Prior to engaging in this discussion, read Chapters 10 and 11 in your text as well as the “Steps for Effective Discharge Planning” article.
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11ch_atlas_disability.pdf
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Learning Objectives
1. Identify the differences between disease management and integrated care programs
2. Discuss the types and prevalence of chronic illness and disability (CID) and its potential impact on economic growth
3. Compare and contrast the different models used to understand CID
4. Discuss the various incentives to improve CID care and reduce costs
5. Compare different care systems for patients with CID in Europe and the United States
6. Discuss new research programs aimed at understanding and reducing the impact of CID
International Approaches to Dealing With Chronic
Illness and Disability
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CHAPTER 11Section 11.1 Introduction to International Approaches to Chronic Illness and Disability
11.1 Introduction to International Approaches to Chronic Illness and Disability
The United States has experienced four decades of growth in chronic illness and disability (CID), which now accounts for a majority of health-related diseases and deaths. Although the United States was the first to reach this milestone, other developed and many devel- oping countries are catching up. According to the World Health Organization (WHO), 63% of deaths in 2008 were attributable to noncommunicable diseases (NCDs), principally cardiovascu- lar disease, diabetes, cancer, and chronic respiratory ailments (WHO, 2011c). However, in con- trast to popular belief, only 20% of these deaths occured in high-income countries, whereas 80% occured in low- and middle-income countries, where the majority of world’s population resides (WHO, 2005).
The management of CID is one of the most important challenges the world faces. As the global population ages, the prevalence of CID is expected to increase significantly, particularly in lower income countries. The social and economic implications of this epidemic are profound. Some see it as the most significant (though predictable) potential crisis that governments will confront. Currently, the management of CID accounts for 2% to 15% of national health expenditures in some European countries. Indeed, millions of people are pushed below the poverty line each year because of higher out-of-pocket expenses for medications and health care services.
How CID is managed varies from country to country and within countries. Approaches include care coordination led by a general practitioner (GP), multidisciplinary teams, managed discharge, nurse-led care, and case management. Newer approaches such as disease management programs (DMPs) and integrated care programs are also receiving attention. This chapter discusses these approaches in more detail. In addition, some countries are experimenting with registries, while others are integrating surveillance for selected risk factors (blood glucose level, blood pressure, cholesterol, alcohol and tobacco use, poor diet, overweight and obesity, and physical inactivity) into their national health care information databases.
Governments, civil society, and the private sector are forging partnerships and collaborations in order to implement key activities related to CID. Also, funds to influence risky behaviors related to CID are being developed, and payers, providers, and patients are being offered incentives for compliance and improved outcomes. Almost all these new strategies have as their key component involving the patient in developing treatment plans and goals, prevention, and targeted interven- tions based on standardized guidelines. The strategies aim to enhance functional status, improve quality of life, and prolong life. However, among countries, these endpoints are approached differently.
Building on the context of what the student has already learned about how chronic illness is viewed, experienced, and treated in the United States, this chapter discusses these subjects from an international point of view. The content is intended to help the student view the problem of chronic disease in a broader, more global context, as it truly is a world problem, not just a U.S. problem, and certainly will loom larger in the future.
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CHAPTER 11Section 11.2 How Big a Problem Is CID?
11.2 How Big a Problem Is CID?
Chronic diseases cause more deaths than any other type of disease. CID is expected to increase as the worldwide population grows and its average age increases. Throughout the world, society makes elevated blood pressure, high cholesterol, and obesity equally “avail- able” (that is, the environmental conditions are contributing to its development). Thus, diseases previously associated mostly with wealthy populations (cardiovascular disease, cancer, chronic respiratory disease, and diabetes) are fast becoming diseases of the poor. Of the projected 64 million deaths worldwide in 2015, 41 million (64%) are expected to result from chronic disease (WHO, 2005). The economic impact of CID—particularly in developing countries—will be substan- tial if not adequately addressed.
Global Growth Comparison With the United States As of August 19, 2013, the U.S. population stood at 316.5 million, and the world population, at 7.1 billion (U.S. Census Bureau, 2013). In the United States, about 14% of this 316.5 million are 65 years old and older, and the number of seniors is growing rapidly. Chronic disease touches the lives of just about every American in one way or another. Approximately 47% (133 million) of the U.S. population suffers from some form of chronic disease (CDC, 2005); that percentage is expected to increase to 49% by 2030 (see Figure 11.1). The Centers for Disease Control and Prevention (CDC, 2006b) reported that about one fourth of individuals with chronic conditions report limitations in one or more daily activities, a cohort size that is also increasing.
Figure 11.1: Percentage of the U.S. population with chronic conditions, 1995–2030
Just about every American is affected by chronic diseases, either directly or indirectly, and approximately 47% suffer from a chronic condition.
Source: Wu, S-Y., & Green, A. (2000, October). Projection of chronic illness prevalence and cost inflation. RAND Corporation.
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CHAPTER 11Section 11.2 How Big a Problem Is CID?
The cost of chronic disease to the U.S. economy is currently estimated at $1.3 trillion annually and is expected to balloon to $4.2 trillion by 2023 (DeVol & Bedroussian, 2007).
Compared with their European counterparts, twice as many older adults in the United States have heart disease and arthritis. The U.S. population also has higher rates of cancer (12.2% com- pared with 5.4% of Europeans) and diabetes (16% versus 11% of older Europeans). The most common reasons given for these differences are tobacco use and obesity, both of which are more prevalent in the United States. About one third of older U.S. adults are classified as obese versus 17.1% of older Euro- peans, and 53% are active or for- mer smokers compared with 43% of European adults (Thorpe, Howard, & Galactionova, 2007).
In the United States, 72.5 million adults and 12.5 million children and adolescents are obese (CDC, 2010a, 2011e). Obesity is a growing con- cern worldwide, particularly the rapid increase reported in low- and middle-income countries as they transition to western diets high in processed food, fats, salt, and sugar. Obesity is also associated with higher medical costs, a lower quality of life, and an increased disease burden and mortality rate (see Figure 11.2).
Digital Vision/Thinkstock
Consuming processed food promotes obesity that leads to cardiovascular and glucose-processing diseases.
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CHAPTER 11Section 11.2 How Big a Problem Is CID?
Figure 11.2: Percentage of deaths attributable to raised body mass index by country, all ages, 2002
Obesity is a growing concern worldwide.
Source: Beaglehole, R., & Epping-Jordan, J. (Eds.) (2005). Preventing chronic diseases: A vital investment, 53. Geneva, Switzerland: World Health Organization, p. 53. Retrieved from http://www.who.int/chp/chronic_disease_report/full_report.pdf. Copyright . World Health Organization (WHO). Used by permission.
The cost of chronic disease is enormous, accounting for 75% of U.S. health care spending (CDC, 2013d) and is predicted to grow as the nation’s average age increases. These persistent conditions favorable to CID lead to death, lifelong disability, compromised quality of life, lost economic oppor- tunity, and burgeoning health care costs. Public and private total health care spending amounted to a staggering $1.5 trillion in 2005 (CDC, 2005) and is expected to reach $6 trillion by midcentury (DeVol & Bedroussian, 2007).
Within the U.S. health care system, Medicare beneficiaries experienced a high prevalence of chronic disease, according to a 2010 study. The most common diseases were hypertension (58%), high cholesterol (45%), heart disease (31%), arthritis (29%), and diabetes (28%). Of greater concern, more than two thirds of these individuals had at least two or more chronic conditions (Centers for Medicare & Medicaid Services [CMS], 2012). They also represented a dispropor- tionate share of Medicare spending. In 2010, the average annual spending for Medicare fee-for- service (FFS) beneficiaries was $2,025 for those with one chronic condition or none (32% of bene- ficiaries), $5,698 for those with two to three conditions (32%), $12,174 for those with four or five conditions (23%), and $32,658 for the remaining 14% with six or more chronic conditions (CMS, 2012). This last group also accounted for 70% of all Medicare hospital readmissions (CMS, 2012).
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CHAPTER 11Section 11.2 How Big a Problem Is CID?
Progress toward controlling these chronic diseases has been made but has not been consistent. For example, the American Recovery and Reinvestment Act of 2009 allotted $650 million for reducing the risk factors for, and promoting measures to prevent, chronic disease by encouraging higher levels of physical activity, improving nutrition, lowering the prevalence of overweight and obesity, and decreasing tobacco use and exposure to secondhand smoke (U.S. Department of Health and Human Services, 2013d).
Also, although the United States has seen a 60% decline in age-adjusted death rates from cardio- vascular disease as a result of reduced tobacco use, improved blood pressure, cholesterol control, and new and more effective treatments (Halpin, Morales-Suarez-Varela, & Martin-Moreno, 2010), the prevalence of heart disease is increasing in developing countries (e.g., southeast Asia and the eastern Mediterranean). The CDC estimated that 80% of heart disease, stroke, and type 2 diabe- tes, and that 40% of cancer could be prevented by eliminating just three risk factors: poor diet, inactivity, and smoking (CDC, 2009). Note that some of the differences in CID prevalence among countries reflect their uneven screening practices.
Global Epidemic of Chronic Disease As underscored, CID accounts for the majority of deaths globally. A report from a 2011 United Nations (U.N.) meeting (in which 113 member states participated) noted 300 million CID- related deaths in the last decade, with low- and middle-income countries seeing the fastest growth (Alwan, 2010). And approximately 70% of individuals who die from CID in low- and middle-income countries die before the age of 70. Almost 30% of these deaths are of individu- als younger than 60 years, compared with only 13% in high-income countries. The loss of such a large proportion of the working population reduces productivity, increases health care costs, and puts a significant burden on national economic development. It also traps millions of peo- ple who often pay for health care out of pocket in chronic poverty. In Mexico, for example, it is estimated that to treat all the patients with obesity-related diseases would cost US$500 per case annually—more than Mexico’s total health care budget (Alwan, 2010).
Regions of the world where NCDs account for the majority of deaths include the Americas, the eastern Mediterranean, the European region, southeast Asia, and the western Pacific. To illus- trate the magnitude of this problem, note this comparison: Deaths from CID are estimated to be 13 times higher than deaths due to communicable, maternal, perinatal, and nutritional causes combined. Only in low-income countries do the nutritional causes result in more deaths.
