Walter Wodchis Presentation - Canadian Centre for Health Economics

Walter Wodchis Presentation - Canadian Centre for Health Economics

Es#mates of the Cost of Chronic Disease Walter P Wodchis, PhD CCHE Seminar Series University of Toronto February 20, 2015 Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) Overview 1.  Background: Chronic Disease – the 21st
century public health challenge
2.  The Public Policy Question
3.  Estimating Costs of Chronic Disease
i.  Methods
ii.  Results
iii.  Implications & Uses
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 2 Mul#morbidity Research Team YuQing Bai, Susan Bronskill, Andrea Grunier, Natasha Lane, Colleen Maxwell, Anna J. Koné Pefoyo, Yelena Petrosyan, Kednapa Thavorn ** ** credit for mul7morbidity cost results Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 3 Background: Life expectancy We are living longer Ref: Chief public health officer of Canada 2010.
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 4 Background: BeEer outcomes 80 Mortality-­‐Rate by Cause: Canada 2000-­‐2011 800 70 700 60 600 50 500 40 400 30 300 20 200 10 100 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total All Causes per 100k Number of Cause-­‐Specific Deaths per 100k Because of our success in surviving … primarily cardiovascular disease Other neoplasms Diabetes Alzheimer's AMI Other chronic IHD Heart failure Other heart disease Hypertension Stroke Asthma Other respiratory Renal failure Total, all causes of death 0 Ref: Statistics Canada Table 102-0551 Deaths and mortality rate, by selected grouped causes, age group and sex, Canada, annual.
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 5 Background: BeEer outcomes Deaths are shiOing from younger to older popula#ons 100% Propor#on of AMI Deaths by Age: 2000-­‐2011 Canada 90% 80% 90+ 70% 85-­‐89 60% 80-­‐84 50% 40% 75-­‐79 30% 70-­‐74 20% 65-­‐69 10% < 65 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Ref: Statistics Canada Table 102-0551 Deaths and mortality rate, by selected grouped causes, age group and sex, Canada, annual.
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 6 Background: BeEer outcomes Deaths are shiOing from younger to older popula#ons 100% Propor#on of Stroke Deaths by Age: 2000-­‐2011 Canada 90% 80% 90+ 70% 85-­‐89 60% 80-­‐84 50% 75-­‐79 40% 70-­‐74 30% 20% 65-­‐69 10% < 65 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Ref: Statistics Canada Table 102-0551 Deaths and mortality rate, by selected grouped causes, age group and sex, Canada, annual.
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 7 Background: Outcomes Everyone does not benefit equally… Ref: Statistics Canada Table 102-0551 Deaths and mortality rate, by selected grouped causes, age group and sex, Canada, annual.
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 8 Background: Healthcare $$ Our healthcare costs are mostly for the popula#on at older ages but also younger individuals with chronic disease Total Annual Health System Cost by Age Ontario
2008 ($Millions)
$1,200
$1,000
$800
$600
$400
$0
0
4
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
68
72
76
80
84
88
92
96
100
$200
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 9 Background: Healthcare $$ But the curves belie the distribu#on: Health Care Costs are Systema#cally Highly Concentrated 0% 1 5 10% 10 20% 34% 30% Expenditure Threshold (2009 Dollars) 35% $41,526 Expenditure Threshold (2010 Dollars) 33% Expenditure Threshold (2011 Dollars) $44,906 $42,499 40% 50% 50 66% 65% 66% 60% $7,597 70% 78% 78% $3,668 80% 98% $7,718 77% $7,961 $3,815 $3,709 98% 98% 90% $307 100% Popula7on Health Expenditure 2009 $316 Health Expenditure 2010 Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) $333 Health Expenditure 2011 10 Background: Top 1% Cost Users • 
The clinical conditions in acute care for which people in
the highest 1% of spending are treated vary by age
and include:
•  Children - cancers, low-birth weight premature
infants and agranulocytosis
• 
Adults - cancer and some chronic condition
treatments (COPD, CHF, Diabetes, Cirrhosis),
palliative
• 
Older Adults - the addition of hip-fracture, stroke,
MI, and arrhythmias and the prominence of CHF
