Patients First E-Book

Terrence Montague

• Herausgeber: John Wiley & Sons
• Kategorie: Ratgeber
• Sprache: Englisch

Seitenzahl: 327

Veröffentlichungsjahr: 2010

Beschreibung

PATIENTS FIRST CLOSING THE HEALTH CARE GAP IN CANADA "This book is a must read for those who are interested in our health care system and who want to make it better. Dr. Montague provides an interesting overview of his journey through hospital wards, clinical trials, patient registries, patient health management and chronic disease management programs. Drawing on his diverse and unique background, he gives an important history of the past, analysis of the present and a glimpse of our future." --David Johnstone, MD President, Canadian Cardiovascular Society "Based on significant practice and research experience in the public, private and academic worlds, over many regions of Canada, Dr. Montague reveals to the reader, consumer, decision maker and patient an evolving and, until now, largely overlooked dimension in optimizing care and outcome. This optimization is important not only within the context of an individual's care, but within the scope of an entire practice, community or even nation." --Ross Tsuyuki, PharmD Director, The Epidemiology Coordinating and Research Centre, University of Alberta "Listen to Dr. Montague. He well understands both the problem and the solution, which is to pull out all the stops and to put patients first. He advocates patient health management to close the many care gaps. This will result in improved health for millions of Canadians and then, if we do it right, by emphasizing research and evidence-based health care and not merely budgets, our health care system will become more cost effective and our population healthier and more productive." --Mark Poznansky, PhD President, Robarts Research Institute

Leseprobe

Table of Contents

Title Page

Copyright Page

Dedication

Foreword

Foreword

Acknowledgements

Introduction

The Physician as Healer

The Evolution of the Care Gap

Closing the Care Gap

PART 1 - THE THEORY

Chapter 1 - HOW WE GOT TO WHERE WE ARE

A Short History of Health Care in Canada

The Threat—Is Medicare Sustainable?

Where Are We?

Managing Health Care: Commitment and Action To Get the Outcomes We Want

Chapter 2 - DEFINING QUALITY OF CARE

The Patients’ View

The Physicians’ View

Chapter 3 - THE CARE GAP AND ITS CAUSES

The Causes of the Care Gap

Chapter 4 - THE PRESCRIBING GAP

Chapter 5 - THE COMPLIANCE, CONCORDANCE AND ADHERENCE GAPS: CHALLENGES AND OPPORTUNITIES

Adherence by Disease Setting

What Is the Gold Standard?

Traditional Causes of Patient Non-adherence with Therapy

The Concordance Model for Patient-Physician Interaction

Who Owns the Adherence/Compliance Issue and What Can Be Done To Improve Things?

What Works?

Summary Conclusions

Chapter 6 - ACCESS, HEALTH AND THE ECONOMY: CAN WE AFFORD ACCESS GAPS?

How Much Do We Spend on Health Care, and Can We Afford It?

What Are We Buying with Our Health Care Dollars—Is There Value?

Is the Link between Health and the Economy Accepted in Canada?

How Do Health Expenditures Relate to Access and the Care Gap?

Chapter 7 - THE CARE GAP GORILLA: BIGGER GAPS FOR OLDER PATIENTS

The Evidence

Why Are Age-Related Practice Patterns Important?

Underlying Causes

Conclusions on the Aging Gorilla

PART 2 - THE PRACTICE—PATIENT HEALTH MANAGEMENT (PHM)

Chapter 8 - BACKGROUND AND RATIONALE OF PATIENT HEALTH MANAGEMENT

What Is PHM?

Why Patient Health Management?

How Does PHM Relate to Traditional Medical Science and Practice?

The Origins of Disease Management and Patient Health Management

The Hawthorne Effect

Chapter 9 - LEARNING EXPERIENCES: THE EPIDEMIOLOGY COORDINATING AND RESEARCH ...

Leadership

Institutions

The Epidemiology Coordinating and Research (EPICORE) Centre

The Heart Function Clinic

Knowledge Creation

Hope with a Small “h”

Chapter 10 - A PIVOTAL EXPERIENCE: IMPROVING CARDIOVASCULAR OUTCOMES IN NOVA ...