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CHAPTER 11Section 11.2 How Big a Problem Is CID?
Figure 11.3: Total deaths by cause, World Health Organization region, World Bank income, and sex, 2008
Conditions identified in the figure are more likely to result in death for men and women who live in lower- middle–income countries.
Source: Alwan, A. (2010). Global status report on noncommunicable diseases. Geneva, Switzerland: World Health Organization (p. 10). Retrieved from http://www.who.int/nmh/publications/ncd_report_full_en.pdf. Copyright . World Health Organization (WHO). Used by permission
Significant increase in the prevalence of CID is expected to occur in low- and middle-income coun- tries as a result of increased longevity, population growth, and greater commercial globalization, resulting in changes in behavioral, occupational, and environmental risk factors. Worldwide, CID deaths are projected to increase by 15% between 2010 and 2020, with the greatest increases occurring in Africa (where currently more people die from infectious diseases than from CID), southeast Asia, and the eastern Mediterranean. No increase is forecast for the European region (Alwan, 2010). The largest increases in CID-related mortality will occur in Africa and countries with similar national gross national products (Alwan, 2010). By 2030, CID in low- and middle-income countries will result in 3 times as many disability-adjusted life years and nearly 5 times as many deaths than any other cause (WHO, 2008).
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CHAPTER 11Section 11.2 How Big a Problem Is CID?
Prevalence and Risk Factors for CID in Geographic Regions In 2008, the leading causes of CID for individuals younger than age of 70 were cardiovascular diseases, cancers, respiratory disease (including asthma and chronic obstructive pulmonary dis- ease [COPD]), digestive diseases, diabetes, and other NCDs (Alwan, 2010). Cardiovascular disease (heart disease and stroke), cancer, respiratory diseases, and diabetes account for 86% of all deaths in Europe and a substantial amount of disability.
Figure 11.4: Proportion of global noncommunicable deaths in people younger than age 70 by cause, 2008
Cardiovascular diseases are the leading cause of deaths for individuals under the age of 70.
Source: Alwan, A. (2010). Global status report on noncommunicable diseases (p. 10). Geneva, Switzerland: World Health Organization, 11. Retrieved from http://www.who.int/nmh/publications/ncd_report_full_en.pdf. Copyright . World Health Organization (WHO). Used by permission
Country income has a significant impact on regional variations in the frequency and types of cancers. Within upper-middle–income and high-income countries, prostate, breast, lung, and colorectal (decreasing frequency) are the most commonly diagnosed cancers in males and females. In low- and middle-income countries, by contrast, the most common types are lung, stomach, and liver cancer in males; and breast, cervix, and lung cancer in females. With the exception of cervical and liver cancers, rates for all cancers rose in proportion to increased country income. Thus, in the future, the greatest growth in cancer incidence is expected in the low- and middle-income countries.
Globally, 10% of individuals 25 years old and older had been diagnosed with diabetes in 2008. Of the six WHO geographical regions considered, the prevalence of diabetes was highest in the eastern Mediterranean region and the region of the Americas. European and western Pacific regions had the lowest prevalence. The prevalence was lower in low-income countries (8%) than in upper-middle–income countries (10%; Alwan, 2010).
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CHAPTER 11Section 11.2 How Big a Problem Is CID?
Four modifiable behaviors (tobacco use, physical inactivity, unhealthy diet, and harmful use of alcohol) have been strongly associated with and causally linked to the majority of CIDs. These behaviors have a relationship to several metabolic or physiological changes: hypertension, over- weight and obesity, increased blood glucose levels (hyperglycemia), and increased cholesterol levels (hyperlipidemia). Among these changes, hypertension has been associated with the most deaths (13%), followed by tobacco use (9%), physical inactivity (6%), hyperglycemia (6%), and overweight and obesity (5%; WHO, 2011a).
To give an example of the connection with these risk factors, 80% of coronary heart disease and cerebrovascular disease result from tobacco use, physical inactivity, and unhealthy diet (WHO, 2009, 2011a). These risk factors are present to varying degrees in various regions and based on income levels within regions. And, overall, tobacco use is higher among men than among women world- wide. However, striking intercountry sex differences emerge that appear to be related to social and economic factors: Both higher income and increased female empowerment are associated with more similar smoking patterns among women and men (Hitchman & Fong, 2011). Globally, more than 31% of adults aged 15 years and older were insufficiently active in 2008, and the highest inac- tivity scores were tallied for the Americas and the eastern Mediterranean, and the lowest were in southeast Asia. When the data are assessed by income, a greater percentage of the population in high-income countries is inactive compared with low-income countries. High levels of inactivity are also seen in some middle-income countries, especially among women (WHO, 2011a).
It is increasingly accepted that a diet of processed foods high in fats and sugars promotes obesity that leads to cardiovascular and glucose-processing diseases. More high-fat foods are consumed in the Americas and Europe than in Africa and southeast Asia. The availability of saturated fats is around 8% in low- and lower-to-middle–income countries, but 10% in upper-middle–income and high-income countries (WHO, 2011a). Per capita alcohol consumption in the European region (12.2 liters) is a dramatic 24 times higher than in the eastern Mediterranean (0.6 liters). Alcohol consumption in upper-middle– and high-income countries (~10 liters) is more than double that of low- and lower-middle–income countries (~ 3 to 4 liters; WHO, 2011a).
The direct results of these high-risk behaviors are increased mortality and morbidity associated with hypertension, overweight and obesity, hyperglycemia, and hyperlipidemia. In 2008, about 40% of adults aged 25 years and older were reported to have hypertension. The highest reported prevalence was in Africa (46%), and the lowest, in the Americas (35%). High blood pressure is a risk factor for stroke and coronary heart disease. Being overweight or obese can lead to hyperten- sion, cholesterol imbalance, and insulin resistance. The risk of developing coronary heart disease, ischemic stroke, and type 2 diabetes increases steadily with increasing body mass index. Being overweight appears to be more of a problem for upper-middle– and high-income countries (the Americas, Europe, and the eastern Mediterranean) than for the low- and lower-middle–income regions (African, southeast Asia, and the western Pacific) (WHO, 2011a).
The problem does not appear only in adults. The number of children with weight problems has increased globally since 1990 and is rising the fastest in lower- and middle-income countries. In 2008, 40 million (6%) of preschool children had a weight-for-height ratio more than two standard deviations above the WHO child growth median.
High total cholesterol is another major risk factor for ischemic heart disease and stroke in both high- and low-income countries. The European region (54%) had the highest prevalence of ele- vated total cholesterol, followed by the Americas (48%), the eastern Mediterranean (39%), the western Pacific (38%), southeast Asia (30%), and Africa (23%; Alwan, 2010).
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CHAPTER 11Section 11.3 Definitions of CID
Web Field Trip Did you know that NCDs—such as heart disease, stroke, cancer, asthma, and diabetes—are the world’s biggest killer? These diseases develop as a consequence of a person’s lifestyle and living environment. Young people are hit hard by NCDs, because lifestyle habits are often adopted at this stage of life and frequently remain well into adulthood. Watch the video “Non-Communicable Diseases: The Common- wealth Shines a Light” (http://www.youtube.com/watch?v=OOyYip7Lsl8).
Critical Thinking Questions
1. What is the advantage of targeting these problems early in life? 2. How do you see the social and physical environment influencing various unhealthy
behaviors in the countries featured?
Although the number of CID-related deaths is expected to increase significantly in the coming decades, North America, Latin America, and Europe are making progress toward reducing smok- ing prevalence and blood pressure. Efforts are also being made to reduce people’s salt and fat intake and the harmful use of alcohol, and to increase time spent in physical activity. The invest- ment is bound to pay off for these countries: Just three behavioral modifications—eating a healthy diet, increasing physical activity, and maintaining a healthy body weight—can reduce a person’s risk of type 2 diabetes by 50%.
11.3 Definitions of CID
There are a number of ways to define CID. The U.S. National Center for Health Statistics defines a disease as chronic if it lasts more than three months, cannot be prevented by vaccines or cured by medication, and rarely disappears (“Definition of Chronic Disease,” 2012). In Australia, a CID is described as an illness that is prolonged in duration, does not often resolve spontaneously, and is rarely completely cured (Australian Government Department of Health and Aging, 2012). A CID is also sometimes labeled as an NCD, defined as a lasting medical condition that is usually noninfectious (except for HIV/AIDS) in origin. The WHO defines chronic disease as having a duration of more than three months and generally slow progression (WHO, 2013a). See Chapter 2 for a fuller discussion of various models for understanding chronic illness and disability.
Approval of the International Classification of Functioning, Disability, and Health (ICF) by the World Health Assembly in 2001 led to the development of a universally accepted conceptual model for classifying disability by body functions and structure, domains of activity, and partici- pation and environment factors. The ICF standard is used to measure health and disability at the individual, institutional, and societal level (WHO, 2013c). It makes health information from multi- ple settings, across various applications, and across countries comparable, and enables social pol- icy makers to devise interventions, strategies, and policies regarding prevention and treatment. (See Chapter 2 for more details about the WHO’s ICF model and for a discussion of contemporary issues in its implementation.)
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CHAPTER 11Section 11.3 Definitions of CID
Societal Attitudes Toward Disability In the first half of the 20th century, persons with disabilities were often viewed as unhealthy, defective, or deviant. During the last half of the 20th century, attitudes regarding people with disabilities changed significantly, especially in the United States.
United States Many legislative and societal changes that occurred in the 1960s and 1970s in the United States, such as the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963, the 1964 Civil Rights Act, and Section 504 of the Rehabilitation Act of 1973, prohib- ited discrimination against otherwise qualified handicapped persons in any federally supported program. The 1990 Americans with Disabilities Act (ADA) broadened those protections by guar- anteeing all persons with disabilities a chance at full inclusion into the mainstream of American life. The ADA, in turn, has had a direct influence on attitudes toward people with disabilities (Uni- versity of Florida, 2013).
