Disease management in Canada: Surmounting barriers to adoption

Disease management in Canada: Surmounting barriers to adoption

ORIGINAL ARTICLE Disease management in Canada: Surmounting barriers to adoption by Christopher R. Gallant, Neil J. MacKinnon, and Denise A. Sprague ...

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Disease management in Canada: Surmounting barriers to adoption by Christopher R. Gallant, Neil J. MacKinnon, and Denise A. Sprague

Christopher R. Gallant, BSc, MHSA, is a Medical Student at Memorial University in Newfoundland.

Neil J. MacKinnon, PhD, FCSHP, is the Associate Director for Research, Associate Professor at the Dalhousie University College of Pharmacy in Halifax, Nova Scotia and has also been crossappointed to the faculty of medicine. A pharmacist, Neil completed his master’s and PhD degrees in the U.S., focusing on medication use issues in the managed care environment. Denise A. Sprague, BSc(Pharm), ACPR, is a Doctor of Pharmacy student, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia.

Abstract Disease Management (DM) programs are used to optimize economic outcomes and improve patient outcomes. Despite this, relative to the United States, Canadian health care organizations have been slow to adopt them. The objective of this article is to examine the concept of DM programs, the existing evidence to support their use and the barriers to their adoption in Canada. Several solutions aimed at overcoming the barriers to DM in Canada are proposed. Résumé Les programmes de gestion de la maladie (GM) sont utilisés pour optimiser les résultats économiques et améliorer les résultats pour les patients. Malgré tout, par rapport aux États-Unis, les organismes de soins de santé canadiens ont été lents à adopter les programmes de GM. L’objet du présent article est d’examiner le concept de GM, les preuves existantes à l’appui de son utilisation et les obstacles à son adoption au Canada. De nombreuses solutions visant à surmonter les obstacles à la GM au Canada sont proposées.


acing the economic prospects of an insurmountable national debt load, the Canadian political environment of the 1990s became largely preoccupied with the notion of reducing government expenditures. As the most resource-intensive program, health care found itself the target of cut-backs aimed at capitalizing on systematic efficiencies. During this period, health care expenditures as a percentage of Gross Domestic Product (GDP) fell from a 1992 high of 10.1% to a low of 9.0% in 1997, representing the largest decline in health expenditures across all Organisation for Economic Co-operation and Development (OECD) nations with the exception of Finland.1 Although it can be argued that this experience was not entirely negative, these policy decisions led health care leaders to become intimately involved with organizational mergers and restructuring, the search for more effective and cost-efficient approaches to doing business, turbulent relations with human resources and an ongoing fight for financial resources. In light of the resulting budget-driven focus, the balance in maintaining quality and access to ensure positive population outcomes became increasingly difficult. Over the same period, the United States health care system also faced considerable challenges through an aging population, increasing consumer demands and escalating technological costs. These pressures fostered substantial growth of Managed Care Organizations (MCOs) focused primarily on cost containment and reduction of clinical practice variation.2 As a result of the interaction of funding mechanisms and competitive market forces in the U.S., an ideology for the provision of health care services termed “Disease Management” (DM), which may be referred to as Disease State Management (DSM) or patient health management, was developed. Arising from the U.S. experience, there has been significant international recognition of the benefits of DM strategies. Movement towards integrated DM approaches would seem prudent when one considers the challenges Healthcare Management FORUM Gestion des soins de santé – Winter/Hiver 2007


