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The challenge of community care

The prevalence of medical conditions linked to ageing and lifestyle places an increasing burden on European healthcare systems. Eucomed, the voice of the medtech sector in Europe, examines three areas of community healthcare and the opportunities and challenges they present for industry.

There is no standard definition for community care, as this method of health management can vary from country to country. However, it is generally seen as the treatment of patients outside of an acute care setting.

Community care includes: primary care (e.g. GOP services), outpatient clinics, care in the patient’s home, residential care (e.g. nursing homes, long-term care homes, palliative care homes, hospices), rehabilitation or recovery centres (e.g. ‘step-down’ centres); ambulatory care (e.g. IV chemotherapy, total parenteral nutrition).

Community care in an ageing population

For the first time in history, the vast majority of Europe’s citizens are able to lead active, healthy and participative lives well into old age. The European Commission estimates that the proportion of people over 60 in Europe will have doubled to 40% of the total population by 2050.

This will mean an increasing number of care-dependent older people who will be in great need of community care. Along with the challenges that ageing societies bring, new opportunities arise for innovative firms due to increased demand for new or adapted goods and services.

Evidence suggests that disabled and older people tend not to want institutional care, and families and other informal carers strongly prefer to continue to care for their dependent family members in their own home and the local community.

With innovative and cost-effective products, the medtech industry has the capability to provide European citizens with solutions that can change the way healthcare is delivered while improving their quality of life at home or in local communities. In a time of patient-centred care, homecare meets the needs of patients but also reduces the costs of healthcare.

Studies suggest that 20-30% of people older than 75 years who are admitted to an acute hospital setting are admitted inappropriately. These people also remain in the hospital longer; at times, 30-40% of the acute beds are being used for people who do not need acute hospital care. The costs associated with acute care are often much higher than those of community-based care: it is estimated that the cost of care in an institution is 10 times that of home nursing.

In the UK, the transfer of patient care and funding into the community setting has accelerated in recent years. 80% of the NHS budget in the UK is channelled through PCTs (though some of this will be paid to the acute setting via commissioning of services) and 20% through acute hospital trusts.

This article looks at two areas of community healthcare: continence care and wound care.

1. CONTINENCE CARE

Studies suggest that 7-8 % of the total European population suffer from urinary incontinence, including over 50% of female residents in long-term care facilities. Obesity and diabetes contribute to urinary incontinence. With a future population dominated by older people, and with an important number of overweight and obese people, incontinence will affect more and more European citizens.

Patients suffering from incontinence usually find it difficult to discuss their condition with their doctors. Many adults try to self-treat and often take inappropriate measures that make the situation worse. It is therefore difficult to evaluate how many patients suffer from incontinence and how much it costs our economies.

Faecal and urinary incontinence are constantly associated with adverse effects on the quality of life for patients. The patient perception of the impact of faecal or urinary incontinence on their lifestyle is important. Incontinence cannot be considered as an illness, but as a symptom of a bowel or bladder disorder. Even mild incontinence affects every aspect of life and needs to be taken seriously.

Depending on the cause and severity of the incontinence, several options are available to improve bowel or bladder control. The recommended first line treatment is the least invasive option available. For most patients, surgery for stress incontinence should be considered as tertiary care after conservative approaches (lifestyle and physiotherapy) and drug treatment have not worked.

Management with medical devices

Purpose-made absorbent products are a major aspect of incontinence management in the community. These products enable users to maintain their dignity and confidence in everyday work and social activities. Other devices include male external urinary sheaths and catheters. The latter can be long-term (indwelling) or used short-term or sporadically (intermittent).

Incontinence products are certified as reliable and safe according to internationally recognised standards (ISO 15621 and ISO 16021). They are tested by many different manufacturers, test laboratories, hospitals and others, using a diverse range of technical methods and user evaluations. Like all medical devices, incontinence products require CE Mark approval before being sold in EU countries.

The benefits that adult incontinence products bring to health systems are considerable. They:

• save care assistant time in changing and disposing of products

• reduce the need for care of skin irritations, infections and bed sores

• save costs and time in washing soiled clothes and bed linen.

Incontinence products give the individual an opportunity to manage their incontinence so as to minimise absence from working life and need for acute care. They also improve the quality of life of those who cannot or are not willing to undergo surgery or take long-term medication.

The reimbursement paradox

Despite the clear benefits of these products to patients and the healthcare system, there are still reimbursement inequalities in European countries and communities that hamper access to incontinence products:

• There is a wide disparity between countries, from no reimbursement at all to a well-developed reimbursement structure. For countries with a well-developed reimbursement structure covering all homecare, there are overall fewer institutional beds than the European average, while the opposite can be observed in countries with less reimbursement overall for homecare.

• In countries where reimbursement is funded through sick funds, considerable variations exist in reimbursement practices. However, some of these are due to systems with a base package valid for all insured people, where individuals have the freedom to choose their sick fund with ‘top-up’ insurance payments.

• In some countries, homecare is the responsibility of local government. This very often results in disparities in homecare services and reimbursement, with individuals receiving different services and reimbursement according to where they live.

• Reimbursement systems in some countries take into account the financial situation of the individual, so that reimbursement is based on income level. In other countries this is not the case, and many patients are not reimbursed enough to enable them to stay in a homecare setting.

The differences between various reimbursement systems lead to considerable disparities in the ability of individuals to cope. Eucomed believes that every incontinence sufferer should have the same right to reimbursement, regardless of place of living, economic situation or status. Reimbursement should reflect the economic burden that managing incontinence represents for the sufferer; at the same time, it should be sustainable and affordable to society.

