An Inconvenient Truth:
A Sustainable Healthcare System
Requires Chronic Disease Prevention
and Management Transformation
INVITED ESSAY
Matthew W. Morgan, MD, MSc, FRCP(C)
Partner, Courtyard Group
University of Toronto
University Health Network
Nicholas E. Zamora, BSc Pharm, MBA, CHE
Specialist, Courtyard Group
Michael F. Hindmarsh, MA
President, Hindsight Healthcare Strategies
Affiliate, MacColl Institute for Healthcare Innovation,
Group Health Cooperative, Seattle, Washington

ABSTRACT
Canada’s initial success at shortening wait times will not transform our healthcare
system unless it is matched with equal success in the prevention and management of
chronic diseases. A growing body of evidence highlights the significant gap between
recommended care and actual care received for those at risk for or living with chronic
illnesses. This quality gap not only results in significant preventable morbidity and
mortality but also lengthens wait times for healthcare services and threatens the
sustainability of our healthcare system.
6
An Inconvenient Truth
A national strategy on chronic disease prevention and management (CDPM)
that leverages the federal, provincial and territorial (FPT) response to wait times
will not only transform chronic illness care but also help to ensure the sustainability
of our healthcare system.
We begin this paper by highlighting some of the facts behind this inconvenient
truth. We then review and provide examples of several best practices in CDPM.
We suggest that these best practices provide the foundation for a national CDPM
strategy and argue that the FPT mandate for wait times be expanded to encompass
CDPM and result in “care guarantees.” We conclude with a high-level preliminary
analysis of costs and benefits of this strategy to transform CDPM in Canada.
The Inconvenient Truth:
The Burden of Chronic Disease
It is an inconvenient truth that Canada’s
initial success at shortening wait times will
not transform our healthcare system unless it
is matched with equal success in the prevention and management of chronic diseases. It
is also an inconvenient truth that it is only
a matter of time before someone in Canada
living with a chronic disease successfully
makes the case that he or she unnecessarily
suffered as a result of inadequate care received
from a healthcare system that is not meeting
the minimum standards in chronic disease
prevention and management (CDPM). As
a country, we must not wait for the CDPM
equivalent of the Chaoulli case (2005). A
national strategy on CDPM that leverages
the federal, provincial and territorial (FPT)
response to wait times will not only transform
CDPM but also help to ensure the sustainability of our healthcare system.
We begin this paper by highlighting some
of the facts behind this inconvenient truth.
We then review and provide examples of
several best practices in CDPM. We suggest
that these best practices provide the foundation for a national CDPM strategy and argue
that the FPT mandate for wait times be
expanded to encompass CDPM. We conclude
with a high-level preliminary analysis of costs
and benefits of this strategy to transform
CDPM in Canada.
Although Canadians are generally living
longer and healthier lives, many of us are
living with multiple chronic diseases. These
two statements may seem contradictory, but
they are not. As our population ages and as
medical advances continue to convert acute
life-threatening diseases into chronic illnesses,
our healthcare system is challenged to meet
the growing burden of chronic disease. The
vast majority of patients in the healthcare
system today are people living with one or
more chronic diseases. To quantify the extent
of the problem, it is estimated that more than
half of all North American adults have a
chronic disease, two-thirds of medical admissions via emergency are due to the exacerbation of a chronic disease, 80% of primary care
physician visits are related to chronic disease
and more than two-thirds of all medical costs
involve chronic disease (Rapoport et al. 2004).
Patients living with chronic illnesses are at
higher risk of developing additional chronic
diseases, as highlighted by a recent analysis of
Medicare beneficiaries in the United States
(Thorpe and Howard 2006). In this analysis, more than half of all adults were being
managed for five or more chronic conditions,
accounting for 76% of the total healthcare
spending and virtually all growth in spending
from 1998 to 2002.
7
HealthcarePapers Vol. 7 No. 4
guaranteed care that
meets minimum standards. These guarantees
Avoidable Toll
are as important as
29,000 kidney failures
wait time guarantees if
2,600 blind
we are to improve the
9,600 deaths
health of individuals and
10,000 deaths
populations and ensure
the sustainability of our
37,000 deaths
healthcare system.
This significant gap
68,000 deaths
between recommended
care and received care
has been referred to as
the “quality chasm” (Institute of Medicine
2001). In Canada, this chasm can be attributed
to a number of factors, including the following:
Table 1. Projected toll in the United States resulting from the
quality gap
Condition
Shortfall in Care
Diabetes
Average blood sugar not measured
for 24%
Colorectal cancer
62% not screened
Pneumonia
36% of elderly did not receive
vaccine
Heart attack
39–55% did not receive needed
medications
Hypertension
<65% received indicated care
In 2003, McGlynn and colleagues
completed a large multi-city review of care
received by 6,712 adult Americans. The
researchers concluded that adherence to
recommended care is low for chronic conditions, ranging from 45% for diabetes to 68%
for coronary artery disease. Extrapolation of
these findings to the entire US population
suggests that this shortfall in care results in a
significant avoidable toll in terms of morbidity
and mortality, as highlighted in Table 1.
This poor performance is not unique to
the United States, as assessed by Schoen and
colleagues in 2005. These researchers found
that physicians’ compliance with basic chronic
disease practice guidelines in six countries was
poor. Although all countries scored reasonably
well when individual indicators of the guidelines were considered (e.g., annual evaluation
of cholesterol in patients with diabetes), all
countries scored poorly when compliance
with multiple basic indicators was assessed, as
depicted in Table 2. Canada scored the lowest
in terms of compliance with multiple indicators of diabetes care. Simply put, our current
healthcare system does not enable physicians and other members of the healthcare
team to provide coordinated, comprehensive
chronic disease prevention and management.