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poised by an aging population in an environment of limited resources, increasing consumerism and exponential growth in technological costs. In addition to these factors, the need for action is emphasized given the multitude of complexities in providing chronic disease care. From the Canadian perspective, after more than 10 years of DM advancement, the uptake of multifaceted DM strategies for chronic disease can be characterized as “lukewarm” at best. Given the relative delay of such efforts in Canada, it appears that barriers exist to the adoption of chronic DM programs. The focus of this paper is to investigate the barriers to DM program uptake in the Canadian context. The analysis will review the need for DM in Canada, the definition of DM, the Expanded Chronic Care Model as an approach to DM structure and existing Canadian DM programs. The barriers to DM adoption within the health system’s current approach are reviewed, before finally providing recommendations to health care leaders, government and other stakeholders on an appropriate course of action for the future. Why disease management? After a decade of significant structural reform, fragmentation in care still exists within the common health service delivery approaches of the U.S. and Canada. Departments are often thought of as separate entities, managed by various players utilizing a myriad of methods, with general disregard of how each piece relates to the whole.3 This is widely referred to as “operating in silos.” Some have faulted this componentbased approach by submitting that it ignores close interrelations between components, allows the service component to supersede the disease in determining basic unit costs and aligns clinicians, as patient advocates, against budget-conscious administrators.4 In short, such challenges directly counter the team-based synergies that health care leaders often seek to foster. Recognition of the importance of preventing such silos from developing is widespread; however, many organizations struggle to effectively achieve this culture change.5 “Care gaps” also illustrate how our health system’s traditional focus falls short of meeting the needs of those suffering from chronic disease.6 Montague6 refers to “care gaps” as the large differences between what “best care” could be as opposed to the “actual level of care” provided. In this context, “best care” can be thought of as a treatment that has been proven efficacious through randomized clinical trials, while “actual level of care” provided is that which is available within the typical community setting. As Montague points out, the problem is that the knowledge born out of these trials is not immediately transmitted into action, and as a result the delivery system maintains the status quo while patients are forced to accept less than optimized clinical outcomes. Montague identified the following care gap sources: suboptimal diagnosis, suboptimal prescription of appropriate therapy, patients’ suboptimal compliance with therapy, suboptimal access and elder care.6 Disease management offers guidance in efforts to reorganize the delivery system to overcome these challenges. DM


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TABLE 1 Nine mandatory components for disease management programs3 Disease management components 1. 2. 3. 4. 5. 6. 7. 8. 9.

Continuum of care perspective Focus on patient health-related outcomes Optimization of economic outcomes Use of evidence-based clinical practice guidelines Focus on chronic diseases Implementation of Continuous Quality Improvement (CQI) processes Integrated health care databases Feedback to health care providers Expanded role for drug therapy monitoring

also presents unique challenges due to a lack of consensus regarding essential components of DM programs. This lack of clarity fuels perceptions that the DM approach is no different than other health care administration fads of the recent past. There are questions as to whether DM represents new advancements in the treatment of disease or whether it is simply another profitable business opportunity for pharmaceutical companies, disease management entities and for-profit health care organizations.7 Although this argument warrants a general caution while investigating DM, one should not allow it to dissuade further investigation of the concept. The Disease Management Association of America (DMAA) defines DM as “Disease Management is a system of coordinated health care interventions and communications for populations with conditions in which patient self care efforts are significant.”8 It supports the physician or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies and evaluates clinical, humanistic, and economic outcomes on an going basis with the goal of improving overall health. Table 1 highlights the essential components of a successful DM program.3 DM focuses on prevention and wellness rather than solely on costly acute care interventions. However, cost containment has not fallen by the wayside; DM is a method of improving outcomes for patients in a manner that optimizes health care resource use. DM is not simply a cost containment measure; when used appropriately through the monitoring of health outcomes, it has the potential to result in an enhanced level of quality care. In a meta-analysis of published works spanning the period from 1987 to 2001, Weingartner et al. identified DM approaches that effectively enhanced quality of care.9 Patient education, provider education and provider feedback were the most common interventions utilized in the 118 DM programs included in the analysis. Provider education, feedback and reminders were associated with significant improvement in provider adherence to guidelines and improvement in patient disease control. From the patient perspective, education, reminders and financial incentives were associated with significant improvement in patient disease control.