Europe In Europe, a growing tendency to see disability as a human rights issue (Quinn & Degener, 2002) and self-organization by people with disabilities (Campbell & Oliver, 1996) have also changed attitudes. One 2001 European study reported that eight out of 10 Europeans felt at ease in the presence of people with disabilities (European Opinion Research Group [EORG], 2001). Countries where people were most at ease included Denmark, the United Kingdom, Sweden, the Nether- lands, Spain, and Ireland. Germany and Greece were at the lower end of the scoring. The 2005 Disability Discrimination Act passed by the U.K. Parliament directed public-sector organizations to promote equality for persons with disability (Prime Minister’s Strategy Unit, 2005).
Still, more than 40% of Europeans feel other people are uneasy in the presence of individuals with disabilities and unanimously agree that more effort and money should be applied to integrate people with disabilities into society. Interestingly, the public believes this is not a personal respon- sibility, but the responsibility of central and local public authorities (EORG, 2001). Respondents to a 2009 British survey expressed the belief that benevolent prejudice against the disabled was widespread; however, they did not consider themselves prejudiced (Staniland, 2009).
Table 11.1: Perceived prejudice against disabled people in the United Kingdom, 1998–2009
A Lot (%) A Little (%)
Hardly Any (%)
None (%) Don’t Know (%)
Sample Size
1998 25 51 15 6 2 3,139
2000 35 51 9 3 6 3,422
2005 25 50 17 8 1 3,193
2009 26 53 15 5 1 2,282
Source: Staniland, L. (2009). Public perceptions of disabled people. Evidence from the British Social Attitudes Survey 2009. London, UK: Office for Disability Issues. HM Government. Retrieved from http://odi.dwp.gov.uk/docs/res/ppdp/ppdp.pdf.
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CHAPTER 11Section 11.3 Definitions of CID
Except for an unexplained 10% jump from 1998 to 2000 in the percentage of people who felt there was “a lot” of prejudice against the disabled, the numbers have remained relatively steady in the last 10 years. Eight out of 10 people believed that most people would feel very or fairly uncom- fortable if people said negative things about disabled people at shops, among their friends, or at work. However, 40% felt that disabled individuals were not as productive as nondisabled people some or most of the time. More people felt more uncomfortable interacting with people with learning or mental health difficulties than with those with physical or sensory impairments.
Global Attitudes A large literature review of the stigma relating to disabilities found that the impact was remark- ably similar across different countries, conditions, and public health programs (van Brakel, 2006). Another review (Lauber & Rossler, 2007) revealed that the stigmatization of people with mental illness is widespread in Asia, where the mentally ill are sometimes considered dangerous and aggressive. Their illness is often attributed to supernatural, religious, or magical causes. The atti- tude of mental health professionals and family members toward people with mental illness is often stigmatizing as well, which results in low rates of treatment seeking in this population—that is, if treatment is actually available.
With the increasing recognition that people are disabled by environmental factors as well as by physical or mental disorders, medically focused solutions are giving way to more interactive approaches. However, this attitude appears to be more prevalent in developed countries relative to developing countries, where people with disabilities are often not considered potential mem- bers of the work force. Globally, 80% to 90% of the disabled in developing countries are unem- ployed compared with 50% to 70% in industrialized countries (United Nations, 2007).
Disability was addressed in an international context when the United Nations’ Standard Rules on the Equalization of Opportunities of Persons with Disabilities connected disabilities with human rights issues (U.N. General Assembly, 1993). This resulted in the adoption of United Nations Con- vention on the Rights of Persons with Disabilities (CRPD) in 2006. However, even though policies and research indicate that attitudes toward disabled people have improved overall, information, education, training, and increased awareness are still needed at the individual level to change negative attitudes. In many countries, long-held cultural beliefs still determine how persons with disabilities are viewed and the extent to which they are included or excluded in society. It is hoped that as the countries and cultures change and learn from one another, views about disability and barriers to inclusion into society change as well.
Psychosocial Adaptation In some countries, suffering from a chronic disease (particularly mental illness) can mean stigma and adverse psychosocial effects. Individuals can experience disruptions in interpersonal relation- ships, interaction with their physical environment, and deterioration in psychological or emotional health (Marini & Stebnicki, 2012). In some less developed countries, having a mental illness is still equated with involvement with black magic, and individuals may be ostracized by their own families. In addition to being stigmatized, pain, bereavement, anxiety, frustration, and depression are often part of the burden of chronic disease (Suhrcke, Fahey, McKee, 2008). A Finnish study reported that adults with persistent chronic illness, which limits daily life, have more depression and lower self-esteem than healthy individuals (Hurre & Aro, 2002).
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CHAPTER 11Section 11.3 Definitions of CID
Psychological health can improve with a community-based self-management education program, which successfully helped participants gain confidence by becoming more self-sufficient (Brady et al., 2013). In addition, psychosocial assessments should be part of any diagnosis paradigm. Because chronic stress is often a precursor to chronic illness, consideration should be given for referring patients to existing interventions and appropriate therapies. The need is also great for increased social inclusion—particularly of older people with chronic diseases or cognitive impairments.
Debate as to the consequences of acceptance versus denial of a chronic condition continues. Research commonly reports that behaviors consistent with denial lead to poorer illness manage- ment and higher levels of sorrow and depression (Bechtold Kortte, Wegner, & Chwalisz, 2003; Carver et al. 1993; Jones 2003; Revenson & Felton, 1989). However, just as much research chal- lenges the association of acceptance with positive health outcomes (Antoni & Gookin, 1988; Dean & Surtees, 1989; Greer, Morris, Pettingale, & Haybittle, 1990; Pettingale, Morris, Greer, Haybittle, 1985). The labels acceptance and denial may not be useful when describing a person’s response to chronic illness. It may be better to view chronic illness in the context of a situation in which the individual goes through shifting beliefs, perceptions, expectations, attitudes, needs, and experi- ences about the meaning of living with chronic illness (Alvani, Parvn Hosseini, & Alvani, 2012).
Compounding the psychosocial difficulties are problems associated with often being unemploy- able and the impact this has on family income and personal esteem—especially if the ill person is the primary breadwinner. Australia, Singapore, and Thailand have documented lower salary levels for persons with CID compared with the general population (Alvani et al., 2012). For those with chronic conditions who try to remain productive, many feel discriminated against because their employers won’t agree to flexible hours to accommodate treatment or because the workplace isn’t adapted to the employee’s needs. Even more challenging is the hidden bias in the hiring pro- cess for people with disabilities (Shier, Graham, & Jones, 2009). Worries about loss of income can lead to mental suffering and depression (McCabew & De Judicibus, 2005). To combat these prob- lems, a European directive adopted in 2010 prohibits any kind of discrimination in employment, including those with disability, in the 27 European Union (E.U.) member states (Belgian Presidency of the Council of the European Union, 2010).
The Medical Model of CID In sharp contrast to the ICF model for understanding and treating CID (discussed in Chapter 2) is the medical model. This lens for viewing CID emphasizes pathology and focuses on assessment, treatment, and prognosis with the aim of returning the disabled individual to society cured. In this model, the problem related to the chronic illness resides within the individual. So if he or she is incurable, then by implication, that individual is dysfunctional, because any limitation in functional capacity is compared with the societal norm (Stucki, Gieza, & Melvin, 2007). In the medical model, the power to fix the problem lies within the medical community, not the individual or society.
The Social Model of CID The social model incorporates the philosophy of ICF, but without the coding system. It views struc- tures within society as the problem, more so than the individual. The social model holds that a complex form of “institutional discrimination” (including poverty, inaccessible information and transportation, discrimination in employment, prejudice, and an overemphasis on the medical model) prevents the disabled from achieving their full functioning capacity. A comparison of the thinking behind the two models is shown in Table 11.2.
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CHAPTER 11Section 11.3 Definitions of CID
Table 11.2: Comparison of medical and social models
Medical Model Thinking Social Model Thinking
Perception of individual Individual is faulty Individual is valued
Typical courses of action Diagnosis Strengths and needs defined by self and others
Labeling Identify barriers and develop solutions
Biases Impairment becomes focus of attention
Outcome-based program is designed
Approach to offering solutions Assessment, monitoring, programs of therapy imposed
Resources are made available to ordinary services
Effect on individual Ordinary needs put on hold Relationships nurtured
Typical outcome Reentry if normal enough or permanent exclusion
Diversity and inclusion welcomed
Tendency toward progress Society remains unchanged Society evolves
Source: Rieser, R. (2010). Disability equality: Medical model/social model. Worldofinclusion.com. Retrieved from http://www.worldof inclusion.com/medical_social_model.htm. Copyright © World of Inclusion, Ltd. Used by permission.
Using Bronfenbrenner’s Model to Better Understand CID Bronfenbrenner’s ecological model of human development is essentially an integrative model and includes components similar to the ICF model. It explains how environmental influences affect an individual’s psychological development. As emphasized in Chapter 1 and throughout this text, Bronfenbrenner’s model includes five distinct system levels that are at increasing distances from the person: the microsystem, the mesosystem, the exosystem, the chronosystem, and the macrosystem. This model can also describe how individuals interact with different levels of their health care system.
Micro Perspectives At the micro level, the ICF model sees the individual in a personal context, taking into consider- ation such factors as age, sex, personal attitudes about risk, family support, and genetic endow- ment. It also encourages a personalized medical approach to care. This model holds that chronic disease affects the individual’s level of consumption and capital formation (savings), labor produc- tivity and supply, and self-esteem, as well as education level attained.
Meso Perspectives At the meso level, the ICF model encourages patient and family participation in health care plan- ning and decision making. Patient-centered care encourages integration of all the patient’s pro- viders as part of a mesosystem.
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CHAPTER 11Section 11.4 Economics of CID
Web Field Trip A video produced by the WHO explains the impact of public health on the economy and the impor- tance of public health services that help individuals avoid getting ill, protect them from diseases, and promote healthy lives: http://www.youtube.com/watch?v=8KrFLetj6CQ&list=PLL4_zLP7J_mgigUiG9 MbXet9ttXgbSVQu.
Critical Thinking Questions
1. Do you agree or disagree with the narrator’s statement that public health initiatives yield “more health gain for much less cost?”
2. Do you think that public health programs are part of the solution for CID, or could the public’s money be better spent on other efforts?