Canadians living with diabetes should be
•
•
•
•
•
•
•
8
A healthcare system designed around the
acute care setting that focuses on the delivery of episodic care, where urgency trumps
severity
Highly fragmented care delivery resulting
in patients being “lost in transition”
A lack of investment in interoperable
clinical information systems that enable
providers to appropriately share needed
information for effective clinical decisionmaking
Poor adoption by clinicians of advanced
clinical decision support tools that effectively incorporate reminders, protocols
and guidelines at the point of care
Reluctance to measure performance and
quality improvement, both on an individual patient level and a population basis
A misalignment of incentives and reimbursement strategies that overcompensate
for service delivered and under-compensate
for performance and quality improvement
A lack of attention in effectively involving
patients and their families as active partners in the management of their chronic
illness
An Inconvenient Truth
Table 2. Six country performance on diabetes care
Indicator
Canada
Australia
New
Zealand
A1C in past 6 mo. (%)
90
86
79
Foot examination in
past yr. (%)
52
57
66
Eye examination in
past yr. (%)
73
73
66
Cholesterol checked in
past year. (%)
91
93
87
All 4 services received
in past yr. (%)
38
41
40
tion of scarce
acute-care
and emer85
90
91
gency services for the
75
70
65
management
of patients
83
69
85
with complications
92
92
95
resulting from
their chronic
58
56
55
illnesses. In
making the
connection
between access to services and demand for services, it is essential to recognize that many of
these complications either are avoidable or
can be significantly delayed by CDPM best
practices. If, as a country, we do not effectively
address CDPM, not only will our healthcare
system become economically unsustainable,
but we will start to see a reversal in both quality of life and life expectancy gains that have
occurred over the last 50 years.
United
Kingdom
As a result, Canada’s physicians, nurses, pharmacists and other clinicians have not been able
to provide the standard of care that is required
to minimize the burden of chronic disease.
Offering all the right tests and providing all
the right therapies for most of our patients
most of the time is not currently achievable,
especially when it comes to the complex care
of patients with multiple chronic illnesses.
Canada’s poor showing in CDPM was
recently described in the Commonwealth
Fund International Health Policy Survey of
Primary Care Physicians (Schoen et al. 2006).
Table 3 highlights that Canada as a nation
ranked last in measuring CDPM activities,
managing CDPM activities and integrating
multidisciplinary teams. Unlike the United
Kingdom, which scored first in most categories, Canada lacks a national vision, direction and funding to help ensure standards of
CDPM services, integration and coordination.
Since 1948, the United Kingdom has been
driving healthcare transformation through its
National Health Services and has developed
a CDPM strategy that is a key component of
primary care reform and regionalization.
This inconvenient truth not only negatively impacts patients living with chronic
illnesses but also results in escalating costs and
lengthening wait times due to the consump-
United
States
Germany
Best Practices in CDPM
In order to address this CDPM care deficit,
we must invest in best practices that provide
comprehensive, coordinated care delivery
across the continuum. These models of care
must be population-based and patient-centric
and should encompass health promotion,
disease prevention and disease management.
The most widely adopted and studied model
is the Chronic Care Model (CCM), developed at the MacColl Institute for Healthcare
Innovation at Group Health Cooperative of
Puget Sound. This model provides a framework to improve patient and system outcomes
and is depicted in Figure 1 below.
The CCM creates practical, supportive, evidence-based interactions between an
informed, activated patient and a prepared,
proactive practice team. Informed, activated
9
HealthcarePapers Vol. 7 No. 4
the patients’ care.
Prepared, proactive
practice teams are
CDM-Related Activities of
CAN
UK
GER
NZ
NETH AUS
US
Primary Care Physicians
those that have the
right information,
Overall Ranking
7th
1st
2nd
3rd
4th
5th
6th
tools and personMeasurement activities:
nel at the time of
Participated in collaborative QI
6th
4th
2nd
1st
3rd
4th
5th
care delivery and
efforts
throughout the
Conducted clinical audit of patient
7th
1st
5th
2nd
6th
3rd
4th
duration of the
care
patient-provider
Sets formal targets for clinical
5th
1st
1st
3rd
4th
6th
2nd
relationship.
performance
Appropriate deciReporting “well prepared” re
7th
2nd
1st
5th
3rd
4th
5th
sion support is
patients with multiple chronic
easily accessible
diseases
in order to
Reporting “well prepared” re
6th
3rd
1st
6th
2nd
4th
7th
deliver evidencepatients with mental health
problems
based clinical
care and selfManagement activities:
management
Least difficulty in generating list of
7th
1st
4th
2nd
3rd
5th
6th
support. The
patients by diagnosis
interaction is
Gave patients with chronic diseases
7th
5th
1st
6th
4th
3rd
2nd
now one in which
plan to manage care at home
all clinical and
Multidisciplinary team activities:
behavioural assessPractice routinely uses
4th
1st
3rd
5th
2nd
4th
6th
ments are available
multidisciplinary teams
as required. The
Routinely uses clinicians other than
7th
1st
2nd
3rd
4th
5th
6th
providers underdoctors to help manage patients
stand the patients’
with chronic diseases
confidence level
Routinely uses clinicians other than
7th
1st
2nd
3rd
6th
5th
4th
in managing the
doctors to provide primary care
services
chronic condition. Clinical
Countries included in the comparison are Australia, Canada, Germany, the Netherlands, New Zealand, the United
care is tailored
Kingdom and the United States.
Adapted from 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
to the individuals and based on
best practices
patients are those who understand their
supported by evidence. Collaborative goal
disease process and are empowered as selfsetting and problem solving result in a
managers of their own care. The patients take
shared care plan that both the patients and
advantage of the clinicians’ medical expertise,
the providers understand. Critically, there
rather than assuming the clinician will “fix”
is active, sustained follow-up to ensure the
them. Family and caregivers are included and
patients can manage their treatment plan and
appropriately involved in the management of
engage in improved self-management support.
Table 3. Seven country comparison of chronic care delivery in
primary care
10
An Inconvenient Truth
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in diabetes, asthma
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systems or self(Wagner 1998) Reprinted with permission of the American College of Physicians.
management
support. In these
The CCM identifies essential elements
studies, no single element emerged as essenof a healthcare system that encourage hightial or superfluous, but 19 of 20 studies that
quality CDPM in the community and the
included a self-management component
health system, and within self-management
showed improved care. Studies with multisupport, delivery system design, decision
faceted interventions were more likely to
support and clinical information systems.
have a greater impact on patient outcomes
Within each of these elements, there are
(Bodenheimer et al. 2002; Renders et al. 2001).
specific concepts (“change concepts”) that
A retrospective data analysis of managed
teams use to direct their improvement efforts.
