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Management of Chronic Health Conditions - The Price of Living Longer Print E-mail
The Quarterly 2011


This article was written by Dr Susan Keam, derived from material presented by Professor Gavin Frost on 5 September 2010 at RACMA/HKCCM 2010.

We haven't forgotten that major communicable diseases, poliomyelitis (still an issue in Africa), or cholera (still a problem in many parts of the world), or HIV/AIDS, or SARS, or H5N1 influenza, or H1N1 influenza still exist and can have a major impact on life expectancy.

However, if we look at life expectancy over the past 100 years, we see that something interesting is happening. For instance, in Australia, we see that it has increased significantly in this time. In the decade from 1901-10 the average life expectancy for males was around 55 years and for females, around 59 years. By 2000 average life expectancy had increased by more than 20 years to just over 77 years for males and nearly 83 years for females. This produces major changes in the population distribution "pyramid" (figure 1), which has now become a polygon. What is particularly interesting is the change in population demographics between 1956 and 2006 – we see that the proportion of the population aged 0-4 years has diminished significantly, while the proportion of those aged 80 years or more has increased, and in particular the number of women aged 85 or older has tripled. The change in age structure reflects the changes in life expectancy as well as a change in the fertility rate. In Australia, the fertility rate of 1.78 is just below the replacement rate.

Figure 1: Age structure of the Australian population, 1956 and 2006.

The trends in life expectancy rates at birth and at age 65 years show that we are living longer (figure 2) and one of reasons for this is that deaths from infectious diseases have tumbled (figure 3). The reduction in deaths from communicable diseases is due to many factors including vaccination programmes and improvements in water quality, sanitation and nutrition.

Figure 2: trends in life expectancy at birth and at 65 years

The small increase in infectious diseases deaths seen in the mid 90's is due to the impact of HIV/AIDs. Despite this, there have been a significant reduction in the number of deaths due to infectious disease in Australia – from around 170 per 100 000 of population in 1922 to around 10 or 20 per 100 000 at the current time.

Figure 3: Infectious diseases trends in men and women in Australia between 1922 and 2007.

Australia spends most of its health budget on hospitals, which is strange, given that people live longer and have (you would hope) less need for hospital services. However, like many things in life, hospital use grows to fill the available capacity. In Australia around 60% of recurrent health expenditure goes on hospitals and medical services (figure 4), which is consistent with the 60-70% of total health budget spent on curative services that is seen in many other developed countries worldwide. Public health expenditure is low (2.2%), while the expenditure on medications is a major source of increase in health cost in Australia, given the high degree of government subsidy towards a list of useful drugs.

Figure 4: Health expenditure in Australia in 2007-2008

We've started to look at the trend in potentially preventable hospitalisations (e.g. admissions to hospital with vaccine-preventable diseases (e.g. measles) or acute or chronic respiratory disease due to smoking), especially as hospitals are an expensive way to deliver good health care. This is of interest, in terms of the strategy we hope to be rolling out in Australia, which looks at the management of the concerns raised by the increase in life expectancy.

If we look at health expenditure as a proportion of GDP in 2007, the USA has the highest ratio at 16% (an increase of 2.6% since 1997) and the cost per person has doubled since 1997, rising from A$5353 to $A10,352. Australia's health expenditure is more modest (8.9% of GDP in 2007; an increase of 1.3% over the 10-year period), but has also faced a doubling of cost per person since 1997 (from $A2371 to $A 4732). What we need to look at is how health expenditure is generated – what are the government payments, what are the per-person payments and how are they distributed throughout the population. If we look at an example of the needed redistribution of health services in rural China, where data from 2006 suggest that the government is paying 40.7% of the total cost of the health care service, and 49% is in the hands of individuals, whereas in Australia the government pays two thirds of the expenditure, and total out-of-pocket costs for individuals are around 18.7%. Abegunde, Mathers et al. (2007) have projected age-standardised death rates for 2005 from chronic disease in 23 countries (figure 5).

Figure 5: Projected age-standardised death rates for 2005 from chronic disease in 23 countries.

The highest death rates predicted across all countries were due to cardiovascular disease and diabetes, cancer and chronic respiratory disease. While communicable diseases are still occurring, in almost all countries they have been overtaken by the chronic diseases associated with living longer. Presuming that the current expenditure on chronic diseases continues, Abegunde Mathers et al. have predicted that many countries will have significant GDP losses over the 10 year period from 2006 to 2015. For instance, China stands to lose $US13.81 billion by 2015 unless it is able to alter the way in which chronic disease is managed. Some countries are affected more than others, but no country is spared.

The Australian National Chronic Disease Strategy (Dowrick 2006), which is a nationally agreed agenda to encourage coordinated action in response to the growing impact of chronic disease on the health of Australians and the health care system, lists five health priority areas:

  • Asthma
  • Cancer
  • Diabetes
  • Heart, stroke and vascular disease
  • Osteoarthritis, rheumatoid arthritis and osteoporosis.

Implementation of the strategy will be the responsibility of the individual jurisdictions in Australia.

We can ask - How is this list an integrated proposal? Why not just allocate more money to hospitals to treat people with these diseases? The answer relates to the way in which we manage chronic conditions, and the strategy is structured in such a way that it reflects the phase of illness. To be successful, chronic disease management must be built on the following steps:

  • Known and potential ways of reducing risk
  • Finding disease early
  • Managing acute conditions (especially those that are acute exacerbations of chronic disease
  • Quality long-term care instead of unnecessary hospitalizations
  • Quality care in the advanced stages of disease.

As leaders in the health care debate, it behoves us to be attentive to those changes in the health care environment which trigger political responses to health care funding changes, to offer well founded advice in the best interest of patient care. We need to accept that as players (whether we like it or not) in the politics of health care, our professionalism and commitment to patient care mark us as different from many of the other actors!

Professor Gavin W Frost

1. The Australian Institute of Health and Welfare (AIHW) www.aihw.gov.au
2. Dowrick,C. The Chronic Disease Strategy for Australia. MJA 2006; 185 (2): 61‐62
3. Abegunde DO,Mathers CD,Adam T, et al. The burden and costs of chronic diseases and low‐ income and middle ‐ income countries. Lancet 2007; 370: 1929‐38

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