Page 221 - HA Convention 2016 [Full Version]

Service Enhancement Presentations HOSPITAL AUTHORITY CONVENTION 2016

F6.7 Managing Service Demands 10:45 Room 421

Chronic Disease Trajectory – a Tool for Patient Care and Demand Management
Woo PPS, Wan CH, Ng ACM, Shea RHW, Chi KKH, Chan SYC, Tsui ELH, Lo SV
Strategy and Planning Division, Hospital Authority Head Office, Hong Kong

Introduction

Chronic conditions cause disability and suffering. In Hong Kong, as the population ages in coming decades, a significant
increase in the number of persons with chronic conditions is expected. Hence, HA is facing pressing challenges in managing
and providing care for patients with multiple chronic diseases.

Objectives

(1) To quantify chronic disease burden and understand the trajectory so as to target healthcare planning for the vulnerable
population; and (2) to provide insights on service models of preventive care and interventions to enhance management of
chronic diseases.

Methodology

Based on the data in the Clinical Management System (CMS) in the HA and the Hong Kong Cancer Registry (HKCaR),
together with clinical specialists’ input on the definition of selected chronic diseases, a virtual registry for patients with
chronic disease(s) is built. It includes patients ever fulfilling the pre-defined definitions throughout the years who were treated
in the HA, while death is the only exit criterion of the registry. In this study, selected chronic diseases include top five common
cancers (colorectal, breast, liver, lung, prostate), diabetes mellitus (DM), coronary heart disease (CHD), stroke, hypertension
(HT), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) stage five, hip fracture and glaucoma.
Patients were grouped into a single or combination of these chronic diseases in each year and being tracked for their disease
progression over time. Corresponding service utilisation, such as inpatient bed days occupied (IP BDO), specialist outpatient
(SOP) clinic attendances, operations and procedures done etc. can also be tracked using CMS data.

Results Wednesday, 4 May

The number of HA patients with selected chronic diseases rises from 1.08 million in end of 2010 to 1.35 million in end
of 2014, representing an average annual growth rate (AGR) of 5.8%. In 2014, the proportion of male chronic patients is
48%, while the median age of all chronic patients is 65. Chronic patients accounted for 85% and 54% of acute IP BDO
and SOP first attendances in the medicine specialty respectively. 56% and 32% of them have combinations of 1 and 2
diseases respectively, while the top 3 disease combinations are “HT only”(41%), “HT and DM”(17%) and “HT and CHD”(6%).
Longitudinal data allows the study of disease trajectory and patient journey in details. It provides insights, especially on the
service models for patients in different stages of chronic diseases, and allows the analyses for pressure points, characterising
patient profiles in their care transitions for multi-morbidity trajectories and identification of effective preventive care and
interventions in the delivery system. These research findings allow us to target healthcare planning for persons with different
chronic diseases in terms of hospitalisation and treatment and many other potential applications.

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