Präsentation - Swiss Family Docs Conference • Home

Skillmix – wieviel
Teamansatz braucht es
wirklich
in der Hausarztpraxis?
Prof. Dr. Dr. Thomas Roseman
Institut für Hausarzutmedizin, Universität Zürich
Agenda
Versorgung chronisch Kranker - wo stehen wir?
Wer macht was - wie ist die Evidenz?
Woher nehmen - eine Ressourcenfrage?
Ausblick
Diabetics who received recommended
preventive care services
Base: Adults with diabetes
Percent received all four diabetes services*
80
67
59
60
40
36
55
43
40
39
31
20
0
AUS
CAN
FR
GER
NETH
NZ
UK
* Hemoglobin A1c checked in past six months; feet examined for sores or irritations in
past year; eye exam for diabetes in past year; and cholesterol checked in past year.
Data collection: Harris Interactive, Inc. 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.
US
Blood Pressure Under Control Last Time Checked
Has Heart Disease, Hypertension, and/or Diabetes
Percent yes, under control
100
85
85
85
84
84
83
80
79
78
74
69
69
60
40
20
0
CAN
NOR
US
NZ
SWE
FR
AUS
GER
NETH SWIZ
Base: Has heart disease, hypertension, and/or diabetes and blood pressure checked in past year.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
UK
Chronic Care-Model (CCM)
Gemeinwesen
Ressourcen,
Entscheidungsstrukturen und
Prozesse
Gesundheitssystem
Organisation der
Gesundheitsversorgung
Entscheidungs- klin. InformationsUnterstützung des
Gestaltung der
Selbst-Managements Leistungserbringung unterstützung
systeme
Aufgabenteilung
Patientenregister,
EbM-Leitlinien
Stärkung der
im
Praxisteam,
Recall,
für Arzt + Patient,
Eigenstrukturierter Ansatz
individueller
Kooperation
verantwortung
regelm. Monitoring Fachspezialisten
Therapieplan,
(„Empowerment“)
el. Patientenakte
informierter
aktivierter
Patient
Wagner et al. 2000
produktive Interaktionen
verbesserte Ergebnisse
vorbereitetes
“pro-aktives“
Versorgungs- /
Praxisteam
5
Support for Doctors Working in
Teams and Groups to Improve Patient Care
Percent reporting it is very important/important for improving patient care
100
Important
86
Very important
75
44
50
25
65
36
42
30
0
Doctors and nurses working closely as Doctors practicing with other doctors in
teams, with expanded role for nurses
groups, rather than on their own
Note: Subgroups may not sum to total because of rounding.
Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2011.
Evidenz – substitution of GPs by nurses
1966 to 2002: 4.253 articles were screened of which 25
articles, relating to 16 studies
…. many studies had methodological limitations, and patient
follow-up was generally 12 months or less.
…Doctors' workload may remain unchanged either because
nurses are deployed to meet previously unmet patient need or
because nurses generate demand for care where previously
there was none. Savings in cost depend on the magnitude of
the salary differential between doctors and nurses, and may be
offset by the lower productivity of nurses compared to
doctors.
Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271.
Auswahl der Studien
Einschlusskriterien:
•
Vergleich Pflegekräfte mit Hausärzten, Pädiatern oder
Geriatern
•
Tätigkeit der Pflegekraft entspricht der des Arztes (kein
zusätzlicher Sevice)
•
Management der Patienten deligiert oder in
Eigenverantwortung
•
Alle Altersgruppen und soziale Schichten
•
Jede Art von Kontakt, (Erstkontakt und/oder
kontinuierliche Versorgung)
•
Jede Art von Behandlungsanlass/Erkrankung
•
Beschränkt auf “primary care”, keine Spitalambulanz,
Poliklinik, etc.