Why Nova Scotia?

The ICONS Partnership

The ICONS Measurements and Results

Who Is Hospitalized with Heart Disease?

How Were Patients Treated?

What Were the Patient Outcomes?

Transition of ICONS

A Closing ICONS Lesson

Chapter 11 - OTHER EXPERIENCES IN PATIENT HEALTH MANAGEMENT

Alberta Strategy to Help Manage Asthma (ASTHMA)

Vers l’excellence dans les soins aux personnes asthmatiques (VESPA)

Maximizing Osteoporosis Management in Manitoba (MOMM)

Falls, Fracture and Osteoporosis Risk Control and Evaluation (FORCE)

Recognizing Osteoporosis and Its Consequences in Quebec (ROCQ)

AIMS, MAAUI, CANOAR and CURATA

Diabetes Hamilton

PART 3 - WHAT HAVE WE LEARNED SO FAR?

Chapter 12 - WHAT WORKS: THE ACTION PLAN

Recurring Themes

The Mantra: Things Can Be Better

Commitment

Measurement and Communication

Enabling Involvement—Patients Empowered

The Power of Hope

Combining versus Isolating

Chapter 13 - WHAT DOESN’T WORK

Is There Anything to Be Avoided?

PART 4 - VISION FOR THE FUTURE

Chapter 14 - THE STRATEGIC ALTERNATIVES

What Could Feasibly Be Done Differently to Make Things Better?

Beyond Patient Health Management

Out of the Wilderness

Chapter 15 - SKATE TO WHERE THE PUCK WILL BE: WAYNE GRETZKY’S STRATEGIC PLAN

Do

Appendices

Bibliography

Index

Copyright © 2004 by Terrence Montague

All rights reserved. No part of this work covered by the copyright herein may be reproduced or used in any form or by any means—graphic, electronic or mechanical—without the prior written permission of the publisher. Any request for photocopying, recording, taping or information storage and retrieval systems of any part of this book shall be directed in writing to The Canadian Copyright Licensing Agency (Access Copyright).

For an Access Copyright license, visit www.accesscopyright.ca or call toll free 1-800-893-5777.

Care has been taken to trace ownership of copyright material contained in this book. The publishers will gladly receive any information that will enable them to rectify any reference or credit line in subsequent editions.

This publication contains the opinions and ideas of its author(s) and is designed to provide useful advice in regard to the subject matter covered. The author(s) and publisher are not engaged in rendering medical, therapeutic, or other professional services in this publication. This publication is not intended to provide a basis for action in particular circumstances without consideration by a competent professional. The author(s) and publisher expressly disclaim any responsibility for any liability, loss, or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this book.

Library and Archives Canada Cataloguing in Publication

Montague, Terrence J., 1945-

Patients first : closing the health care gap in Canada / Terrence J. Montague.

Includes index.

eISBN : 978-0-470-67522-9

1. Medical personnel and patient—Canada. 2. Medical care—Canada. I. Title.

RA449.M.1’0971 C2004-905433-3

Production Credits:Cover and interior design: Adrian So R.G.D. Author photo: Julie Hallé Printer: Tri-Graphic Printing Ltd.

This book is dedicated toPatricia Ann, Kathryn Lynn, John Joseph, Connor Damien, Declan Taylor and Delaney Kim Montague

And to the memory ofGarner King, MD, Gold Medallist, Class of 1964

and

Norman Davies, MD, Gold Medallist, Class of 1980

Faculty of Medicine, The University of Alberta

Foreword

MARK POZNANSKY, PhD, PRESIDENT, ROBARTS RESEARCH INSTITUTE

Patients matter.

They actually matter most, so the title of Terry Montague’s book is really bang on. The system needs to put patients first because they are the whole point of the health care system.

The solutions to our health care problems are not that complicated, and, quite frankly, Terry Montague gets it. He does a terrific job of describing the problem of the care gap and offering the solution: patient health management.

There are two fundamental reasons why readers should take Terry Montague’s book seriously. The first is that the care gap represents a huge obstacle to achieving a healthy and therefore productive society. The second is that the gap between the care we need as a society and what is actually delivered is widening in almost every area. We have only to look at the increasing incidence and costs associated with a range of diseases that have large preventable or controllable components: Type 2 diabetes, atherosclerosis, stroke and cardiovascular disease, osteoporosis and smoking-induced lung cancer.