2. WOUND CARE

Wound care is present in all areas of the healthcare system. It involves the three main healthcare disciplines: nursing, surgery and general practice. The patient population requiring wound care is across the spectrum from babies to the elderly. Care is needed for acute wounds such as trauma and surgical wounds and for chronic wounds such as pressure ulcers and diabetic ulcers. Some wounds can take years to heal.

There are between 1.5 and 2 million patients at any time in the EU with a wound under treatment, and at least 4 million patients develop a new wound annually. Providing wound care is a major cost to the healthcare system.

Infection prevention is a crucial aspect of wound care. Surgical wound infection is estimated to affect 30-40 surgical patients per 1000 operations. Excess mortality among patients contracting a surgical wound infection is 5%. Recent surveys of European hospitals show that around one in five inpatients has a pressure ulcer, and over 50% of these are hospital-acquired.

The treatment of chronic wounds will become even more important for healthcare systems in Europe as the population ages, because the prevalence of chronic wounds is highly correlated with age. Bearing in mind the impact of wounds on patient health and on costs to healthcare providers, ensuring that wounds are appropriately diagnosed and treated is essential.

Research has shown that costs can be reduced at the same time that patient outcomes are improved. This can be done by improving the skills of healthcare providers in diagnosis, treatment decision-making, monitoring and referral. A wide variety of innovative wound care products are available that can improve patient outcomes and reduce the burden of wounds on EU healthcare systems.

There are many different categories of wound care products, depending on the nature of the wound and the result desired. Many wound care products can be used in conjunction with others. Some types of product include hundreds of different brands, developed to meet the needs of many different wounds and medical conditions.

Barriers to better healing

The quality of wound care varies markedly across, and in some cases within, member states of the EU. The main reason is local budgetary constraints, which have an adverse impact on patient care and result in added burden to the healthcare system.

Inadequate wound care treatment is at the root of many healthcare-acquired infections. These are not limited to hospitals, and can affect patients in other areas of healthcare such as nursing homes. Better wound care provides a means to address some of the imminent budget issues by ensuring that treatment costs are minimised through effective prevention of wound complications, and by effective diagnosis and treatment. At present a significant proportion of the resource devoted to wound care is effectively wasted because the treatments are inappropriate or inefficient.

Patient access to new treatments faces many obstacles, but the most important driver of change is the frustration of unmet demand from patients eager to reintegrate themselves into the workforce and society. Despite the persistent advocacy of European organisations in support of wound care, a great body of policy work is still needed to improve patient outcomes.

The effect of lack of access for patients is felt most acutely in sectors where critical care means the difference between long-term invalidity and a productive life. Raising awareness of policy issues is therefore crucial for more effective wound management.

Raising the wound profile

On 6 October 2009 a ‘Better Treatment for Patients Day’ was organised in the European Parliament. This event was about public health and patient access, with wound care as a highlighted example. Hosted by two MEPs, Françoise Grosstête (EPP, France) and Antonyia Parvanova (ALDE, Bulgaria), it advocated changes in EU health policy to improve patient access to quality treatments and improve health outcomes.

The lunch debate, organised by the Eucomed Advanced Wound Care Sector (AWCS) and the European Wound Management Association (EWMA), attracted over 40 participants from various sectors, including health associations, industry, national permanent representations, the European Parliament and the European Commission. Its theme was how to improve the understanding between European decision-makers, the medtech industry, patients and civil society regarding the importance of wound care for patient safety, recovery time in hospitals and health expenditure. The debate generated a positive discussion that will contribute to the effectiveness of future policies.

Following the debate, delegations consisting of clinicians, patients and industry representatives visited four selected MEPs (members of the ENVI Committee) to discuss this topic further. Six other MEPs were willing to meet at another time, and five more showed interest.

The event provided a good opportunity to raise awareness of wound care issues in the European Parliament, underlining the impact on society of effective wound management.

AWCS and EWMA are working to lessen the burden of wounds on the European healthcare system, and to improve the development of authorities for research and exchange of best practice. They aim to promote education for health providers and the global integration of wound care policies.

The Eucomed Wound Care Policy Paper, published by AWCS in October 2009, used a holistic approach to focus on the patients and their access to the best available care, including diagnosis, correct treatment decisions, monitoring and referral.

Furthermore, important efforts have been invested in the Patient Outcomes Group. This is a project led by EWMA in close collaboration with industry that aims to build a consensus among central stakeholders regarding Pan-European evidence guidelines for wound care.

Safe as houses

Community care represents a large fraction of the healthcare budget. If managed appropriately, it can benefit many more people in Europe. With the challenges of an ageing population and more sedentary lifestyles, community care will become more and more important in the years to come.

The burdens of incontinence and wounds affect millions of people in Europe. If they are not treated appropriately, they have a considerable negative effect on patients’ quality of life and on the economy. Innovative medical technologies can help to make community care more effective and less burdensome to healthcare systems, while improving the experience of patients in their own homes or in nursing homes.

Today, medical technologies are available to treat most long-term conditions and to help patients and their relatives better manage these conditions. However, the access of patients to these technologies is still blocked or delayed by lack of public awareness and inequalities in reimbursement. Healthcare policy-makers need to be well informed on these issues. The active collaboration of governments with European medtech trade associations is essential to shape healthcare systems and accelerate patient access to more effective and affordable treatments.

This article is based on parts of Eucomed’s Focus on Community Care, quarterly newsletter issue 68 (Autumn/Winter 2009).

Eucomed, the European Medical Technology Industry Association, is the voice of the medtech industry in Europe. For more information, visit www.eucomed.com.

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