Identification
Screening
Records identified per database searched:
COCHRANE (n=362) MEDLINE (n=1348)
EMBASE (n=1204) CINAHL (n=1429)
Records identified by hand searching
reference lists of included studies and
key reviews (n=440)
Total records identified through database
searching (n = 4343)
Records after duplicates removed (n = 4133)
Records screened (n = 3960)
Records excluded
(n = 3480)
Potentially relevant and eligible for
detailed evaluation (n = 480)
Eligibility
Excluded with reasons
(n = 217)
Full-text examination (n = 263)
Excluded with reasons
(n = 218)
Potentially relevant studies for appraisal examination
44 publications
Included
Excluded at data
appraisal (n = 12)
Studies included in quantitative analyses:
26 reported in 32 publications
Herkunft der Studien
Patientenzufriedenheit
Patientenzufriedenheit
13
Lebensqualität
14
Mortalität
15
Kosten
Study or subgroup
N
direct costs - all patients
1
Dierick-van Daele, 2009 747
2
Dierick-van Daele, 2009 747
Nurses
Mean(SD)
Physicians
N
Mean(SD)
SMD (95% CI)
IV, Fixed
31.94(36.29)
144.4(53.18)
650
650
40.15(49.94)
145.87(67.15)
-0.19 (-0.3 to -0.08)
-0.02 (-0.13 to 0.08)
direct costs - patients <65 years
3
Dierick-van Daele, 2009 747 161.57(33.98)
4
Dierick-van Daele, 2009 747 161.57(33.98)
5
Dierick-van Daele, 2009 747 161.57(33.98)
650
650
650
170.75(46.58)
168.9(46.58)
170.1(46.58)
-0.23 (-0.33 to -0.12)
-0.18 (-0.29 to -0.08)
-0.21 (-0.32 to -0.11)
direct costs - total costs of clinicians
6
641
11.71(25.23)
Venning, 2000
7
641
17.69(33.41)
Venning, 2000
8
641
18.11(33.43)
Venning, 2000
9
641
11.29(25.18)
Venning, 2000
651
651
651
651
14.14(29.62)
20.68(33.41)
20.7(33.43)
14.11(29.63)
-0.09 (-0.2 to 0.02)
-0.09 (-0.2 to 0.02)
-0.08 (-0.19 to 0.03)
-0.1 (-0.21 to 0.01)
costs per patient for drug treatment at 6 months follow up
10
86
89
35.5(48.8)
71.7(63.1)
Chan, 2009
cost per Quality of Life Years
11
673
3.18(0.69)
Campbell, 1998
670
-0.64 (-0.94 to -0.34)
3.05(0.69)
0.19 (0.08 to 0.3)
direct cost: study practices vs a external reference
12
Dierick-van Daele, 20091397 165.69(40.37) 1350 168.25(40.48)
13
ierick-van Daele, 2009 1397 145.08(60.07) 1350 141.09(63.03)
14
Dierick-van Daele, 20091397 35.76(43.35) 1350 39.21(42.99)
-0.06 (-0.14 to 0.01)
0.06 (-0.01 to 0.14)
-0.08 (-0.15 to -0.01)
-4
-2
Nurses cheaper
0
2
P hysicians cheaper
4
Methodische Qualität
Nurse oder MPA – eine Frage der
Aufgabe und der Ressourcen
Studie
Effekt
PraxArt:
Chronic care for osteroarthritis patients
+
Arthritis Rheum. 2007 Dec 15;57(8):1390-7.
PRoMPT:
Primary care Monitoring for depressive Patients Trial
+
Ann Intern Med. 2009 Sep 15;151(6):369-78.
CARAT:
+
Cardiovasc Diabetol. 2010 Jun 15;9:23. (protocol)
CAMON:
Case management in oncology rehabilitation
+
Trials. 2011 Apr 28;12:103.
CHARMED:
Chronic care for age-related macular degeneration
?
Trials. 2011 Oct 11;12:221.
Chronic Care for chronic obstructive lung disease
CAROL
Teammitglied: MPA Pflegekraft
?
Woher nehmen?
Careum Working paper 1, Obsan, Schweizerisches, Gesundheitsobservatorium, Neuchâtel 2009
19
Role of Nurse in Care Management
Base: Adults with any chronic condition
Percent said nurse is regularly involved in management of condition
80
60
48
40
20
18
22
29
26
33
33
13
0
AUS
CAN
FR
GER
NETH
Data collection: Harris Interactive, Inc.
Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.
NZ
UK
US
“Physician workload and practice size”
N=1188 practices
Blood Pressure Under Control Last Time Checked,
by Medical Home
Has Heart Disease, Hypertension, and/or Diabetes
Percent
Medical home
100
88
85
80
82 84 82
71
79
75
84 83
78
88
No medical home
86
80
90
82
76
73
70
70
65
58
60
40
20
0
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
Base: Has heart disease, hypertension, and/or diabetes and blood pressure checked in past year.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
UK
US
Patient Engagement in Care Management for
Chronic Condition, by Medical Home
100
Percent reporting positive patient
engagement in managing chronic
condition*
Medical home
No medical home
80
76
73
67
60
59
56
54
51
47
40
38
38
34
33
24
29
51
45
32
27 29
20
46
16
15
NOR
SWE
0
AUS
CAN
FR
GER
NETH
NZ
SWIZ
UK
* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make
treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.
Base: Has chronic condition.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
US
Die Zukunft gehört dem Team
• Die Evidenz im Hinblick auf einen optimalen skillmix ist
unzureichend – quantitativ wie qualitativ
• Valide ökonomische Evaluationen fehlen
• Dennoch: es gibt Hinweise auf positive Effekte des
Skillmix. Wahrscheinlich wird mehr „Qualität“ erzielt aber
keine Kostenersparnis
• Es braucht methodisch gute Studien im Schweizer Setting
• Die Ressourcenfrage darf nicht unberücksichtigt bleiben
• Für die erfolgreiche Implementierung braucht es eine
adäquate Strategie