Chris van Weel International Conference On Healthcare Reform - - PowerPoint PPT Presentation

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Chris van Weel International Conference On Healthcare Reform - - PowerPoint PPT Presentation

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Now more than ever: The role of primary care and family physicians to secure relevant health care for populations and people Chris van Weel International Conference On Healthcare Reform January 17 2009 Going back to the future, for health

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SLIDE 1

Now more than ever:

The role of primary care and family physicians to secure relevant health care for populations and people

International Conference On Healthcare Reform January 17 2009

Chris van Weel

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SLIDE 2

Going back to the future, for health care XXIst century

  • Steadfast Flexibility of Care
  • Equality (delivered quality)
  • Equity (individual needs)
  • Rediscovering ‘old’ values
  • Presentation
  • Ecology of Medical Care
  • Two research examples
  • Conclusion: integrated primary

care

Professor Chris van Weel

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SLIDE 3

Challenges in delivering health care

  • Specialty model
  • Disease specific, a doctor for every disease
  • Technology, supplier driven
  • Disease in isolation
  • Disease-mechanism
  • Biochemical determinants
  • Episodes in isolation
  • Disuptive care
  • Body – mind anomaly
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SLIDE 4

Global Perspective

common denominator

  • Health Systems differ
  • Enhance, impede roles & functions
  • Perverse incentives
  • Mission health care generic
  • ‘Ecology of medical care’
  • Morbidity in context
  • Variation in care
  • System consequence, no discipline

characteristic

* White et al NEJM 1961 Green et al NEJM 2001

Professor Chris van Weel

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SLIDE 5

The Ecology: Community/Population Perspective and Three Transitions

  • Domain Health Problems
  • Selfcare
  • Primary care
  • Secondary care
  • Role Patients
  • Health care structure

* White et al NEJM 1961 Green et al NEJM 2001

Professor Chris van Weel

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SLIDE 6

Health care policy move

  • From hospital to primary

care

  • From specialist to

community

  • From professional to

selfcare

  • Societal perspective

* White et al NEJM 1961 Green et al NEJM 2001

Professor Chris van Weel

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SLIDE 7

‘Reach’ of Primary Care

  • Primary care morbidity
  • Unique domain illness,

disease

  • Population perspective
  • Needs, intersectorial
  • Patient perspective
  • Personal doctor
  • Empowerment, needs vs.

demands

  • System perspective
  • Navigating resources

* White et al NEJM 1961 Green et al NEJM 2001

Professor Chris van Weel

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SLIDE 8

Domain of Primary Care

unique clinical domain

  • Top-10 Chronic Diseases
  • Obesity
  • Hypertension
  • Chronic nervous complaints
  • Deafness
  • COPD
  • Chr. Isch. Heart disease
  • Varicose veins
  • Hyperlipemia
  • Depression
  • Psoriasis

* White et al NEJM 1961 Green et al NEJM 2001

Professor Chris van Weel

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SLIDE 9

Professor Chris van Weel

Effectivness Primary Care*

* Starfield B. Is primary care essential? Lancet 1994

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SLIDE 10

The Family Physician (GP)

(Norman Rockwell 1947)

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SLIDE 11

Two emprirical examples:

Does the epidemiological setting matter?

A-priory chance Comparing hypertension treatment of physicians internal medicine and family physicians

Does the integral approach matter?

Disease orientation versus person-centred care The outcome of depression in family medicine

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SLIDE 12

Professor Chris van Weel

PERFORMANCE FPs - PHYSICIANS

(hypertension)

UNCOMPLICATED COMPLICATED FP PHYSICIAN

Gerritsma en Smal, 1982

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SLIDE 13

Professor Chris van Weel

PERFORMANCE FPs - PHYSICIANS

(hypertension)

UNCOMPLICATED COMPLICATED FP Few interventions Limited time Purposeful PHYSICIAN

Gerritsma en Smal, 1982

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SLIDE 14

Professor Chris van Weel

PERFORMANCE FPs - PHYSICIANS

(hypertension)

UNCOMPLICATED COMPLICATED FP Few interventions Limited time Purposeful More interventions More time Exploring PHYSICIAN

Gerritsma en Smal, 1982

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SLIDE 15

Professor Chris van Weel

PERFORMANCE FPs - PHYSICIANS

(hypertension)

UNCOMPLICATED COMPLICATED FP Few interventions Limited time Purposeful More interventions More time Exploring PHYSICIAN Protocol driven Relative limited time Purposeful

Gerritsma en Smal, 1982

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SLIDE 16

Professor Chris van Weel

PERFORMANCE FPs - PHYSICIANS

(hypertension)

UNCOMPLICATED COMPLICATED FP Few interventions Limited time Purposeful More interventions More time Exploring PHYSICIAN More interventions More time Exploring Protocol driven Relative limited time Purposeful

Gerritsma en Smal, 1982

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SLIDE 17

Professor Chris van Weel

LESSONS OF THE EXAMPLE

  • Importance of clinical environment
  • Frequent health problems (early diagnosis, follow-up)
  • Practice primarily focussed on ‘norm’
  • Exceptions require additional interventions
  • Generic but context dependent
  • International position of family practice.
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Two emprirical examples:

Does the epidemiological setting matter?

A-priory chance Comparing hypertension treatment of physicians internal medicine and family physicians

Does the integral approach matter?

Disease orientation versus person-centred care The outcome of depression in family medicine

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SLIDE 19

DOES PERSON CENTRED CARE MATTER?