and COPD
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 11 Background – Implica#ons •  The reasons for repeated care and ongoing health care use among top 1%/5% of users are the same reasons for which survival and later age mortality is appearing in the popula7on….Chronic condi7ons •  But it is people who are suffering from many condi7ons that makes managing any one condi7on highly problema7c. •  As a result, the issue is no longer chronic disease management for CDM programs… •  It is mul7ple chronic disease for which there are no programs i.e. Mul7morbidity Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 12 Background -­‐ Mul#morbidity •  Mul7morbidity is highly prevalent and is the norm, par7cularly for older adults (1-­‐9). •  The prevalence can reach 98% depending on the sekngs, data sources and pa7ent’s characteris7cs •  Drama7c increase during the last decades •  Prevalence of having 3 chronic diseases increased by approximately 60% between 1985 and 2005 in Dutch popula7on and by 300% among those with 4 or more condi7ons (10) •  Increasing number of people living with mul7ple chronic diseases will con7nue •  Because of successes in health care and decrease in mortality that allows people to survive to more medical condi7ons, and to live with more than one chronic illness (11-­‐12) Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 13 Background -­‐ Mul#morbidity •  High burden of illness among individuals with mul7morbidity due to the number and combina7on of condi7ons (9, 13, 14). •  Mul7morbid pa7ents exhibit lower HRQOL, higher u7liza7on of health care services, increased disability and increased mortality (1, 15-­‐19). – 
– 
– 
– 
high costs resul7ng from their frequent use of health services accounted for 75% of US health care expenditures in 2001 (20). admissions for ambulatory condi7ons and preventable complica7ons (15, 9). prescribed medica7ons (21, 6). Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 14 Mul#morbidity: Some references Useful References: 1. 
2. 
3. 
4. 
Fried Lp et al. J Clin Epidemiol. 1999 Jan;52(1):27-­‐37 For7n M et al. Health Qual Life Outcomes. 2007;5:52. For7n M et al. BMC Health Serv Res. 2010;10:111. For7n M et al. Ann Fam Med. 2005 May-­‐Jun;3(3):
223-­‐8. 5.  Glynn LG et al. Fam Pract. 2011 Oct;28(5):516-­‐23. 6.  O'Kelly S et al. Respir Med. 2011 Feb;105(2):236-­‐42. 7.  Uijen AA et al. Eur J Gen Pract. 2008;14 Suppl 1:28-­‐32. 8.  Van den Akker M et al. J Clin Epidemiol. 1998 May;
51(5):367-­‐75. 9.  Wolff JL et al. Arch Intern Med. 2002 Nov 11;162(20):
2269-­‐76. 10. Uijen Aa & Van. Eur J Gen Pract. 2008;14 Suppl 1:28-­‐32. 11. Pearson WS et al. Journal of Primary Care & Community Health. 2012;3(1):51-­‐6. 12. For7n M et al. Can Fam Physician. 2005 Feb;51:244-­‐5. 13. Broemeling AM et al. Centre for Health Services and Policy Research,2005. 14. Starfield B. Prim Health Care Res Dev. 2011 Jan;12(1):
1-­‐2. 15.  Boyd CM, For7n M. Public Health Reviews. 2010;32:451-­‐74. 16.  For7n M et al. Qual Life Res. 2006 Feb;15(1):83-­‐91. 17.  Pearson WS et al. Journal of Primary Care & Community Health. 2012;3(1):51-­‐6. 18.  Oldridge NB et al. J Clin Epidemiol. 2001 Sep;54(9):
928-­‐34. 19.  Menok A et al. J Clin Epidemiol. 2001 Jul;54(7):680-­‐6. 20.  Anderson G. Robert Wood Johnson Founda7on; 2010 21.  Laux G et al. BMC Health Serv Res. 2008;8:14. 22. Caughey GE et al. Diabetes Res Clin Pract 2010;87:385-­‐393 23. Vogeli C et al. J Gen Intern Med 2007;22 Suppl 24. Barne5 K et al. BMJ Qual Saf. 2011 Mar;20(3):275-­‐81. 25. Ekdahl A. Eur Geriatr Med. 2011. 26. Public Health Agency of Canada. Chronic Diseases. 2011 Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 15 The Public Policy Ques#on •  I will argue that mul7morbidity is the bigger issue … S7ll policy makers are faced with many compe7ng interest groups clamoring for a5en7on and looking to launch specific interven7ons that can be shown to have impact: –  Ontario Diabetes Strategy –  Memory Clinics for Demen7a –  Lung Health Strategy –  Mental Health Strategy … … … (I need to add spending es@mates to these programs) Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 16 The Public Policy Ques#on •  How can the government decide where to invest scarce resources to address the issue of chronic disease? •  What are the opportunity costs? •  I argue that opportunity costs can be es7mated by measuring high health care system burden and gaps in care where bridging the gaps in care can improve health without increasing health care costs. Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 17 The Research Ques#ons •  What do we need to know to address this policy ques7on: 1.  What are the costs associated with chronic disease in Ontario? 2.  What are the health system costs associated with mul7morbidity in Ontario? 3.  Are there remediable quality and cost implica7ons associated with chronic disease and mul7morbidity in Ontario? Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 18 Study Methods: Popula#on •  Ontario residents aged 0-­‐105 as of the index date of the study (April 1, 2009 or April 1, 2012 for different analyses) with one of the following 16 condi7ons (n=6,639,089): Cardiac arrhythmia Osteoporosis Acute myocardial infarc7on Rheumatoid arthri7s Hypertension Osteo-­‐ and other arthri7s Chronic coronary syndrome Depression Conges7ve heart failure Demen7a Stroke Cancer Asthma Diabetes Chronic obstruc7ve pulmonary disorder Renal failure -> For 2012 we added Mental health other than depression or dementia
n = 7,548,806
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 19 Study Methods: Popula#on •  Validated ICES derived chronic disease databases were used to iden7fy prevalent cases of: • 
• 
• 
• 
• 
• 
Acute Myocardial Infarc7on, Hypertension, Conges7ve Heart Failure, Asthma, Chronic Obstruc7ve Pulmonary Disorder, and Diabetes Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 20 Study Methods: Popula#on All other diagnoses: •  One acute care code in an acute care episode (Canadian Ins7tute for Health Informa7on Discharge Abstract Database, CIHI-­‐DAD), •  OR 2 relevant ICD9 codes in OHIP physician billing records •  (OR Cholinesterase Inhibitors recorded in the Ontario Drug Benefit Program, ODB -­‐ for Demen7a only) … within 2 years prior to the index date (April 1, 2009) This is generally the approach of the ICES derived databases. Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 21 Study Methods: Data Sources •  Addi7onal databases were used for several measures: –  Pa7ent demographics derived from the Registered Persons Data Base (RPDB) –  Neighborhood income, and components of the Ontario Marginaliza7on Index (Depriva7on, Ethnic Concentra7on, Dependency, Instability) derived from Sta#s#cs Canada Census data –  Hospitaliza7ons, Alternate Level of Care (ALC) days based on CIHI-­‐DAD –  ED-­‐visits based on the CIHI Na7onal Ambulatory Care Repor7ng System (NACRS) Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 22 Study Methods: Cos#ng Methods •  Cos7ng Analysis based on methods described in HSPRN Report: –  Prices from Management Informa7on System (MIS) and related sources from Ontario Ministry of Health and Long Term Care (MOHLTC) Health Data Branch, OHIP Architected Payment Database –  U7liza7on includes CIHI DAD, NACRS, Con7nuing Care Repor7ng System (CCC & LTC), Na7onal Rehabilita7on System, Home Care Database, OHIP, Assis7ve Devices Program, ODB Guidelines_on_PersonLevel_Cos7ng_May_2013, HSPRN. Toronto. May 2013. h5p://hsprn.ca/uploads/files/Guidelines_on_PersonLevel_Cos7ng_May_2013.pdf Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 23 Study Methods: Cos#ng Methods 1 2 3 Type of Service
Database
Unit
Weight
Acute Hospitalization
Same Day Surgery
Emergency Department
Ambulatory Visits
Rehabilitation Hospital
Complex Continuing Care Hospital
Long Term Care Facility
Mental Health
Home Care
Primary and Specialist (OHIP) care
Pharmaceutical
Laboratory Testing
DAD
NACRS
Weighted Case
RIW
Weighted Case CACS RIW
Cost Per Weighted Case (CPWC)
Cost Per Weighted Case (CPWC)
NACRS
Weighted Visit CACS RIW
Cost Per Weighted Visit (CPWV)
NRS
Weighted Case
RCW
Cost Per Weighted Case (CPWC)
CCRS
CCRS
Weighted Day
Day
CMI
N/A
Cost Per Weighted Day
Cost Per Diem
OMHRS
Weighted Day SCIPP CMI
OHCAS, HCD
Visit
N/A
OHIP
Visit
N/A
ODB
Visit
N/A
Unit Cost
Cost Per Weighted Day
Cost Per Visit
OHIP Fee