Medicare organizations in the United States
Change concepts are the principles by which
that had implemented numerous components
care redesign processes are guided. Once
of the CCM (reminders, registries, selfimplemented, these change concepts result in
management programs, clinical guidelines
improved patient and system outcomes.
and linkages to community resources) showed
For a greater understanding of the model,
significantly improved process and clinical
please visit www.improvingchroniccare.org.
outcomes for their patients with Type 2 diabeIn addition, see Barr and colleagues’ review of
tes (Fleming et al. 2004). These and other
CCM in Canada in Healthcare Quarterly (2003).
studies can be viewed via the bibliography on
the Improving Chronic Illness Care (ICIC)
Evidence Supporting the CCM
website (www.improvingchroniccare.org).
The CCM has been implemented widely, and
Implementing the CCM and Other
a growing body of evidence suggests that it
Best Practices
can improve outcomes and decrease costs. A
systematic review of the literature found that
To help organizations in succeed, the MacColl
32 of 39 studies that evaluated the use of the
Institute brought in experts in CDPM and
model in diabetes demonstrated improved
created “learning collaboratives.” These
patient outcomes, and that in 18 of 27 studies
collaboratives are based on the Institute for
the use of the model resulted in reduced costs
Healthcare Improvement’s Breakthrough
Figure 1. Chronic Care Model
11
HealthcarePapers Vol. 7 No. 4
Series quality improvement methodology
and provide organizations with the required
expertise, tools and learning environment for
success. Over a one-year period, these teams
meet for three two-day sessions. Between
sessions, the practice teams implement CCM
changes for the condition of interest, collect
data and report monthly on their improvements with their pilot populations. Results
to date show that more than 70% of teams
participating in these learning collaboratives
have created system change that improves
both process and clinical outcomes. Three
examples of these results follow:
•
•
•
step guide titled “Improving Care in the
Practice” (http://www.improvingchroniccare.org/improvement/collaboratives/index.
html). While not extensively tested, this guide
provides practice teams with a seven-step
process to begin transforming chronic illness
care using best practice tools to test, implement and measure changes in care. This guide
is available free of charge at the ICIC website.
In 2006, Singh completed a comprehensive review of the CDPM literature – more
than 35,520 studies, of which 560 met the
inclusion criteria. This extensive analysis
includes randomized trials and systematic
reviews and summarizes the varying levels of
evidence for CDPM interventions that have
been applied internationally:
Twice as many patients with major
depression have recovered in six months
Inner-city kids with moderate or severe
asthma are at 13 or fewer days per year
with symptoms
Readmission rates of patients hospitalized with congestive heart failure were cut
nearly in half
•
•
•
•
•
•
•
One of the most notable sets of
learning collaboratives is the Bureau of
Primary Healthcare’s Health Disparities
Collaboratives. The bureau oversees the 850
federally funded community health clinics
in the United States that serve the poor and
uninsured. To date, almost all 850 clinics have
gone through at least one collaborative, and
results suggest that there have been significant
improvements in processes of care for patients
with diabetes, asthma, cardiovascular disease,
depression and human immunodeficiency
virus. There are currently hundreds of thousands of patients in disease registries who are
receiving planned care and enhanced selfmanagement support. To read more about the
Health Disparities Collaboratives, visit www.
healthdisparities.net.
In addition to the collaboratives, the
MacColl group has developed a step-by-
•
•
•
Broad chronic care management models
Involvement of patients in decisionmaking
Provision of accessible structured
information
Self-management education
Self-monitoring and referral systems
Electronic monitoring and telemonitoring
Identification of people at high risk of
hospitalization
Integration of community and hospital
care
Greater reliance on primary care
Use of nurse-led strategies, where
appropriate
This report is available at www.hsmc.bham.
ac.uk/news/TransformingChronicCare.pdf,
and is a must-read on CDPM.
CDPM Best Practices in Canada
The CCM is being studied, adapted and
implemented by a number of provinces,
mostly in Western Canada. British Columbia
has created the Expanded Chronic Care
Model, which includes the necessary elements
12
An Inconvenient Truth
to encompass health promotion and disease
prevention as well as disease management.
This expanded model was introduced in 2003
by Barr et al. British Columbia has also made
a significant investment in the development
and implementation of a chronic disease
management toolkit that includes flow sheets
used by providers at the point of care, and in
the creation of a provincial registry of patients
that is used for performance management
and an incentive program that reimburses
family physicians for high-quality management of congestive heart failure, diabetes and
hypertension. For more information, see www.
health.gov.bc.ca/cdm.
Alberta’s Capital Health Region and
Calgary Health Region are both implementing comprehensive CDPM programs based
on the CCM. These programs leverage a
common provincial electronic health record
that will include patient registries and clinical decision support capabilities. HealthLink
Alberta, a nurse telephone advice service
(available 24 hours a day and seven days a
week) and health information service, is also
being used to better coordinate and deliver
CDPM. In addition, Alberta is investing in
primary care initiatives aimed at improved
CDPM and fostering new relationships with
specialists and community services to better
support patients with chronic illnesses. Selfmanagement support programs for patients
living with chronic illness are being successfully developed and implemented. Learning
collaboratives are being implemented
throughout Alberta.
Saskatchewan is running learning collaboratives for all its primary care health providers
and creating a cadre of practice facilitators
who support primary care within the health
authorities.
Manitoba is undertaking a Chronic
Disease Prevention Initiative, which expands
on a number of chronic disease programs
including a regional diabetes program, a renal
health outreach program, chronic disease
monitoring and surveillance and the Healthy
Living Resource/Institute (www.gov.mb.ca/
health/diabetes/priorities.html).
The Western provinces have also collaborated on the Western Canada Chronic
Disease Management Infostructure initiative, funded by Health Canada’s Primary
Health Care Transition Fund. This initiative
resulted in the creation of high-level business
requirements and CDM data standards and
HL7 message specifications, which are being
incorporated into provincial CDM standards
(www.whic.org).
In Ontario, the Ministry of Health and
Long-Term Care, in partnership with the
Ministry of Health Promotion, has endorsed
the Expanded CCM through the development of a Chronic Disease Prevention and
Management Framework. This framework is
widely communicated and supported by the
newly launched Local Health Integration
Networks, which are responsible for managing healthcare resources and improving
the health status of people from a regional
perspective. The government also established
a Diabetes Expert Panel, which used the best
practice interventions within the framework
to guide the development of its provincial
strategy to implement a Diabetes Prevention
and Management infrastructure and system
redesign. The Group Health Centre in Sault
Ste. Marie is considered to be a Canadian
best practice in population-based CDPM.
Through its electronic health record and coordinated primary care health service model, it
has been able to deliver care more consistent
with best practices for its patients with diabetes and with congestive heart failure, with
fewer resources.
