Caring for older patients with complex needs

Caring for older patients with complex needs

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From the inception of the NHS, its performance relative to health care systems in other countries has been the subject of public debate. Such comparisons have often shown the NHS performs neither as well as its supporters sometimes claim, nor as poorly as its critics often allege.

In the Commonwealth Fund’s ranking of health care system performance across 11 OECD countries, performance varies considerably across the different domains of the assessment. While the NHS performs well on measures of access, equity and administrative efficiency, health outcomes remain an area of relative weakness – with the UK ranked only 9 out of 11. A 2018 review of the NHS’s performance by the Health Foundation, Institute for Fiscal Studies, The King’s Fund and the Nuffield Trust found that although the gap is closing, the mortality rate in the UK among people treated for some of the biggest causes of death, including cancer and cardiovascular disease, is higher than average among comparable countries.

Although the UK spends around 10% of GDP on health – about 1 percentage point higher than the OECD average – spending on long-term care is below the OECD average. Informal carers shoulder a heavy burden, with nearly one in five (18%) of people aged 50 and older caring for a relative, the fourth highest among the 18 OECD countries with comparable data.

While important methodological progress has been made with international comparisons of quality of care and health care system performance, these comparisons often raise more questions than they answer. For example, if one country outperforms another, does that reflect differences in how health services are organised, differing levels of investment within health care systems or the impact of wider social and economic factors?

When done well, international comparisons have the potential to provide policymakers with information on how different care strategies might influence care quality and cost. Such comparisons offer the potential for mutual learning and sharing policy knowledge between countries. An example from the early 2000s is the macro-level comparison of the NHS with California’s Kaiser Permanente health system, which found that Kaiser achieved better performance at roughly the same cost as the NHS. The findings of this study were a wake-up call for the UK and have been cited as responsible for significant NHS policy changes, such as greater investments in predictive risk models and a renewed focus on integrated care.

The COVID-19 pandemic has reignited interest in international scientific endeavour and led to a massive increase in global collaboration around the use of patient-level medical record data to support rapid knowledge pipelines. An essential enabler of this work has been the development of common data models – frameworks that allow the data from across the world to be standardised in ways that facilitate comparison. These advances present opportunities to address some of the longer term health challenges facing health care systems worldwide.

Improving health care for patients with high needs
A key challenge facing many health care systems is how to best design services to provide care to high-need patients. This clinically diverse group of patients includes individuals with extreme functional limitations and those with multiple complex chronic illnesses. Although these patients constitute a relatively small proportion of the population, they often account for a large and growing proportion of medical expenditure across systems and are most likely to experience poor-quality care. For example, in the US it is estimated that 5% of the population accounts for over 50% of the country’s annual health care spending. Costs are similarly concentrated across other countries, such as England, Germany, the Netherlands, Spain, Switzerland, and Canada.

Despite this, there are limited data on the diverse ways in which high-need patients are managed across health care systems. Traditional comparative metrics, such as those produced by the OECD and the Commonwealth Fund and used by studies like the Kaiser Permanente comparison, are based on aggregate national data that relate to the care delivered in certain settings, for example hospitals. They do not use patient-level data that follow an individual patient through the health care system.

About the ICCONIC research
Launched in 2018, ICCONIC aims to advance international comparisons research by using patient-level data to develop metrics that allow health care systems to be compared in terms of the care delivered across the entire patient care pathway. This development is especially important for patients with complex needs, who often require services that cross many settings.

ICCONIC includes research partners from 11 OECD countries: Australia, Canada, France, England, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. It is led by researchers at Harvard University and LSE, and co-funded by the Commonwealth Fund and the Health Foundation. Additionally, the Health Foundation has produced the analysis for England.

The ICCONIC partners have focused on two types of patients that represent priority groups of people with substantial and complex care needs and could be studied using data from patient-level electronic health records (EHR):

– Patients aged 65 or older who sustain a hip fracture and are admitted to hospital for surgery. This group was selected to represent a high-need population of older adults living with frailty.
– Patients between the ages of 65 and 90, hospitalised with heart failure and with a comorbidity of diabetes. This group was selected to represent a high-need population of older people who have multiple long-term health conditions.

These two groups represent priority areas for the NHS. Hip fracture is the most common reason for older people needing emergency anaesthesia and surgery, and leads to prolonged dependence for many of those who survive. The number of people living with multiple health conditions is growing. These now account for over half of NHS costs for hospital admissions and three-quarters of primary care prescriptions, a fact that is a major motivation for establishing integrated care systems (ICSs) as statutory bodies via the Health and Care Bill.

The ICCONIC findings shed light on the different ways in which health systems in countries care for older patients with complex needs. In this long read we set out to examine some of the more striking results for England, reflect on whether these can be seen as part of a wider trend and consider the implications for clinicians and policymakers in the context of the COVID-19 recovery.

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