Example: FPs’ treatment depression

van Os TW, van den Brink RH, Tiemens BG, Jenner JA, van der MK, Ormel J. Communicative skills of general practitioners augment the effectiveness of guideline-based depression treatment. J.Affect.Disord. 2005;84:43-51.

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SLIDE 20

OUTCOME FPs DEPRESSION CARE

CLINICAL COMPETENCE: OUTCOME:

van Os TW et al, J.Affect.Disord. 2005;84:43-51

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SLIDE 21

OUTCOME FPs DEPRESSION CARE

CLINICAL COMPETENCE: OUTCOME: Follows guideline Does not follow guideline

van Os TW et al, J.Affect.Disord. 2005;84:43-51

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SLIDE 22

OUTCOME FPs DEPRESSION CARE

CLINICAL COMPETENCE: OUTCOME: Follows guideline Good Does not follow guideline Poor

van Os TW et al, J.Affect.Disord. 2005;84:43-51

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SLIDE 23

OUTCOME FPs DEPRESSION CARE

CLINICAL COMPETENCE: EMPATHY OUTCOME: Follows guideline Good Does not follow guideline Poor

van Os TW et al, J.Affect.Disord. 2005;84:43-51

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SLIDE 24

OUTCOME FPs DEPRESSION CARE

CLINICAL COMPETENCE: EMPATHY OUTCOME: Follows guideline FP-Patient relation good Follows guideline FP-Patient relation poor Does not follow guideline FP-Patient relation good Does not follow guideline FP-Patient relation poor

van Os TW et al, J.Affect.Disord. 2005;84:43-51

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SLIDE 25

OUTCOME FPs DEPRESSION CARE

CLINICAL COMPETENCE: EMPATHY OUTCOME: Follows guideline FP-Patient relation good Follows guideline FP-Patient relation poor Does not follow guideline FP-Patient relation good Does not follow guideline FP-Patient relation poor Poor

van Os TW et al, J.Affect.Disord. 2005;84:43-51

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SLIDE 26

OUTCOME FPs DEPRESSION CARE

CLINICAL COMPETENCE: EMPATHY OUTCOME: Follows guideline FP-Patient relation good Follows guideline FP-Patient relation poor Does not follow guideline FP-Patient relation good Poor Does not follow guideline FP-Patient relation poor Poor

van Os TW et al, J.Affect.Disord. 2005;84:43-51

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SLIDE 27

OUTCOME FPs DEPRESSION CARE

CLINICAL COMPETENCE: EMPATHY OUTCOME: Follows guideline FP-Patient relation good Follows guideline FP-Patient relation poor Poor Does not follow guideline FP-Patient relation good Poor Does not follow guideline FP-Patient relation poor Poor

van Os TW et al, J.Affect.Disord. 2005;84:43-51

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SLIDE 28

OUTCOME FPs DEPRESSION CARE

CLINICAL COMPETENCE: EMPATHY OUTCOME: Follows guideline FP-Patient relation good Good Follows guideline FP-Patient relation poor Poor Does not follow guideline FP-Patient relation good Poor Does not follow guideline FP-Patient relation poor Poor

van Os TW et al, J.Affect.Disord. 2005;84:43-51

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SLIDE 29

EFFECTIVENESS of FAMILY PRACTICE

  • Knowledge what is effective
  • Cost-effectiveness health care (Starfield)
  • FP density ~
  • Life expectancy
  • Early diagnosis of malignancies (melanoma)
  • For subspecialist this relation inverse!
  • Poor understanding of why it is effective
  • Black box, counterintuitive
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SLIDE 30

Role, function family physician

  • Medical generalist
  • All health problems
  • All stages
  • All Individuals
  • Need driven
  • Community oriented
  • Family or household focus
  • Social determinants
  • Personal doctor
  • Patient centred
  • Integrated care
  • Continuity of care

Professor Chris van Weel

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SLIDE 31

VERTICAL vs HORIZONTAL PROGRAMS OF CARE

H I V A I D S M A L A R I A T B C O P D

INTEGRATED PRIMARY CARE

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SLIDE 32

STRUCTURE ANOMALY

  • Horizontal programming more effective, efficient
  • Focus: responding to needs
  • Target: unselected patients & communities
  • Where the science is
  • Vertical programs more sexy
  • Focus: supply driven
  • Target: pre-selected groups & episodes
  • Where the money is
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SLIDE 33

Fifteen by 2015

Organize special programs through primary care: make a smal part of special program money (15%) available for primary care development

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SLIDE 34

International Classification of Primary Care ICPC

  • Developed by Wonca
  • 1987, WICC
  • Maurice Wood
  • Primary care focus
  • Specificity of generalist
  • Relation with WHO
  • Relation ICD
  • International Standard
  • Europe, Australia
  • WICC (chair Michael Klinkman):
  • ICPC-3

Professor Chris van Weel

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SLIDE 35

Understanding effectiveness of primary care:

practice, ICPC, R&D

  • Need of comprehensive data
  • Dynamics primary care
  • Information beyond diagnosis
  • Reflecting context of primary care
  • Build on primary care experience
  • Primary care position in the

medical home

Professor Chris van Weel

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SLIDE 36

Conclusions

  • Now more than ever:
  • Primary care matters
  • It safes lives, and not only money
  • Better population health and better functioning health care system
  • Core concepts acknowledged
  • Personal, continous, social/family context, trust
  • Primary care can be, and must be, developed
  • Academic outreach of teaching, training
  • It is not ‘an art’
  • Better understanding of its effectiveness urgently needed
  • Research and development
  • No need to postpone action