A prescription for better care of chronic diseases

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By James Schibanoff, MD | 01 November 2006

Diabetes, heart and lung diseases, and Alzheimer’s are among a steadily lengthening list of conditions that account for a significant portion of all healthcare costs in the U.S. In fact, chronic illnesses are the largest, fastest-growing, and most expensive aspect of health services, yet care for these conditions remains fragmented and relatively poor in quality. This sets up a vicious cycle in which uncoordinated care contributes to further patient suffering—both for lack of an integrated approach at the provider level and from patients’ own lack of knowledge and skills to help themselves. But there is hope in the form of a guideline-driven approach that enables care managers to help families, caregivers, and especially the patients themselves play a bigger role in treating chronic illnesses.

Hardly a blip on the radar

To best understand how this approach works, we start by recognizing the fundamental differences between inpatient, or acute care “episodes,” and chronic illness. In an acute care situation, the patient often is in an operating room or intensive care unit, where the focus is on the quality of the medical team and perhaps the technology employed to save or improve a life. For a patient with chronic illness, the relationship with the healthcare system is often defined by what the World Health Organization calls the “radar syndrome,” in which the patient appears at an emergency room or doctor’s office exhibiting specific symptoms, is treated and discharged, and then simply disappears from the radar screen—that is, until the next crisis. In chronic disease, the patient is out of view of providers more than 95% of the time, so patient behavior determines nearly all outcomes, including adherence to the treatment plan, checking blood pressure, controlling diet, doing exercise, and avoiding smoking.

We’re convinced that evidence-based care guidelines can serve as a small but critical piece in resolving the radar syndrome characteristics of chronic treatment. Such guidelines are rooted in an empowerment theory, analogous to the parable, “Give a man a fish and he eats for a day; teach him to fish and he eats for a lifetime.” Guidelines can help facilitate the entire care process, arming caregivers with the questions they need to ask and the steps they need to follow to do a better job caring for their patients, while at the same time giving patients the materials they need to take better care of themselves. By bringing together information and materials for everyone involved in the patient’s care, a guideline-driven approach can help ensure that care is optimized between emergency room or doctor visits and that the need for acute, reactive interventions is minimized. And because guidelines can be outpatient-based, there’s an important bottom-line impact.

Defragmenting treatment

Traditionally, there have been two approaches by health plans in the treatment of chronic disease patients:

  1. Outsourcing the management of patients with chronic conditions to companies that specialize in a particular condition, or
  2. Management of care by insurance companies directly.

The risk with the first approach is that it can result in a fragmented system of care. Someone with diabetes, for example, might have one company looking out for her blood sugar levels and another treating the kidney or eye disease that has evolved from the diabetes. Add to that the possibility that the same patient has a history of high blood pressure and you start to get the picture of the complexity—and potential for gaps or omissions—inherent to this treatment approach. The second approach is superior to the first because the care can be better coordinated. Traditionally, this approach has also fallen short because insurance companies have lacked all the information they need to keep the patient on track through regular assessments and treatment monitoring.

Evidenced-based research process

An evidence-based research process starts with the review and analysis of all documentation that is potentially applicable to chronic conditions, resulting in a unique set of content. This fact gathering and analysis is conducted using a clinically-sound process that includes the following steps:

  • Study of all relevant medical literature
  • Review of findings and recommendations by experts from a wide range of related fields of medical practice—physicians, dieticians, physical therapists, nurses, etc.
  • Field testing
  • Identification of best practices
  • Follow-up conversations with customers regarding satisfaction with use

After guidelines have been developed based on the best current medical evidence, they are integrated into a practical care plan using a set of proprietary workflow tools that make up a comprehensive and user-friendly treatment combination. Together, the clinical guidelines and the workflow tools are then used by the patient and members of his or her care management team to drive the right questions and actions in every patient encounter, thereby reducing inconsistencies in the care plan and in variability of treatment steps.

Patients become more active participants

Patient education and care team collaboration is essential to successful use of the tools. Education efforts should be directed at key intervention steps that the patient can perform, such as testing blood sugar in diabetes or peak flow rate in asthma, and that he or she can follow up on, such as adjusting medication doses. In addition to advancing knowledge of the disease, other patient education objectives include enhancing the patient’s general problem-solving skills and making the materials accessible in a variety of formats, e.g., print and e-mail. Unlike the traditional medical care model, in which the professional is the all-powerful expert, guidelines foster collaboration between patient and healthcare professional. It is essential that they work together as a team, using the guidelines and tools to share information, solve problems, and discuss experiences and outcomes.

Chronic care guidelines facilitate questions and discussions that give patient and caregiver an overall view of care status, while highlighting any gaps that may exist or interventions that need to take place. There also are links to other sources of related information. In the not-too-distant future, chronic care guidelines will allow drill-down access to additional sources of information, including treatment options and a record of treatment progress.

Integrated care programs such as those supported by guidelines and tools can help achieve favorable cost and care outcomes in treating chronic disease, but they are not stand-alone solutions. It is important that patients be motivated and eager to help themselves, and that treatment managers make appropriate use of guidelines and best practices.

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Even with the proper degree of commitment and sharing, there will still be a need to employ some of the most extensive and costly aspects of our healthcare system—such as hospital care and diagnostic procedures—in order to ensure the best overall solution for the patient. However, a model based on evidence-based guidelines in chronic disease care has great merit and deserves further investment. There’s no question that in the long run these efforts will save money. For example, if you decrease a person’s likelihood of heart failure, the patient not only feels better, but may be more productive on a job or in life generally. Healthcare dollars can be saved by reducing the need for doctor and hospital visits, tests, medications, therapies, etc.


Research findings encourage further investment

Recent research into the benefits of using a guideline-driven approach is quite encouraging, as it demonstrates that the prudent use of guidelines can lead to improvements in hospitalization rates, healthcare costs to insurers and employers, and patient satisfaction and quality of life. There’s a lot to be said for a process that promotes self-empowered decision making and treatment, use of best practices, and technology-facilitated communication—all in the pursuit of helping patients take more responsibility for their own care, improving the use of care management resources, and helping to ease the enormous burden of today’s healthcare costs.


James Schibanoff is a principal and editor-in-chief for the Milliman Care Guidelines in the company’s San Diego office. He represents Care Guidelines to consumer and patient groups, regulatory bodies, and medical specialty societies, and also responds to clinical inquiries from users. Board certified in internal medicine and pulmonary medicine, Jim previously served as chief medical officer of a San Diego healthcare system and as chief executive officer of two San Diego hospitals. He has been ranked among the top 40 most influential physicians in the country by Modern Healthcare magazine.