Macro Perspectives At the macro- (and exo-) system level, the ICF model is actively engaged in policy and legislative changes. These efforts are meant to increase access to care, change social norms about chronic disease, and modify behavior and environmental factors to lessen the risk for disease, disability, and death while enhancing the chances for health, mobility, and longevity. Epidemiological and other research data are used to track the prevalence and course of chronic diseases, as well as to modify it at the population level. U.N. initiatives to protect the rights of the disabled are an exam- ple of the macro sphere’s influence.
11.4 Economics of CID
The European medical community recognizes that to sustain quality health care in the face of the CID epidemic new thinking about the allocation of health care funding is necessary. Like other services, health care spending has opportunity costs; that is, the benefits of health care must outweigh the cost to society. In other words, spending on health care is economically sustainable only up to the point at which the social cost of health spending exceeds the value pro- duced by that spending. It is generally accepted that the healthier the society, the more productive it is; thus, the economic benefits of a healthier society must be incorporated into any calculation.
The indirect costs of CID go well beyond reduced income owing to lost productivity. Indeed, the costs of household members caring for ill family members, the selling of assets to pay for medical care, and the lost opportunities for the young who drop out of school to care for ill adults are all part of the economic burden of chronic illness.
In Europe, a major policy focus is to ensure equitable access to health care regardless of the ability to pay and to ensure quality and value for money spent. Although this philosophy is firmly established, the debate on how to achieve these objectives is ongoing. Policy makers disagree on whether to increase private or public funds to bridge the gap between what is currently spent on health care and future needs, which will include a burgeoning demand for long-term care and care for persons with chronic illness (Thomson, Foubister, & Mossialos, 2009).
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CHAPTER 11Section 11.4 Economics of CID
A variety of strategies has been used to achieve the goals of equitable access and value in the health care sector in the face of CID demands. These include greater reliance on high- technology assessment, efforts to coordinate and direct strate- gic resource allocation, provider payment reforms that link pay to performance, incentives to enhance provider responsive- ness, and the use of pooling: In most European states, all public funds for health care are col- lected nationally, often gath- ered into a single pool. Despite the best efforts, however, as the share of older people in the pop-
ulation increases and the share of the working population decreases, the demand for health care may exceed funding capacity and become unsustainable (Thomson et al., 2009). This demographic “time bomb” can be defused by either increasing revenue, reducing services by shrinking cover- age, or improving efficiency. After experimenting with various service-delivery models, the Euro- pean region still struggles to find the right formula.
Sources of Funding Health care in Europe is financed by a combination of public contributions (taxes and social insur- ance) and private sources (e.g., health insurance, medical savings accounts, out-of-pocket pay- ments, and cost sharing). During the past 20 years, a major shift has occurred from taxes to social insurance as the dominate form of financing health care in many of the newer member states of central and eastern Europe. In these countries, the greatest proportion of total expenditures on health care are paid through public expenditures. Figure 11.5 compares the financial sources of health care in 10 countries in the European region.
iStock/Thinkstock
The indirect economic costs of CID include the costs of household members caring for ill family.
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CHAPTER 11Section 11.4 Economics of CID
Figure 11.5: Percentage of total expenditures on health in the European region by main contribution mechanism, 2005
Social insurance and taxes are primary sources of health care financing for several European nations.
Note. OPP = out of pocket; “other” includes medical savings accounts, cost sharing, and informal payments.
Source: Thomson, S., Foubister, T., & Mossialos, E. (2009). Financing health care in the European Union: Challenges and policy responses. European Observatory on Health Systems and Policies (Figure 2.2b). Copenhagen, Denmark: Retrieved from http://www.euro.who.int/__data/assets/pdf_file /0009/98307/E92469.pdf. Copyright . World Health Organization (WHO). Used by permission.
Pooling covers the costs of those who need health care with the contributions of healthy individ- uals. In the U.S. private sector, the equivalent of pooling is community rating in health insurance (discussed in Chapter 10), in which risk is shared throughout the insured population. In some E.U. member states, although local taxes or individual health insurance funds are used to finance health care, measures are in place to reallocate these resources to poorer regions, poorer mem- bers, or members at higher risk of ill health (in the United States, individual states run “high-risk pools” to help cover the ill or uninsured). In Europe, unified pools of publicly generated health care resources enhance efficiency, provide more equitable access, minimize duplication of pooling efforts, and may even improve administrative efficiency (Thomson et al., 2009).
France and Germany have increased their reliance on funding health care with income not related to earnings by placing tax allocations on employers to generate more revenue. Also, centralized systems of collecting funds improve collection standards and increase revenue. Cost sharing also encourages cost-effective patterns of use. (Most low-income individuals and those with chronic illness are exempt from this policy.) Note that, even in Europe, where the public model domi- nates, private insurance still flourishes in some markets, usually serving wealthier and better- educated groups.
The coming shift from acute care to long-term chronic care requires a financing system with the ability to enhance pooling, coordinate and direct resource allocation, match resources to need, shape the nature of supply, and create incentives to enhance provider responsiveness (Thomson et al., 2009).
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CHAPTER 11Section 11.4 Economics of CID
Methods of Payment In countries where health care is financed through a tax base, supplies and services are purchased through territorial entities. These take the form of regional or local health authorities, or specially created purchasing organizations such as Primary Care Trusts in the United Kingdom. Some E.U. member states (United Kingdom, Finland, Italy, and Portugal) and some regions of Spain and Swe- den have introduced purchaser–provider splits, a service delivery model in which third-party pay- ers are kept organizationally separate from service providers to create competition among sup- pliers (Tynkkynen, Keskimaki, & Lehto, 2013). Another way of controlling costs is a combination of capitation and FFS payments, which are most often used to pay primary care providers. Spe- cialists are paid on an FFS basis, in which social insurance contributions are the basis of financing, whereas specialists are often salaried employees in tax-financed health systems. Hospital costs are often budgeted. However, case-based payment is increasingly used either to define budgets or as a retrospective form of payment.
Incentives to Improve CID Care and Reduce Costs Financial incentives can lead to quality improvements but only when the needs of all stakeholders are balanced (Leatherman et al., 2003). Several payment methods have been tried in Europe to incentivize payers to make appropriate decisions (Busse & Mays, 2008). However, most methods are related to the structure or process of care rather than the individual, and the methods vary by region. Table 11.3 displays the different categories of incentives used in Europe and their targets: the individual, the structure of care, the process of care, and the outcomes.
Table 11.3: Incentives for improving chronic care in European countries.
Financial Incentives Targeting the Individual
Financial Incentives Targeting the Structure of Care
Financial Incentives Targeting Processes of Care
Financial Incentives Targeting Outcomes of Care
• Piloting of “year of care” payment for the complete package of chronic disease management that individuals with chronic conditions require, e.g., based on validated “care pathways” for diabetes (Denmark, United Kingdom)
• Per-patient bonus for physicians for acting as gatekeepers for chronic patients and for setting care protocols (France)
• Bonus for DMP recruitment and documentation (Germany)
• 1% of overall health budget available for integrated care (Germany)
• Points for reaching process targets (United Kingdom: GP contract)
• Points for reaching outcome targets (United Kingdom: GP contract)
• Points for reaching structural targets (United Kingdom: GP contract)
--- • Additional services (e.g. patient self- management education) reimbursable only if physicians and patients participate in DMP (Germany)
---
Note: DMP = disease management program; GP = general practitioner.
Source: Adapted from Busse, R., & Mays, N. (2008). Paying for chronic disease care. In E. Nolte & M. McKee (Eds.), Caring for people with chronic conditions: A health system perspective, (195–221). Maidenhead, U.K.: Open University Press. Copyright World Health Organization (WHO). Used by permission.
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CHAPTER 11Section 11.4 Economics of CID
Although no conclusive European studies have shown the effectiveness of these incentives, con- clusions can be drawn from U.S. studies. One in particular looked at the relationship between financial incentives designed to improve health care quality and a quantitative measure of health care outcomes. The authors cautioned against focusing too narrowly on incentivized tasks or areas of quality that might lead to “gaming the system” without any true improvements in care. They believed that using mixed-payment approaches might lead to better outcomes (Peterson, Wood- ard, Urech, Daw, & Sookanan, 2006). Other researchers found that financial incentives might be good for individual providers but less effective for groups of providers (Baron & Kreps, 1999). Also, small- to medium-sized multidisciplinary teams that improved six interrelated components— self-management support, clinical information systems, delivery system redesign, decision sup- port, health care organization, and community resources—were found to produce good outcomes and reduce costs (Bodenheimer, Wagner, & Grumbach, 2002a, 2009b).
Only the U.K. National Health Service’s (NHS) contract for GPs specifically includes incentive pay- ments (pay for performance) that target the delivery of particular outcomes (Roland, 2004; Smith & York, 2004). Some evidence from a U.K. study suggests that positive outcomes can be achieved when incentives, coupled with outcomes and quality variables, make up about 25% of practice income (Campbell et al., 2007).
New health reforms in Germany encourage the allocation of extra money for sickness funds when patients with chronic diseases are enrolled in a DMP. Another reform in Germany (Schang, 2009) and the Netherlands (Van Ginneken, Busse, & Gericke, 2007) provides extra financial incentives for payers and insurers by taking individual morbidity criteria into account.
For individual patients in Europe, relatively few financial incentives exist. However, France and Germany offer modest cost-sharing mechanisms when patients with chronic diseases enroll in DMPs. Also in France, patients who participate in and comply with their DMP at every doctor’s visit are exempt from copayments for chronic disease care. Another strategy yet to be tried in Europe is lowering premiums or contribution rates for patients with chronic diseases who enroll in a DMP. At the macro level, policy makers have been encouraged to offer financial incentives for integrating or linking chronic care programs, provide financial incentives that encourage conti- nuity of care, and align compensation plans across different sectors for health professionals who work together in the chronic care sector (Busse, Blümel, Scheller-Kreinsen, & Zentner, 2010).
Because chronic care implies long-term care, benefits are often seen only after many years of treatment. When offering incentives to encourage providers to provide high-quality care, pol- icy makers must take this factor into consideration and assure providers that their investment is worthwhile.
