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Never too early

Tackling chronic disease

to extend healthy life years

A report from the Economist Intelligence Unit

Sponsored by Abbott


Never too early: Tackling chronic disease to extend healthy life years

Contents

Introduction 2

About this research 4

Executive summary 5

Heading off chronic disease: New approaches to prevention 7

• A preventable scourge 7

• Changing incentives

• Market-driven prevention

The role of employers: Workplace initiatives to tackle chronic disease

• Mission: Healthier workers

4

6

8

9

• Healthier companies, too 20

• What works? 21

Managing chronic disease: Rethinking provision of care 23

• The separate worlds of acute and chronic care 23

• Managing chronic care: keys to success 25

• High touch and high tech 26

Conclusion 28

Appendix: Interview programme and expert panel participants 29

© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

Introduction

“We are in the age of the old. Let’s celebrate,” says Mary Baker, president of the

European Brain Council. The premise of her statement, especially for Europe, is

indisputable. The United Nations Population Division reports that life expectancy

in Europe has risen by an average of ten years since 1960 and two years in the past

decade alone. It forecasts that average life spans across Europe will rise from 75

years currently to 82 years by 2050.

This is of course good news, but even good news can have a dark side. In the case

of Europe’s longevity, the sunny outlook is clouded by the fact that not all those

extra years will necessarily be healthy ones. The advanced years of many Europeans

will be prematurely burdened by the need to cope with one or more chronic

diseases, the incidence of which is climbing alarmingly. Moreover, the rising tide

of chronic illness is threatening the viability of Europe’s healthcare systems, which

are ill-equipped to cope financially, operationally or strategically with increasing

numbers of long-term patients.

That said, increased longevity promises opportunities too, as the swelling ranks

of older Europeans represents a largely untapped human resource. To raise

awareness of those opportunities, the European Union has established the

European Innovation Partnership (EIP) on Active and Healthy Ageing, part of

a broader programme aimed at improving co-ordination between the EU and

member states to encourage innovation. The specific aim of the EIP on Active and

Healthy Ageing is to find ways to add an average of two healthy life years for each

European by 2020.

Like much of the debate around extending healthy life years, the EIP focuses

almost exclusively on improving care for Europeans over the age of 65. Yet better

care for the aged is only one aspect of ensuring healthy ageing; the other is

ensuring that people arrive at old age in a healthy condition in the first place. The

health practices of people in their 40s and 50s—and much earlier as well—has a


© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

significant impact on their health in their later years. Indeed, some health experts

suggest that the focus on health should begin at birth, and perhaps even before—

in other words, that it is never too early to start taking steps that result ultimately

in a healthier and longer old age. “The strategy for healthy ageing should be a

continuum from birth,” says Desmond O’Neill, president of the European Union

Geriatric Medicine Society. “The challenge is not to take the foot off the pedal.”

This study hopes to make a contribution to European efforts to extend healthy

life years by focusing on what can be done well before retirement to increase the

odds for healthy longevity. The focus is in particular on measures to prevent and

manage chronic diseases, since these have the greatest impact on the health of

older Europeans. The research considers the effects of poor co-ordination among

healthcare providers, governments, civil society, private employers and the public

on making the necessary changes to the healthcare system to improve the healthy

longevity of both individuals and the system. It identifies best practice initiatives

in prevention, early intervention and management of chronic diseases that can

contribute to healthy ageing. In addition, it highlights effective ways to shift the

focus from reactive, hospital-based care of the sick towards a proactive, preventive

and patient-centred approach to improving health.

© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

About this

research

In late 2011, with a view towards contributing to the debate surrounding the EU’s

European Innovation Partnership on Active and Healthy Ageing, the Economist

Intelligence Unit undertook this study of ways to manage the rising tide of chronic

disease. This research, which was sponsored by Abbott, focuses on tackling chronic

disease as one of the chief ways of extending healthy life years in Europe.

As an initial step, the Economist Intelligence Unit convened a panel of experts on

November 21st in Brussels to discuss the focus of the study. This report is based

on the insights gained in that discussion, as well as on extensive desk research

and subsequent in-depth interviews with 35 experts in chronic disease and

healthy ageing. We would like to thank all participants in the expert panel and the

interview programme, who are listed in the Appendix.

The Economist Intelligence Unit bears sole responsibility for the content of this

study. The findings and views expressed in the report do not necessarily reflect the

views of the sponsor. Paul Kielstra was the principal researcher of this study. Delia

Meth-Cohn and Aviva Freudmann were the authors. Conrad Heine, Trevor McFarlane

and Stephanie Studer contributed research and interviews.


© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

Executive

summary

The promise of healthy ageing in Europe is

clouded by the rising incidence of chronic

disease. These diseases, whose hallmark is

a gradual and long-term deterioration of

function rather than a sudden acute event,

increasingly threaten both the quality of life of

older Europeans and the ability of healthcare

systems to cope with their demands. In the

absence of reforms in both the care of individual

patients and the overall design of healthcare

systems themselves, the rising tide of chronic

illness threatens to overwhelm the resources of

healthcare by mid-century, ensuring that ageing

is a burden and not an opportunity for Europe.

Most of the work on healthy ageing, including

the European Union’s Innovation Partnership

on Active and Healthy Ageing, focuses on how to

improve care for the aged. This study refocuses

attention on getting people to old age in a

healthier condition by looking at what can be

done throughout people’s lives to increase the

odds for healthy longevity. Here are some of the

key findings of this research:

• Chronic diseases threaten to overwhelm

Europe’s healthcare system. Between 70% and

80% of European healthcare costs are spent on

chronic care, amounting to €700bn in the EU.

Chronic diseases account for over 86% of deaths

in the EU.

• This scourge is largely preventable. Scientists

believe that much of the disease burden can be

prevented, or at least substantially delayed,

through a combination of primary prevention

measures, screening and early intervention.

• An ounce of prevention is worth a pound of

cure. The “four basics” of primary prevention

are already well known: a healthy diet, regular

exercise, avoiding tobacco and eschewing

excessive alcohol intake.

• Prevention also includes early diagnosis and

intervention. While primary prevention focuses

on healthy living, secondary prevention (early

screening and diagnosis) and tertiary prevention

(early intervention to slow the progress of

diseases identified) also play important roles in

reducing the burden of chronic disease.

• It is never too early to tackle chronic diseases

such as cardiovascular and respiratory illnesses,

Type 2 diabetes, cancer, dementia, kidney and

liver diseases, obesity and being overweight.

Indeed, healthy practices begun in infancy—and

perhaps even earlier, in vitro—can help to

forestall the onset of disease.

• Care of chronic conditions has distinct

needs compared to acute care, and must be

refashioned accordingly. To ensure appropriate

care for chronic disease sufferers as well as free

up medical resources for acute-care patients,

© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

communities and healthcare systems should

direct more resources to wellness, prevention and

disease management programmes for chronic

patients.

• Healthcare should be integrated and

patient-centred to the greatest extent

possible. Integration of medical services and

other services such as mental health, in-home

sanitary care, and instruction in self-monitoring

and self-care methods are crucial components of

creating an integrated, patient-centred chronic

care system. This is particularly important for

patients suffering from more than one chronic

disease, who often must co-ordinate their own

care among silo-like specialised care providers

under the current system.

• Healthcare should be devolved as far as

possible down the provider chain. As part of

patient-centred healthcare, patients should

be encouraged to do as much as possible for

themselves, with appropriate support from a

variety of providers—not all of them necessarily

specialised doctors. Pharmacists, nurses,

community workers, home care workers and

others can all play a part, and are often in a

better position than doctors and hospitals to

provide time-intensive coaching and personal

attention to patients.

• Employers and health insurers have major

contributions to make in fighting chronic

disease. Health and wellness programmes

are increasingly being offered by progressive

employers as a way to ensure that older workers

are able to remain on the job longer. Health

insurers are also increasingly sponsoring health

and wellness programmes as incentives to

encourage healthy lifestyles and practices.

• Mental healthcare is an important part of the

mix in the prevention and treatment of chronic

illnesses. Researchers have found that isolation

and loneliness among those whose function is

impaired owing to chronic disease aggravates

their condition. Several promising initiatives aim

at reducing that loneliness through individual

case management and personal health coaching.