ODB Fee
1.  Brief episodes and hospital visits
2.  Longer term episodes
3.  Ambulatory Encounters/visits
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 24 24 Study Methods: Cos#ng Methods Acute Inpa7ent Care: CPWC & Case Cost •  Case Cost of pa7ent i at hospital j in a given year y is given by: Case Cost ji(y) = RIWi(y)* CPWCj(y)
Note: Depending on the research objec@ve, CPWCj can be calculated at the hospital, regional or provincial level. •  Cost per Weighted Case (CPWC) at hospital i in a given year y: N
j
j
j
CPWC (y) = Total Acute Care Costs (y) / Total Weighted Cases (y)∑ RIWi
where Total Weighted Cases for all pa7ents i=1...N at hospital j are given by i =1
ealth OOutcomes utcomes or nforma7on nd CCare are ((HOBIC) HOBIC) HHealth ffor BBe5er IInforma7on Leveraging the culture Using oUsing f performance excellence in he5er ealth systems aand 25 Study Methods: Cos#ng Methods Complex Con7nuing and Long Term Care Case-­‐Mix Cos#ng •  Con7nuing care pa7ents are classified into 44 Resource U#liza#on Groups (RUG-­‐IIIs) based one their clinical condi7on, physical and cogni7ve func7oning and treatment in the last 14 days. •  Each of the RUG-­‐IIIs has an associated Case Mix Index (CMI) that approximates the per day cost of caring for a resident in that RUG group rela7ve to the average resident. •  CIHI calculates each CMI based on average resource use per day for each RUG, including health care provider wage rate and staff 7me. •  Star7ng 2010, Case-­‐Mix methodology will be adopted in the Long-­‐
term Care (34 RUG groups). ealth OOutcomes utcomes or nforma7on nd CCare are ((HOBIC) HOBIC) HHealth ffor BBe5er IInforma7on Leveraging the culture Using oUsing f performance excellence in he5er ealth systems aand 26 26 Study Methods: Cos#ng Methods Complex Con7nuing & Long Term Care •  Note: CCC pa7ents are assessed every quarter with CCRS assessment including their CMI score. •  Mul7ple CMIs can be associated with pa7ent’s stay in CCC/LTC. This needs to be properly reflected in cost calcula7on. CCC/LTC utilization over time
2
1.9
1.8
1.7
1.6
1.5
CMI
1.4
1.3
1.2
1.1
1
0.9
0.8
0.7
0.6
1
2
3
Time (Quarters)
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) Actual utilization
27 Study Methods: Cos#ng Methods Visits: Physician and Home Care U#liza#on data: OHCAS, HCD, OHIP Cos#ng •  Fee-­‐for-­‐service physician visits: Visit/Procedure Cost = OHIP fee (indexed by Billing Code) Home Care Visit Cost = Provincial average cost per visit by
service type
Visit Costj= average cost per visit by service type j
or Visit Cost =No. of Hours * Provincial average cost per hour for
shifts (nursing shift, homemaking, respite )
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 28 28 Study Methods: Cos#ng Methods Primary Care Physician Capita7on Payments age
sex
Case Costi = Capitation(t ) × Multiplier
Capitation (t) is the monthly base capitation payment specific to
each type of Physician Model (FHN, FHO, FHG, CCM)
Multiplier includes age-sex specific multiplier plus any additional
(e.g. comprehensive care multiplier, old-age multiplier etc)
But need to determine use/consumption by identifying that patient
i is in Model X (FHN, FHO etc) in month t (CAPE database)
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 29 29 Study Methods: Cos#ng Methods Total alocatable system costs ≈ $30.5 of $42 B spending
Health sector costs iden7fied in the administra7ve data for all of following services: •  Inpa7ent Acute •  Same Day Surgery •  OHIP FFS •  Inpa7ent Mental Health •  Oncology and Dialysis outpa7ent •  OHIP non-­‐FFS •  Inpa7ent Rehabilita7on •  Long Term Care Home •  OHIP non-­‐physician •  Inpa7ent Complex Con7nuing Care •  Home Care •  OHIP Laboratory •  ED visits •  Assis7ve Devices •  Pharmaceu7cals (ODB and NDFP) Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 30 Study Methods: Cos#ng Methods •  Es7ma7ng costs associated with chronic condi7ons and mul7morbidity. •  Some modeling choices: –  Regression-­‐based approaches (Dependent variable cost, independent variables chronic condi7ons + control) –  Propensity-­‐matched approaches (Match pa7ents on set of covariates associated with condi7on, measure differences in cost among matched pairs) Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 31 Study Methods: Cos#ng Methods Modeling choices: •  Es7ma7ng incremental cost of each chronic disease – use matching –  Why? Because we can closely align profiles of comparators for each disease •  Mul7morbidity – use regression-­‐based –  Why? Because there is too much heterogeneity in predictors of condi7ons (factors associated with hypertension are very different from demen7a). Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 32 Study Methods: Cos#ng Methods Incremental costs of each chronic condi7on Matching: •  Hard match on age, sex, LTC/community •  Propensity match on chronic condi7ons (Collapsed ADG – largely independent of specific condi7on), rurality, geographic loca7on, neighborhood income quin7le (SES) •  Caliper 0.2 of S.D. of logit Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 33 Study Methods: Cos#ng Methods Matching: •  What should be the comparator popula7on from which to draw control pa7ents? A.  All Ontarians without condi7on (13.2 Million less popula7on with condi7on) B.  All Ontarians with one of other major chronic condi7ons (~ 7M less pop with condi7on) –  Back to the policy ques7on. Is it a ques7on of whether or not to invest (A.) or is it a ques7on of which condi7on to invest in (B.)? Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 34 Study Methods: Cos#ng Methods Mul7morbidity Cost Es7mates •  Generalized linear models (GLMs) with a log link func7on by age groups (<65 vs. ≥ 65): –  Dependent variable: total health care costs (2009 $CAD) –  Independent variable: number of medical condi7ons (1, 2, 3, 4 and 5+ condi7on (s)) –  Adjusted for sex, primary care model, rurality index, SES factors in quin7les: income, depriva7on index, ethnicity concentra7on, instability, and dependency •  Incremental costs: Ĉ2vs. Ĉ1, Ĉ3 vs.Ĉ2,Ĉ4 vs.Ĉ3, and Ĉ5 vs.Ĉ4 Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 35 Study Methods: Quality/Cost Diabetes as Example (preliminary analyses): •  Quality of Care : Composite quality –  HbA1c tests (4 in 2 years) & LDL screening (2 in 2 years) & eye exam (1 in 2 years) –  Measure quality in 2007-­‐2009 and in 2009-­‐2011 … examine costs in 2012/13 –  0 = compliant in neither; 1 = compliant in one period; 2 = compliant in both (2) periods –  Compare incremental costs with propensity matching of 1 and 2 to 0 Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 36 Results: Note -­‐ Epidemiology Mul#morbidity is increasing across all ages Popula+on$and$Count$of$condi+ons$in$2003$
1"condi1on"
2"condi1ons"
3"condi1ons"
4"condi1ons"
5+"condi1ons"
popula1on03"
200000"
175000"
150000"
125000"
100000"
75000"
50000"
Ontario Population Count
225000"
225000"
Ontario Population Count
Popula+on$and$Count$of$condi+ons$in$2009$
175000"
150000"
125000"
100000"
75000"
50000"
25000"
25000"
0"
0"
1" 5" 9" 13" 17" 21" 25" 29" 33" 37" 41" 45" 49" 53" 57" 61" 65" 69" 73" 77" 81" 85" 89"
Age$
Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 1"condi1on"
2"condi1ons"
3"condi1ons"
4"condi1ons"
5+"condi1ons"
popula1on09"
200000"
1" 5" 9" 13" 17" 21" 25" 29" 33" 37" 41" 45" 49" 53" 57" 61" 65" 69" 73" 77" 81" 85" 89"
Age$
Results: Descrip#ve Sta#s#cs •  Total health care costs 2009: $26,454,246,811 –  86% of (allocable) Ontario’s health care spending in 2009 –  Of these, 79% of total costs ($20,861,738,030) was spent on individuals with mul7morbidity –  Total costs for pa7ents with Demen7a had the highest average costs per capita ($26,722), followed by Renal Failure ($20,655) and Conges7ve Heart Failure ($18,906) (total … not incremental) Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 38 Results: Ques#on 1 1.  What are the costs associated with chronic disease in Ontario? Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 39 Results: Prevalence of Condi#ons Condi#on AMI Asthma Prevalence Apr 2012 11,994 1,902,121 Condi#on Prevalence Apr 2012 Depression 1,388,188 Diabetes 1,199,808 Cancer 981,778 Hypertension 2,755,432 Cardiac Arrhythmia 375,946 Osteoarthri7s 3,186,543 CHF 228,084 Osteoporosis 324,166 COPD 272,186 Other Mental Health Coronary Syndrome 684,762 Renal Failure 194,674 Demen7a 175,082 Rheumatoid Arthri7s 163,151 Stroke 145,156 Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 1,775,706 40 Total Annual Cost Per Person Alive at Index Results: Incremental Average Cost $1,200 $10,000 $8,000 $1,029 $1,000 $879 $6,000 $4,000 $2,000 $-­‐ Cost Per 30 days Alive (Line & $) $800 $636 $575 $519 $600 $395 $224 Long Term Care $400 $192 $126 $200 $138 $ 132 $79 $ 65 $ 37 $39 $13 $ (60) $(2,000) Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) Other $-­‐ $(200) Drug/Device Hospital Physician Total/30 days $3,000 Other $2,500 $2,000 Long Term Care Drug/
