Caring for chronic diseases in a “fragmented” health care system



Imagine a world of ‘human perfection’ where disabled people are a distant memory, edited out by medical enhancement and economic cost-benefit analysis: a world where thanks to generic selection and economic crises disabled people find themselves expendable. Is such a world desirable? Not necessarily so, says artist and computer animator Simon McKeown from the University

Full Post: Is human ‘imperfection’ such a bad thing?

Ed Wagner, MD, MPH, knew there had to be a better way. He and Group Health colleagues set out 15 years ago to explore how best to engage patients with chronic diseases in effective care.

With Robert Wood Johnson Foundation support, they developed the Chronic Care Model. More than 1,500 U.S. and international medical practices have adopted the Model. Now the largest roundup of evidence on how the Model performs in practice confirms that it works. This review is in the January/February 2009 issue of Health Affairs, focused on a key part of reforming health care: caring for chronic diseases in a “fragmented” health care system.

“Like an auto body shop, U.S. health care is set up for quick fixes to acute problems,” said lead author Katie Coleman, MSPH, a research associate at Group Health Center for Health Studies. “But for chronic problems, this can be expensive, ineffective, and inefficient.” The Chronic Care Model is a framework to redesign daily medical practice. It aims to transform the health care system from acute and reactive to proactive and planned-and based more on evidence about populations, less on habit. Chronic diseases include diabetes, depression, and asthma. The world’s main cause of death and disability, they are becoming more common as populations age.

“Redesigning medical practices according to the Model generally improved health care and helped patients control a broad range of chronic diseases,” Coleman said. Reviewing 82 studies published since 2000, she found the Model helped people stay healthier and get better care.

“The Chronic Care Model has been adopted more widely than we ever dreamed,” said Wagner, a review co-author. He directs the MacColl Institute for Healthcare Innovation at Group Health Center for Health Studies. The Model guides quality improvement efforts based nationally, regionally, and in Pennsylvania, Minnesota, and North Carolina. “We felt obliged to see if the accumulating evidence justifies this spread,” he added. “We’re cautiously optimistic that it does.”

The team excluded studies of “disease-management” interventions that worked with patients without engaging medical practices. In many such programs, Coleman said, commercial vendors encourage “high-cost” patients to manage their own chronic diseases better-while the medical practice stays the same. In the January 2009 Annual Review of Public Health, she concluded these interventions, also called “carve-outs,” tend to be less effective than are those that use the Model. Not only helping people care for their own diseases, Model-based interventions also help medical practices make clinical changes to redesign how they deliver health care.

The Chronic Care Model comprises six interrelated system changes: effective team care; planned interactions; self-management support; community resources; integrated decision support; and patient registries and other supportive information technology (IT). Registries track patients with specific chronic diseases, helping medical teams to make the most of each office visit and follow evidence-based care guidelines. Electronic medical records, while useful, are not required. “There’s no magic bullet, including IT,” said Brian Austin, another review co-author, who is the associate director of Group Health’s MacColl Institute. “No single element suffices alone.”

Controlling chronic diseases better should save money. But the review concluded that realizing these savings may take longer than the studies, most of which ended within a year. And insurers, not healthcare providers, may get the savings. That is because most healthcare is reimbursed as fees for services-tests and treatments-not for patient support or disease control or prevention.

“We need to study whether the Model is cost-effective-and find good ways to spread it to smaller practices,” said Coleman. One promising option, with growing “buzz,” is a reinvention of general or primary care that Group Health has piloted and is adopting at all its 26 medical centers: the Patient-Centered Medical Home. At its heart is the Chronic Care Model.

“The Agency for Healthcare Research and Quality is working to spread the Model and strengthen the evidence for its impact on quality and costs,” said Cindy Brach, MPP. The review’s other co-author, she is a senior health policy researcher at AHRQ, a federal agency in Rockville, MD. Funding from the Robert Wood Johnson Foundation and the AHRQ supported the review.

http://www.ghc.org/

Link




A white paper, How is a Shortage of Primary Care Physicians Affecting the Quality and Cost of Medical Care?, released today by the American College of Physicians (ACP) documents the value of primary care by reviewing 20 years of research. An annotated bibliography based on a literature review of more than 100 studies documents the

Full Post: How is a shortage of primary care physicians affecting the quality and cost of medical care?



The American College of Physicians (ACP) and the Infectious Diseases Society of America (IDSA) have released a joint statement on the importance of adult vaccination against an increasing number of vaccine-preventable diseases. The statement has been endorsed by 17 other medical societies representing a range of practice areas. According to the Centers for Disease Control

Full Post: Adults need vaccines to protect from preventable diseases, say medical societies



In the last decade, more than 60,000 patients in the United States were asked to get tested for hepatitis B virus (HBV) and hepatitis C virus (HCV) because health care personnel in settings outside hospitals failed to follow basic infection control practices, according to a new study by the CDC. This first full review of

Full Post: Hepatitis B and C in U.S.



A strategy to change practice in intensive care units was effective in implementing earlier nutritional support for critically ill patients, but the change did not result in a reduced risk of death or reduced length of stay in the ICU, according to a study in the December 17 issue of JAMA, the Journal of the

Full Post: Multi-faceted strategy improves nutritional support for ICU patients, but not outcomes



The United States can learn from the Dutch Health Insurance System model, according to an article by Pauline V. Rosenau, Ph.D., in the December issue of the Journal of Health Politics, Policy and Law. Rosenau, professor of management, policy and community health at The University of Texas School of Public Health at Houston, co-authored the

Full Post: United States can learn from Dutch healthcare system