Quebec developed the Program to
Integrate Information Services and Manage
Education (PRIISME) in 1999, and since
13
HealthcarePapers Vol. 7 No. 4
then has implemented numerous multidisease projects. This public/private sector
partnership with GlaxoSmithKline provides
personalized education to patients with
chronic illnesses and specific training to
healthcare professionals.
The Atlantic provinces are in the midst
of a multi-province project called Building
Table 4. Select examples of CDPM best practices in Canada
Scope of Program
Organizational
Delivery System
Design/
Self-Management
IT and Decision
Support
Impact of Change
1. Risk assessment for
prevention/proactive
management services
2. Implementation of
best practices
3. Focus on system &
GP office redesign
4. Self-management
support
5. Multi-disciplinary
practice team
1.Decision support
tool - “CDM Toolkit”
2. Data analysis to
assess gap in quality
of care and burden of
demand on system
1. Increase
compliance with
evidence based
guidelines for people
with diabetes and
CHF
2. Decrease
hospitalization of
people with diabetes
3. Decrease standard
mortality rate for
people with CHF
1. Regional booking
system; single point
of referral
2. Triage system with
delegated care to
right provider at the
right time
3. Virtual support
for primary care
providers with
connections to care
team
4. Ongoing client
support
1. CDM IS for
registration and
ongoing tracking of
outcomes
2. Analyzes patient
and population data
3. Reminds at
appropriate points
in care continuum;
decision support
4. Supports workflow
consistent with
clinical practice
guidelines
1. Improved wait
times for program
2. Increased system
capacity (almost
tripled new referrals)
3. Reported
behaviour change
7–14 days post
intervention;
sustained behaviour
change
4. Reduced need for
medical specialist
1. Provider support
- nurse case
management
2. Algorithm-driven
care plans
3. Client programs
- “Living Well with a
Chronic Condition”
program
( includes: exercise,
education, selfmanagement)
1. Foundation for
data collection,
tracking and
reporting is the
electronic CDM IS
2. Analyzes patient
and population data
3. Reminds at
appropriate points
in care continuum;
decision support
1. Better A1Cs for
patients with diabetes
2. Better scores on
6-minute walk test
for patients with
COPD
3. Better WOMAC
scores for patients
with osteoarthritis
4. Reduced wait
times – wait for
diabetes education
program
5. More satisfied
healthcare providers
1. Victoria, British Columbia
1. Ministry of Health
embraces BC’s
Expanded Chronic
Care Model
2. Endorsed by BC’s
Health Authorities
3. Started with
diabetes, CHF,
depression, HT &
prevention
1. Strategy and vision
2. Support
for learning
collaboratives
3. Incentives to use
tools
4. Performance
management
2. Capital Health Region, Edmonton, Alberta
1. Integration of
regional chronic
disease programs:
asthma, COPD, CV
risk, heart failure,
renal disease, obesity
2. Adaptation of
health system to
focus on primary care
1. Clear vision and
strategic commitment
to support CCM
2. Focus to achieve
horizontal and
vertical CDM
program integration
3. Formal networks
with community
providers and
partners
4. Visible physician
champions
3. Calgary Health Region, Calgary, Alberta
1. Endorse CCM and
other proven models
of CDM
2. Build on strengths
of current system
and within existing
operations
3. Infrastructure to
regionally manage
multiple conditions
including - diabetes,
COPD, arthritis,
osteoarthritis, CHF &
chronic pain
1. Integrate CDM
strategies into current
operations e.g.,
home care
2. Support for
champions and
change management
3. Provide the
evidence with key
indicators (RCTs not
required)
4. Provide financial
incentives - MDs bill
for patients that are
case managed
14
An Inconvenient Truth
Table 4. Continued
4. Group Health Centre, Sault Ste. Marie, Ontario
1. 60,000 patient
membership (75% of
regional population)
for all primary and
specialty care with
diagnostic services
2. Longestestablished
membershipbased health care
organization.
3. Over 60 physicians
1. Regional physician
group practice
2. Blended funding
– capitation based
pay with mix of fee
for service (incentives
for preventative care)
3. Population based
service delivery
4. Quality
improvement
research to inform
practice patterns
1. Multi-disciplinary
team approach to
education and service
delivery
2. Centralized
Appointment
Centre: allows
urgent direct contact
with physician’s (or
NP’s) office; same
day clinic – when
physician is out of
office: extended
office hours
3. Telephone health
advisory service
4. Risk stratification
and service delivery
based on evidence
1. Electronic Medical
Record (EMR)
accessed at all service
delivery sites and
many professionals in
the community
2. Practice
Management
Application (PMA)
includes roster
management,
registration,
appointments,
billing, transcription,
scanning; PMA is
interfaced seamlessly
to EMR
3. CDPM best
practice workflow
sheets integrated
with EMR
1. Increase
participation of
patient and family
in decision making,
self-care and
adherence to agreed
management plans
2. Increase
collaboration among
health care team
3. Increase patient
access to continuity
of care and best
practices
4. Decrease
modifiable CV risk
factors
5. Appropriate use
of cardioprotective
medications
CCM = Chronic Care Model; CDM = chronic disease management; CDPM = chronic disease prevention and management; CHF = congestive heart failure;
CPG = clinical practice guideline; COPD = chronic obstructive pulmonary disease; CV = cardiovascular; GP = general practitioner; IS = information system;
IT = information technology; NP = nurse practitioner; PCP = primary care physician; RCT = randomized controlled trial; WOMAC = Western Ontario McMaster
Osteoarthritis Index.
Better Tomorrows. The objective is to teach
primary care providers about chronic illness
management and provide them with the
necessary tools to engage in practice change.
Table 4 summarizes CDPM best-practice
interventions implemented by several leading organizations in Canada. These efforts in
British Columbia, Alberta and Ontario are
profiled with a description of their impact.