In general, healthcare providers are increasingly

incorporating mental health services as part of

treatment for chronic-care patients.


© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

1

Heading off chronic disease

New approaches to prevention

“An ounce of prevention is worth a pound of cure,” wrote

American statesman Benjamin Franklin in the 18th century.

Although his dictum was meant to apply to all facets of

life—and not only to medical cures—his wisdom is nowhere

more applicable than in 21st century Europe. Today in Europe,

many pounds of cure are being expended to fight chronic

illnesses that in many cases could have been prevented in

the first place.

A preventable scourge

Chronic disease is shaping up as a modern-day scourge.

According to the European Chronic Disease Alliance, a

coalition of medical professional organisations, over 100

million European citizens—or 40% of the population above

the age of 15—have a chronic disease. That proportion rises

progressively through the age ranks, with the result that

Europeans reaching retirement age are more likely than not

to suffer from at least one chronic condition. According to the

World Health Organization (WHO), two out of three Europeans

who have reached retirement age have had at least two chronic

conditions. Although Europeans are increasingly living longer

on average, the high incidence of chronic disease at retirement

age suggests that for far too many this longevity will not

necessarily mean many years of healthy, full functioning.

For Europe’s healthcare systems—and the national budgets

that largely support them—this trend also suggests an

unhealthy future. According to the European Public Health

Alliance (EPHA), between 70% and 80% of European

healthcare costs are spent on chronic diseases. This

corresponds to €700bn in the EU, and this figure is expected

to rise in the coming years, according to the EPHA. Worldwide,

the figures are even more dramatic. The World Economic Forum

calculates that the global economic impact of the five leading

non-communicable diseases (NCDs)—cardiovascular disease,

chronic respiratory disease, cancer, diabetes and mental illhealth—could

total US$47trn by 2030 (see Chart 1). Unless the

rising tide of chronic disease is reversed, such costs—which

Chart 1

Doubling the burden by 2030

Chronic disease cost burden, 2010 and 2030 (VSL estimates*)

(US$ tr)

2010: total 22.8

14.8

0.5

5.1 2.4

High income

Lower middle income

Upper middle income

Low income

2030: total 43.4

19.7 17.4 5.3

1.0

*The VSL approach is used to estimate the economic burden of NCDs in 2010 and to project that burden in 2030. The VSL data are taken to be the value of life of a representative

median-aged member of the corresponding national population. Constructing the VSL estimates/projections requires the estimation of DALYs in 2010 and 2030.

Source: 'The Global Economic Burden of NCDs', World Economic Forum and Harvard School of Public Health, 2011.

© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

include output loss as well as direct healthcare spending—

could have a severe impact on national economies and their

healthcare systems.

One of the main reasons healthcare systems around the world

are ill-suited to dealing with chronic disease is that they

were designed to respond to acute, short-term illnesses and

injuries, rather than to prevent and manage the gradual, longterm

deterioration that characterises chronic disease. Indeed,

the rising ride of chronic disease represents a sea change in

the type of illnesses affecting people worldwide. More than

60% of deaths worldwide are due to NCDs, killing 36 million

people each year, according to the World Economic Forum.

Chronic diseases account for over 86% of deaths in the EU,

according to the Chronic Disease Alliance.

Astoundingly, scientists believe that much of this scourge

is preventable—or at least can be substantially delayed.

According to the WHO and the NCD Alliance, simple measures

that fall under the rubric of “primary prevention”, such as

eating a healthy diet, avoiding tobacco use and excessive

alcohol, and increasing physical activity can prevent 80% of

premature heart disease, 80% of Type 2 diabetes and 40% of all

cancers. A recent large longitudinal study in the Netherlands

found that eating a Mediterranean diet, regular exercise, not

smoking, and maintaining a healthy weight collectively added

15 years to an average woman’s life span and 8.5 years to an

average man’s life span.

“These measures are so well known as to be almost banal,” says

Professor James Vaupel, founding director of the Max Planck

Institute for Demographic Research in Rostock, Germany, and

head of its Laboratory of Survival and Longevity. “The bottom

line is, you are more likely to reach age 80 if you listen to what

your mother told you.” But the trend towards healthier living

is weak, at best. “People think they need expensive food to

have a good diet, but the Mediterranean diet is cheap and

smoking costs lots of money,” notes Piet van den Brandt,

professor of epidemiology at Maastricht University and author

of the Dutch study. A 2010 study by the OECD and the European

Commission found that over one-half of adults living in the EU

are overweight or obese, and that the rate of obesity has more

than doubled over the past 20 years (see Chart 2). Similarly,

although smoking rates have fallen, smoking is still very much

part of the culture in many parts of Europe.

Prevention is not only a matter of healthier living. Early

diagnosis and the right kind of early intervention and disease

Chart 2

Growing girths

Overweight and obese populations in Europe, males (representative sample of countries)

(%)

Overweight

60

Obese

60

50

40

30

39.6

40.1

43.7

44.8

41.0

45.5

42.5

41.0

51.5

45.0

43.5

39.2

50

40

30

20

10

0

13.4

11.8

22.1

14.9

16.1

20.5

10.5

15.7

30.7

10.3

17.8

13.4

14.8

8.3

20

10

0

Bulgaria

Denmark

England

Finland

France

Germany

Italy

Poland

Russia

Slovakia

Spain

Sweden

Switzerland

Note: Overweight defined as % Body Mass Index 25-29.9; and obesity defined as % Body Mass Index 30+.

Source: International Association for the Study of Obesity, 2011.


© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

management—known as secondary and tertiary

prevention—can also make considerable

contributions to reducing mortality from chronic

diseases. (For fuller definitions of primary,

secondary and tertiary prevention, please see

box, “Prevention: Three lines of defence”.).

Shifting priorities

Although policymakers are well aware of the shift

in the nature of the burden on the healthcare

system, that knowledge has yet to be translated

into an overhaul of the system. Funds are still

directed in the same way they have been all

along—to caring for hospital-bound patients,

and to treating diseases after they occur rather

than trying to prevent them from occurring.

Much of healthcare spending is still oriented

towards single-organ and single-occurrence

events—such as heart attacks or acute

appendicitis—rather than on the less dramatic

long-term deterioration of function associated

with chronic disease.

As a result, most funds expended in the

healthcare system are directed towards solving

yesterday’s problems rather than today’s and

tomorrow’s problems. In particular, vast sums

are directed towards fighting diseases when

they are close to killing patients rather than

earlier in life when they are not immediately life

threatening. “About 27% of [US] Medicare spend

is in the last year of a patient’s life,” notes Dr Paul

Keckley, executive director of the Deloitte Center

for Health Solutions. “The policy debate is, is it

Prevention: Three lines of defence

The medical system has developed a typology

for the wide range of practices covered by

the general term “prevention”. Preventive

measures are carried out by both individuals and

healthcare providers, and fall into three general

categories:

• Primary: Primary prevention aims to protect

healthy people from developing a disease in

the first place, through such measures as good

nutrition, regular exercise, avoiding tobacco

and alcohol, and receiving regular medical

check-ups. Primary prevention may also extend

to population-wide measures such as improving

air and water quality, mass immunisation, and

strengthening family and community ties to

promote mental health.

• Secondary: After risk factors have been

found to be present, and/or signs of an illness

have actually appeared, secondary intervention

consists of screening for illnesses, particularly

when risk factors are present, and early

intervention measures to slow the progress of

the disease while it is still in its early stages.

For example, a patient with signs of a heart

condition might take daily low dosages of

aspirin to prevent a first or second heart attack.

Alternatively, secondary prevention might

consist of an enhanced regimen of screening

and monitoring to track the progress of the

disease as well as monitor response to therapies

and track any required adjustments in dosing.

In some cases, drug therapies can be introduced

to delay or slow down development of a disease

such as Alzheimer’s.

• Tertiary: For patients who already have

illnesses such as diabetes, heart disease,

cancer or chronic musculoskeletal pain, tertiary

prevention consists of measures to slow down

physical deterioration. Such measures might

include participating in cardiac or stroke

rehabilitation programmes, joining chronic pain

management groups, or participating in support

groups for patients with mental or psychological

problems. While these measures are technically

no longer strictly preventive—the patient has

already been diagnosed with the disease—they

do help to limit the debilitating effects of the

illness, and thereby improve quality of life and

extend life years in comparative health.

© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

better to reinvest those resources in preventative

management of chronic disease, or is it better to

spend an inordinate amount of resources on endof-life

care.”

Similarly in Europe, the Organisation for

Economic Cooperation and Development has

determined that only 3% of current health

expenditure in Europe is invested in prevention

and in public health programmes (see Chart

3). This shows the extent of the difficulty of the

shift from curative to preventive investment.

And yet for healthcare professionals, the link

between early prevention and intervention,

on the one hand, and healthy longevity, on

the other, is clear. “Every single measure of

prevention—say, reducing smoking or obesity

or cholesterol—means that during the ageing

period your quality of life will be much better,”

says Bernat Soria, a former minister of health

in the Spanish government. Clearly, the healthy

longevity of both individuals and healthcare

systems would be well served by a reordering of

the current spending priorities.

Available data on the benefits of early diagnosis

and intervention point in the same direction as

that on the impact of healthier lifestyles. In the

case of many chronic diseases, the onset of the

disease can be delayed, and its progress slowed,

by secondary and tertiary prevention measures

as well as primary prevention measures.

Advances in genomics are helping doctors to

identify risk factors, which in turn helps them

to identify vulnerable population groups, as

well as population groups likely to respond

to specific treatments. Various screening and

diagnostic devices are then used to identify

individuals at risk or showing early signs

of disease. Identifying risk factors and/or

biological markers—any protein or other

substance in the blood whose concentration

can indicate the presence or future onset of a

disease—provides a powerful incentive for both

patients and doctors to take further action

to prevent the onset of the disease or slow

its progress.

Chart 3

Prevention: Making a start

Proportion of European health expenditure invested in organised public health and prevention

programmes, 2008

(%)

7.0

7.0

6.0

6.0

5.0

4.0

3.0

2.0

1.0

0.0

Romania 6.0

5.7

4.9

4.1

4.0

3.9

3.7

Finland

Netherlands

Bulgaria (2007)

Hungary

Slovenia

Germany

Sweden

3.6

Slovak Republic

3.0

EU average

2.9

Estonia 2.8

Czech Republic 2.7

2.7

Belgium

2.4

Spain

2.3

Switzerland (2007)

2.1

Poland

2.0

Norway

1.8

France

1.6

Austria

1.6

Iceland

1.4

Latvia (2007)

1.4

0.7

0.7

Denmark (2007)

Lithuania

Italy

5.0

4.0

3.0

2.0

1.0

0.0

Sources: OECD Health Data 2010; Eurostat Statistics Database, 2010.

10

© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

“The latest statistics from the International

Diabetes Federation show that 50% of people

with diabetes do not know that they have it,”

notes Dr Maha Taysir Barakat, medical director

at the Imperial College London Diabetes Centre

in Abu Dhabi. “The challenge is how to increase

the chance that those who don’t know they have

diabetes will take the test and go to a health

provider who can help them. The sooner you

start managing someone with diabetes, the

better the long-term outcome. That will have an

impact on extending healthy lives.”

From diagnosis to treatment

There is also promising clinical work under way

to identify the biological markers—such as the

build-up of plaques and tangles in the brain—

that point to the likely future development

of Alzheimer’s disease, the principal form

of dementia. Many doctors argue that early

screening to determine if such markers are

present can lead to a regimen of exercises, diet

changes and possible drug therapies, which

together can delay the onset of the disease and

slow its progress once it appears. Researchers

are also trying to develop a clearer view on

what biological markers, and especially in what

concentrations, would prove the effectiveness of

different therapies in fighting the disease.

Similarly, clinicians generally believe that

measuring certain biological markers in the

blood or urine can identify patients at risk of

kidney diseases, can detect diseases in the

earliest stages, and through early detection

can be treated effectively. A clinical trial,

published in the Clinical Journal of the American

Society of Nephrology Studies in 2007, showed

promising results in terms of lower death and

hospitalisation rates after participation in

an early intervention programme. The trial

compared results obtained for around 1,000

hemodialysis patients enrolled in such a

programme, and another 1,000 patients in a

control group. By the end of one year, the death

rate of early-intervention patients was around

43%, compared with 56% for the control group

of long-term hemodialysis patients. Within the

first 90 days, the mortality rate for participants

in the early intervention programme was 20%,

compared with 39% for the control group.

“Screening is a very good idea for renal disease,

because when we are effective, we are very

effective,” says Johannes Mann, professor

of medicine and head of the Department of

Nephrology, Hypertension and Rheumatology

at Schwabing General Hospital in Germany.

“Screening is especially effective when we

prevent people from going on to dialysis. I see no

negative aspects to screening for kidney disease.

For other diseases, the case can be different.

There has been a long debate about prostate

cancer, for example, where you might be able to

recognise the disease earlier but not necessarily

change its course.”

Improving the links between diagnosis and

treatment is crucial if preventive healthcare is

to be effective. Among other things, it would

provide a needed incentive to shift resources

from treating the sick to preventing illness.

However, this process is not simple. In particular,

there is a thicket of conflicting scientific studies

on the costs and benefits associated with

screening and early intervention. For example,

mammography to detect breast cancer in

women—once considered an obvious health

measure—has fallen into controversy. Some

respectable research institutes have found an

unexpectedly strong probability that, in some

populations, mammography could yield false

positives or highlight pre-cancers unlikely

to become full-fledged cancers, but which

nonetheless lead to interventions. These studies

suggest that, for the populations in question,

if a highly sensitive test is used, the probability

of a false positive may exceed the likelihood of

finding real cancers and saving lives—in effect

saying that, statistically, the costs of the test

exceeds its benefits in such cases.

© The Economist Intelligence Unit Limited 2012

11


Never too early: Tackling chronic disease to extend healthy life years

The same questions have been raised in screening

and early intervention for respiratory and for

cardiovascular illnesses. To ensure they detect as

many real cases as possible, clinicians may use

a highly sensitive measurement, which may also

yield some false positives. “The classic example

is asthma: we tend to diagnose twice as many

asthmatics as those that actually have asthma,”

says Mr Keckley of the Deloitte Centre for Health

Solutions. “So we are not particularly good at

doing these things. There are some great studies

that show that our primary care system is failing

to adequately apply the evidence to diagnostics.”

Blanket screening does not just carry the

potential danger of adding unnecessary costs

to healthcare systems, it also carries the risk

of creating psychological risks to the people it

is trying to help. Joep Perk, cardiologist and

professor of health sciences, and chairman of

the Joint European Societies’ Task Force for

Cardiovascular Prevention in Clinical Practice,

points to a programme to screen men over 65 for

abdominal disease. “The psychological effect

has not been sufficiently studied. In much of our

screening work we do not pay enough attention

to the unrest that we create in people,” he says.

“I am a national co-ordinator for cardiovascular

disease prevention, and it is part of my duty

to speak to doctors about their prevention

methods. One once said to me about screening,

‘I do not want to make healthy people sick!’

This is the reverse side of the coin. It needs

more attention.”

towards a solid economic case for redirecting

funds from treatment to prevention. The absence

of hard data linking specific prevention measures

to reduced incidence of specific diseases is

slowing the process of acting on that knowledge

to change spending priorities and overhaul an

outmoded healthcare system.

Changing this state of affairs requires three

things.

First, public health officials need to measure

systematically the returns on investment

of various health prevention measures,

particularly for more expensive screening

and early intervention programmes. Walter

Ricciardi, president of the European Public

Health Association, believes that his profession

is partly to blame for the lack of evidence-based

medical care so far. “Before, public health people

said, ‘prevention is beautiful, let’s do it,’ but

did not look at the costs and benefits,” he says.

“It is possible for prevention programmes to

generate significant savings, but certain ones

might also be costly and yield little benefit. The

problem is that too often evidence is simply

not collected either way.” Professor Ricciardi

believes that these programmes need to be able

to demonstrate value so that policymakers can

decide whether to adopt them. (Please see box,

“From sickness to health: Abu Dhabi’s radical

refocusing initiative” for an innovative attempt to

collect this evidence systematically and translate

it into a new healthcare financing model.)

