Thanks for inviting me to speak to the Standing Committee on Health on the topic of chronic diseases related to aging. I'm a researcher of health services, particularly in the area of frail elder care. Those are individuals with chronic diseases that have resulted in a significant loss of function. I'm also a family doctor at a place called the Mid-Main Community Health Centre in Vancouver, and many of my patients have one or more chronic conditions.
My presentation today is therefore informed both by my research on chronic disease in the frail elder population and my practical experience in supporting patients to manage chronic diseases at all stages of their conditions and their lives. I will try to briefly cover four topics today. My first is about defining chronic disease. Since the committee is charged with looking at chronic disease, I'd like to point out that our definition of what is and isn't chronic disease is ever-expanding. Let's take diabetes, for example. Ten years ago, to be a diabetic, my patients had to have a fasting blood sugar of over eight. Today, this threshold has moved down to seven. When the cut-off changed, all of a sudden those who had not been diabetic were now classified as having the disease.
Likewise, we've expanded our definition of what is and isn't high cholesterol, and we now diagnose osteoporosis based on the results of a test, whereas in the past we diagnosed this disease based on clinical signs and symptoms of bone loss. These types of shifts are significant. One researcher calculated that simply expanding the diagnosis of what is high cholesterol from 6.2 to 5.2 in the United States resulted in an 82% increase in individuals with a diagnosis of hypercholesterolemia, or over 4.3 million people.
In some cases, this could be a good thing. There is some evidence that the earlier we detect certain conditions, the better we're able to prevent progression of disease. However, the expansion of who we define as having disease also has some potential downsides. One downside is that when we diagnose chronic disease based at such an early stage, it's impossible to predict which individuals will actually end up developing noticeable complications of the condition, and we know that labelling alone, telling someone they have a chronic disease, can have negative health implications. Unnecessary labelling will cause avoidable harms to patients and their families.
Another downside is that a simple decision to lower the bar for who is a diabetic has implications for costs to the health care system that go far beyond one person who now becomes labelled as having the disease. With more frequent diagnosing of diseases comes more frequent laboratory testing and increased prescribing, so that in 2009 we Canadian physicians wrote 80%, that's eight zero percent, more prescriptions than we did 10 years earlier.
A recent British Columbia study reported a 42% increase in public expenditures from laboratory testing over the last decade. This was highest for those over 75 years, but the increase applied to all age groups.
As these changes to our definition of who has disease remain, there's been no discussion about what are the societal impacts of such a decision. Is all this increased activity of medical testing and prescribing really improving our population health, and what other things might the money be spent on?
While one might question whether our current and seemingly relentless medicalization of life is actually increasing the health and quality of life of our population, it is true that if management of our diseases like diabetes and heart disease are not well done, the result is recurrent visits to the hospital, declining function, and poorer quality of life. So the next topic I'd like to address is what does the research tell us about the best way to care for individuals with chronic disease.
We now have very good evidence that supporting patients to self-manage their disease is one of the most effective approaches. Self-management support involves a combination of helping individuals develop confidence in their ability to monitor their conditions, manage their symptoms, adopt healthy behaviours, and actually participate in decisions about their care. There's also evidence that the best way to do this is to provide those with chronic illness with a primary care medical home that can integrate and coordinate their care, give them continuity of care from a team of family doctors, nurses, and other providers, health professionals, and support workers who know them, understand their values, and are available 24/7, so that when things go wrong, they are able to help them respond in the most appropriate manner.
The presence of an electronic medical record is also essential to provide care in such a model.
Here in Canada, as part of the 2004 health accord, all of the provinces began to experiment with ways to improve primary health care, with the goal of doing a better job of supporting patients in chronic disease management. In many jurisdictions, doctors' offices have begun to deploy sophisticated reminder systems to identify patients with diabetes, heart disease, and other conditions. Some practices, including my own, have begun to experiment with group visits, in which our diabetic patients are invited to come into the office at the same time. Apart from providing regular proactive follow-up care, group visits also give patients an opportunity to share strategies for disease management that we physicians have never even thought of. So the challenge of the next decade is to devise ways to scale up these successes so that our primary health care system is robust and prepared for the expected gradual increase in patients with chronic disease as our population ages. As part of this challenge, we also need to integrate our primary medical care and our home and community care. These are currently functioning as two separate entities. Integration of both those systems is very important.
Thirdly, I'd like to focus on those individuals whose diseases tend to get worse as they get older despite everybody's best efforts. With age, people often accumulate multiple and more serious conditions that often have a significant impact on day-to-day function. Shopping, banking, housekeeping, to say nothing of the simple tasks of getting in and out of bed and toileting and so on, can all be impacted. We clinicians tend to refer to this as frailty. Frail elders with multiple chronic diseases, especially those with advanced Alzheimer's, in general do not fare well in the traditional medical system. We doctors are poorly trained to care for them. Our high-tech acute-care hospitals focus on rescue and on life prolongation, rather than on quality of life or the alleviation of distressing symptoms.
Frail elders have a short life expectancy, often despite aggressive medical intervention. My colleague Dr. John Sloan has written an excellent book on the importance of building models to care for frail elders outside of the hospital using a paradigm that tries to understand and support their health goals. Some family doctors and nurses are experimenting with models of care that try to do this. These models need to be expanded and scaled up in the decades to come.
Finally, even if we do a good job of caring for frail elders outside of hospital in their homes, there will still be a need for full facility-based long-term care with 24-hour nursing supervision for the most disabled, who are no longer able to function independently. It's predicted that by 2041, 4% of Canadians—that's 1.6 million individuals—will be aged 85 and older, and all provinces will likely need to expand their nursing home beds. In most provinces, long-term care is publicly subsidized, but service delivery is provided by a mix of public or government-run non-profit and private for-profit organizations.
Health policy in many provinces appears to be moving in the direction of increasing contracting of residential care by health ministries to for-profit facilities. Based on my own research and my review of the Canadian and U.S. research evidence on the link between ownership and care quality, contracting out care to private for-profit facilities is likely to result in care of inferior quality compared to care provided in public and non-profit facilities.
For example, one key measure of quality in residential care facilities or nursing homes is staffing levels. Studies have consistently found that for-profit facilities have lower nurse staffing levels than do non-profit and public facilities. Other indicators of poor care quality, such as rates of pressure ulcers or bedsores, are also found to be higher among residents in for-profit facilities. The link between for-profit facility ownership and poorer care does not imply that all for-profit facilities provide poor care; far from it. However, the evidence suggests that, as a group, such facilities are less likely to perform as well as non-profit or public facilities.
In summary, first, the rules about who does and who doesn't have a chronic disease are changing, and as a society we may well wish to have broader inputs into that conversation. Second, there's increasing evidence that chronic disease care is best provided by supporting individuals to self-manage their condition through primary care medical homes.
While family doctors and other service providers in the community are making baby steps toward building these homes, this work needs to be scaled up in the years to come.
Thirdly, for those with multiple chronic diseases who have become functionally disabled—usually frail older people—we need to develop a new approach to care that involves understanding individual values and goals of care and keeping care provision outside of the hospital setting as much as possible.