Of particular note is that each organization
has a commitment to a CDPM vision and
strategy, strong leadership and information
technology (IT) investment in order to ensure
its healthcare system is designed to empower
patients, support providers and improve the
health of the population served.
program on the American healthcare system
(Bigelow et al. 2005). The assessment was
based on a simulated model that included
components and programs that were consistent with the elements of the CCM and with
programs defined by the Disease Management
Association of America (DMAA) (www.
dmaa.org/definition.html). The simulated
model developed by RAND included the
following key components:
•
•
•
•
Costs and Benefits of a National
CDPM Program
The RAND Corporation assessed the socioeconomic impact of implementing a CDPM
•
15
Population identification processes
Evidence-based practice guidelines
Collaborative practice models to include
physician and support-service providers
Patient self-management education (may
include primary prevention, behaviour
modification programs and compliance/
surveillance)
Process and outcomes measurement,
evaluation and management
HealthcarePapers Vol. 7 No. 4
Table 5. Potential benefits of a combined CDM program†
Region
USA
Canada
Region*
100%
50%
50%
(millions)
(millions)
(thousands)
in-patient stays
(3.6)
(0.2)
(6.5)
in-patient nights
(26.3)
(1.5)
(46.6)
hosp outpatient & ER visits
(4.9)
(0.3)
(8.7)
office/disease mgmt visits
33.2
1.9
58.9
($billions)
($billions)
($millions)
hospital
(30.1)
(1.7)
(53.4)
physician
-
-
-
1.9
0.1
3.3
other
-
-
-
Total
(28.3)
(1.6)
(50.2)
Days Affected
(millions)
(millions)
(thousands)
schooldays lost
(12.9)
(0.7)
(22.9)
workdays lost
(28.2)
(1.6)
(50.0)
total days abed
(244.6)
(13.9)
(433.7)
(thousands)
(thousands)
(ones)
(394.1)
(22.4)
(699)
Adoption
Utilization Measures
Expenditures
medications
Mortality
deaths
Combined program for diabetes, congestive heart failure, asthma and chronic obstructive pulmonary
disease.
*Includes 1 million people.
†
Table 6. CDPM regional program* costs
Cost Categories
Year 1
Operating
Disease registry
8.0
3.8
Patient portal
3.5
2.4
Provider portal and connectivity
3.5
2.4
Complex case managers & software support
3.0
6.0
Care plan coordination services
(administration systems and outreach calls)
8.6
5.2
Scheduling
4.8
2.0
Other (evaluation & program operations)
1.6
2.2
Project Totals
33.0
24.0
*Program for prevalence of 4.6% diabetes, 0.8% congestive heart failure, 1% chronic obstructive
pulmonary disease and 8.3% asthma.
16
• Routine reporting/feedback loop (may include
communication with patient,
physician, health plan and
ancillary providers and practice profiling)
RAND’s model applies
consolidated results from
published literature on
comprehensive integrated
disease management
programs for four chronic
diseases (diabetes, congestive heart failure, asthma and
chronic obstructive pulmonary disease) in order to
predict the costs and benefits
of an implementation across
the entire US population.
Table 5 highlights the
results of the RAND analysis
and the potential changes to
the healthcare system based
on an enrolment of 50%
of the US population with
chronic disease. As depicted,
the traditional physician visits
are replaced with proactive multidisciplinary team
encounters that enforce
adherence to best practices,
resulting in a reduction of
in-patient admissions. The
projected trajectory of system
utilization, spending, productivity and mortality are markedly reduced – overall saving
the national system US$14.2
billion in expenditures and
reducing deaths by 197,000
each year.
Using this model, we
extrapolated the results to the
An Inconvenient Truth
Table 7. Financial summary of national CDPM program
74,000 people,
including 23,000
people with
diabetes, 4,000
people with
Regional CDM
1
33
24
50
Model*
congestive heart
failure, 5,000
†
Canada
32
1,063
779
1,610
6.3
people with
* Based on a region of 1 million Ontarians.
chronic obstrucDirect extrapolation from Ontario to Canada based on population.
Breakeven calculated by amortizing capital over 4 years and applying cumulative benefits as net of cumulative expenses
tive pulmonary
based on 50% adoption.
disease and
41,500 people
Canadian environment of 32 million people
with asthma (based on Ontario prevalence data
(see Table 5). This projected an annual reducfrom the 2003 Canadian Community Health
tion of 1.5 million in-patient nights, a cost
Survey database prevalences). For Canada, the
avoidance of $1.6 billion and 22,360 fewer
program would reach over 2.3 million people
deaths. Our Canadian analysis assumed a
with chronic diseases. For this analysis,
similar prevalence of disease and equivalency
benefits from the program were recognized
of healthcare costs between the United States
12 months after the start of each program.
and Canada, and we also assumed an adoption
Using a direct population-based extrapolarate of 50%.
tion, Table 7 shows that it would take approxThese benefits are significant, but at what
imately $1 billion in upfront costs (capital)
cost? To further explore this, we developed a
and $780 million in annual operating costs
financial model based on a Canadian regional
to implement a national CDPM program
population of 1 million. Elements of the
for four key disease groups. This effort has
model were consistent with the key compothe potential to realize annual benefits of
nents specified in the RAND study, includ$1.6 billion in avoided healthcare costs,
ing a disease registry, patient and provider
assuming a 50% adoption rate.
education portals, case managers and outreach
Figure 2 illustrates that cumulative
phone calls with supportive administrabenefits would surpass the cumulative costs
tive and management systems. We assumed
between years six and seven. By year 10, the
that basic computing infrastructure and
cumulative return on investment is more
secure Internet connectivity were in place for
than $9 billion to the Canadian healthcare
primary care settings. Table 6 provides details
system. This return could be higher if adopon these costs.
tion rates increased or if costs were reduced
We then extrapolated the costs to the
through consolidation of IT infrastructure
entire Canadian population of 32 million
into a multi-regional or provincial program.
and made the assumption that 32 programs,
On the contrary, if benefits were not realized
each covering a million people, would be
until three or four years after implementarequired. We also assumed that one disease
tion instead of after year one as assumed in
group program would be rolled out each year
the model, then the breakeven point would
until all four disease programs were launched
be pushed out to a later date. Adoption of
by year five. This regional program would
the program by providers and adherence
provide direct CDPM services to almost
to providers’ advice by the patients are two
Program Target
Population
(millions)
Upfront
Capital
($millions)
Annual
Operating
Costs
($millions)
†
‡
17
Annual
Net
Benefits
($millions)
Breakeven‡
(years)
HealthcarePapers Vol. 7 No. 4
Figure 2. Projected cumulative benefits and cumulative costs of a chronic disease
management program to a maximum of 50% adoption
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critical elements to realizing the program
benefits. The costs and benefits used in this
model are based on an adoption by 50% of the
population with the four chronic diseases. In
summary, this analysis comes with a significant disclaimer – “if there is no pain, there is
no gain” or, in healthcare IT terms, “no adoption equals no benefits.”