While these concerns over how best to implement

screening require attention, the overall case

for pursuing prevention over cure is clear and

urgent. Scientists have concluded that most

chronic disease is preventable, or at least can

be held at bay for much longer than it is today.

Yet for such knowledge and clinical insights to

be translated into a reorienting of spending

priorities towards prevention, policymakers

must be persuaded of the overall applicability

of the selected clinical trials, which would point

Second, healthcare policymakers need to move

away from talking broadly about prevention,

screening or treatment for chronic diseases and

start taking a more differentiated and focused

view of the efficacy of specific measures for

preventing or delaying the onset of specific

diseases, for specific groups of people, and

identifying those who are most likely to benefit

and those who are likely to be non-responders.

Ironically, the successful push for recognising

chronic disease management as a separate focus

12

© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

for healthcare in Europe is now creating an

obstacle for its better diagnosis and prevention.

“EU policy does not include any disease-specific

policies except for cancer. This is a huge barrier

for cardiovascular disease,” says Sophie O’Kelly,

head of European affairs for the European Society

of Cardiology and a founder of the Chronic

Disease Alliance. Diseases are bundled together

as ‘chronic disease’–“which is a start, but it’s

not enough. It makes it difficult in turn for EU

member states to adopt specific prevention

strategies to address cardiovascular disease.”

Third, healthcare officials will need to find a

way of overcoming the problem of short-term

costs versus long-term benefits. Investing in

prevention requires waiting a decade or two

to determine the effect of measures and enjoy

From sickness to health: Abu Dhabi’s radical

refocusing initiative

Abu Dhabi may be best known in healthcare

circles for its alarmingly high and rising rates

of obesity and diabetes—and for having lots

of money to throw at the problem. But the

emirate is actually testing one of the first totalpopulation

action plans on chronic disease,

built around screening, planning and action.

The Weqaya prevention programme was

launched in 2008 by a group of international

health experts within the emirate’s

government. Weqaya began with a simple 15-

minute opt-out screen for cardiovascular risks.

This covered 95% of the population in its first

few years and in 2011 moved into the second

screening round (screening will be repeated at

least every three years, more often for those at

the highest risk). Each screened person receives

an individual report, which outlines in a simple

traffic light form the main risk areas, like high

blood pressure and high body mass index, and

a set of personalised actions, from diet changes

and exercise, for example, to visiting the doctor

to receive therapy.

“Now we’ve started the second round of

screening, we can start to assess trends

across the population and over time, plus see

what really works in our population,” says

Oliver Harrison, Director of Public Health and

Policy at the Government of Abu Dhabi. One

big success was to get people with problems

going to see doctors. “In the first round of

screening we found that one-third of people

with diabetes didn’t know they had it, one-half

with hypertension and two-thirds with high

cholesterol. Assessing Weqaya overall, we’ve

seen a 40% improvement in blood glucose levels

and a 45% improvement in lipids, plus the costs

of the programme are very modest—less than

US$20 per person per year.”

With all health data collected and stored in a

universal health database (again developed inhouse),

Abu Dhabi is now taking the individual

results and bundling anonymised data for

target groups, such as employers and local

governments. Bundled data help to set local

priorities and to measure the level of impact.

This form of benchmarking can be used to

identify (and praise) best practice which can be

disseminated, and identify those who are not

putting in the effort. Of course, the data can

also be aggregated to the population-level to

project the level of demand for health services,

and strengthen the case for policy interventions

such as tobacco control and improving the

walkability of Abu Dhabi.

Dr Harrison also plans to use the data to

revolutionise healthcare financing—an issue

even in oil-rich Abu Dhabi as chronic diseases

skyrocket along with costs. By calculating the

expected cost of disease over the next decade,

based on the measured risk factors, Abu Dhabi

is planning to reimburse disease management

companies directly for improvements in

measured health over time. “This allows us to

transfer risk with a new financing model,” he

says. “We have geared the numbers so the more

we pay for health, the more we save on future

health spend.”

© The Economist Intelligence Unit Limited 2012

13


Never too early: Tackling chronic disease to extend healthy life years

the benefits in lower healthcare costs. “We

have elections every four years, but medical

complications [in the absence of prevention] will

appear in 15 to 20 years,” notes Dr Soria. “So

today’s politicians will not pay the future price

for poor prevention measures.”

Changing incentives

In the case of the medical system, incentives are

at the core of the short-term bias. Despite the

rising tide of chronic illnesses, the incentives

for practitioners are still to treat the sick

rather than keep them out of the system.

Healthcare in Europe developed as a sickness

system rather than a health system, and this

is where, generally speaking, it remains. “It’s

a global phenomenon—the urgent crowds out

the important,” says Derek Yach, senior vicepresident

of global health and agricultural policy

for US-based Pepsi-Cola. “Prevention is always

sacrificed in face of the curative load in front

of people.”

In the absence of comprehensive evidence

linking preventive measures to significantly

retarded rates of chronic disease development

and therefore lower future costs for healthcare,

“the prevention case often sounds vague and

fluffy—but there are specific actions with big

positive outcomes,” Mr Yach says. “Part of the

problem is that we lump many types of actions

under the term ‘prevention’. But some of these

are done within the health service by doctors and

nurses, such as screening and vaccination; then

others are population-wide measures such as

tobacco taxes, marketing controls, and efforts to

reduce salt intake, and for these you need broadbased

partnerships.”

This broad approach was articulated 25 years

ago in the intergovernmental Ottawa Charter

for Health Promotion, which concluded that,

for change to occur, “healthy choices need

to be the easy choices—for individuals, for

healthcare providers, and for a wide range

of other stakeholders who have an impact on

public health.”

Putting that insight into practice means a

broader reconfiguration of incentives—one that

goes well beyond the healthcare system. “The

real thing we need to crack is how to move the

non-communicable diseases discussion outside

of the healthcare sector, as no one single sector

alone will be able to address its complexity,” says

Dr Jané-Llopis, head of healthcare programmes

at the World Economic Forum. “We need to align

the incentives currently in place for healthy

living. For example, subsidies for agriculture

should incentivise crops that are beneficial for

health; incentives should be aligned to promote

walking. Unless we work this out between

government, industry and individuals, there is no

way we will manage to change our behaviours.”

“It has to come from the whole of society to make

it work,” notes Ms O’Kelly of the European Society

of Cardiology. “If you just have a campaign to

promote fruit and vegetables, but still have

advertising for chocolate bars, one will offset

the other. What is needed is comprehensive,

consistent and cross-sectoral co-operation, as

recommended by our prevention experts.”

In addition to joining up the dots to promote

what is healthy, researchers are finding that peer

support is far more effective than education

and proscription in getting people to change

behaviour. Generally, Professor Ricciardi says,

“The approach has been to say ‘smoking is

dangerous’, ‘drinking alcohol is dangerous’,

but few interventions have understood the

psychology behind those behaviours.” In

contrast, simple reinforcement of healthy

choices, given by an observer or peer group,

makes behavioural change much more likely.

Much of the evidence of this in Europe comes

from the Nordic countries, where smaller and

more homogenous populations make such

personalised, community-based interventions

easier than in larger, more heterogeneous

populations. The most famous example comes

from the Karelia region in Finland, which

dramatically reduced its high rate of heart

14

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Never too early: Tackling chronic disease to extend healthy life years

disease over the past 30 years through concerted

community action (please see box, “North

Karelia: Joining the dots”).

Mr Perk of the European Society of Cardiology

tells of a successful Swedish programme involving

all 26 primary healthcare centres of Kalmar

County in south-eastern Sweden. Each centre

has a nurse who acts as a ‘lifestyle counsellor’

for patients, providing a half-year of ‘lifestyle

training’. “It’s been hugely successful, chiefly

because we extended it to primary care centres,”

Dr Perk says. “If you see after half a year that

target levels (such as blood pressure, blood lipids

and glucose) are still elevated, then the doctor

says, ‘OK, let’s see what else we have in the

cupboard. Is it now time for drug treatment?’”

Similarly in Denmark, a programme of visits

by nurses to all citizens over the age of 75 at

least twice a year has had a positive impact

on the target population—not because of any

medical services that the nurses perform, but

rather because of the attention they give to the

individuals’ health and well-being.

