Care for chronic diseases

This is the third in the BMJ's series of theme issues on managing chronic diseases. This focus reflects the increasing demands on practitioners and health systems around the globe posed by mounting numbers of chronically ill patients.¹ The term “chronic disease” usually connotes the prevalent chronic degenerative diseases such as diabetes, coronary artery disease, hypertension, and chronic obstructive pulmonary disease. But papers in the three theme issues argue that a much broader array of health problems generate similar needs for patients and similar challenges for health services—these include diseases such as chronic uveitis, gastro-oesophageal reflux disease, multiple sclerosis, depression, and osteoporosis.

Despite the clinical differences across these chronic conditions, each illness confronts patients and their families with the same spectrum of needs: to alter their behaviour; to deal with the social and emotional impacts of symptoms, disabilities, and approaching death; to take medicines; and to interact with medical care over time. In return, healthcare must ensure that patients receive the best treatment regimens to control disease and mitigate symptoms, as well as the information and support needed effectively to self manage their health and, in many instances, their death. Evidence shows that we are not doing very well, and that the fault lies less in ourselves and more in our systems of care.²

All three BMJ issues have presented or reviewed evidence showing that changes to the organisation and delivery of care can improve the quality of care and certain outcomes of chronic disease. The most successful interventions are complex and have many components. Their aims include increasing clinical expertise and decision support; improving patients' self management; increasing the effectiveness of practice teams and their interactions with patients; and having more accessible and useful clinical information (p 925).³,⁴ Such changes can reduce unwarranted variations in care (p 961),⁵ encourage patients to engage and stay with care programmes, and encourage more appropriate patient behaviour and decision making.⁶ In an editorial in the second BMJ issue on managing chronic disease, one of us (EHW) expressed the hope that by the third issue more widespread dissemination of these changes would be seen in practice.⁷

That hope seems to have been overly optimistic. Although research has shown the efficacy of these promising interventions, the effectiveness—the benefit in real clinical practice—has only begun to be tested. Will system changes tested for one disease be readily adaptable to other illnesses, to much younger patients, or to the many older ones with multiple chronic conditions? Will changes that improve healthcare delivery in Europe and the United Kingdom also work in less developed countries—for example, for AIDS care (pp 854 and 914)?⁸,⁹ We can't answer these questions yet, because we need further evidence that a common set of practice enhancements and systems will meet the needs of patients with one or more chronic conditions, wherever they live.

Furthermore, although the commonest chronic illnesses last for decades, most tested interventions for improving self management—an essential component of quality care for chronic illness—have been of relatively short duration and delivered outside usual medical practice. A recent meta-analysis of self management programmes for diabetes found that many succeeded in lowering serum concentrations of glycosylated haemoglobin, but their benefits diminished over the ensuing 6-12 months.¹⁰ How can the effect be sustained? Collaborative counselling and problem solving provided by primary care teams, as recommended or tested in these theme issues,⁶ may maintain and extend the benefits of these programmes over time, but this important hypothesis needs further study.

Meanwhile, the ideal drug treatment for most chronic illnesses gets more complicated every day, as trials of new agents and more complex regimens show both benefits and harms. Evidence based care for diabetes, heart failure, coronary artery disease, AIDS, and other chronic conditions now includes more complex drug regimens and the associated risks of adverse effects and potential interactions. Yet very few drug trials include patients with multiple chronic diseases, leaving an important gap in the evidence. Effective and safe chronic illness care will assure that practice teams prescribing and managing drug therapy have adequate knowledge and experience with these more complex drug regimens. This may entail the more active involvement of specialists with primary care teams.

So, there is much more to do. We hope that the evidence collected in these three special issues of the BMJ will provide a solid foundation on which to build. They have, at least, uncovered a new generation of research questions needing urgent study. Such evidence, and the growing burden of chronic diseases, particularly in the world's poorest regions, should make researchers, funders, and policy makers think a lot harder about testing better, more effective, and more relevant ways to deliver care.

See pp 954, 914, 925, 961