This model does provide some sensitivity
to adoption rates since a significant proportion of the annual operating costs are human
resources and can be scaled up or down as
the program rolls out. Once the program is at
steady state with 50% adoption, there is about
a $2 dollar return to the system for each dollar
spent. There is also the potential to extract
further benefits if this program was integrated
with a comprehensive lifestyle program that
encourages health promotion and disease
prevention through healthy behaviours such as
exercise, eating well, not smoking and compliance with other prevention measures including
preventive medication (e.g., cholesterollowering drugs). Then, the savings to the
system would be even greater due to the
reduction of risk factors and the subsequent
������
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reduction in the prevalence of chronic diseases.
Overall, there was an attempt to be
conservative with the model by using conservative numbers for the benefits and overestimating the costs of the program. Limitations
of the analysis include the following:
•
•
•
•
•
18
US costs for providing healthcare services were used to show benefits and are
typically considered to be higher than
Canadian costs by 15%
The value in US dollars was directly
translated into Canadian dollars, which
assumes approximately a 15% discount
on costs, which counteracts the impact of
using US costs
Infrastructure costs were based on the
implementation in a region, without existing components to leverage
The regional costs were based on number
of patients served and did not factor in
that certain diseases require more effort to
care for and manage (e.g., RAND assumed
that asthma patients take about 45% of the
effort required for diabetes patients)
There is an overestimation of the costs
An Inconvenient Truth
resulting from scaling up the regional
program costs by 32 times based on a per
capita extrapolation without consideration for economies of scale created from
a multi-regional or provincial IT solution
or reduced costs due to multi-regional
purchases
compared with 2004–2005, thus showing no
evidence of the so-called ballooning effect.
A national CDPM strategy should be
modelled after Canada’s approach to wait
times:
•
A National CDPM Strategy: Leveraging
Canada’s Approach to Wait Times
In 2004, the first ministers agreed that timely
access to care across Canada is a national priority (Health Canada 2004). Specific measurable commitments to Canadians were made to
address wait times. These included benchmarks
for wait times for five services, comparable
indicators of access, the setting of targets by
certain dates, annual reporting of progress and
the establishment of a $5.5 billion Wait Times
Reduction Fund allocated on a per capita basis.
In response, provinces and territories developed
strategies, made investments and committed
resources to build capacity and shorten wait
times. Major investments were made in human
resources, equipment, training and information
systems. Annual reporting of progress is ongoing, and public websites have been established
with near real-time reporting in some jurisdictions to support transparency and patientprovider decision-making.
Although early days, there is now preliminary evidence that strategies to address wait
times are working in Canada. A recent report
from the Canadian Institute for Health
Information (CIHI) showed a significant
increase in the number of priority area surgeries in 2005–2006 compared with the previous
year (CIHI 2007). Of the provinces studied
(data were not available for Quebec), there was
a 7% increase in (or nearly 42,000 additional)
procedures. For surgeries performed outside
of the priority areas, there was a 2% increase
in the number performed in 2005–2006
•
•
•
The first ministers need to agree
that improving the quality of care for
Canadians living with chronic illnesses is
a national priority that is key to sustaining
the improvements in wait time reductions
and the viability of our healthcare system.
The existing quality of care gap should
be assessed through the use of evidence
based CDPM performance indicators,
and targets should be set for improved
performance.
Annual reporting of progress should occur.
A CDPM fund should be established.
The concept of establishing “wait time guarantees” is also valid for CDPM transformation. The establishment of “care guarantees”
would ensure that quality of care remains a
priority and that funding is in part linked to
performance. More important, care guarantees would help ensure that Canadians at risk
of, or living with, chronic illnesses receive a
minimal standard of care.
Provinces and territories can leverage
their wait time investments and apply their
experience in reducing wait times to improving CDPM. The investment in information
systems and interoperable EHRs is required
by providers and patients to improve CDPM
as well as reduce wait times. In addition, all of
the following elements used by provinces and
territories to address wait times are equally
important to transforming CDPM and
include (1) ensuring clear accountability for
all key stakeholders of the healthcare system;
(2) aligning incentives to support CDPM
strategic goals; (3) empowering patients by
democratizing knowledge about CDPM;
19
HealthcarePapers Vol. 7 No. 4
(4) increasing system capacity with more and
better use of resources; (5) seeking the expert
advice of providers and local communities;
and (6) tracking, monitoring and improving
performance using disease registries, standardized data and targets.
All of the key components of the wait
times strategy along with the supporting
tools and reporting mechanisms are needed
to transform CDPM in Canada. For CDPM
success, accountability resides primarily with
primary care providers and patients; however,
the regional health authorities, specialists,
community services, home care agencies,
government and public health agencies all
have significant roles and responsibilities.
Empowering patients with knowledge that
enables them to be active, involved participants in their care is the underlying principle
of the CCM and is necessary for success.
Increasing system capacity through better use
of resources is the goal of “planned care,” in
which scheduled disease management visits
with providers and with groups of patients
living with the same chronic illnesses can
help obviate the need for urgent, unscheduled episodic visits to primary care providers, emergency departments and other acute
care services. The early and frequent use of
CDPM experts both as policy and program
development advisers and as clinical decision support experts is also key to success.
Tracking, monitoring and improving CDPM
performance using a single disease registry for
a given population is crucial, as are the use of
interoperable clinical information systems, the
standardization of CDPM data and establishment of performance targets that can be
compared across practices, regions and provinces and territories.
Two critical success factors for CDPM
transformation are regionalization and
primary care reform. Without these, we will
not achieve large-scale, rapid improvement in
population-based outcomes. Alberta is clearly
leading on both fronts and has established
clear accountability structures and is delivering care in effective ways that improve the
health and wellness of individual patients and
entire populations. Alberta has also recognized the importance of primary care reform
that focuses on multidisciplinary teams that
are funded to deliver care consistent with
the CCM. Alberta has established Primary
Care Networks based on tripartite agreements among the primary care physicians,
the provincial government (Alberta Health
and Wellness) and the Alberta Medical
Association. With such agreements in place,
a regional approach to CDPM provides the
levers to better design, coordinate and deliver
comprehensive CDPM programs that appropriately involve primary care providers, acute
care services, specialists, home care services,
community services and public health agencies. Regional CDPM programs can effectively scale to manage patients with multiple
chronic diseases in a coordinated manner, with
the vast majority of services being provided
by primary healthcare teams in conjunction with community-based services. Alberta
health regions also enjoy increased purchasing power that can be used for the investment
and deployment of interoperable electronic
health records, population-based disease
registries and other advanced clinical information systems required to standardize care and
measure performance.