Such one-on-one interaction, together with

peer group communication through word of

mouth, social media and the like, can be far more

effective in promoting healthy choices than topdown

exhortations from governments, doctors

or any other authority figures. Experiments in

behavioural economics have shown that the very

act of tracking and measuring—for example,

recording blood sugar readings for pre-diabetics,

or tracking athletic performance levels for a

person prone to overweight—creates an incentive

system that changes behaviour.

Market-driven prevention

Insurers, among others, are starting to build

programmes around these insights as a way to

reduce their future disease burdens. For example,

as a supplement to care provided by medical

professionals, Techniker Krankenkasse, a German

insurer, has offered its “TK-Gesundheitscoach”

North Karelia: Joining the dots

A key to ensuring well-targeted intervention

is to involve a wide range of public and private

sector organisations in a joint campaign. A case

in point is the North Karelia Project in Finland.

In 1971 the representatives of this Finnish

province petitioned the national government

for help in dealing with the high level of heart

disease. The result was a five-year pilot scheme,

later extended for several decades, which

focused on reducing risk factors, in particular

smoking and poor diet.

Much of the work involved campaigns giving

people information on why and how to change

their own behaviour. These efforts required the

co-operation of health services, community

groups, schools and non-governmental

organisations (NGOs), as well as supermarkets

and other relevant companies. Healthcare

professionals provided anti-smoking assistance,

and food stores made healthy options available.

The pilot proved so successful that it was

rolled out across Finland. In North Karelia,

meanwhile, improvements continued for many

years: between 1972 and 2002, average serum

cholesterol levels dropped by around 18%.

Deaths from coronary heart disease fell by

87% between 1972 and 2002, compared with a

decline of 75% in the entire country.

The keys to the project’s success, according to

Finland’s National Public Health Institute, were

community commitment and organisation, the

flexible use of multiple strategies, and, above

all, the collaboration of numerous players

including health providers, industry and

government.

© The Economist Intelligence Unit Limited 2012

15


Never too early: Tackling chronic disease to extend healthy life years

programme since 2008. All insureds with chronic

diseases who meet certain criteria are eligible

for a personal coach, who contacts the insured

by telephone and, on a voluntary basis, supports

the patient’s therapy, monitors its success,

and increases the patient’s abilities of selfmanagement.

The key is the ongoing relationship

built on trust between the coach and the patient,

which creates an incentive for patients to

co-operate.

The results are tangible. When the programme

began, the Techniker Krankenkasse launched

a longitudinal study to track results and the

outcomes so far are positive. For every chronic

disease, participants report significantly better

subjective health than the control group. These

better results are saving the company money.

For patients with cardiac disease, lower rates

of heart failure and heart attack could mean

a very significant reduction in costs. The final

evaluation of the project’s outcome is planned for

July 2013.

In addition to creating incentives through

personal reinforcement of healthy choices,

insurers are starting to offer financial incentives

for healthy behaviours, such as visiting doctors

for screening purposes, and disincentives for

unhealthy ones, such as smoking. In Germany,

several health insurers (Krankenkasse) are

starting to offer rebates on healthcare premiums

to subscribers who prove they have made regular

visits to a gym.

Similarly in South Africa, the US and Canada,

the Discovery insurance company offers a

points-based system of rewards for insureds who

exercise, buy healthy foods or reach specified

goals for athletic performance. Participants

earn points for specified healthy behaviours

and thereby rise through various levels, from

blue to gold—with rewards adjusted to starting

levels of fitness. As they rise through the

fitness measurement system, participants are

given rewards, ranging from reduced insurance

premiums to expenses-paid holidays. To support

the programme, Discovery formed alliances with

various partners, such as supermarkets to offer

discounts on certain healthy foods, and with

airlines to offer discounted flights.

This type of short-term reward, along with the

reinforcement offered by measurement and

personal attention, support a shift to healthy

habits more decisively than do the promise of

a healthier life decades from now. This insight

underlies the development of healthy lifestyle

and early diagnosis programmes among

insurers and employers. Policymakers, too, are

experimenting with both carrots and sticks such

as smoking bans, high taxes on unhealthy foods

and subsidised rates for sports facilities.

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Never too early: Tackling chronic disease to extend healthy life years

2

The role of employers

Workplace initiatives to tackle chronic disease

Employers, too, can play a crucial role in tackling chronic

disease early and an increasing number of companies are

focusing on improving employee health. A recent survey by

Towers Watson, a human resources consultancy, found that

while only 30% of companies in Europe, the Middle East and

Africa (EMEA) had a global health strategy in place, a further

47% intended to introduce one in the next five years. Although

these strategies include numerous elements, in 77% of cases

they currently or will involve wellness and health promotion.

The reason for the spread of employee health programmes

is not altruism. Chronic diseases exert a high toll on labour

productivity (see Chart 4). The World Economic Forum

estimated that high-income countries lose US$26trn in

economic output each year as a result, and that translates into

a concern for all large companies. “What employers are really

interested in is a healthy workforce today,” says Natalie-Jane

Macdonald, UK manager of BUPA. “But the things they do also

help individuals to be healthier as they move into old age.”

The main hurdle with relying on businesses to be an integral

part of the health puzzle is that healthcare is still relatively

low on the business agenda—and companies are certainly not

incentivised to invest heavily in employee health for the sake

of a healthier retired population in the future. Nevertheless,

companies are increasingly seeing the business value of taking

a more proactive approach to maintaining health. A Harvard

Business School study found that the return on investment of a

Chart 4

Output suffers

Total economic cost of chronic disease, US, 2003

(US$ bn)

300

Treatment expenditures (Total = US$277 bn)

Lost economic output (Total = US$1,047 bn)

300

250

271

280

250

200

200

150

171

150

100

105

94

105

100

50

0

48

Cancers

33

Hypertension

46

Mental

disorders

65

Heart

disease

45

Pulmonary

conditions

27

Diabetes

14

Stroke

22

50

0

Source: The Milken Institute, 2009.

© The Economist Intelligence Unit Limited 2012

17


Never too early: Tackling chronic disease to extend healthy life years

comprehensive, well-run programme could be as

high as 600%, while the World Economic Forum’s

head of health programmes, Dr Jané-Llopis, says

“the most conservative figures are a return on

investment of US$3-4 for every one US dollar.”

Mission: Healthier workers

There are three main driving forces for companies

to introduce healthcare programmes, weighted

differently across countries: the rising cost

of covering employees’ healthcare costs; the

shortage of skills and the need to retain workers

as they get older; and the growing burden of

absenteeism and low productivity through

ill health.

German companies also feel the impact of

rising healthcare costs passing through the

system and raising employer contributions. In

addition, they are strongly motivated to tackle

the growing skills shortage by keeping a steadily

ageing workforce healthy and productive. In

the past, “companies fired people who were sick

rather than working on improving the labour

environment,” notes Professor Norbert Klusen

of Germany’s Techniker Krankenkasse, a health

insurance fund. “That has changed completely.

Employers ask us to analyse absenteeism and

create prevention programmes. We have done so

for thousands of companies and they are working

quite successfully.”

US companies tend to be the most advanced in

providing healthcare because they pay directly

for medical costs. “The US has the ‘advantage’

of being saddled with medical costs at corporate

level, giving companies an incentive to

improve the health of their employees,” says

Sean Sullivan, president and chief executive

of the Institute for Health and Productivity

Management. “Keeping employees out of hospital

has a direct impact on the bottom line.” (For an

example of a comprehensive corporate approach

to preventive health, please see box, “Dow: A

focus on prevention”.)

Dow: A focus on prevention

Klaus Böttcher, head of the department of

performance and contract management for

KKH Allianz, a German health insurer, has seen

a similar change in attitudes as businesses

recognise the implications of ageing populations.

Until very recently, companies encouraged

early retirement as a way to maintain healthy

workforces. “Now company leaders realise that

this was not a good idea,” he says. “They are

not able to find enough young, highly qualified

workers, so they ask us to collaborate and offer

prevention programmes.”

Dow is a global leader in corporate healthcare. It

started developing healthcare programmes ten

years ago and has developed a comprehensive

and strategic approach to preventive health.

A team of health promotion managers runs a

broad variety of activities and initiatives all

feeding into each other. Dow Health Days, for

example, focus on a specific issue (Walk at Dow

Day, Dow No-Tobacco Day). There are opt-in

six-week group programmes focusing on areas

like stress resistance or weight management.

