How to Bend the Cost Curve
Total health expenditure as a % of
GDP
Increasing Efficiency in
Canada’s Healthcare System:
The Transformative Potential of
e-Technologies
Robyn Tamblyn, PhD
McGill University
Source: CIHI, National Health Expenditure Trends, 2009
Is Canada Getting Value for
Money?
Canada’s aging population
¾ Chronic conditions are more
common in older people
¾ Includes: arthritis, cancer,
COPD, diabetes, heart
disease, high blood pressure,
and mood disorders
Source: Calculated by the Commonwealth Fund based on the Commonwealth Fund 2004 and 2005 International
Health Policy Surveys, the 2006 Commonwealth Fund International Survey of Primary Care Physicians, and the
Commonwealth Fund Commission on a High Performance Health System National Scorecard.
ER Use in Past Two Years
Any ER use
80
64
60
40
59
53
Access to Doctor When Sick or Needed Care
Used ER for condition
treatable by regular doctor,
if available
80
Source: Health Council of Canada, Population Patterns of Chronic Health Conditions in Canada, 2007
Same-day appointment
80
60
60
60
54
42 43
40
40
40
26
20
6
8
6
UK
US
AU
S
CA
N
FR GER ETH
N
Base: Adults with any chronic condition
Data collection: Harris Interactive, Inc.
Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.
34
26
20
20
0
0
18
23
18
14
8
8
3
0
NZ
40
26
19
17
9
0
36
26
23
20
H
A
S
N
R
AU CA FR GE NET
60
48
45
41 39
6+ days wait or never able
to get appointment
80
NZ
UK
US
S
N
AU CA
F R G ER ET H
N
NZ
UK
US
AU
S
CA
N
FR GER ETH
N
Base: Adults with any chronic condition
Data collection: Harris Interactive, Inc.
Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.
NZ
UK
US
Targeting Transformative Efficiency
Gains with New Technologies
Patient Empowerment
1. Patient Empowerment Tools
2. Personalized Decision Support
3. Population Health Surveillance
Increasing efficiency of contact: The “My Health
Manager” patient-primary care team e-visit system
Chen et. al Health Affairs , April 2009
Self-Management Tools: Personal Health
Supporting
Disease
Self-Management
Records
and Patient
Portals
Increasing efficiency of contact: The “My Health
Manager” patient-physician e-visit system
Chen et. al Health Affairs , April 2009
Systematic Review of Telehealthcare: Reducing the
Risk of Asthma-Related Hospital Admissions
Mclean et.al CMAJ, August 9, 2011
Systematic Review of Telehealthcare: Improving
HRQL in Asthma Patients
Cost-Minimization Analysis of Tele-Homecare for
COPD
Mclean et.al CMAJ, August 9, 2011
Opportunities to Prevent or Ameliorate Adverse
Drug Events
Pare et. al, Telemedicine and e-Health, Vol. 12 No. 2, 2006
IVRS: Monitoring the Early Effects of
Medication
Ghandi et al. NEJM, April 2003
N = 661
Ameliorable ADE’s (51)
•Failure of physician to respond to
medication-related symptoms - 32
(63%)
•Failure of patient to inform physician of
symptoms – 19 (37%)
Preventable ADE’s (20)
•Selection of wrong drug – 9 (45%)
•Wrong dosage – 2 (10%)
•Wrong frequency of use – 2 (10%)
•Preventable by advanced systems of
medication ordering – 7 (35%)
Practice Monitoring Tools: Alerting Physicians
about New Problems with Medications
MOXXI
Systems
IVRS
Monitoring
Detection of Adverse Drug Events and
Prescription Issues Using IVRS
Forster et. al CIHR grant #2456 2010
ENROLLED (N = 496)
Problem with
medication
233 (47.0%)
No problems with
medication
263 (53.0%)
Adverse
Drug Event
127 (25.6%)
Primary
NonCompliance
91 (18.3%)
Advice
Requested
45 (9.1%)
Personalized Decision Support
Systematic Review of the Effectiveness of Computerized
Decision-Support on Quality of Care and Patient Outcomes
Garg et.al. JAMA, March 9, 2005
Using Individualized Risk Assessment Tools to
Inform and Enhance Treatment Practices
Incorporating Epidemiological Science
into Risk-Benefit Assessment
Improvement in Quality of Care
Number of
Trials
Success Rate
Diagnostic Decision-Making
10
40%
Patient Care Reminder Systems
21
76%
Disease Management Decision-Support
37
62%
Drug Dosing
29
66%
Improvement in Patient Outcomes
Number of
Trials
Success Rate
All systems
52
13%
Designing New Smart Alerts that Provide Person‐Specific Risk Assessment ⎛ 0.304 * class_2 + 0.035 * class_3 +
⎞
⎜
⎟
⎜ 0.253 * class_4 + 0.105 * class_5 +
⎟
⎜ 0.088 * class_6 + 0.088 * class_7
⎟
⎟
⎜
hazard _ total = hazard _ nm * EXP ⎜ + 0.225 * class_9 + 0.056 * class_11 + ⎟
⎜ 0.008 * class_13 + 0.106 * class_15 + ⎟
⎜
⎟
⎟
⎜ 0.099 * class_16 + 0.047 * class_17
⎜
⎟
⎝ + 0.147 * class_18 + 0.07 * class_23 ⎠
⎛ 0.038* age_65+ 0.047* female+ 0.123* gb + ⎞
⎟⎟
hazard_ nm = EXP⎜⎜
⎝ 0.287* ci - 0.0023* lw
⎠
)
)
risk _ nm = 100* (1 − (1 − baseline
100 ^ hazard_ nm
Providing Immediate Feedback on the
Consequences of a Change in Medication
Reductions in Fall-Related Injury Risk With
Personalized Alerts
Tamblyn et. al, JAMIA (under review)
Starting Risk
0.2
Mean Reduction in Modifiable
Risk After 6 Months
0.15
0.1
0.05
0
Intervention
Control
Daily Surveillance of ER
Visits and Rescue
Alert!
