Meeting the needs of chronically ill people

This special issue of the BMJ and this month's issue of the Western Journal of Medicine once again focus on the needs of patients with chronic illness, on the advances in clinical and behavioural management, and on the challenges of assuring that patients receive optimal care. Achieving such optimal care challenges both patients and their care givers. This is especially so in developing countries, which are facing rapid increases in the prevalences of major chronic diseases.

Evidence based care for many chronic illnesses requires increasingly complicated drug regimens, ongoing support of self management, and close monitoring. Articles in this week's BMJ describe modern management for coronary heart disease, diabetes, asthma, and anticoagulation therapy. They emphasise that achieving the best possible outcomes depends on competent self management and decision making by patients, as well as clinical treatments.

But audits and surveys of medical practice continue to attest to the difficulty of assuring that most patients receive such care.¹,² Many chronically ill patients have socioeconomic factors, disabilities, and comorbid conditions that make it harder for practitioners and practice systems to help them. In Western countries, people from ethnic minorities often receive poorer care and experience worse outcomes in chronic disease than the rest of the population. For example, Griffiths et al describe the variety of barriers to good care that probably contribute to the high rates of hospital admission for South Asian patients with asthma in East London (p 962).³ Many doctors and practice settings are poorly equipped to care for patients with disabilities and chronic illness. Cheng et al found that patients with multiple sclerosis and considerable disability were less likely to receive appropriate preventive care than those with less disability, despite their undiminished life expectancy (p 968).⁴ Comorbidity is a huge problem, providing further obstacles to high quality care. Nearly two thirds of Americans aged 65 or older have two or more chronic conditions, and one quarter have four or more conditions (Gerard Anderson, personal communication).

A recent study in Canada found that patients with diabetes, emphysema, and severe mental disorders were less likely than patients without these conditions to receive appropriate oestrogen replacement therapy, lipid lowering medications, or treatment for arthritis.⁵ Two papers in the companion theme issue of the Western Journal of Medicine⁶,⁷ discuss the frequent co-occurrence of mental disorders and other chronic diseases, the negative health impacts of this interaction, and the difficulties of appropriate detection and treatment.

Given the importance of preventive care, managing comorbidity, and coordinating care, primary care will and should remain the best healthcare setting for most chronically ill patients. But treatments are advancing rapidly and becoming more complex, and it is essential that primary care has the necessary expertise to manage chronic diseases. Consistent evidence indicates that specialists are more knowledgeable about the management of conditions associated with their specialty and more likely to practise in accordance with guidelines.⁸,⁹ The challenge is to reach more patients with specialist expertise without massive translocations of care. Shared care arrangements hold real promise and deserve more intensive study.¹⁰

A recent report from the US Institute of Medicine on the “quality chasm” in health care concluded that “trying harder will not work, changing systems will.”¹ The paper by Olivarius et al in this issue illustrates the point (p 970).¹¹ Representative Danish general practices significantly improved long term control of diabetes through a variety of educational interventions and prompts for the doctors and through structured care offering patients planned, quarterly consultations. These visits enabled patients and their doctors to set treatment goals aimed at reducing cardiovascular risk factors.

The system changes that improve care of diabetes are essentially the same as those found to improve care for other chronic conditions. Collectively, these changes equip healthcare teams with relevant data and skills and enable them to interact more productively, and they provide patients with the information, skills, and confidence to manage their health wisely. The chronic care model developed by the MacColl Institute for Healthcare Innovation,¹² an attempt to synthesise these concepts of system change, has been used in more than 300 healthcare organisations in the United States.

It has been almost two years since our first theme issue on the management of chronic diseases, and there has clearly been substantial progress since. We hope that our third theme issue, scheduled for October 2002, will present evidence of more widespread diffusion of these advances.

Papers pp 962, 968 See also Primary care p 970