Allocation of Care Like the United States, an increasingly large percentage of the European population consists of older individuals, many with multiple chronic health problems; therefore, the European model of coverage for everyone may prove difficult to maintain. Rationing of care may be necessary. Some type of health care rationing is practiced by almost all developed countries that offer universal health care. These countries calculate the cost–benefit ratio of treatments to ensure that scarce medical resources are not wasted on expensive treatments that have little chance of success. The growing need for chronic care complicates the allocation of care even further.
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CHAPTER 11Section 11.4 Economics of CID
A chronic care model classifies patients by need and level of intervention:
• Level 1 patients need support mainly for self-management. • Level 2 patients, with multiple diseases or poor ability to manage their own care,
need support from care teams, who use common protocols and pathways. • Level 3 patients require active disease management by medical teams. (Economist
Intelligence Unit, 2013)
The RAND Evaluation (2013) study, which examined 51 sites that use the chronic care model, found a much better chance that patients in such facilities received the correct therapy and expe- rienced improved outcomes. For example, the duration of hospital stays for patients with conges- tive heart failure was reduced by an average of 35%.
In the United States, there are few restrictions on the use of health care interventions, regardless of cost or clinical effectiveness—at least for the moment. Europe, in contrast, remains commit- ted to universal coverage and equity to access, although the limits of coverage and the extent of services are subjects of debate. In both regions, caring for patients with CID needs to evolve away from the acute care model. Incentivizing doctors and hospitals to spend more time treating chronic illnesses is the first step. Some European countries are already experimenting with such a shift. For instance, the United Kingdom is experimenting with incentive payment in which doctors receive more money for keeping patients out of the hospital and hospitals are penalized for high rates of patient readmissions.
Human Resource Challenges Human resources are central to every component of the emerging social models of chronic care. Developed countries are rethinking approaches to staffing and utilization, bringing them more in line with the chronic care model developed in the United States (Wagner, 1998). This reor- ganization is based on the fundamental differences between acute and chronic care treatment. Unlike acute conditions, chronic conditions are irreversible, long-term, and require supervision across many settings and different types of providers; they must include a component of self- management (Nodhturft et al., 2000).
Developing Integrated Services Many developed countries are experimenting with an integrated approach to chronic care that involves practitioners across a spectrum of specialties, both medical and social. This integration requires a work force that can manage service transitions, have a flexible attitude, and exercise good communication and team-building skills.
In Sweden, district nurses provide the first line of assessment for chronic care cases and direct them to the appropriate resources. Then, county-owned health centers provide services managed by interdisciplinary teams of doctors, nurses, and other providers at multiple sites. In England, pri- mary care trusts and practice-based commissioning groups coordinate chronic care through local community providers of primary care. These providers include GPs, nurses, and other community staff. The trusts are also in charge of commissioning acute hospital services.
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CHAPTER 11Section 11.4 Economics of CID
Chronic shortages of medical staff, in particular doctors and nurses, are already occurring. It is a prob- lem that is only expected to get worse. Shortages occur not only in developing countries, but also in developed countries such as Australia, Canada, and the United States. In the meantime, although doctors are spending more of their time seeing CID patients with both stable and uncontrolled ill- nesses (Østbye et al., 2005), these patients are not necessarily receiving quality health care.
New models of chronic disease management often incorporate a patient self-management com- ponent and involve the patient’s family in care decisions. This model seeks to better respond to individual needs and embodies a central role for the service user and his or her family. It also incorporates the patient’s perspectives and preferences in the care process, while offering the patient the educational and psychosocial support needed for an effective care partnership. Figure 11.6 illustrates the relationship of the patient to the supportive care networks, which corresponds to the human ecological model of micro, meso, and micro spheres of influence.
Figure 11.6: Patient-centered health care model
On a larger scale, it is important that a person’s health care system and government are willing to understand and support his or her health conditions.
Source: European Diabetes Leadership Forum (2012). The diabetes epidemic and its impact on Europe. European Diabetes Leadership Forum (p.22). Copenhagen, Denmark: Author. Retrieved from http://www.oecd.org/els/health-systems/50080632.pdf. Copyright . OECD. Used by permission.
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CHAPTER 11Section 11.4 Economics of CID
Patient-Centered Service and Self-Care When designing self-care systems, it is important to recognize that the work force that cares for the chronically ill is made up of three categories: formal caregivers (those who provide institutional or pro- fessional services), informal caregivers (those who look after chronically ill and disabled relatives), and self-care providers (the patients).
There are two main ways to reconfigure chronic care: redefining existing roles and creating new types of providers (Dubois, Singh, & Jimani, 2008). Doctors also need to redefine their existing roles. A new division of labor is needed in which tasks bet- ter performed by nurses, pharmacists, community workers, or trained laypersons are diverted from the doctor. Many doctors spend too much time performing administrative duties instead of treat- ing patients. A transfer of responsibilities requires a supportive policy framework with standards of care and clear protocols in order to avoid uneven levels of service and gaps in needed services. Other types of health care professions can be enlisted to coordinate and manage care programs, record per- formance, monitor statistical outcomes, and assure quality at every stage.
The chronic care model advocates that patients be as involved as possible in designing and carry- ing out their own care. It is hoped that patients who are in charge of whether to take their medi- cine, exercise, avoid harmful foods, and calculate their insulin requirements are more likely to do what is necessary to slow the progress of their disease (Dubois et al., 2008).
Wavebreak Media/Thinkstock
The chronic care model encourages patients to be involved in their own care.
Case Study: Live Well With COPD The “Live well with COPD” program in Québec, Canada, is one example of a patient-centered care program. It allows the individual to assess his or her own needs, determine how and by whom these needs should be met, and adopt behaviors that are likely to influence optimal physical, psychosocial, and mental functioning. COPD centers consisting of multidisciplinary teams offer courses about the disease, its symptoms, and management; telephone follow-up; and individual counseling. Patients are encouraged to take full responsibility for self-management and not pass this responsibility off to a third party. At the same time, the program recognizes that the needs of chronic care patients may include help with chores such as shopping, cooking, and bathing.
Support in carrying out everyday tasks and personal contact from nonmedical providers can improve patients’ outlook and quality of life while relieving the burden on the medical system and family members. Also, the approach has been scientifically validated: A randomized trial found that patients enrolled in COPD self-management programs experienced approximately 40% fewer hospital admis- sions and emergency department visits for the exacerbation of their condition (Bourbeau et al., 2003).
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CHAPTER 11Section 11.5 CID and Government Policy
11.5 CID and Government Policy
As this text has explored, individuals in most countries suffer from the same primary chronic diseases—cardiovascular respiratory, cancer, and diabetes. In the United States and else-where, the behavioral risk factors (e.g., tobacco use, overweight and obesity, hyperten- sion, alcohol abuse, and lack of exercise) are the same, though their frequency varies from country to country. Despite evidence of the link between these risk factors and chronic illness, success in addressing the challenges associated with these risks has been patchy at the national and pan- national (e.g., E.U.) levels.
Although recognized as essential, the transition from medical care with an acute care focus to one with a chronic care focus has been slow. The long-term, complex nature of chronic care and treat- ment, which is coordinated by a variety of health care professionals with access to the necessary drugs and equipment and which extends into the realm of social care, has confounded traditional top-down, government-led responses. Efforts to integrate policies, finances, and provider services to suit the needs of patients and caregivers and facilitate the input of community and private expertise have been sluggish. Most countries are experimenting with policies to prevent disease and spur early detection. DMPs and other novel approaches to financing and staffing are being tried, but they are harder to implement.
Four Health Care Systems Four main health care systems are in use today: the Beveridge model, the Bismarck model, the national health insurance model, and the out-of-pocket model. All four models can be seen in the United States health care system (Physicians for a National Health Program, 2010).
The Beveridge Model In the single-payer Beveridge model, health care is provided and financed by the government through taxes. Most of the system is owned and controlled by the government, which has greater control over costs. United Kingdom, Spain, most of Scandinavia, and New Zealand are examples of countries using the Beveridge model.
The Bismarck Model The Bismarck model uses an insurance system in which the insurers are called “sickness funds.” Although these funds resemble health insurance in the United States (they are usually financed jointly by employers and employees through payroll deduction), the insurance companies cannot make a profit or deny anyone coverage. Instead, Bismarck-type health insurance plans are non- profit systems required to cover everyone. Germany, France, Belgium, the Netherlands, Japan, Switzerland, and, to a degree, Latin American countries use the Bismarck model.
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CHAPTER 11Section 11.5 CID and Government Policy
The National Health Insurance Model Founded in Canada, the national health insurance model has elements of both the Beveridge and Bismarck models. It uses private-sector providers, but they are paid from a government-run insur- ance program that every citizen contributes to. These universal insurance programs tend to be cheaper and simpler to administer compared with the U.S. “for profit” model. Taiwan and South Korea have adopted this model.
The Out-of-Pocket Model The out-of-pocket model is practiced by most of the nations that are too poor or disorganized to provide any kind of mass medical care. To put it bluntly, this is a purely market-driven system in which the wealthy get medical care and the poor stay sick or die prematurely.
Prevention Strategies for CID Many countries are moving from an approach to chronic disease that focuses on just treatment to an approach that focuses on early detection, prevention, and support for lifelong well-being. Pre- vention strategies function at three levels: primary (removing the cause), secondary (identifying the disease at early stages when it can be treated), and tertiary (activities intended to cure, ame- liorate, or compensate for the disease). The approaches vary according to the health care system, cultural views, and the dominant political opinions of each region. The amount of community, business, and individual responsibility also depends on views about the role of institutions and individual autonomy (Busse & Schlette, 2003). Scandinavian policies, for example, attach consider- able importance to environmental factors and social conditions. Other countries, such as France, Germany, and the United States, focus more on the individual’s attitude to risk factors such as tobacco, alcohol, and nutrition (Busse, Zentner, & Schlette, 2006).
Case Study: Success Stories From Finland and Poland In the 1970s, heavy tobacco use, high-fat diets, and low vegetable intake were the norm in Finland. Finland also had the highest death rate from cardiovascular disease. However, death rates in men with heart disease fell by 65% largely because of several factors: community-based interventions, legislation banning tobacco advertising, the introduction of low-fat dairy and vegetable oil products, changes in how farmers were paid (linking payment for milk to its protein level rather than fat content), and incen- tives for communities achieving the greatest cholesterol reduction (Vartianinen et al., 2000).