Device $1,500 $1,000 $500 Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) Osteoporosis Osteoarthri7s Asthma Depression Hypertension Rheumatoid Arthri7s Other Mental Health Coronary Syndrome Cancer Cardiac Arrythmia Diabetes Stroke Demen7a COPD AMI $(500) CHF $-­‐ Hospital Renal Failure Total Annual Cost Per Condi#on ($Millions) Results: Incremental Popula#on Cost Physician Results: Comparator Differences Comparison of Total Incremental Annual Average Costs
% Pop Control MCC Control Popl'n MCC Cost Cost Incremental Incremental Difference Case Cost Diabetes $7,708 $5,184 $5,340 $2,524 $2,254 11% $18,680 $12,162 $12,049 $6,519 $6,788 -­‐4% $4,545 $3,326 $3,769 $1,219 $680 44% $13,897 $9,662 $9,600 $4,235 $4,167 2% Osteoarthri7s $4,123 $3,672 $4,035 $450 $264 41% Rheumatoid Arth. $7,715 $6,903 $6,734 $813 $1,231 -­‐52% $10,489 $9,066 $9,279 $1,423 $1,466 -­‐3% $6,825 $7,369 $7,334 $(544) $(510) 6% CHF Hypertension COPD Cardiac Arrhythmia Osteoporosis Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) Results: Ques#on 2 2.  What are the health system costs associated with mul7morbidity in Ontario? Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 44 Results: Total Average Cost age < 65 Others Con7nuing care age ≥ 65 Drug Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) Hospital En7re cohort Physician Total ≥5 4 3 2 1 Total ≥5 4 3 2 1 Total ≥5 4 3 2 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 1 Mean annual costs ($) Costs increase rapidly with incremental condi#ons Results: Adjusted Total Health Care Costs 10,000 9,000 Mean costs ($) 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 1 2 3 4 Number of medical condi#ons < 65 years old ≥5 ≥65 years old Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 46 Results: Incremental Costs (<65 years) 4,500 4,000 Mean costs ($) 3,500 3,000 $2,073
2,500 2,000 1,500 $798
1,000 $534
500 $377
0 1 2 3 4 ≥5 Number of medical condi#ons Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 47 Results: Incremental Costs (≥65 years) 10,000 9,000 8,000 Mean costs ($) 7,000 6,000 $3,831
5,000 $1,652
4,000 3,000 $1,280
2,000 $1,026
1,000 0 1 2 3 4 ≥5 Number of medical condi#ons Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 48 Results: Ques#on 3 3.  Are there remediable quality and cost implica7ons associated with chronic disease and mul7morbidity in Ontario? Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 49 Results: Ques#on 3 Incremental Annual Cost in 2011/12 Caution! Preliminary results !
600 400 200 0 -­‐200 1 vs 0 -­‐400 2 vs 0 -­‐600 -­‐800 -­‐1000 Comparison of Diabetes Quality Compliance in either 2007 or 2009 (1) or in both (2) Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 50 Summary •  At the individual level, the highest average per-­‐
person costs were highest for renal, CHF, demen7a and stroke. •  At the popula7on level, the highest total spending was for diabetes, other mental health, hypertension, renal and CHF. •  Health care costs increased significantly with increasing numbers of medical condi7ons. •  Quality of Diabetes care can be improved without increasing total system costs. Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 51 Summary •  Measuring incremental costs associated with quality in individual condi7ons (e.g. Diabetes) holds promise, but measuring quality for mul7morbid pa7ents is a greater challenge (no clear clinical measures) •  Measures of health outcomes are essen7al to understand true opportunity costs of disease burden. Health Outcomes for in Be5er Informa7on Leveraging the culture Using of performance excellence health systems and Care (HOBIC) 52