DISEASE MANAGEMENT IN CANADA: SURMOUNTING BARRIERS TO ADOPTION TABLE 2 Barriers to disease management adoption in Canada and their impact Barrier


Lack of partnerships between health care providers

• Health care services provided in silos • Forgoes the opportunity to capitalize on community resources that may enhance outcomes

Lack of measurement tools and systems to inform decision-making

• Impedes evidence-based decision-making • Shared registries, electronic health records, patient/provider reminder systems and education are needed • Requires substantial human and financial resources to advance

Lack of published Canadian precedents

• The largely American literature base can be challenging to adapt to a Canadian context

Lack of patient-focused model in health care delivery

• Remains a challenge for leaders, providers and patients • Predominance of the medical model complicates the building of effective multidisciplinary teams

Lack of recognition that staff are our most important resource

• Widespread health system reorganization has change-fatigued staff

Competing resource demands

• DM program development, implementation and evaluation may be time, labour and cost intensive initially

Lack of change management capacity in organizations

• Widespread health system reorganization has left many organizations lacking leaders with the vision, understanding and skills required to advance this change effort

Antiquated provider incentive systems

• Impedes the necessary provider participation in change efforts

Lack of purchaser/provider split in Canadian medicare

• Forgoes a dimension of competition found in other public medical insurance systems throughout the world that holds providers responsible both fiscally and in terms of quality

Tax-based funding of health care system

• Forgoes the provision of incentives for employers to get involved in wellness programming, and governments attempt to spearhead these efforts

Lack of patient willingness to participate

• Not willing to pay for services • Not willing to participate in self-management aspect of programs

Although DM may provide an effective solution to the gaps in providing health care, Canada has been slow to adopt this concept. Table 2 highlights the barriers to adoption of DM, some of which have been identified by Montague10 and through our discussions with key informants. Disease management in action If the current management of chronic diseases is truly fragmented, where does a solution lie? The question of how best to manage and prevent chronic disease is an essential international concern, and as such a number of models have been presented throughout the literature and practice.11,12 The Chronic Care Model (CCM), also referred to as the Wagner Model,13 proposed by Wagner et al. in 1996 and revised in 2003, has gained widespread credibility in the U.S. As of 2002, it was being used in over 500 health care organizations.14 The model concept was based on a literature review and input from a large panel of national experts.15 The resulting model recognizes that the provision of chronic care takes place over the wider community environment and the health care system. It is based on the hypothesis that improved functional and clinical outcomes for DM are facilitated through the interaction between informed, activated patients and the proactive health professional team. The components of this integrated delivery system supporting this interaction include

self-management support, delivery system design, decision support and clinical information systems. Enter a Canadian perspective: the Expanded Chronic Care Model (ECCM) developed by Barr et al.16 Building on the CCM, these authors proposed modifications that broaden the model to address prevention and the field of health promotion’s determinants of health. Relative to the CCM, incorporating the population health promotion perspective broadens efforts to reduce the burden of chronic disease by supporting affected individuals and communities with action on the determinants of health while delivering high-quality health care services. This involves a paradigm shift away from hospitalfocused care “fixing” individuals at the acute level towards building empowered communities emphasizing prevention of illness and disease before they occur. If the environment is that much stronger, the potential health outcomes for individuals who receive care in the traditional sense will be that much greater. DM strategies (similar to those proposed under the CCM and ECCM) appear to have been more widely adopted in the U.S. relative to Canada at this time. Compared to Canada, the U.S. health system differs from a funding perspective as employers are largely involved in matching health insurance premiums of their employees. Insurance premiums have been escalating by double digits each year and having an impact