In addition, there is more targeted outreach

through a Health Assessment Programme, which

begins when employees join the company and

continues throughout their career, assessing

health risks, followed by counselling and

referral where necessary.

Dow has rolled out preventive health

programmes for all its employees worldwide and

claims the payback is substantial. It has seen

a 23% reduction in smoking among employees

since 2004 and an improvement in weight at

a time when the rest of the country is getting

heavier. Its targets are to reduce key indicators,

such as average levels of smoking, body

mass index, blood pressure and so on, by ten

percentage points over ten years.

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Never too early: Tackling chronic disease to extend healthy life years

BMW has embraced this shift as a way to ensure

that it remains competitive. In 2007 the luxury

German car company realised that the average

age of its workers in its Dingolfing plant in

Bavaria would rise from 39 to 47 over the

next decade. Rather than seeking to find and

train younger workers, the company looked at

redesigning production to help older workers

keep working and remain healthy.

The first step was research. BMW created

Line 2017, with 41 volunteer employees who

collectively matched the demographics that

were expected to exist at the plant in that

year. They employed a research team to collect

information from the employees on all the

aches and pains they experienced on the job,

as well as suggestions on how conditions might

be improved to reduce or eliminate these.

Employees on the experimental line also voted

on which of these changes they thought would

be most desirable.

None of the innovations was huge: they included

items such as softer flooring, adjustable

worktables, easy exercises and lighter work

shoes. The health implications were, however,

dramatic. Absenteeism due to sick leave dropped

from 7% to 2%. The company also benefited

financially. Although the speed of the line was

reduced by one-third, productivity increased

by 7% and had an almost zero error rate. When

the experiment ended, the volunteers returned

to their old lines, but BMW is rolling out the

changes—and researching new ones—across all

its Bavarian plants.

“Enabling older employees to be productive

longer is not just about helping workers stay

healthy; it’s about creating an environment

conducive to health, activity, and continuous

learning,” says Dr Michael Hodin, executive

director of the Global Coalition on Aging. “The

result will help extend active and healthy years

in employment and, more importantly, is the key

to winning the competitiveness race of the 21st

century,” he says.

Healthier companies, too

Reducing absenteeism has been one of the major

focuses of corporate healthcare programmes

in the UK and France, where companies feel

less direct pressure from rising medical costs.

Unilever has led the way in the UK with the

launch of a pilot “Fit Business” programme in

2009, which was rolled out across the UK in 2010

after showing a decline of 19% in sick leave, a

reduction in obesity of 26% and reduced risk

of developing cardiovascular diseases. At a

cost of only £35,000, the returns from lower

sick leave alone were threefold. Unilever’s

programme focuses on free health checks with

clear explanations of what is being measured,

and easy-to-use advice on nutrition and exercise.

The programme is evaluated on three criteria:

absenteeism, employee involvement and a survey

on the impact on attitudes towards work and life.

A French railway operator. SCNF. is also focusing

on reducing absenteeism through its new

healthcare scheme. Average days lost to nonwork-related

illness has been rising steadily,

growing by 14% between 2007 and 2010. So the

company launched a “Healthier Life” scheme

in February 2012, following a successful pilot

project in Brittany. All workers will be screened

for body mass index and those regarded as

overweight will receive advice on diet and

exercise and will be monitored on a monthly

basis. The company has set a target to reduce sick

leave by 32%.

The focus of the programmes can vary depending

on the needs of the staff. One particularly serious

concern for many firms is stress, which the Towers

Watson survey listed as the leading health issue

among EMEA companies. KKH-Allianz developed

an anti-stress programme for a hospital in

Hannover where nurses faced high stress levels.

A multi-pronged approach, which combined

advice on how to work in a way that reduced or

eliminated stress, how to live with heightened

stress levels and programmes in muscle

relaxation, has reduced the number of sick days

markedly, and let people stay on the job longer.

© The Economist Intelligence Unit Limited 2012

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Never too early: Tackling chronic disease to extend healthy life years

What works?

Not all plans are successful. The key is that

“company leaders and department leaders

want to collaborate,” says Mr Böttcher of KKH-

Allianz. “It works only if you go top down into the

company.” Mr Sullivan of the Institute for Health

and Productivity Management stresses that

although top executive leadership needs to make

health into a corporate priority, ‘champions’ are

needed to keep it a priority. “You need to have

mid-level management champions who help to

build it into a culture, reinforce practices and

values, with ‘cheerleading’ and encouragement,

to get these policies down to employee levels,” he

says. He also emphasises the need for systematic

screening. “If you just rely on health risk

assessments, you will miss half the people who

don’t know they actually have a health problem,”

he says.

Beyond that, the keys to success are:

• Agree on simple measures and evaluate

them with clear targets and key performance

indicators.

• Make initiatives simple and convenient for

participants.

• Be consistent and ensure that goals are

supported by the work environment.

• Make it part of the culture of the business with

support from the top.

• Allow flexibility—to recognise differences and

the need to adapt.

• Make the programme long-term, be persistent

and make sure it lasts.

• Ensure confidentiality.

For enlightened firms where executives

understand the utility, corporate wellness

programmes can improve profits while helping

employees to a healthier old age. But for

companies to become an integral part of national

prevention and healthy ageing strategies,

policymakers need to encourage workplace

initiatives. “The corporate employee is a

representative of individuals in the community

who are at risk of developing diabetes,” says Dr

Barakat of the Imperial College London Diabetes

Centre in Abu Dhabi. “We frequently see patients

who were very fit at school and university, but

as soon as they get a desk job find it difficult

to include exercise within their day-to-day

activities. The outcome is that weight begins

to creep up, and then blood pressure begins

to creep up, and then blood sugar levels begin

to creep up.” Among the remedial solutions

discussed to help solve this growing problem

include sponsorship of football tournaments,

walkathons, fitness challenges and nutrition

coaching, among others.

Companies are also a crucial piece of the puzzle

because they have an incentive to finance

preventive services. “You won’t get wellness

and health promotion through a national health

service, because they are focused on paying for

illness—not on keeping people healthy,” says Mr

Sullivan. “But at the corporate level, they have a

direct incentive to head it off.”

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Never too early: Tackling chronic disease to extend healthy life years

3

Managing chronic disease

Rethinking provision of care

In the long term, the sustainability of Europe’s healthcare

systems will depend on two factors: reorienting its focus

from treating illness to promoting health, and improving

the management of chronic diseases to make it both more

effective and more cost-efficient. Far from reducing the quality

of healthcare, reforms that achieve these two goals will also

help to extend healthy lives for all Europeans—allowing for a

better allocation of medical resources and the continued use

of expensive therapies where needed, while ensuring that

chronic care addresses the real needs of the patients rather

than that of specialised practitioners and hospitals.

The separate worlds of acute and chronic care

What would it take to reorient the healthcare systems around

the management of chronic diseases rather than treating

them as just a species of acute care? Researchers have been

working on ways to differentiate chronic care from acute care

since the late 1990s, when three US institutes, the McColl

Institute for Healthcare Innovation, the Robert Wood Johnson

Foundation and Improving Chronic Illness Care (ICIC), created

and developed a Chronic Care Model, designed as a support

system for individuals with impaired functioning. The approach

requires care to revolve around interaction between an

informed, active patient and a prepared, active practice team,

drawing on resources from both the community and healthcare

systems.

A variant of the model was created by Kaiser Permanente, a US

health insurance group. It is based on the Kaiser Triangle, a

notional, three-tiered pyramid with low-intervention patients

at its base and high-intervention patients at its peak (see

illustration). Level 1 patients, the vast majority of chronic

disease sufferers, mainly need support for self-management.

Level 2 patients are higher risk, either because of multiple

diseases or poor abilities to manage their own care, but

can still be supported by teams using common protocols

and pathways. Level 3 patients are the most complex cases

requiring active disease management by medical teams.

In 2010 the RAND Corporation think tank evaluated 51 sites

that had reorganised care in line with the model and found a

much better chance that patients in such facilities received

the correct therapy and saw improved outcomes. For example,

congestive heart failure patients treated in Chronic Care model

facilities reduced the duration of their hospital stays by 35%

on average.

