Chronic Disease and Aging: Applying the Chronic Disease Model to Older Persons
Dr. Wagner observed that primary care is increasingly dominated by chronic illness and geriatric care, but the status quo model of the structure and provision of primary care is ill-suited to the changing population that it is serving.
Primary care serves a growing population of heterogeneous individuals with multiple chronic illnesses. The pressures thereby placed on primary care are giving rise to evocations of the “demise” or “collapse” of primary care. A large portion of patients are receiving inadequate evidence-based care that fails to control their chronic health conditions. Further, primary care visits are largely devoted to routine management of these conditions.
Physicians increasingly struggle to provide adequate, evidence-based care, but studies show that the time required to comply with evidence-based practice requirements would exceed the standard workday by several hours.
Dr. Wagner suggested approaches to improve healthcare outcomes under these circumstances. One, patients must receive adequate drug therapy; two, patients must self-manage their conditions and take greater responsibility for their health status; three, preventive interventions must be provided at timely intervals (with secondary prevention and early detection being key); four, there must be evidence-based monitoring and self-monitoring; and five, care must feature adequate follow-up tailored to the condition’s severity. Good surveillance is essential due to the fluctuating nature of chronic illness.
Dr. Wagner stated that, depending on the illness, roughly half of all patients or fewer are receiving evidence-based treatment for their conditions. For example, one-quarter of patients reporting depressive symptoms receive treatment or referral for treatment.
Discussing the “quality chasm,” he noted that the current care system is unequipped to handle the challenges described, and no increase in applied effort will improve a system failing at a structural level. Measures such as team changes, case management, patient reminders, and patient education have resulted in improved outcomes. Changes showing the greatest impact are those that educate patients to better manage their conditions. Other effective measures alter the organization and delivery of care. Further, use of nonphysician team members, planned encounters, modern self-management support, specialized care management for high-risk patients, and population management using electronic registries are effective.
Fundamentally, the most productive healthcare interactions result from the interaction between an informed, active patient, and a prepared practice team.
Such interactions take the form of the “planned visit,” using patient data, team and practice organization, and decisional support to assure productivity.
The most important IT enhancement is implementation of a patient registry that includes every patient who meets certain criteria for high risk (the presence of one or more chronic illnesses). This facilitates well-organized interactions. Registries can be a rapid source of information (patient details, medications), aid planning, and serve as a valuable tool for monitoring performance across the practice.
He emphasized that the vast majority of the population prefers a primary care physician; countries with better primary care have better health outcomes; and U.S. states with higher primary care/population ratios have reduced costs and better quality. He promoted primary care’s ability to marry gerontology with effective chronic disease management. Primary care must do this if it is to survive.