Chronic disease services patients in the Northern Alliance Hospital Admission Risk Program-Chronic Disease Management

Abstract

© 2009 Tshepo Mokuedi RasekabaThis study was a cross-sectional epidemiologic evaluation of the clinical, sociodemographic, lifestyle and hospital utilisation characteristics of patients with diabetes, chronic obstructive pulmonary disease and chronic heart failure. Patients were enrolled in chronic disease management services of the Northern Alliance Hospital Admission Risk Program-Chronic Disease Management (Northern Alliance HARP-CDM Program). The program was established in accordance with the Department of Human Services’ (Victoria, Australia) initiative to intervene against increasing acute hospital demand by patients with chronic disease and complex needs. Amongst others, the Northern Alliance HARP-CDM Program provides services for patients with diabetes, chronic heart failure and chronic obstructive pulmonary disease. Patient cohorts with these three chronic diseases were the focus of this study. The Northern Alliance HARP-CDM Program catchment comprises of a culturally and linguistically diverse (CALD) population in the northern part of metropolitan Melbourne. Patients in this region mainly access acute hospital services at the Northern Hospital. The study sought to explore whether the CDM services enrolled patients whom based on their characteristics, fit the risk profile of the intended HARP-CDM target patient population. The study cohorts demonstrated a CALD make up of above Victorian state averages. The majority (60%) were born overseas, preferred a language other English and were over 60 years old. In contrast to previously published studies, CALD did not demonstrate a significant contribution to disease control, quality of life or level of hospital utilisation. Place of residence for these patients showed clusters within some Local Government Areas. This has implications for service location, access and disease surveillance. Also, it presents opportunities for area targeted health promotion and prevention and overall service location. The majority (77%) of those with chronic heart failure had an abnormal left ventricular ejection fraction. The diabetes cohort was characterised by higher HbA1c (9%) than the target of less than 8%. Similarly the patients had greater than recommended waist circumferences (Males 106cm vs. 94cm; Females 106 vs. 80cm) places them at an increased risk of cardiovascular disease. For those with COPD, 42% had severe pulmonary impairment (FEV%predicted ≤ 40%) while 36% were moderate in the moderate category. There was increased hospital utilisation with increasing age for those with COPD. With the exception of the diabetes cohort, there was no significant evidence as to the role of ethno-cultural factors in the study cohorts’ health, quality of life or level of hospital utilisation. However, ethno-cultural factors may contribute to the complexity of patient management processes and warrants further investigation. Prior to enrolment in the Northern Alliance HARP-CDM Program, patients who could be considered high users of emergency department services made up 20% of those in the diabetes service, 43% in the COPD service and 50% amongst those in the CHF service. Similar figures for hospital admissions ranged from 20% for the diabetes services to 56% for the CHF service cohorts respectively. Although the diabetes service was the biggest of the three the majority of patients in the service had no previous history of acute hospital utilisation. Members of the diabetes service cohort were characterised by hospital utilisation rates lower than the Northern Hospital’s (ED: 34 vs. 72 per 100 patients, Admissions: 33 vs. 68 per 100 patients in the Pre HARP-CDM Period). Patients in the COPD service (ED: 115 Pre and 158 during HARP-CDM) and CHF service (160 Pre and 159 during HARP-CDM) had ED presentation rates per 100patients that were higher than the hospital’s (72 and 69). The rates suggest the first 14 months of the Northern Alliance HARP-CDM Program were associated with increased hospital utilisation by patients enrolled the Northern Alliance HARP-CDM Program. The increments were greater than increases for the Northern Hospital for the same periods. Contrary to the intended goal of reducing acute hospital utilisation, the majority of the clientele did not fit the primary HARP-CDM Program criteria of high acute hospital users. But patients who were enrolled following previous hospital utilisation were well-targeted. However there are several patients who are likely HARP-CDM Program candidates who fall though the gaps between the acute hospital services and the program. It is recommended the program and services increase enrolments and access for the target patient populations. There is a need for early intervention chronic disease management and health promotion. This service would cater for clients who by virtue of having a chronic disease are at risk but are currently not high acute hospital users. Such a service would free up vacancies in the Northern Alliance HARP-CDM Program, thus enabling increased intake and equitable access for the target patient population, especially those who fall though the gaps as referred to earlier. Funding for such a service is available through DHS. In light of strong evidence for exercise rehabilitation and its ability to positively impact patient outcomes, quality of life, survival and hospital utilisation, consideration needs to be given to this as part of the Northern Alliance HARP-CDM Program chronic disease management care model