1. Innovative practices for
complex chronic disease
management: prevention and
health promotion
Richard Smith
Director, UnitedHealth Chronic
Disease Initiative
Granada Form, June 2010

2. Agenda
• UnitedHealth/NHLBI centres of excellence
to counter chronic disease
• Grand Challenges in Chronic Disease
• Conceptual difficulties in prevention and
health promotion in complex chronic
disease
• Three stages of prevention
• Examples of innovation at each level
• Conclusions

4. Deaths from chronic disease are displacing deaths
from infectious disease even in rural Bangladesh

5. 11 UnitedHealth and NHLBI Collaborating Centres of
Excellence to counter chronic disease

7. National Heart, Lung, and
Blood Institute
• Part of the National Institutes of Health, the largest funders of health
research in the world
• NIH mission :Acquire new knowledge that will lead to better health for
everyone
– Support research
– Train young investigators
– Communicate research results to the medical community and the public
• NHLBI mission: Conducts and supports basic research, clinical
investigations and trials, observational studies, demonstration and
education projects related to the causes, prevention, diagnosis, and
treatment of heart, blood vessel, lung, and blood diseases; and sleep
disorders.
• Annual budget: Over $3 billion

8. NHLBI Global Health Initiative
• Has created an Office of Global Health
• Is guiding the Global Alliance for Chronic Disease
• Commissioned an Institute of Medicine report on global
cardiovascular disease
• Has committed $35m in cash to its nine centres. Much of
it funding complex interventions (mostly RCTs)
• Now making more funds available
• Other institutes at NIH may follow; Fogarty already does
a lot

9. UnitedHealth Group
• UnitedHealth Group (UHG) is a health and wellbeing company with
a wide range of competencies, including co-ordination of health care
and information technology
• $90 billion revenue; buys health care for 70m people; 70 000 staff;
operates in 40 countries—but mostly US
• A third of the business is organising health care for governments—
mostly Medicare and Medicaid programmes in the US; also working
with the NHS in Britain
• Has committed $15m in cash and kind to the creation of the centres
• Wants not simply to fund centres but to work in partnership with
them

10. Patients with five or more chronic conditions
account for two thirds of Medicare spending

11. Multiple chronic conditions leads to an increase in
unnecessary admissions to hospital

12. What do we hope to achieve?
• Raise the importance of chronic disease control and prevention
globally and regionally
• Eventually reduce morbidity and premature mortality from chronic
disease
• Increase the number of individuals, institutions, and communities
equipped to counter chronic disease
• Develop and spread equitable programmes for preventing and
countering chronic disease
• Create, develop, and sustain a global network for research into
countering chronic disease
• Build constructive partnerships and avoid reinventing the wheel
• Ensure that the whole is more than the sum of the parts

13. What are the centres doing?
• A very wide range of activities, including:
– Surveillance
– Community interventions through schools, workplaces, health services,
government, and the media
– Develop tools for estimating risk in low income countries
– Guidelines for use by non-doctors
– Programmes with community health workers
– Primary prevention strategies in primary care, including using the polypill
– Secondary prevention studies
– Disease management
– Policy development
– Advocacy
– Training and education

15. Goals of the Grand Challenges
• A. Raise public awareness
• B. Enhance economic, legal, and
environmental policies
• C. Modify risk factors
• D. Engage businesses and community
• E. Mitigate health impacts of poverty and
urbanisation
• F. Reorientate health systems

16. Conceptual difficulties in prevention and health
promotion in complex chronic disease
• Little evidence specifically on prevention in
those with complex chronic disease
• Programmes should be patient not disease
centred and driven by the values of the patient—
for example, does it make sense to encourage a
patient near the end of life to stop smoking?
• Prevention and “disease management” merge in
those with complex chronic disease

17. Four levels of prevention
• Primordial prevention--creating economic, environmental and
social conditions that are conducive to health and that minimise the
likelihood of developing disease.
• Primary prevention-- addressing specific causal factors, like
tobacco use, poor diet and physical inactivity in the case of chronic
disease, in order to reduce the chances of people developing
disease.
• Secondary prevention--targeting people with a disease which is
established but usually at an early stage in order to limit the
exacerbation of the disease and the development of complications.
• Tertiary prevention— working with patients with well-established
disease to minimise suffering and complications.

19. Causes of chronic diseases

20. What should be the priorities?
• Social determinants
• Risk factors, particularly tobacco control
and hypertension (salt reduction)
• Improve health systems

22. Framework Convention on
Tobacco Control
• Only treaty negotiated by WHO
• Comprehensive strategy
– Price and tax strategies to reduce demand
– Non-price strategies to reduce demand
– Strategies to reduce supply
• Most countries have signed
• Could we have something similar for other
risk factors?

23. Primary prevention of chronic
disease in individuals

25. Polypill concept
• Five pills in one (statin, three anti-hypertensives
at half dose, folate acid, NOT ASPIRIN)
• Everybody takes from age 55
• Reduce heart attacks and stroke by 50-80%
• Costs $1 a month; several pills available in India
• Evidence that pill will reduce lipids and blood
pressure
• No primary care RCT; one about to begin in
India

26. A “disruptive” technology: objections
• Says medical model of “diagnose and
treat” doesn’t work: “tailoring” of drugs
better than
• May encourage unhealthy lifestyles
• Destroys lucrative drug markets
• Medicalisation

27. Why remote patient management transforms chronic care
Early intervention – constant monitoring
• Integration of care – exchange of data and communication across multiple
co-morbidities, multiple providers, and complex disease states
• Coaching – techniques to encourage patient behavioral change and self-
care
• Trust
• Workforce – shift to lower levels of healthcare workers, including medical
assistants, community health workers and social workers for much of the
interaction with the patient
• Productivity – more effective use of provider time at each level of worker

28. BUT……
• None of these can be accomplished by merely connecting a sensing
device in the home.
• All of them require substantial reorganization of systems of care,
and financing that rewards discontinuous leaps forward in
performance.
• That’s why these innovations take
some 17 years on average to
implement

29. Conclusions
• Most of the work (and cost) of health systems is now
related to chronic disease, particularly complex chronic
disease
• The world has mostly not woken up this new reality
• It needs to wake up, and many changes will be needed,
including a real shift towards prevention of chronic
disease and health promotion
• There are innovative ideas at all levels of prevention of
complex chronic disease
• Health systems are usually very slow to implement these
ideas—but they need to do so, particularly with the
increasing unsustainability of current systems