Why is the care gap growing? The reasons seem obvious. The health care system in Canada is being driven by the health care budget and therefore rations the health care dollar. If it were being driven by population health—that is, by putting patients first—things would be better. The struggle, therefore, is between rational patient care and the health care budget.

Patients First offers some fairly specific solutions. As a first step, our health policy leaders have to fully understand the problem and the proposed solution outlined here. The underlying value statement for this entire debate was well put by former U.S. Surgeon-General C. Everett Koop: “That we spend significantly on health care is not the question; that we spend wisely is.”

A confounding problem that Terry alludes to is the fact that the future doesn’t look any brighter if we simply stay on our present course. Futurists Juan Enriquez (As the Future Catches You, 2001) and Christopher Meyer and Stan Davis (It’s Alive: The Coming Convergence of Information, Biology and Business, 2003) predict changes in our understanding of biology and medicine that will make the explosive changes of the past decade look tame. Powerful new advances in technologies, such as bioinformatics and nanotechnology, will provide previously unimagined opportunities in medicine and in the business of medicine. We will be able to predict and diagnose disease through genomic, proteomic and non-invasive imaging techniques in a manner that we’ve only dreamed of. Therapies will be much more rational and personalized, and we will be able to follow the specific progression or regression of disease and allow for the more specific modulation of therapy. The opportunities for improved patient health will be enormous. Equally enormous, however, will be the potential costs to the health care system if the developments are not managed properly.

For one thing, proper management means closing the care gap, meaning that a much greater percentage of patients with diseases such as hypertension, osteoporosis and Type 2 diabetes, for example, will have to receive the proper treatment in a timely fashion. To ensure that our health care system can sustain this level of care, we have to make sure that the most effective therapy is given to those in need and that we also refrain from wasting money by using high-tech and expensive medicine inappropriately. Research and well-founded clinical trials must be the norm for introducing all new medical/health care interventions. We can ill afford to use our health care dollars on diagnostic, surgical or medical interventions that have not been proven efficacious.

In returning to the issue of budget-based vs. evidence-based medicine, the obvious question is how a system of patient health management, as proposed by Terry Montague, will affect the budget. The short answer is that we don’t know for sure. But surely spending money wisely to build a healthier population is a good thing. Furthermore, with a little luck and good judgement, a healthy population may in fact repay the health care dollar with considerable savings, as healthier people won’t incur the chronic costs that can be prevented with better care.

Listen to Terry Montague. He well understands both the problem and the solution, which is to pull out all the stops to put the patients first. He advocates patient health management to close the many care gaps. This will result in improved health for millions of Canadians and then, if we do it right, by emphasizing research and evidence-based health care and not merely budgets, our health care system will become more cost effective and our population healthier and more productive.

Foreword

ROSS TSUYUKI, BSc (PHARM), MSc, PharmD, DIRECTOR, THE EPIDEMIOLOGY COORDINATING AND RESEARCH CENTRE (EPICORE),UNIVERSITY OF ALBERTA

Health care is an important core value of Canadians. While we can be rightly proud of our health care system, it is time for an upgrade.

In Patients First, Dr. Montague offers a critical assessment of our health care system and a vision of how to fix it. The difference between this and other “health care reform” books is that he provides his own insight from many health care experiences in Canada, both large and small, and does not not merely postulate theories of health care improvement. Patients First offers what can be described as a popular view of health care delivery—the best care for the most people on a timely basis. It offers a broadbrush scope, engaging not only the perspective of a physician or provider of care, but the perspective of the whole health system, never losing sight of the fact that the system exists to serve the patient.

In my view, this book should be read by the following consitutents:

You, the public: The public must become more involved in the health care discussions on the sustainability of Medicare, particularly the relation of its quality, access and costs. The public voice—your voice—can keep us focused on who the health system is designed to serve—patients. Patients First will familiarize you with the concept of care gaps,where usual care is not necessarily best care. It will show you how multidisciplinary teams of all stakeholders, including providers, patients, governments and health policy decision makers can challenge and improve these gaps through affordable, community based actions.