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on the profitability of many U.S. companies.17 This trend has provided an incentive for companies to become involved in DM and wellness. The experience of General Motors (GM) Corporation serves to illustrate this point. As the world’s largest automaker, GM of Detroit covered nearly 1.25 million employees, retirees, dependants in 2001 at a cost of US$3.99 billion on health care expenses. To put this amount into perspective using current exchange rates, in 2001, GM’s health care expenditures were approximately 33% higher than Nova Scotia’s projected 2007/08 health care budget.18,19 GM’s pioneering involvement in DM began over a decade ago, when rising health care costs prompted senior management to speak with union officials about how these expenses could be jointly influenced without sacrificing benefit components.20 In light of already staggering health costs, a heavily weighted baby boomer employee population and the increased care costs associated with an aging population, DM appealed as an option to enhance outcomes. Currently, the GM disease management programs are nurse navigator-based, emphasizing employee education, self-management and health care compliance. Further, GM has established process requirements as well as outcomes requirements to measure the results and effectiveness of its DM programs.20 In short, the focus of health benefits has shifted from protecting enrolees from financial hardship due to illness, to now helping employees manage and prevent illness. As a result, the return on GM’s investment has been measured in savings from the prevention of unnecessary treatment, return of employees from illness to work on schedule, enhanced employee quality of life and increased productivity.20 Conversely the tax-funded Canadian health system provides only limited incentives for employers to get involved in wellness programming. Although such programs would complement the health system efforts by rounding out the ECCM, employers question short- and medium-term returns on such investments. Many insurance providers have developed products for this niche to improve productivity and decrease sick days; however, marketing them towards bottomline-oriented employers remains difficult.a This is not to say that the Canadian system is completely barren of DM initiatives. In fact, a number of projects focused either on a particular disease or geographic area have been initiated across the nation. The Alberta Strategy to Help Manage Asthma (ASTHMA) Project and Improving Cardiovascular Outcomes in Nova Scotia (ICONS) are two of the larger DM projects implemented in Canada to date.21,22 Not only did ICONS increase utilization of appropriate cardiovascular therapy and decrease hospitalization rates, an economic analysis estimated that the $6.22 million invested in the project by the private sector led to a global net increase in total Canadian wealth of $10.23 million, including $2.27 million returned to the government through taxes.23 In New Brunswick, the publicly controversial four-year Healthy Futures plan is shifting away from the traditionally focused acute/episodic care system through reduction in numbers of beds in order to free up ––––––––––––––––––––––––––––––––––––––––––––––––––––––––– a


Personal communications with S. Stewart, 2005.

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funding for upstream health education and wellness efforts.24 Initiatives include the development and dissemination of practice standards for diabetes, heart failure, hypertension, Chronic Obstructive Pulmonary Disease (COPD), hyperlipidemia and asthma throughout community and hospital practice across the province. Many other provinces have also advanced in this regard. Newfoundland and Labrador have implemented a Chronic Disease Management Collaborative in several rural areas with plans to expand into urban regions.25 The Saskatchewan Chronic Disease Management Collaborative was launched in 2005 to improve care of patients with coronary artery disease and diabetes across the province.26 After less than a year of operation, the collaborative significantly improved patients’ access to family physicians and more patients were receiving the appropriate medications, tests and services for their medical conditions. A heart failure DM program in Montreal has also proven successful.27 Two hundred and thirty patients recently discharged from hospital were randomized to receive either standard care or follow-up by a multidisciplinary heart failure clinic that used evidence-based treatment plans and individualized patient education. At the end of the six-month study period, patients who attended the clinic experienced significantly fewer hospital readmissions, decreased length of hospital stay and improved quality of life. The evidence of successful DM in British Columbia is also compelling.28 The province initiated its approach to DM through the allocation of human and financial resources both at the Ministry and health region level towards improvements in DM strategies articulated in a province-wide plan. The Ministry of Health Services has compiled and committed to annually updating chronic disease patient registries for diabetes, Congestive Heart Failure (CHF), Chronic Kidney Disease (CKD), hypertension, asthma, COPD, rheumatoid arthritis and osteoarthritis. These data act as the backbone of program and service planning. Clinical guidelines have been developed and updated for several chronic diseases, including diabetes, CHF, hypertension, CKD, asthma, hepatitis B and C, as well as major depressive disorders. In addition, with respect to diabetes and CHF care, financial incentives have been put in place to reward providers for each patient with a confirmed diagnosis whose clinical management is consistent with B.C.’s clinical practice. B.C.’s success has also led to the use of the province’s Chronic Disease Management toolkit in the Yukon as part of the Yukon Diabetes Collaborative.29 Conclusions The past decade has challenged the Canadian health care system to evolve in response to cost containment pressures sometimes at the sacrifice of access and quality dimensions. The care of chronic illnesses is prone to gaps in diagnosis, prescription, compliance, access and age. The net impact of these issues adversely affects the provision of efficient quality chronic care in Canada. This represents a sizeable concern for the population at large as chronic care accounts for the majority of health system expenditures and results in substantive negative economic impacts for society.