(continued)
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CHAPTER 11Section 11.5 CID and Government Policy
Tobacco Control Many European countries enact tobacco-control policies that increase prices, levy taxes, educate the public, restrict sales, ban smoking in public places, and offer behavioral assistance to quit (Busse & Schelette, 2007). Ireland, Italy, Malta, New Zealand, Norway, Singapore, and Sweden have introduced a complete ban on smoking in public places and at work. Russia, which has one of the highest rates of smoking in the world, banned smoking in many public places in June 2013. Similar regulations have been introduced in other countries, including Australia, the Czech Repub- lic, England, Finland, Germany, Hungary, Portugal, Scotland, the Philippines, and Spain. The Phil- ippines has reported significant drops in the number of teenage smokers and a drop from 23% to 14% in the number of adult smokers in Singapore (WHO, 2005).
Case Study: Success Stories From Finland and Poland (continued)
Figure 11.7: Heart disease and lung cancer death rates among men aged 30 years and older in Finland
Finland had the highest death rate from cardiovascular disease.
Source: World Health Organization. (2005). Preventing chronic diseases: A vital investment (p.93). Geneva, Switzerland: Author. Copyright . World Health Organization (WHO). Used by permission.
One of the most dramatic declines in death rates from heart disease occurred in Poland in the 1990s. The decline was attributed to the replacement of dietary saturated fat with polyunsaturated fat. The trend was associated with a simple top-down government intervention: the removal of price subsidies on butter and the availability of cheaper vegetable oils (Zatonski & Willett, 2005).
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CHAPTER 11Section 11.5 CID and Government Policy
Taxation can reduce smoking as well as raise reve- nue for health promotion and disease prevention programs, as shown in the Australian state of Vic- toria and subsequently in several other countries, including Thailand. A 10% price increase in tobacco products has been shown to reduce demand by 3% to 5% in high-income countries and by 8% in low- and middle-income countries (WHO, 2005).
Anti-Obesity and Hypertension Programs Obesity prevalence can be modified through pub- lic information and education and by targeting children and adolescents, taxing unhealthy food, planning the urban environment, and prohibiting certain foods (Novotny, 2008). Higher prices have been shown effective for controlling alcohol and soft-drink consumption, while subsides can encour- age healthier food choices (WHO, 2005).
Programs targeting at-risk youths and adults with high blood pressure and aimed at increasing their participation in physical activity have succeeded in Brazil. For example, education sessions and per-
sonalized advice given to a group of people with high blood pressure and diabetes resulted in a 96% increase in regular physical activity (Matsudo et al., 2004). Similar programs for weight loss, dietary control, physical activity, and moderate alcohol consumption are being combined to control hypertension and reduce the incidence of ischemic heart disease (Chobanian et al., 2003; Novotny, 2008). Holistic approaches to preventing hypertension involve an array of stakeholders: representatives of local government, the food industry, cultural groups, schools, sports clubs, and public and private health institutions. They all work together to promote healthy behaviors in schools, families, and communities; change urban design to support healthier and more active lifestyles; strengthen community leadership and action; and support primary care prevention and early intervention (WHO, 2005).
Vaccination and Screening Programs Chronic disease prevention programs in Europe often use vaccinations. For example, the human papilloma virus vaccine to prevent cervical cancer is now part of immunization programs in Austria, Germany, France, Italy, Belgium, Luxembourg, Norway, Sweden, Switzerland, and the United King- dom (Arun, 2007).
Screening programs are used for early detection of cancers. In a number of Latin American coun- tries, cervical cytology screening programs have been in place for more than three decades and have resulted in significant decreases in the incidence of cervical cancer (Sankaranarayanan, Budukn, & Rajkumar, 2001). The U.K. government formulated a national cancer plan in 2000, specifying targets and standards for prevention that include a national screening program for colon cancer.
Thanassis Stavrakis/Associated Press
Many European countries are enacting tobacco-control policies as a form of disease prevention.
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CHAPTER 11Section 11.5 CID and Government Policy
Disease Management CID management approaches vary across and within countries. They can take the form of DMPs, nurse-led care, integrated care composed of a multidisciplinary team, or managed discharged. DMPs focus on specific diseases such as diabetes, asthma, and cancer, to guide patients through the health care system. The National Sickness Fund in France piloted a DMP called Sophia, tailored to the needs of diabetic patients and relying mainly on nurses working in call centers (Bourgueil & Or, 2010). By the end of 2010, approximately 62,000 patients had joined the program. (No out- come data have been reported.)
In the United Kingdom and the Netherlands, nurse practitioners perform some tasks (e.g., pre- scribing certain medications and administering certain treatments) that traditionally fell within the doctor’s realm. In Germany, community nurses play a similar role, and they also run clinics in Hungary, Italy, and the Netherlands. Integrated approaches—being tried in the United Kingdom, Canada, and New Zealand (Novotny, 2008)—use clinical care systems as part of a broader, multi- faceted approach to disease management and self-care. These approaches, which often include a multidisciplinary team led by a GP, empower patients and foster enhanced communication among patients, care providers, funders, and treatment suppliers. They also strive to streamline admin- istration, care payment mechanisms, care management, and health systems as well as enhance skills, education, and information-sharing among all stakeholders (Nolte, 2011; Novotny, 2008).
Primary care traditionally provided by solo-practice is still in operation in many countries (Austria, France, and Germany). Some now include enhanced functions in patient self-management, which may involve the patient in developing a treatment plan and setting goals under the supervision of a doctor.
Community-based intervention seems to be a buzzword in many countries. The city of Bogotá, Colombia, has built parks, bike paths, and pedestrian walkways dedicated to leisure activities (WHO, 2005). In Tianjin, China, a project was launched in 1984 that included training new health personnel, improving health education and counseling, and making environmental changes to reduce chronic disease risk factors at the community level (Tian et al., 1995). A community-based rehabilitation program that included mobility training and training to perform normal daily activ- ities improved quality of life in permanently blind patients in rural south India by 95% (Vijayaku- mar, John, Datta, Thulasiraji, & Nirmalan, 2004). Guidelines and protocols, often developed by international bodies of doctors, provide decision-making support for these programs. Elements of disease management are outlined in Table 11.4.
Table 11.4: Key elements of disease management
• Comprehensive care: multidisciplinary care for entire disease cycle.
• Integrated care, care continuum, and coordination of the different components.
• Population orientation (defined by a specific condition).
• Active client–patient management tools (e.g., health education, empowerment, self-care).
• Evidence-based guidelines, protocols, and care pathways.
• Information technology, system solutions.
• Continuous quality improvement.
Source: Velasco-Garrido, M., Busse, R., & Hisashige, A. (2003). Are disease management programmes (DMPs) effective in improving quality of care for people with chronic conditions? Copenhagen, Denmark: WHO Regional Office for Europe (Health Evidence Network report). Retrieved from http://www.euro.who.int/document/e82974.pdf. Copyright . World Health Organization (WHO). Used by permission.
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CHAPTER 11Section 11.5 CID and Government Policy
Outcomes Early intervention to reduce risky behaviors is seen as the best way to reduce the consequences of those behaviors, for example, cardiovascular disease, diabetes, chronic respiratory disease, and cancer.
Anti-Obesity Programs The Ensemble Prévenons l’Obésité Des Enfants (EPODE) is a European prevention program aimed at changing the environment and facilitating the adoption of healthier lifestyles in everyday life to prevent childhood obesity. It involves political commitment, as well as social and support services at the community level. It is the largest program geared toward childhood obesity and is active in more than 17 countries, including Mexico and Australia. Few studies have reported outcomes to date; however, a small study conducted in France reported that community-based programs like EPODE were significantly more effective than school-based programs in reducing obesity among school-aged children (see Figure 11.8). This study did not report that EPODE programs reduce obe- sity, only that interventions targeting a variety of population groups can have synergistic effects on overweight prevalence.
Figure 11.8: Impact of community versus school programs on weight reduction in children
Community-based programs were more effective in reducing obesity among school-aged children.
Source: Romon, M., Lommez, A., Tafflet, M., Basdevant, A., Oppert, J. M., Bresson, J. L., . . . Borys, J. M. (2009). Downward trends in the prevalence of childhood overweight in the setting of 12-year school- and community-based programmes. Public Health and Nutrition, 12, 1735–1742.
1992 0
8
20
18
C h
il d
h o
o d
o b
e s
it y
p re
v a
le n
c e
( %
)
12
4
16
6
10
2
14
Years 2004
School-based approach Community-based approach
NS; p = 0.7
NS
CT=comparison towns; FLVS=Fleurbaix Laventie Villa Santa Study; NS=not significant
p < 0.0001/FLVS 2004
p < 0.0001/FLVS 2000
2000
12.6%
17.8%
8.8%
14.3%
11.4%
CT FLVS
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CHAPTER 11Section 11.5 CID and Government Policy
Although the promoters of such programs view scientific evaluation as important, they do not strictly follow evidence-based standards. They caution that evaluation is expensive and time-consuming and add that lessons may be garnered from deeper evaluations. They call for an optimum balance between scientific standards and feasibility. In short, they hold that the social implications of community-based interventions should take precedence over statistically signifi- cant evidence that the program reduces obesity (Borys et al., 2013). Other studies cited by Borys et al. include a pilot study using EPODE methodology, which reported a 9% decrease in the num- ber of overweight and obese children after four years, and another reporting a 2% decrease in overweight nursery school children during a one-year period (Borys, 2010; EPODE International Network, 2012).
Tobacco Control The European Network for Smoking Prevention (ENSP) is an international organization whose purpose is to coordinate action among organizations active in tobacco control in Europe by sharing information and experience and through coordinated activities and joint projects. The programs use price increases, bans, subsidies for treatment, media campaigns, and package warnings to reduce smoking prevalence. The effects of antismoking measures supported by ENSP have been very successful, as seen in Table 11.5. Whether ENSP programs indirectly reduce chronic diseases has not been reported, however.