There is a growing body of evidence in Europe too that a

combination of medical and “social” care—the latter often

involving both in-home visits and community-based activities

for those able to participate—is more beneficial for patients.

A 2008 review of chronic care by the European Observatory

on Health Systems found “sufficient evidence that single or

multiple components of the model improve quality of care,

clinical outcomes and healthcare resource use”. The benefits

The 'Kaiser Triangle', illustrating different

levels of chronic care

Case Highly complex patients

manage

Disease High-risk patients

management

70-80% of people with

Supported self care chronic conditions

Population-wide

prevention

Source: NHS and University of Birmingham.

© The Economist Intelligence Unit Limited 2012

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Never too early: Tackling chronic disease to extend healthy life years

Chronic care in Denmark

A good example of integrated care, involving

doctors and community organisations, comes

from Denmark. The Østerbro Health Centre

in Copenhagen is a joint venture of the city’s

health administration, a large municipal

hospital and local general practitioners. It

provides one-year rehabilitation programmes

for patients with a range of chronic conditions.

This programme may include physiotherapy

and co-ordination of various specialists a

patient may need to see. Central to the clinic’s

offerings is the effort to teach the patient how

to self-manage, including education specific to

the disease, dietary counselling, and smoking

cessation courses where necessary.

Early assessments of results showed that 86% of

patients had started to exercise more and 42%

had changed their diets. Over 90% of general

practitioners in the area have referred patients,

and 96% of those thought the programme

valuable to their patients.

are measurable in terms of improved levels

of functioning, slowing down the progress

of diseases, and reduced demand for acute

intervention by doctors and hospitals. (For an

example of such an approach, please see box,:

“Chronic care in Denmark”.)

With the weight of increasing evidence, it is an

apparent paradox that chronic care facilities,

based around improving the functioning of

patients and reducing demand for expensive

acute care, are still an exception. As a British

general practitioner, Dr James Morrow, explains:

“A lot of patients are stuck in hospital beds as

bed blockers, and a lot of hospital admissions

are triggered by a lack of readily available care

in the community.” Improving the options for

affordable care outside of hospitals could go a

long way toward alleviating this problem.

There are three main constraints to expanding

chronic care, none of which is insurmountable

but all of which need concerted effort by many

players to overcome.

The first is the need for task-shifting from doctors

and hospitals to the patients themselves, as

well as nurses, pharmacists, community workers

or trained laypersons. Creating this division of

labour will, as a first step, require giving doctors

and hospitals incentives to separate chronic from

acute care, and turn more of the former over to

others. Some European countries are already

experimenting with such a shift. The UK, for

example, is experimenting with paying doctors

based on their success in keeping patients out

of hospital, and penalising hospitals whose

discharged chronic-care patients are back within

30 days after being treated for an acute episode.

Patients, too, need help to understand that this

shift of care responsibilities does not amount to

“passing the buck” to less qualified personnel. On

the contrary, it tends to bring appropriate care

closer to patients and make delivery of that care

more personal. Many of the needs of chronic-care

patients, particularly older ones whose diseases

have progressed, have to do with combating

isolation, lack of mobility, and difficulty with

simple chores such as shopping, cooking and

bathing. Support in carrying out such everyday

tasks, as well as personal contact with a care

provider, can go a long way towards improving

patients’ functioning and their quality of life

while also relieving the burden on the medical

system. Among other benefits, individual followup

by non-medical providers can boost adherence

to doctors’ prescribed therapies.

A transfer of care responsibilities to other

medical professionals and to laypeople requires

a supportive policy framework to avoid uneven

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Never too early: Tackling chronic disease to extend healthy life years

levels of service and gaps in needed services.

A clearer division of labour between medical,

paraprofessional and non-medical personnel

could usefully be spelled out at national or

regional level, with standards of care and

clear protocols accompanying the transfer of

responsibilities. In a 2010 study for the University

of Birmingham’s Health Services Management

Centre, researchers Professor Jon Glasby and

Kerry Allen identify a core of services that can

be provided locally, such as co-ordinating

and managing care programmes, recording

performance and monitoring statistics. But

they also suggest a wider set of responsibilities

at regional or national level to ensure a wellfunctioning

system of care, including producing

equipment, setting aims and objectives,

developing and maintaining information

management systems, and assuring quality at

every stage.

The second obstacle to introducing chronic care

on a broad scale is the difficulty of integrating

many different players within and beyond the

healthcare system, in the absence of incentives

for them to co-operate. In Europe, some of the

best examples of well-functioning community

care come from small, homogenous communities,

like Østerbro, where achieving consensus and

working together is relatively simple. In some

rural regions, particularly in southern Europe,

institutions such as pharmacies already play

an active role in dispensing medical advice to

individuals, acting as a parallel support system.

With proper training and standard-setting,

this approach could be used on a broader scale

throughout Europe, not only in the case of

pharmacists but also with nurses, community

workers and others.

The third obstacle is embedded in the financial

incentives surrounding caring for chronic

disease sufferers. Any change in the status

quo is bound to have winners and losers. And

although patients may ultimately be the winners,

in the short term opening up community-based

chronic care facilities can mean closing down

hospitals, or reducing their funding. This is

a political decision, and requires politicians

and policymakers who are willing to take

responsibility for the impact on current players.

Managing chronic care: keys to success

Several important lessons about what works best

have already emerged from the early experiments

with restructuring the care of chronic disease

patients away from the acute care model. One is

that chronic-care patients should be as involved

as possible in designing and carrying out their

own care, avoiding medical “diktats” wherever

possible. This approach has a practical

side: ultimately, patients will be in charge of

taking their medicine or not, doing their exercise

or not, avoiding harmful foods or not, calculating

their insulin requirements or not. A patient

who has been involved in the planning of a care

regimen, and who understands the reasons for

the health measures prescribed as well as their

practical implementation, is a patient more likely

to do what is necessary to slow the progress of

their disease.

Beyond that, a range of practical support

for patients should be readily available

when needed. For example, a diabetic who

has difficulty calculating the total calories

associated with various foods may benefit from

a simple calculator with built-in calorie counts

for different foods. A more maths-challenged

diabetes patient may require an implanted

“glucometer” to measure glucose levels and

receive alerts from a remote support person—

perhaps a nurse on duty—concerning how much

insulin is required. Access to advice and support

can be made available through telephone

hotlines, e-mail and social media forums,

instant-messaging systems, and drop-in centres

for those who prefer consultations in person.

Improving adherence to a medical regime is one

of the key goals set by the European Innovation

Partnership for improving healthy ageing—and it

is not just a problem for the aged.

© The Economist Intelligence Unit Limited 2012

23


Never too early: Tackling chronic disease to extend healthy life years

Patients may also need ongoing support to

ensure that medications they take for one chronic

disease does not aggravate the symptoms of

another disease. It is increasingly common for

patients, particularly in advanced years, to suffer

from more than one chronic disease. In such

cases, general practitioners, community-based

nurses and other caregivers may be in a better

position than medical specialists—who tend

to focus on one disease at a time—to instruct

patients on how to ensure appropriate responses

to several medical issues simultaneously. Coordination

may also involve calling upon different

resources—transport, in-home care, access to

rehabilitation facilities, among others—where

the patient may not have the wherewithal to do

that for himself or herself.

New technologies play an increasingly important

role in facilitating the transfer of chronic care

from doctors’ offices and hospitals to community

centres and patients’ own homes. In particular,

telematics and e-health systems are increasingly

coming into play. Telematics technologies lend

themselves to remote diagnosis—as, for example,

when sensors transmit readings of patients’

vital signs, blood sugar levels and the like to a

medical professional who can alert the patient to

respond to dangerous levels. Electronic health

systems—which can share individual patient data

and population-wide health information across

various healthcare settings—can help to improve

tracking of treatments for different diseases. This

is an especially useful tool when more than one

disease is present in a single individual.

At a more sophisticated level, imaging

technologies can aid in identifying indicators

of disease, as well as helping treatment and

monitoring. As noted above, the fast-developing

science of genomics is helping doctors to

identify at-risk populations, while screening

technologies are increasingly sophisticated

in detecting disease indicators in individuals.

