucose, Hypoglycemia • COPD: Dyspnea, FEV1, exacerbations • CHF: NYHA, decompensations • Resultsavailablesummer 2013

  20. Summary • DMPs in Germany: • Care ismoreorientedaccordingtotheChronic Care Model • Practices aremore pro-active • Patientsaremoreactivated • Care ismorecoordinated • Positive effects on QoLandsurvival • Smallereffects on prescribing, hospitalisationandcosts

  21. Summary • Further developmentof DMPs toadressmultimorbidity • Development ofprimarycarepractice-basedcasemanagementfor multimorbid conditions • PraCMantrialhelpsto understandhowtoselecttherightpatientsfortheright type andintensityofintervention • Long terminvestment in primarycareteamsnecessary

  22. Thankyou!

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