As part of a national CDPM strategy,
the federal government should assess as a
condition of funding whether there is a real
commitment to regionalization and primary
care reform. Alberta should be used as the
gold standard against which the commitment of other provinces and territories
should be benchmarked. Provincial quality
and safety councils could also assist with the
development of performance indicators and
20
An Inconvenient Truth
benchmarks. There is a growing body of international literature on evidence-based quality
indicators from the United States and the
United Kingdom that could easily be adapted
to the Canadian environment (for example, Developing Quality of Care Indicators
for the Vulnerable Elderly, ACOVE Project
in the United States; Quality of Outcomes
Framework from the Information Centre
Services of National Health Services (NHS)
in the United Kingdom.) The Health Council
of Canada has begun reporting on the state
of chronic disease management in Canada
and, along with CIHI, could play a lead role
in public reporting of progress (see Health
Council of Canada, Health Outcomes Report,
“Why Health Care Renewal Matters: Lessons
from Diabetes,” 2007).
Significant investment in clinical information technologies is an essential element of
CDPM transformation. Electronic medical
records, disease registries, self management
devices, clinician and patient portals, telemedicine solutions and ultimately an interoperable pan-Canadian EHR are key enablers of
CDPM. However, these emerging technologies must not be implemented for the sake of
technology but rather to support improved
care delivery. It is essential that clinicians,
healthcare teams and patients be provided
with sensible clinical information management
tools that provide real value. Canada Health
Infoway could play a lead role in allocating
and managing those investments to ensure
that solutions that work and are adopted by
clinicians and patients are rapidly deployed to
advance CDPM transformation in Canada.
chairman of CIHI’s Board of Directors. In
Canada, healthcare spending has risen to
10.3% of the gross domestic product, which
is the highest it has been in 31 years, with an
average per capita spending of $4,548. Our
population continues to age, shifting our
healthcare spending to those aged 65 and
older at an annual cost of $8,969 per capita.
These increases, weighed against provincial
budgets that are already hovering around
45%, are clearly an unsustainable situation.
Something has to give! We contest that it is
our healthcare system that has to give, rather
than the health of Canadians living with
chronic illnesses. Canadians with chronic
illness deserve a transformed healthcare
system that provides coordinated, comprehensive care – a system that results in fewer visits
to the emergency department, fewer complications and a better and longer quality of life.
The inconvenient truth about CDPM is
that it is recognized as a problem more often
internationally than it is domestically. The
World Health Organization (WHO) stated
that “the global epidemic of chronic diseases
continues to grow. In 2005, they caused an
estimated 35 million deaths. Total deaths from
chronic disease are projected to increase by
a further 17% over the next 10 years. This is
happening when the means of preventing and
controlling most chronic diseases are already
well established” (World Health Organization
2005). Many countries, such as India and
Nigeria, have publicly taken on WHO’s challenge to reduce the chronic disease death rate
by 2% per year for the next 10 years.
Canada is well positioned to take on this
challenge. A “made in Canada solution” for
CDPM can be created by leveraging our
unique approach to wait times along with
a greater commitment to regionalization,
primary care reform and a greater investment
in electronic health record technologies. A
national strategy for CDPM transformation
Concluding Thoughts
Canada must move quickly to transform
CDPM, for health and economic reasons.
“For the tenth consecutive year, healthcare
spending continues to outpace inflation and
population growth,” says Graham W.S. Scott,
21
HealthcarePapers Vol. 7 No. 4
Health Canada. 2004. First Ministers’ Meeting on the
Future of Health Care. Ottawa: Author. <www.hcsc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2004fmm-rpm/index_e.html>.
will not only improve the health of Canadians
living with chronic illnesses - it will also
improve the health of our nation. It will help
to ensure the sustainability of our healthcare
system and strengthen our brand recognition
as a country committed to health and wellness.
Health Council of Canada. 2007 (March). Health
Outcomes Report, “Why Health Care Renewal
Matters: Lessons from Diabetes. < http://healthcouncilcanada.ca/en/index.php?option=com_content&task
=view&id=192&Itemid=10>.
Acknowledgement
Institute for Healthcare Improvement. 2003. The
Breakthrough Series: IHI’s Collaborative Model for
Achieving Breakthrough Improvement. Boston: Author.
<www.IHI.org>.
The authors thank Kai Teh, Consultant
Courtyard Group Ltd, for data analysis
assistance.
Institute of Medicine. 2001. Crossing the Quality
Chasm: A New Health System for the 21st Century.
Washington, DC: Author.
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A. Dotts, D. Ravensdale, S. Salivaras. 2003. “The
Expanded Chronic Care Model: An Integration of
Concepts and Strategies from Population Health
Promotion and the Chronic Care Model.” Healthcare
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McGlynn, E.A., S.M. Asch, J. Adams, J. Keesey, J.
Hicks, A. DeCristofaro and E.A. Kerr. 2003. “The
Quality of Health Care Delivered to Adults in the
United States.” New England Journal of Medicine 348:
2635–45.
Bigelow, H., K. Founkych, C. Fung and J. Wang.
2005. Analysis of Healthcare Interventions that Change
Patient Trajectories. RAND Health. Santa Monica,
CA: Author. <http://www.rand.org/pubs/monographs/MG408/>.
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www.ic.nhs.uk/pubs/qofexrep>.
Rapoport, J., P. Jacobs, N.R. Bell and S. Klarenbach.
2004. “Refining the Measurement of the Economic
Burden of Chronic Disease in Canada.” Chronic
Diseases in Canada 25(1): 13–21.
Bodenheimer, T., E.H. Wagner and K. Grumbach.
2002. “Improving Primary Care for Patients with
Chronic Illness: The Chronic Care Model, Part
2.” Journal of the American Medical Association 288:
1909–14.
Renders, C.M., G.D. Valk, S.J. Griffin, E.H.
Wagner, J.T. Van Eijk and W.J. Assendelft. 2001.
