Resource Use for Chronic Condition Management: Substantial Differences Between the Danish and Kaiser Health Systems

Presenter: Michaela Schiøtz, Institute of Public Health, University of Copenhagen

Abstract

Rationale: Patients with chronic conditions consume substantial resources, especially during hospitalizations for disease exacerbations. The Danish Healthcare System (DHS) spends around 54 billion DKK (9.2B USD) annually on chronic conditions, and has targeted chronic condition care in its reform efforts. Prior work indicates that better outpatient care can reduce exacerbation rates and their associated costs, and that there is substantially poorer care coordination during transitions from hospital to outpatient providers in the DHS, compared to that in Kaiser Permanente (KP). Both systems have publicly financed insurance coverage at comparable levels.
Objectives: To investigate clinical event rates for chronic disease exacerbations in the DHS and KP.
Methods: Using the Agency for Healthcare Research and Quality's definitions of ambulatory care sensitive chronic conditions, we compared 2005 and 2006 hospitalization and rehospitalisation (<=30 days) rates, and lengths of stay for each of the five chronic conditions (angina pectoris, chronic pulmonary disease [CPD] including both asthma and chronic obstructive pulmonary disease, congestive heart failure [CHF], diabetes mellitus [DM], and hypertension [Htn]) for patients 65+ years in the DHS and KP. We adjusted for age and gender.
Results: The adjusted hospitalization rates for disease exacerbations differed for all chronic conditions: e.g., in 2006 for angina, DHS rates were 1,327 hospitalizations per 100,000 persons vs.108 in KP; for CPD, DHS=2,016 vs. KP=730; for CHF, DHS=1,187 vs. KP=874; for DM, DHS=765 vs. KP=436; for Htn, DHS=694 vs. KP=73 (p<0.05 for all comparisons). The adjusted mean length of stay for the six chronic conditions did not differ significantly between the two systems. The re-hospitalization rates within 30 days also differed significantly between the two systems: e.g., for angina, DHS=0.44 vs. KP=0.38; for CPD, DHS=0.62 vs. KP=0.41; for CHF, DHS=0.44 vs. KP=0.23; for DM, DHS= 0.33 vs. KP=0.22; and for Htn, DHS=0.27 vs. KP=0.16 (p<0.05 for all comparisons).
Conclusions: Despite comparable levels of insurance coverage, and consistent with different levels of care coordination, there were substantial differences in clinical event rates for disease exacerbations in patients with chronic conditions, between the DHS and KP. These preliminary results suggest opportunities for improving the efficiency of chronic condition management in the DHS, e.g., the higher re-hospitalization rates of 10-20 percentage points translates into 7,450 excess re-hospitalizations alone in 2006. Additional analyses will examine the cost and survival implications.