Health system delivery leadership Make chronic DM planning a priority • Establish DM as an organizational strategic direction, linked to goals and actions that have measurable outcomes • Provide appropriate financial, human and technological resources Invest in administrators to lead change • Offer skill sets complementary to the clinical skill sets required on teams to drive chronic DM efforts forward • Integrate DM planning into succession planning efforts Share lessons learned to advance DM • Canadian literature is currently sparse • Sharing not only benefits of DM but also acts to institutionalize the changes within the organization by recognizing people for their CQI efforts and integrating the celebration of short-term successes Remain open to expanded roles for public-private partnerships • Evidence exists to validate that partnerships with the private sector in the area of DM can benefit both the provider organization and the private sector; however, building these relationships requires time and effort Government Provide financial incentives for providers • Provider “buy-in” is essential in successful DM efforts • U.S. and U.K. groups have moved towards “payment for results” mechanisms • Monitor these developments to assess whether or not Canada can benefit from the adoption of such approaches Provide wellness incentives for employers • Health systems funded from employee payroll taxes provide only limited incentive for employers to get involved in wellness programming • Insurance providers have developed these products and although such programs can lead to improved productivity and decreased sick days, marketing them towards bottomline-oriented employers remains difficult • Tax incentives over a 10-year period would encourage employers’ uptake Utilize a health “lens” in all policy development • Social determinants of health have a significant impact on health status; therefore, policy development processes across departments should consistently seek health stakeholder input Other Academia • Health professional educational models should evolve to effectively foster inter-professional learning and collaboration Canadian College of Health Service Executives • Leadership awareness and support is essential in furthering the advancement of DM in Canada. CCHSE can play a supportive role in ensuring that the topic is included in College publications, educational sessions and communications Statistics Canada and Canadian Institute for Health Information • Identify how the collection, presentation and availability of data can be modified to enhance DM

When implemented across entire populations, models such as the ECCM offer viable solutions to tackle the challenges now facing the system. While the U.S. system has moved to adopt such strategies with proven success both in terms of quality and cost containment, Canada has lagged behind in implementing DM programs. Although several regions are moving in the right direction, implementation is still in its early stages in most areas and the focus is often limited to only a small number of chronic diseases. Given the clinical and economic success of DM, there is clearly a need for more widespread adoption of DM programs nation-wide. Barriers fostering resistance to DM are found across the system and include factors relating to patient expectations, funding models, health professionals and organizational culture. Consequentially, as depicted in Table 3, it is essential that efforts to overcome these barriers be multifaceted. Canadian health care leaders and policymakers are at a crossroads; they must address the issue of escalating health care costs, which cannot be effectively managed without first tackling the questions surrounding quality chronic disease care. At a time of reinvestment into the health care system, given the demographic shift, heightened patient expectations, and an increasing prevalence of chronic disease, the time to act on disease management program development and implementation is now. Evidence has shown that investment in DM programs leads to significant economic returns through improved use of appropriate chronic disease therapy, decreased hospital admissions and decreased length of hospital stay. Therefore, contributions to DM present a considerable opportunity for the public payer to improve the quality, and decrease the financial burden, of Canadian health care. The experience of the past decade offered from projects in Canada, and more specifically the B.C. approaches, can serve to inform the substantial efforts required in this area to ensure that the health system remains sustainable for future generations. Acknowledgments The authors would like to acknowledge the contributions of Emily Black, Dr. Leela John, Grace Johnston, Erika Jones, Karen McCaffrey, Anne McGuire, Jane Mealey, Dr. Terrence Montague and Lawrence Nestman. References 1. Organization for Economic Co-operation and Development. Health at a Glance - How Canada Compares. OECD Observer 2001. [Accessed November 18, 2007] Available from: www.oecd.org 2. McLaughlin CP, Kaluzny AD. Continuous quality improvement in health care: Theory, implementations, and applications – second edition. Gaithersburg, MD: Aspen Publishers 1999. 3. MacKinnon NJ, MacDonald NL. Primer on disease management; 2000. (INET Continuing Education). [Accessed April 26, 2007]. Available from: www.inetce.com 4. Gonzalez ER, Crane VS. Designing a disease management program: How to get started. Formulary 1995;30(8):326-8, 331-3, 337-40.

