In an effort to assess and advance the community-based model of chronic care, we reviewed a contemporary spectrum of Canadian chronic disease management and prevention (CDMP) programs with a participatory audience of administrators, academics, professional and non-professional providers and patients. While many questions remain unanswered, several common characteristics of CDMP success were apparent. These included community-based partnerships with aligned goals; inter-professional and non-professional care, including patient self-management; measured and shared information on practices and outcomes; and visible leadership. Principal improvement opportunities identified were the enhanced engagement of all stakeholders; further efficacy evidence for team care; facile information systems, with clear rationales for data selection, access, communication and security; and increased education of, and resource support for, patients and caregivers. Two immediate actions were suggested. One was a broad and continuing communication plan highlighting CDMP issues and opportunities. The other was a standardized survey of team structures, interventions, measurements and communications in ongoing CDMP programs, with a causal analysis of their relation to outcomes. In the longer term, the key needs requiring action were more inter-professional education of health human resources and more practical information systems available to all stakeholders. Things can be better.
On average, 50% of patients are noncompliant with drugs for chronic health problems, despite their proven efficacy. It is therefore essential to have real-world data to devise suitable methods for improving persistence with these therapies. To measure and compare persistence rates with the angiotensin-converting enzyme inhibitors (ACEIs) in primary and secondary prevention and their determinants.
Two cohorts were reconstructed from the Régie de l'assurance maladie du Québec's databases. The subjects had to be newly treated with ACEIs between January 1, 1998 and December 31, 2000. The primary prevention cohort consisted of 4596 hypertensive patients and the secondary prevention cohort of 1620 patients. The cumulative persistence rates were determined by the Kaplan-Meier method. The determinants of nonpersistence were evaluated with a Cox regression model.
The 1-year persistence rates for the nonexclusive use of antihypertensive agents by initial prescribed agent: enalapril, fosinopril, lisinopril, quinapril, and ramipril were 66%, 64%, 69%, 65%, and 72% in the secondary prevention cohort, and of 66%, 72%, 71%, 72%, and 75% in the primary prevention cohort. The adjusted 1.5-year nonpersistence rates in primary prevention were higher for quinapril and enalapril than for ramipril. In secondary prevention all of the ACEIs were equivalent in nonpersistence rate. In secondary prevention cohort, having dyslipidemia, respiratory disease, >or=4 different classes of drugs/month increase the rate of persistence. Among, the primary prevention cohort, the fact of having diabetes, dyslipidemia, respiratory disease, using >or=4 different classes of drugs/month or prior hospitalization increased significantly the rate of persistence. For both cohorts, the fact of having high number of oral doses/day or elevated health-care resource utilization decreased significantly the rate of persistence.
The 1.5-year persistence rate was low compared with the threshold of 80% generally accepted. The high-risk patients were less likely to discontinue their treatment. These results can be of help in devising methods for improving the effectiveness of these drugs in routine practice.
Health or disease management (DM) has emerged as a promising solution to improve the quality of healthcare and patient outcomes in a cost-efficient way. This solution is particularly relevant in the care of our increasing, and aging, patient populations with multiple chronic diseases. This article reviews the recent history and current status of DM in the province of Quebec and summarizes its evolving perspectives and future prospects. Most DM projects in Quebec have developed from a public-private partnership, and they have addressed several disease states. The results of completed programs confirmed the presence of care gaps--the differences between best and usual care in several disease states. They also identified process changes leading to improved practices and enhanced professional satisfaction among stakeholders. Priorities identified for further research include increased knowledge of the underlying causes of care gaps and greater concentration on the measurement of clinical, humanistic and fiscal outcomes and their causal links to DM structures and processes. Although still embryonic in Quebec and Canada, the available evidence suggests that DM partnerships are practical and functional vehicles to expedite knowledge creation and transfer in the care of whole populations of patients. Future projects offer the promise of updated knowledge and continuously improved care and outcomes.
To manage the future costs and quality of care, a health strategy must move beyond the individual, acute care model and address the care of older people with chronic, and often multiple, diseases. This strategy must address the issue of care gaps, ie, the differences between best care and usual care. It should also embrace broad partnerships in which providers may be a cross-disciplinary team of nurses, physicians and pharmacists; the patient partners may include all patients in the community with a disease or group of diseases; and the system managers should work with all to seek improved long-term care and share the governance of interventions and resources. This partnership is activated by repeated and widely communicated measurements of actual practices and outcomes, facilitating rapid knowledge gain and translation, including unmasking the invisible wait list of unmeasured care gaps. It drives continuous improvement in practices and outcomes. The time is right for such care models. There is increasing evidence of their clinical and financial benefits. There is a clear and immediate opportunity to evaluate them as part of a health strategy for effective chronic care in our aging society. Things can be better.