From Volume to Value: Prospects and Pitfalls in Organising Integrated Dry Eye Practice Units

Abstract

With the advent of aging populations, chronic multifactorial diseases will dominate and strain existing models of health care. A model of healthcare delivery that emphasizes seamless, integrated, team-based care and remuneration for patient outcomes, have proven advantageous in diseases like diabetes mellitus, compared to systems based on isolated medical services. It is, however, unclear whether major chronic ophthalmic diseases including dry eye are also suitable for this model. Multiple co-morbidities such as depression, anxiety, postmenopausal mood swings, sleep disorders, and chronic neuropathic pain in dry eye greatly and unexpectedly increase its healthcare burden, and also produce high levels of patient and physician frustration. Many patients benefit from counseling, social support, and psychological management, but are frustrated by multiple referrals and inefficiency in care coordination. With the new model, patients may have a seamless transition between care settings, better experience and improved outcomes, and likely attain added value per unit cost.Keywords: Eye diseases; Health policy; Practice guidelines as topic; Primary health care; Quality of health care Rethinking Care for Chronic DiseasesThe trend of medical sub-specialization with the development and proliferation of organ-based or medical technique-based healthcare centers has clearly benefited many generations of people in developed and even developing countries [1]. The advantages of providing highend care are mainly in single, acute problems requiring specialized skills. However, incurable and disabling chronic multi-organ diseases are increasing, due to aging of communities and partly, success of specialized disciplines in management of treatable maladies. We define chronic disease as by WONCA International Classification Committee: a health condition that is long in duration-often with long latency and protracted course, multi-factorial in aetiology, no definite cure, changes gradually over time, heterogeneous in susceptibility" [2], including the lived experience of coping with health disruption and impact on psychological and social function [3].In chronic diseases with multiple comorbidities, health-care disciplines should be integrated and centered on the patient. The "Esther network" [4] and Ed Wagner's chronic disease model [5] are examples of integration across the entire continuum of care, including self and community care, which also cater to the bio psychosocial needs of a person [6]. A study involving 113,452 unique patients evaluated the integration of primary healthcare family practice, internal medicine and geriatric practices, and found superior outcomes in terms of depression screening rates and increased adherence to care, with less emergency visits/admissions [7].The traditional model of healthcare, pivoted around specialized tertiary centers ( Figure 1A), is not optimized for chronic disease care. Traditional healthcare models are largely 'serviced-based' , whereby patients are typically charged for each i...