Moreover, telecommunications—online or by

videoconference or simply by mobile phone—can

help to reduce the isolation of those whose

illnesses limit their mobility, thereby supporting

their mental health.

High touch and high tech

The risk associated with some of the new

technologies is that time-pressed caregivers

will substitute medical devices and drugs for

personalised care, perhaps out of a wish to

use the latest and best technology available

even if a lower-tech solution might be more

appropriate. “There is a real danger of overmedicalising

normality, and creating dependent

patients—patients who believe they are ill when

they are normal for their age,” says Dr Morrow.

“The medical profession has always had the

ability to encourage dependency. It requires a

dedicated team to avoid dragging patients into

medical need.”

Clearly, the solution is to focus on providing

the right treatment at the right dose for each

patient, but in the context of personalised

attention wherever possible—in effect combining

high touch and high tech. There is growing

evidence that the high-touch, personal approach

is a crucial and often neglected part of the

package. Social psychologists are making strides

in understanding the links between maintaining

health—or at least avoiding rapid deterioration—

and maintaining good connectedness with

others, whether family members, friends, work

colleagues or the broader community. Staying

active and connected is increasingly seen as a

necessary component of a healthy lifestyle, and

one that contributes to extending healthy life

years. The obverse is also true: isolation and

loneliness aggravate many disease symptoms.

The effort to promote connectedness is a

broad-based one, involving local government,

community leaders, urban planners and many

others. The aim is to design communities —

including housing, transport, shopping areas and

public gathering places—in a way that promotes

activity and interactions with others. This trend

24

© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

fits well with efforts to shift the focus of care

from hospitals to community clinics, day centres

and private homes as much as possible. The focus

is on enabling as normal a lifestyle as possible

for chronic disease patients. It is part of both

the ounce of prevention—slowing the progress

of diseases—and the pound of cure for those

suffering from both illness and isolation.

© The Economist Intelligence Unit Limited 2012

25


Never too early: Tackling chronic disease to extend healthy life years

Conclusion

When it comes to tackling chronic disease to extend healthy

life years, the core problems are clear, and so are the solutions.

On the one hand, lifestyle-determined chronic illnesses are

exploding as the population ages, pushing up costs in a way

that threatens the sustainability of healthcare systems and

many countries’ national budgets. On the other, healthcare

systems are still focused on treating acute cases and are illdesigned

to cope with these growing demands.

So far, the responses of all the major players in Europe have

been scattered and ill-coordinated. The European Innovation

Partnership on Active and Healthy Ageing pointed to this

fragmentation as one of the main barriers to caring effectively

for those over 65. But the same weakness holds for reshaping

the way healthcare is assessed both to prevent and to manage

chronic diseases before people reach old age.

The solution to the disjuncture between the growth in chronic

disease and the focus of the medical system on acute care

require, first and foremost, a reorientation of healthcare to

focus on prevention rather than only on treating the sick. The

focus on prevention should take a variety of forms, including

promoting the well-known basics of a healthy lifestyle and

the use of secondary and tertiary prevention to detect and

diagnose disease early, delay its onset and slow its progress.

Beyond that, solutions to managing chronic disease go far

beyond the traditional healthcare sector. This requires entirely

new forms of partnership and co-operation among a broad

range of actors, including various levels of government,

healthcare providers, insurers, private companies as producers

of goods and services and as employers, and not least,

individuals. The focus of their concerted action should be

on changing behaviour and fighting chronic diseases early

on, rather than allowing them to develop and become even

larger problems.

This research has highlighted examples of successful

initiatives and pilot programmes to tackle chronic disease

and promote healthy longevity. Although these represent

isolated examples, they demonstrate that changes can be

successfully made by medical providers, insurers, employers

and entire communities. This report has identified some of the

obstacles to reforming healthcare to tackle chronic disease,

but has also highlighted possible solutions to the problem

of an unsustainable burden of chronic disease in the future.

The key is for the various players to act in concert to fight

chronic disease, to boost the chances that the bonus of greater

longevity will be converted into the even greater blessing of

healthy longevity.

26

© The Economist Intelligence Unit Limited 2012


Never too early: Tackling chronic disease to extend healthy life years

Appendix

Interview programme and

expert panel participants

Note. The Economist Intelligence Unit hosted an

expert panel meeting on the subject of healthy

ageing in Brussels on November 21st 2011. Panel

members are indicated in the following list with

an asterisk (*). We would like to thank all of the

following individuals, listed alphabetically by

surname, for their contributions to this research:

• Lynda Anderson, director, Healthy Aging

Program, Centers for Disease Control, USA

• Mary Baker, MBE, president, European Brain

Council, UK

• Maha Taysir Barakat, OBE, medical director at

the Imperial College London Diabetes Centre in

Abu Dhabi

• John Beard, director, Department of Ageing

and Life Course, World Health Organization,

Switzerland

• Professor Klaus Böttcher, head of the

department of performance and contract

management, KKH-Allianz, Germany

• Jacqueline Bowman*, executive director,

EPPOSI (European Platform for Patients’

Organisations, Science and Industry)

• Mark Butler, minister of ageing, mental health

and social inclusion, Australia

• David Byrne*, former European Commissioner;

patron, Health First Europe

• Cristina Gutierrez Cortines*, member,

European Parliament (Spain)

• David Forrest*, senior vice-president, Nutrition

International Operations, Abbott

• Helmut Gohlke, internist and cardiologist, and

Board member, German Heart Foundation

• Oliver Harrison, director of Public Health and

Policy, Government of Abu Dhabi

• Unni Hembre, president, European Federation

of Nurses Associations, Belgium

• Michael Hodin, executive director, Global

Coalition on Aging, USA

• Eva Jané-Llopis, head of health programmes,

World Economic Forum, Switzerland

• Paul H. Keckley, executive director, Deloitte

Center for Health Solutions, USA

• Hal Kendig, professor of ageing and health,

University of Sydney

• Norbert Klusen, CEO, Techniker Krankenkasse,

Germany

© The Economist Intelligence Unit Limited 2012

27


Never too early: Tackling chronic disease to extend healthy life years

• Peggy Koopman-Boyden, professor of social

gerontology, National Institute of Demographic

and Economic Analysis, New Zealand

• Natalie Jane Macdonald, managing director,

BUPA, UK

• Johannes FE Mann, professor of medicine,

Friedrich Alexander University of Erlangen; head

of Department of Nephrology, Hypertension and

Rheumatology, Schwabing General Hospital,

Germany

• James Morrow, general practitioner, UK

• Sophie O'Kelly, head of European affairs,

European Society of Cardiology, France

• Desmond O’Neill, president, European Union

Geriatric Medicine Society, UK

• David Oliver, national clinical director for older

people, National Health Service, UK

• Lene Otto*, associate professor and

programme leader, Centre for Healthy Aging,

University of Copenhagen

• Anne Sophie Parent, secretary-general, AGE-

Platform Europe, Belgium

• Joep Perk, cardiologist and professor of

health sciences, chairman of the Joint European

Societies’ Task Force for Cardiovascular

Prevention in Clinical Practice, Sweden

• Walter Ricciardi*, president, European Public

Health Association, Netherlands

• Pascale Richetta*, vice-president, Western

Europe and Canada, Proprietary Pharmaceuticals

Division, Abbott

• Bernat Soria*, former minister of health, Spain

• Sean Sullivan, president and chief executive

officer, Institute for Health and Productivity

Management, USA

• Axel Boersch Supan, head, Munich Centre for

the Economics of Aging, Germany

• Professor Andre Uitterlinden, director,

Netherlands Consortium for Healthy Aging

• Piet van den Brandt*, professor of

epidemiology, Maastricht University

• James Vaupel, founding director, Max Planck

Institute for Demographic Research, Germany

• Petra Wilson, director, public sector

healthcare team, Cisco Internet Business

Solutions Group, Belgium

• Derek Yach, senior vice-president of Global

Health and Agricultural Policy, Pepsi-Cola, USA

28

© The Economist Intelligence Unit Limited 2012


While every effort has been taken to verify the accuracy

of this information, neither The Economist Intelligence

Unit Ltd. nor the sponsor of this report can accept any

responsibility or liability for reliance by any person on

this white paper or any of the information, opinions or

conclusions set out in this white paper.

Cover image - © sjlocke/iStockPhoto


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