Table 11.5: Effects of antismoking measures on smoker prevalence
Measure Effect on smoker prevalence
Price increase by 10% Decline by 4% in countries with high per capita income
Ban on smoking at work Decline by 5–10%
Bans on smoking in pubs, restaurants, and other public places
Decline by 2–4%
Advertising ban Decline by 6% if ban is absolute
Health warning on cigarette packs In the Netherlands, 28% of all 13 to 18 year olds said they smoked less as a result of health warnings.
In Belgium, 8% of those asked said they smoked less because of warnings.
Media campaigns Percentage of smokers declines by 5–10%, depending on how the campaigns are targeted at specific groups.
Withdrawal measures; subsidies for treatment Decline by 1–2% after two years, depending on the people registered.
Source: Thomson, S., Foubister, T., & Mossialos, E. (2009). Financing health care in the European Union: Challenges and policy responses. European Observatory on Health Systems and Policies (Table 5.1). Retrieved from http://www.euro.who.int/__data/assets/pdf_file/0009 /98307/E92469.pdf. Copyright . World Health Organization (WHO). Used by permission.
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CHAPTER 11Section 11.6 Innovations in CID
Nurse-Led Care Primary care nurses with enhanced skill sets provide care for chronically ill patients traditionally treated by family doctors (Dubois et al., 2008). Nurse specialists (e.g., those focusing on COPD or diabetes) have been effective in improving self-care, quality of life, and patient satisfaction (Hor- rocks, Anderson, & Salisbury 2002; Kinnersley, Anderson, & Parry 2000; Singh, 2005; Vrijhoef, Die- deriks, & Spreeuwenberg 2000; Vrijhoef, Diederiks, Spreeuwenberg, & Wolffenbuttel, 2001). As an example, nurse-led heart-failure clinics in Sweden have been associated with better education, better treatment, and social support; improved survival and self-care; and reduced hospital care, events, and deaths (Cline, 2002; Strömberg et al., 2003).
Disease Management The effectiveness of chronic disease management has been examined in a number of studies, with mixed results (Weingarten et al., 2002). Those using provider education, feedback, or reminders were associated with significant improvements in provider adherence to guidelines. Appropriately evaluated DMPs improved the quality of care, as measured by the provider’s increased adherence to evidence-based standards and effective disease control (Velasco-Garrido et al., 2003). A review of 317 studies reported that DMPs improved the process of care and disease control, though not health outcomes or utilization rates. An exception was DMPs that reduced hospitalization rates among patients with congestive heart failure and increased outpatient care and prescription drug use among patients with depression (Mattke, Seid, & Ma, 2007).
Although DMPs seem to improve quality of care, Velasco-Garrido et al. believed that more sup- porting evidence based on scientifically sound methods was needed. Overall, the evidence on DMPs remains questionable, and cost-based studies are inconclusive. A few studies have sug- gested that population-based interventions improve patient care, but none of these studies were randomized (Fireman, Bartlett, & Selby, 2004; Sidorov et al., 2002; Villagra & Ahmed, 2004). Fur- ther, the medium- and long-term impact of DMPs has not yet been studied satisfactorily (Nolte & McKee, 2008a).
Integrated Care Supportive evidence varies depending on the model of integrated care study (Nolte & McKee, 2008b), and large-scale, population-based studies are lacking. Some research has found one or more components of integrated care beneficial, but the evidence does not show whether the whole model is needed to achieve the same benefits (Singh & Ham, 2006). Implementation remains a key challenge. Evidence for cost effectiveness is also controversial. Regional differences in cost structures and the type and burden of chronic disease can influence cost outcomes. So far, no conclusive evidence has shown the cost effectiveness of using new specialties, such as nurse practitioners or case managers.
11.6 Innovations in CID
Innovations in research, pharmaceuticals, personalized medicine, and technology (see “E-Health” in this chapter) can help address problems associated with CID and advance patient care.
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CHAPTER 11Section 11.6 Innovations in CID
Research The European Union is undertaking research projects that address the problem of CID from a number of angles, including cost-effective behavioral modification, health prevention and pro- motion, screening, compliance, and integrated care. More research into the processes underlying chronic disease prevalence and incidence is also in progress. Although often lacking in this area, research with prospective, randomized controlled trial protocols make a better approach than observational studies for generating empirical evidence on health service delivery. Such proto- cols allow different programs to be compared, and they compare endpoints that are relevant to patients’ lives (Beyer, Gensichen, Szeceseny, Wensing, & Gerlach, 2006; Sawicki, 2006).
Pharmaceuticals New drugs and medical devices are essential to advance the prevention and treatment of chronic disease. New antihypertensive drugs, insulin, antidepressants, anti-inflammatories, and inhaled steroids, which were unknown at the end of the 1980s, have been developed to target the disease process.
A larger problem than the need for new drugs or devices is patient compliance. Only about 50% of patients in developed countries adhere to their treatment. The proportion of U.S. patients adhering to their hypertension medication is reported to be a paltry 51% (“Critical Overview of Antihypertensive Therapies,” 2000); in developing countries, the rates are even lower (Guo, He, & Jiang, 2001; van der Sande et al., 2000). Similar patterns of poor compliance have been reported for other conditions such as depression (~ 40% noncompliance; Demyttenaere, 1998). In Australia, adherence to prescribed medication for asthma is only 43%, and for preventive medication, it is 28% (Reid, Abramson, Raven, & Walters, 2000).
Fixed-dose combination therapy (polypill) is being offered as a way to increase medication com- pliance for a variety of illnesses. This dosing method improves compliance by reducing pill burden (Bangalore, Kamalakkannan, Parker, & Messerli, 2007). Other approaches to improve compliance include behavioral, educational, and social support interventions.
Personalized Medicine Another area of great interest is personalized medicine, which selects drug therapy based on individual genetic makeup. Personalized medicine uses optimized drug therapy to achieve maxi- mal response in a subset of individuals. It promises fixed doses, milder side effects, and improved outcomes for qualified patients with chronic illnesses (Lewis, 2005). In pursuit of personalized medicine, the Human Genome Project has led to new drug discoveries that have been applied in many areas of cancer therapy. As it becomes more widespread, the use of personalized medi- cine will force policy makers at the government and regulatory levels, as well as payer organiza- tions (e.g., insurance companies), to rethink how to organize drug licensing and reimbursement (Shane, 2007).
New Provider Settings New types of provider specialties, settings, and qualifications are emerging in many countries. Group practices, medical polyclinics, and nurse-led clinics that are more patient oriented and cost effective are being established (Busse & Schlette, 2003). In Canada, for example, new chronic
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CHAPTER 11Section 11.6 Innovations in CID
care models in which doctors work within teams comprising nurses, social workers, psychologists, dieticians, midwives, and physiotherapists are being developed. The purpose is to create a multi- disciplinary, well-coordinated, 24-hour accessible system (Torgerson, 2005). In Germany, polyclin- ics were opened with GPs, specialists, and other health professionals in 2004 (Busse et al., 2006).
The management of many chronic diseases has been moving progressively to nurse-led clinics in the United Kingdom, the Netherlands, and Scandinavia (Buchan & Calman, 2005; Nolte & McKee, 2008a). Some of these clinics specialize in diabetes, hypertension, allergy, asthma, COPD, mental illnesses, and heart failure (Karlberg, 2008). These developments create new career opportunities for nurses and reduce health care costs.
As discussed earlier, DMPs attempt to coordinate resources across the health care delivery system. They are similar to integrated care systems, except they include social workers. Most DMPs have three main features: a knowledge base, a delivery system with coordinated care, and a continuous improvement process for a specific disease within a specific population (Hunter & Fairfield, 1997). Disease management is a system that tries to deliver coordinated care—organized according to scientific evidence—throughout the clinical course of a chronic illness. Patients are consulted on care-management decisions.
In Sweden, the Swedish Elderly Reform used the concept of integrated delivery systems to decen- tralize health care and coordinate activities while it reduced redundancy (Andersson & Karlberg, 2000). “Chains of care,” as they are called, regard patients as partners instead of objects (Åhgren, 2003). County councils are responsible for organizing health care in this instance. The chain-of- care system has been slow to develop, however, because of resistance from doctors and health care managers (Åhgren & Axelsson, 2007).
In some instances, DMPs are replaced by improved comprehensive integrated care models. In 2005, the United Kingdom launched a health and social care model to improve the quality and accessibility of care for people with chronic conditions and to contain or reduce the associ- ated costs (de Silva & Fahey, 2008). It was based on two chronic care models used in the United States—the Kaiser Triangle and the Evercare model—and featured nurse-led clinics, specialist nurses called “community matrons,” and case management. This model outlined how to identify people with chronic conditions and stratify their care needs. It used a systematic approach to link health and social care with service users and caregivers, and used local methods to support self- care. Evaluation of the program is ongoing, but one study’s results were disappointing, suggesting the program had resulted in little reduction in hospital use, one of its main objectives (Boaden et al., 2006). Other countries are engaging in their own experiments:
• In Spain, pilot projects on the long-term integration of care have been going on for many years. These projects provide complete care from one source and use regional strategies. In the Denia region in Valencia, local, population-based integration models have been tested since 1997 (Campoy, 2005). The management of all public health facilities and the insurance of all public health benefits are controlled by the populace of that region.
• In Germany, various models are being tried to promote more integrated care: DMPs, care models based on the family doctor as gatekeeper, integrated care contracts, and medical polyclinics.
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CHAPTER 11Section 11.6 Innovations in CID
• In France, the Juppé reforms stimulated the development of local provider networks for ambulatory patients and improved interactions between ambulatory and hospital care (Bras, Duhamel, & Grass, 2006; Sandier, Paris, & Polton, 2004).
• The Netherlands has been trying to improve the continuity and quality of care for peo- ple with long-term conditions and to close the gap between primary and hospital ser- vices, which led to the concept of transmural care. Transmural care is attuned to the needs of patients and its provision is based on cooperation and coordination between general and specialized caregivers who share overall responsibility and specific del- egation of responsibilities (Van der Linden, Spreeuwenberg, & Schrijvers, 2001). It is aimed at patients who are not able to be fully independent and manages the interface between acute hospital care and alternative settings (Nolte & McKee, 2008a).
• The Canadian province of Ontario is trying to improve the planning, coordination, and integration of health care through family doctors (family health groups and family health networks) and local health integration networks (Torgerson, 2005).