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Voyage d’études en Suède et Norvège Du 11 au 17 mai 2008 Les soins de santé au Canada sont souvent comparés à ceux qu’on trouve en Suède et en Norvège, deux pays dont l’efficience et l’efficacité sont toujours très |hautement cotées dans les classements mondiaux. Pourquoi ne pas découvrir de première main les raisons pour lesquelles on en parle tant? Joignez-vous à John King, membre du Conseil d'administration du Collège représentant l’Ontario et vice-président exécutif de St. Michael's Hospital, et participez au voyage d’études du Collège en Suède et en Norvège, qui se déroulera du 11 au 17 mai 2008. Veuillez visiter www.cchse.org pour plus d’information ou communiquez avec Chris Parsons, Directeur des Services des conférences, au 1-800-363-9056, poste 26 ou à [email protected]


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14. National Coalition on healthcare. Curing the system 2002. [Accessed May 9, 2007]. Available from: www.nchc.org 15. Improving Chronic Illness Care. The chronic care model;2007. [Accessed April 26, 2007]. Available from: www.improvingchroniccare.org 16. Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, et al. The expanded chronic care model: An integration of concepts and strategies from population health promotion and the chronic care model. Healthcare Quarterly 2003;7(1):73-81. 17. Gabel J, Claxton G, Gill I, Pickreign J, Whitmore H, Holve E, et al. Health benefits in 2004: Four years of double-digit premium increases take their toll on coverage. Health Affairs 2004;23(5):200-9. 18. RBC Foreign exchange converter ($1.1407 US/Cdn). [Accessed April 26, 2007]. Available from: www.rbcroyalbank.com/ 19. Government of Nova Scotia, Department of Finance. Nova Scotia estimates for the fiscal year 2007–2008. [Accessed April 26, 2007]. Available from: www.gov.ns.ca 20. Cubbin J, Shaw D. GM and DM - a winning team. Company operations. Health Management Technology 2001;22(4):28-31. 21. Sharpe HM, Sin DD, Andrews EM, Cowie RL, Man P. Alberta strategy to help manage asthma (ASTHMA): A provincial initiative to improve outcomes for individuals with asthma. Healthcare Quarterly 2004;7(3):55-60. 22. Montague T, Cox J, Kramer S, Nemis-White J, Cochrane B, Wheatley M, et al. Improving cardiovascular outcomes in Nova Scotia (ICONS): A successful public-private partnership in primary healthcare. Hospital Quarterly 2003;6(3):32-8. 23. Crémieux PY, Fortin P, Meilleur M-C, Montague T, Royer J. The economic impact of a partnership measurement model of disease management: Improving cardiovascular outcomes in Nova Scotia. Healthcare Quarterly 2007;10(2):38-46. Abstract available at: www.longwoods.com 24. New Brunswick Department of Health; 2007. Healthy futures: Securing New Brunswick’s health care system. The provincial health plan 2004-2008. [Accessed April 26, 2007]. Available from: www.gnb.ca 25. Health Canada. Newfoundland and Labrador Primary Health Care Initiative (Provincial-Territorial Envelope);2006. [Accessed April 26, 2007]. Available from: www.healthpolicybranch.hc-sc.gc.ca 26. Health Quality Council. Saskatchewan disease management collaborative; 2007. [Accessed April 26, 2007]. Available from: www.hqc.sk.ca 27. Ducharme A, Doyon O, White M, Rouleau JL, Brophy JM. Impact of care at a multidisciplinary congestive heart failure clinic: A randomized trial. CMAJ 2005;173(1):53-4. 28. British Columbia Health Services. Chronic disease management: Update 2004. [Accessed April 26, 2007]. Available from: www.healthservices.gov.bc.ca 29. Health Canada. Yukon Primary Health Care Transition Fund Initiative (Provincial–Territorial Envelope);2006. [Accessed April 26, 2007]. Available from: www.health-policybranch.hcsc.gc.ca