You, the providers: Health care providers—the doctors, nurse, pharmacists and other professionals charged with delivering most of the medical care in Canada, and their advocacy groups—often get stuck in their own narrow perspectives. In Dr. Montague’s broader view of the health delivery system, you will see that care gaps are present in every disease and are preventing patients from achieving the best possible outcomes, and the Canadian society from realizing the best return on our dollars spent. Turf wars and unnecessarily exclusive thinking of the roles of various health care professionals are holding us back from fixing many of these problems using the synergistic power of multi-disciplinary teams. In this book Dr. Montague describes innovative, yet feasible, initiatives that are paving the way to team-based care and improvements in patient outcomes.

You, the health policy makers: Policy makers also tend to take their own narrow perspective, looking at health costs in silos unrelated to the clinical and economic returns that can come with the expenditures on health care. Again, a broader perspective is needed. Appropriate, high-quality care costs money, and the societal benefits may not be directly reaped by one’s own specific department, or silo, within the system—but the clinical benefits do accrue for individuals and collected individuals. And the increased productivity of a healthier population, enjoying a higher quality of life, also accrues economic benefits for the society at large. Things get better, starting with the patient. The good news is that it doesn’t necessarily mean we need to spend a lot more money, but just spend it more wisely, with more accent on what outcomes it is buying.

Dr. Montague’s formula is quite simple: We need to form partnerships and measure the care in health care and relate this to patient outcomes. On a regional basis we need to use this information and work together to improve the system.

As a mentor, colleague, and friend, Dr. Montague has taught me a lot over the years. This book is a distillation of many of the things he has imparted to me—read it and you, too, will gain some of his experience and vision. Having this insight is important because health care is important, patients matter, and things can be better.

Acknowledgements

No man is an island. Certainly no one who ever wrote a book. I wish to gratefully recognize the consideration and assistance of the many people who contributed to this book.

Above all, I salute the insights, editing skills and unfailing good cheer of John Aylen of Kelly+Aylen. His guidance through the many interfaces and challenges of the publishing arena was invaluable and crucial to any success this work might have.

I greatly appreciate the time taken by many friends and colleagues who listened, read and fed back verbal and written contributions on the ideas and experiences related within this book. These collaborators include Alister MacDonald, who first gave me the idea to write this book; Bonnie Cochrane, Serge Labelle, Jean-Luc Blais, Siobhan Cavanaugh, Gregg Szabo, Bernard Houde, Robert Quesnel, Lori-Jean Manness, Eileen Dorval, Michèle Beaulieu, Elaine Andrews, John Sproule, Scott Wilson, Joanna Nemis-White, Chantal Bourgault and André Marcheterre from Merck Frosst; and from academia and the health community at large, Jean-Pierre Grégoire, Richard Plain, David Johnstone, David Marr, Kenneth Rockwood, Hertzel Gerstein, Pierre-Gerlier Forest, Glennora Dowding, Ross Tsuyuki, Koon Teo, Mark Poznansky, Brenda Zimmerman, Durhane Wong-Reiger, Sister Elizabeth Davis and Albert Schumacher.

I wish to recognize the tremendous administrative and grounding support of my assistant, Julie Hallé, whose unfailing practical sensibility and sensitivity gave the proper direction whenever things seemed uncertain or ambiguous.

And I want to express my appreciation and gratitude to my partner, Laurel Taylor, for her unwavering support, innovative insights and consistent optimism throughout this endeavour.

Lastly, I wish to recognize that any errors of fact or opinion in this work are mine alone.

Terry Montague Montréal, Québec

Introduction

This book reflects my professional journey as a physician, from the traditional and individual patient orientation of medicine to a broader vision of achieving optimal health outcomes for whole populations at risk. The central thesis of this book is that things can be better. One way to make them better is to translate the same scientific principles that underlie clinical practice decisions to health policy decisions. As I have become more involved with medical care and patient health at the population level, I have tried to remember to do that. In that sense, an alternative title of this book might be Evolution of Clinician to Politician: The Value of Retaining an Evidence Base.