“Interventions to Improve the Management of
Diabetes Mellitus in Primary Care, Outpatient, and
Community Settings: A Systematic Review.” Diabetes
Care 24: 1821–33.
Canadian Institute for Health Information
(CIHI). 2007. Wait Time Priority Surgeries Increased
Significantly in 2005–2006. Ottawa: Author. <http://
secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_
05feb2007_e>.
Schoen, C., R. Osborn, P. Trang Huynh, M. Doty,
J. Peugh and K. Zapert. 2006. “On the Front Lines
of Care: Primary Care Doctors’ Office Systems,
Experiences, and Views in Seven Countries.” Health
Affairs: (published online 2 November 2006). <http://
content.healthaffairs.org/cgi/content/abstract/25/6/
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Canadian Institute for Health Information (CIHI).
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Chaoulli v. Quebec (Attorney General). 2005. Ottawa:
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Schoen, C., R. Osborn, P. Trang Huynh, M. Doty,
K. Zapert, J. Peugh and K. Davis. 2005. “Taking the
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Vulnerable Elderly, ACOVE Project. 2001. RAND
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briefs/2005/RB4545-1.pdf>.
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22
An Inconvenient Truth
Thorpe, K.E. and D.H. Howard. 2006. “Beneficiaries:
The Role of Chronic Disease Prevalence and Changes
in Treatment Intensity.” Health Affairs 25: w378–88.
Thank you
Tsai, A.C., S.C. Morton, C.M. Mangione and E.B.
Keeler. 2005. “A Meta-analysis of Interventions to
Improve Care for Chronic Illnesses.” American Journal
of Managed Care 11(8): 478–88.
for supporting Breakfast with the Chiefs
Wager, E.H. 1998. “Chronic Disease Management:
What Will It Take To Improve Care for Chronic
Illness?” Effective Clinical Practice 1: 2-4.
Longwoods Publishing Enabling Excellence
World Health Organization. 2005. Preventing Chronic
Diseases: A Vital Investment. <http://www.who.int/
chp/chronic_disease_report/en/>.
some inconvenient truths …
Diabetes
• In 2005, 4.9% of Canadians aged 12 and over
reported being diagnosed by a health professional
as having diabetes, with the highest provincial rates
in Newfoundland and Labrador (6.8%), Nova Scotia
(6.6%) and Prince Edward Island (6.3%).
kidney failure registered in the Canadian Organ
Replacement Registry.
(Source: CIHI’s Treatment of End-Stage Organ Failure in Canada
1995-2004)
Ambulatory Care Sensitive Conditions
• In 2005-06, after adjusting for population and
aging, 389 out of 100,000 Canadians under 75
were hospitalized for conditions where appropriate
ambulatory care can prevent or reduce hospitalization.
While not all admissions for conditions such as
diabetes, asthma and hypertension are avoidable,
appropriate care in the community could potentially
prevent the onset of this type of illness or condition,
control an acute episodic illness or manage a chronic
disease or condition.
Asthma
• In 2005, 8.3% of Canadians aged 12 and over
reported being diagnosed by a health professional as
having asthma.
• In 2000, asthma was the number one cause of hospitalizations among children aged 1 to 9 in Canada.
Arthritis or Rheumatism
• In 2005, 45.9% of Canadians aged 65 and over
reported being diagnosed by a health professional as
having arthritis or rheumatism.
• In 2005-06, the highest provincial rates of ambulatory
care sensitive conditions (ACSC) were in New
Brunswick (666 per 100,000), Prince Edward Island
(655 per 100,000) and Saskatchewan (622 per
100,000). A disproportionately high ACSC rate is
presumed to reflect problems in obtaining access to
primary care.
High Blood Pressure
• In 2005, 14.9% of Canadians aged 12 and over
reported being diagnosed by a health professional as
having high blood pressure.
(Source: CIHI Health Indicators 2007 report)
(Source: Statistics Canada Community Health Survey, in CIHI Health
Indicators 2007 report)
Mental Health
• In 2003-04, there were 62,319 hospitalizations in
Canada for patients diagnosed with a mood disorder
(depression or bipolar disorder).
End-Stage Organ Failure
• The number of new diabetes-related kidney failure
cases more than doubled in ten years in Canada,
increasing from 1,066 in 1995 to 2,139 in 2004.
The type of diabetes driving the increase is type 2
diabetes, linked to obesity and lifestyle.
• In 2003-2004, the average length of stay in hospital
for a mood disorder patient was 20.8 days, compared
to 7.2 days for patients with a non-psychiatric
diagnosis.
• At the end of 2004, there were 18,827 patients on
dialysis and 12,099 living with a functioning kidney
transplant, for a total of 30,924 Canadians with
(Source: CIHI’s Hospital Mental Health Services, 2003-2004)
23
Award of Excellence in Nursing Leadership
2007 LEADERSHIP AWARD NOMINATION
The Ontario Hospital Association (OHA) is pleased to announce the fifth annual Award of
Excellence in Nursing Leadership.
The OHA Award of Excellence in Nursing Leadership is designed to acknowledge outstanding
leadership of an individual nurse in a senior leadership position who is employed in a member
organization (Hospitals, Affiliates and Associates) of the Ontario Hospital Association. The
award will be presented at the OHA HealthAchieve2007 held November 5, 6 & 7, 2007 in
Toronto.
Many individuals across the industry exemplify leadership in healthcare. Nurses in senior leadership positions in Ontario healthcare settings provide a unique contribution of direct care
experience, management ability and system thinking that leads to innovation and effectiveness
at many levels in their organizations and associated communities.
The winner demonstrates outstanding individual contribution in nursing leadership and meets
the following criteria:
• Registered with the College of Nurses of Ontario as a Registered Nurse, Registered Nurse
(Extended Class) or Registered Practical Nurse;
• Employed in a full-time senior leadership position in a member organization of the Ontario
Hospital Association;
• Exemplifies qualities of leadership that are outstanding and that produce innovative and
effective results for staff, patients and the organization;
• Demonstrates a commitment and contribution to professional associations;
• Demonstrates a commitment to the nursing profession through leadership in major initiatives in clinical practice, leadership, education, research or quality improvement activities;
• Demonstrates commitment to ongoing learning and professional development;
• Recognized as an exemplary leader at the forefront of innovation in their community of
peers and colleagues; and
• Contributes as a leader to broad change in health care services integration.
Nomination Deadline: July 17, 2007
Nomination Form available at www.longwoods.com/awards