Things have changed over the last decade in Canadian health care. Focus on health promotion, quality and safety of patient care has increased. Advances have been made in diagnostic, therapeutic and information technologies. Population longevity has increased. And, publicly-funded expenditures have doubled, with disbursements to physicians, hospitals, particularly CEO salaries, and drug costs the leading indicators.

Today, we continue to face challenges. Our population is progressively aging and chronically ailing. There are large care gaps, discrepancies between what usual care is, and what best access, diagnosis, treatment, and compliance should be, particularly for older, female and socially disadvantaged patients. In addition, there are caring gaps. A recent example involved a woman who was injured while visiting an acute-care hospital. She was refused rapid, direct assessment and treatment by hospital staff. Instead she was told to call an ambulance.

Randomized clinical trials are not required to relate such gaps in caring to patients’ perceptions of low quality of life.

Increasing awareness of care and caring gaps, in the face of increasing costs, is causing tax-paying citizens and tax-allocating decision makers to ask what, exactly, are we buying with our health care dollars. They wonder if things can be better.

Definitions of better vary, depending on the vested interests of varied stakeholders. However, several common, or cross-over, success factors have been proposed by academic, administrative, clinical and patient stakeholders. They include: a culture of shared goals, values and plans; community-based care teams, educated and engaged in the principles and best practices of teams, patient-self management and measurement-driven disease management; practical electronic information systems; and, leadership.

Repeated research and symposia have reaffirmed these priorities and recommended
multi-disciplinary, community-integrated disease management networks, supported by
communication of measures of care and outcomes, patient self-management and inter-
professional and non-professional education, is a preferred model for improving our population’s health. Research has also demonstrated such health social networks are cost effective and have a positive impact on provincial economies.

The key practical question, then, is: Will integrated health and management networks be widely implemented in the near future?

One approach that may offer some insight in answering this question, is to apply a variation of game theory, in which a group of very knowledgeable people identify key stakeholders who will exert influence on the decision to, or not to, propagate integrated disease management and, rate their likely position on four key questions: What preference does each influencing stakeholder have? What is the level of commitment to, or how hard will each stakeholder work for, their preference? How much clout do they have in the decision process? And, how resolved are they in their preference; or conversely, how easily will they change their preference?

My initial experience using this approach to predict the likelihood of expanding disease
management across one province suggests the results can provide a map of likely decision
making in the short term, as well as a guide to influence decisions in the longer term. In
this case study the knowledgeable panel was composed primarily of individual community
physicians and nurse practitioners, with representatives of academia, institutional medicine, industry and patients. The decision-influencing stakeholders rated were: the provincial government; regional health authorities; hospitals; community clinics; non-government health organizations (e.g., Heart Foundation); MDs, other care professionals; non-professional care givers; private industry; and, patients.

The results revealed all stakeholders’ preferences were either positive, or strongly positive, in favour of wide adoption of integrated disease management. In terms of commitment, the panel predicted that all stakeholders, except government, would work hard for their preferences. In terms of power to make the decision, most stakeholders’ scores hovered around neutral, with only government rated as strong. Non-professional care givers, patients and non-governmental organizations were rated as strongly resolved to stick with their preference over time; regional authorities, government and MDs were felt to be the easiest to move off their initial preference.

Thus, the broad weight of stakeholder support favoured expanding disease management
initiatives. Patients, care givers and non-governmental organizations have great resolve, but little clout, in the initial decision processes. Government has the most clout, but is the least committed to working for, and are more likely to shift from, their initial decision. One implication of these results is that, possible coalitions of stakeholders with similar preferences, commitment and resolve, may be able work together to re-shape decisions with time.

In summary, patient care and outcomes can be better. We have promising medical and political road maps for how to make them better.

Leadership is needed to facilitate clinically and economically beneficial health decisions and
ensure we do what, otherwise, we might not do.