E-Health Technology is one way to improve the use of resources and quality of care and to increase the amount of time devoted to the needs and wishes of patients (Busse et al., 2006). Successful results are achieved with electronic records, e-prescribing, and many telemedicine services (telediagnos- tics, -consultation, -monitoring, and -training). When implemented effectively, significant returns on investments can be achieved.
Within the framework of the i2010 iniative, many governments have been motivated to intensify their initiatives in various forms of information technology (IT; European Commission, 2009). The plan encourages member states to develop “e-health” strategies to exchange health data using international standards (European Commission, 2004).
Clinical decision making increasingly relies on electronic systems. Standardizing the delivery of care in accordance with evidence-based practices, it is hoped, increases quality of care and con- tains costs (Glasgow, Zwer, Harris, Hasan, & Jowsey, 2008). Support systems can provide person- alized treatment, recommend medications (Coiera, Lau, Tsafnat, Sintchenko, & Magrabi, 2009), assist in diagnosis, identify gaps in a patient’s care, and handle electronic health records. Formal decision support systems have been studied and have often proven beneficial for such conditions as hypertension, diabetes, depression, heart failure, asthma, COPD, osteoarthritis, and end-stage renal failure.
Many governments support holistic information and communications systems such as e-health platforms and electronic health records. E-health platforms have many goals: improve access; increase patient participation; improve efficient delivery; and better coordinate doctors, patients, hospital workers, pharmacists, care workers, health insurers, and public administrators. Prompt communication among these professionals, it is hoped, will free up more time for patient care and track patients more likely to develop diseases. Examples of such platforms include the Canadian Health Infoway, MedCom in Denmark, NHS Connecting for Health in Britain, Health Connect Australia, and an Internet portal in France for chronic conditions (Glasgow et al., 2008). In addition, the European Commission places great hope on telemedicine applications, such as telemonitoring and teleradiology, despite limited evidence suggesting it is cost effective (Euro- pean Commission, 2008).
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Chapter Summary CHAPTER 11
Chapter Summary
Globally, the approach to dealing with CID differs dramatically, depending on income level; social environment; current health care system; and prevailing political, societal, family structure, and belief systems. Governments throughout the world are struggling to consider these factors when designing a health care system for chronic disease, which they all recognize to be their most important health challenge. Health care organizations have recently seen the emergence of new providers, new settings, and new qualifications to try to meet these challenges. Innovations are being designed and tested—not only in products and treatment, electronic health records, and IT services, but also in processes, funding, and care management services.
Epidemiological and economic analyses suggest that policy makers adopt some form of disease management plan with a range of community support systems that include the patient in all decision-making processes. However, choosing the right strategies is difficult, particularly given the limited evidence of their efficacy and cost effectiveness. Several key concepts for approaching CID are continuum of care, psychosocial assessments, enhanced health literacy, equal access to quality care, compliance with treatment, and the broad use of IT (European Union Health Policy Forum, 2013). However, the merits of a more proactive approach focusing on prevention, health promotion, the right mix of financial incentives for all providers, and patient-centered chronic disease management is being debated. The European Union and its member states must plan resources, education, and training to ensure they have the skills needed to implement holistic, patient-centered care. This model of care integrates prevention recommendations into practical advice to patients and families (Waxman, 2004).
Regardless of the obstacles, the European Union and member states appear committed to the total reform of health care management of CID. Countries can no longer ignore the economic impact of doing nothing, because CID impairs economic growth by reducing labor and productivity (Suhrcke et al., 2006). Steady and stable economic growth increases a nation’s capacity to pur- chase the necessary goods and services that promote health. Unhealthy societies impede the pro- cess of economic development (Subramanian, Belli, & Kawachi, 2002). In high-income countries, a 1% increase in the mortality rate decreases the per capita income growth rate in the following five years by approximately 0.1% (Suhrcke, Fahey, & McKee, 2008). Greater effects on the economy are seen in Asia, Russian, and eastern Europe (Suhrcke, Rocco, & McKee, 2007a, 2007b).
The designers of chronic care systems in the European Union, as well as the United Nations, are moving away from blaming the victims of CID. Instead, they are putting CID into a broader social context and making it a human rights issue. This reframing may provide an opportunity for scholars and health care professionals to codify international obligations under the purview of an evolving human right to health care. This rights-based approach might also lay the foundational framework for reducing global health inequalities through foreign assistance. The potential contributions and limitations of applying a human rights framework to advance global health will be something to watch in the future.
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Key Terms CHAPTER 11
Key Terms
2005 Disability Discrimination Act U.K. law to promote the fair treatment (disability equality) for the disabled.
American Recovery and Reinvestment Act of 2009 Economic stimulus package to save and create jobs. The act included direct spend- ing for infrastructure, education, health, and energy; federal tax incentives; and expansion of unemployment benefits and other social welfare provisions.
Americans with Disabilities Act (ADA) A 1990 law that prohibits discrimination on the basis of disability in employment at state and local government, public accommodations, commercial facilities, transportation, and telecommunications. It also applies to the U.S. Congress.
Centers for Disease Control and Prevention (CDC) U.S. government organization to gener- ate the expertise, information, and tools that people and communities need to protect their health through health promotion; prevention of disease, injury and disability; and prepared- ness for new health threats.
chains of care Coordinated activities within health care involving several responsible authorities and medical providers. In Sweden, care is based on evidence-based health care and clinical guidelines, that is, agreements on distribution of medical work, within a county council area, and among different providers of health care.
chronic care model An integrated care system devised in the United States. Com- bines the essential elements of a health care system: community, the health system, self-management support, delivery system design, decision support, and clinical informa- tion systems. Fosters productive interactions between informed patients, who take an active part in their care, and providers, who have the resources and expertise.
community nurses Well-trained health care practitioners who are the first line of defense in the primary health care system in many European countries.
decision support systems Computer-based information systems that support medical diagnoses.
disability-adjusted life year (DALY) A mea- surement of quality of life for an individual who has to live with a chronic condition or disability. It measures health loss by viewing the number of years lived with a condition as a percentage of the total elapsed time. Although measuring the same concept, it is numerically the inverse value (on a scale from 0 to 1) of quality-adjusted life-year.
disease management program (DMP) An integrated, comprehensive treatment plan that specializes in managing individuals with specific diseases, for example, cancer, heart disease, and diabetes.
Ensemble Prévenons l’Obésité Des Enfants (EPODE) A community-centered initiative in France involving doctors, dietitians, and other health professionals; intended to reduce the number of overweight and obese children.
e-prescribing Computer-based electronic generation, transmission, and filling of medical prescriptions.
European Network for Smoking Prevention (ENSP) An international nonprofit organization that coordinates action among organizations active in tobacco control in Europe and pro- motes comprehensive tobacco control policies at both the national and European level.
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Key Terms CHAPTER 11
Human Genome Project An international scientific research project whose primary goal is to determine the sequence of chemical base pairs that make up human DNA and to identify and map the total genes of the human genome from both a physical and functional standpoint.
integrated care program Resembles a DMP but includes self-management support and patient education components; often includes structured clinical follow-up and case management.
International Classification of Functioning, Disability, and Health (ICF) A standard frame- work, developed by the WHO in 2001, for assessing health and health-related states to guide treatment and policy relating to disabil- ity at both individual and population levels.
Juppé reforms Changes in the health care system of France that shifted the balance of the health insurance system away from a work-based system toward a system of uni- versal health coverage and gave parliament a larger role in the definition of health care and financial targets.
Mental Retardation Facilities and Commu- nity Mental Health Centers Construction Act of 1963 An act to provide federal funding for community mental health centers in the United States. Many patients, formerly ware- housed in institutions, were released into the community. Despite the law’s good intentions, many patients ended up homeless in large cities.
patient-centered care Encourages active involvement of patients and their families in the design of their care and in decision making about individual options for treatment.
personalized medicine Customization of health care in which medical decisions, prac- tices, or products are tailored to the individual patient and usually contain a genetic compo- nent specific to him or her.
polypill An oral medication that combines multiple active drug ingredients.
pooling A system of health care financing in which all public funds for health care are collected nationally, often gathered into a single fund. Pooling allows the contributions of healthy individuals to be used to cover the costs of those who need health care.
Primary Care Trusts NHS bodies in the United Kingdom responsible for commissioning primary, community, and secondary health services from providers. They provide funding for GPs, medical prescriptions, hospitals, and mental health services.
purchaser–provider splits A health care deliv- ery model in which third-party payers are kept organizationally separate from service provid- ers to create competition among suppliers.
randomized control trial A type of ran- domized clinical trial (RCT); an experimental research design to test new drugs, treatments, and therapies.
Section 504 of the Rehabilitation Act of 1973 A U.S. law that protects qualified indi- viduals from discrimination based on their disability.
Sophia A disease management program piloted by the National Sickness Fund in France, tailored to suit the individual needs of diabetic patients; relies mainly on nurses work- ing in call centers.
telemedicine Use of technology to remotely diagnose, treat, monitor, and consult with patients.
transmural care A system of integrated pri- mary and secondary (hospital services) health care first tried in the Netherlands.
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Critical Thinking Questions CHAPTER 11
United Nations Convention on the Rights of Persons with Disabilities (CRPD) A conven- tion adopted by the United Nations; views the disabled as individuals with rights who are capable of claiming those rights and making decisions for their lives based on their free and informed consent as well as being active members of society. It is intended as a human rights instrument.
U.S. National Center for Health Statistics An agency that works within the CDC to provide statistical information that will guide actions and policies to improve the health of the U.S. population.
World Health Organization (WHO) Health organization under the United Nations umbrella; provides leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing tech- nical support to countries, and monitoring and assessing health trends.
Critical Thinking Questions
1. Discuss the similarities and differences between the U.S. and European approaches to caring for the chronically ill.
2. Although the epidemic of chronic illness is here, discuss ways in which the issue can be addressed.
3. What are the differences between caring for the chronically ill and those with acute illness? 4. The economics of caring for persons with CID appears enormous. How can its impact
be lessened? 5. Does what you have learned about the epidemic of CIDs facing the world make you favor
health care rationing more or less? Present your argument.
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