Researchers Look to Improve Chronic Care

By Jim Oldfield

Most Canadian patients and their families regard hospitalization for a serious illness, assuming it ends happily, as a rescue worthy of gratitude.

But for patients with chronic disease, that hospitalization may also represent a failure of Canada's health care system—a failure to manage their illness and keep them out of hospital in the first place.

So says Dr. Thérèse Stukel, a scientist in clinical epidemiology at Sunnybrook Research Institute, cross-appointed to the Institute for Clinical Evaluative Sciences, and an adjunct professor at the University of Toronto.

Stukel is leading a team of clinician-scientists and health services researchers from Manitoba and Ontario who will identify and assess the multispecialty physician networks that provide chronic disease care in Canada.

The $1.5 million study, funded by the Canadian Institutes of Health Research, aims to uncover evidence for fundamental changes to the existing model of management for diabetes, heart disease, asthma and depression, among other chronic illnesses.

"The current health care structure and payment system is focused on acute care and is poorly aligned with chronic disease patient needs," says Stukel. Those needs include diet and lifestyle counseling—what Stukel calls "self-management" tools; vigilant monitoring; and access to networks of health practitioners who share patient information effectively.

If higher than average hospitalization rates can be seen as a symptom of inefficient networks, Stukel says, then policymakers, politicians and the public may reconsider the value and structure of multispecialty physician team care. Not only may hospitalization be due to a failure to manage the patients in the outpatient setting, it's an expensive way to treat them, and can create further adverse effects.

Stukel will examine if there are networks that do a better job—delivering improved outcomes for lower costs—for the same sets of patients. She suspects there are, based partly on research in the U.S. that shows large multispecialty practices (HMOs such as Kaiser Permanente and Group Health Cooperative of Puget Sound) involving case managers, dieticians, mental health workers, and sharing of electronic health records, lead to better chronic disease care.

In Canada, awareness that care is embedded within networks is minimal, even among doctors, because those networks are not formally constituted like integrated managed care organizations in the U.S. This makes measuring the performance of those networks and the physicians in them difficult. But, Stukel says, Canadian health administration data captures physician information-sharing and referral patterns, which will enable analysis.

The goal is to encourage efficiency and a systems-based approach to integration and accountability, thus promoting the sustainability of Canada's health care system. "There's a growing epidemic of chronic disease in developed countries," says Stukel. "These patients will need a lot of attention and services over an extended time, placing huge demand on the health care system."