of DailyAsthma
Downloads
of
MedicationAnalysis
to Assess
Control
Computerized Decision Support for EvidenceBased Asthma Management
Information from the Provincial
Insurance Billing Data
Rate of Out-of-Control Asthma Episodes in the
Intervention and Control Group
Tamblyn, Ernst, Winslade: CIHR RCT## NCT00170248
Out-of-Control at First Visit: 704 (15.8%) In-control at First Visit: 3,743 (84.2%)
Population Health
Using e-Technologies to Improve Early Detection
and Intervention
RR: 0.87
95% CI: 0.77, 0.99
RR: 1.00
95% CI: 0.74, 1.36
Figure based on a theoretical model of the impact of public health actions.
Source: World Health Organization
Electronic Lab Reporting: Improvements in Notifiable
Disease Reporting Over Passive Surveillance Methods
Overhage et. al, AJPH 2008
Of 4785 unique cases
944 (20%) identified by
traditional methods
4625 (95.4%) identified by
ELR
311
Automated
(ELR)
3249
550
515
Public Health
73
10
77
Hospital
Syndromic Surveillance: China’s Electronic Hospital Reporting System
Conclusions
Rubella Outbreak in Chinese Middle School
700
Targeted e-Technologies Can Improve
Efficiencies By:
600
500
1. Empowering patients to manage chronic
conditions and provide more timely access to
healthcare.
400
Expected
300
2. Providing person-specific decision
support to reduce morbidity.
200
100
0
5
0
100
150
200
250
300
3. Monitoring infectious diseases to
control outbreaks.
350
Time (days)
How to Bend the Cost Curve
Total health expenditure as a % of GDP, by
country
Supporting outstanding health services
and policy research: where to start?
Source: Commonwealth Fund National Scorecard on U.S.
Health System Performance, 2006
Readmitted to Hospital or Went to ER
from Complications During Recovery
Canada’s aging population
40
20
18
17
17
11
7
9
11
10
NZ
UK
0
AUS
Source: Statistics Canada. Estimates of Population, Canada, the Provinces and Territories (Persons).
CANSIM Table no. 051-0001; and Statistics Canada. Population Projections for Canada, Provinces and
Territories (2005-2031). CANSIM table no. 052-0004
CAN
FR
GER
NETH
Base: Adults with any chronic condition
Data collection: Harris Interactive, Inc.
Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.
US
Diabetics Who Received Recommended
Preventive Care Services
18%
Percent received all four diabetes services*
80
59
40
36
14%
55
16.4%
16.0%
1996
16.4%
14.8%
14.0%
14.0%
13.0%
14.2% 13.6%
13.3%
12.4%
43
10%
2006
14.5%
12.6%
12.4%
12%
40
39
17.4%
16%
67
60
Percentage of Total Health Care Spending
on Pharmaceuticals, 1996 and 2006
10.5%
10.0%
9.3%
8.9%
8.5%
8%
31
6%
20
4%
2%
0
AUS
CAN
FR
GER
NETH
NZ
UK
US
* Hemoglobin A1c checked in past six months; feet examined for sores or irritations in past year; eye exam
for diabetes in past year; and cholesterol checked in past year.
Data collection: Harris Interactive, Inc.
Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.
Feasibility and Acceptability of IVRS
(n=496)
Was the calling system easy
to use?
0%
CAN
FRA
OECD
Median
GER
AUS*
SWED
US
NZ
SWITZ*
DEN
Source: OECD Health Data 2008
Total Retail Drug Expenditure as a Percentage of
Total Health Expenditure, Canada, 1985-2009
If this type of calling system
were provided by your doctor,
would you continue to use it?
¾ Retail drugs were forecasted
to account for ~16.4% of
total health expenditures in
2008 and 2009 (CIHI, 2008)
“…It’s a sign of just how desperate
overcrowded facilities are to free up
beds…The bottleneck starts outside of
hospital and is caused by a shortage of
both home and long-term care.”
¾ Growth in per capita spending
due to:
¾ Increased volume of drugs
purchased
¾ Types of drugs
¾ Population aging (moderate
effect)
Automating the Completion of Adverse Event
Reports Within the Patient’s Chart
Electronic Lab Reporting: Improvements in Notifiable
Disease Reporting Over Passive Surveillance Methods
Overhage et. al, AJPH 2008
Timeliness
Completeness
Æ Cases identified on average 7.9 days
earlier by ELR
Æ
More timely for 13 out of 16 conditions (81%)
Æ
ELR identified 4.4 times as many cases
as spontaneous reporting
Æ
Of 18 reporting fields:
10 present more often in ELR
5 present in more often in spontaneous reports
3 present equally in both methods