Time for chronic disease care and management

Abstract

To manage the future costs and quality of care, a health strategy must move beyond the individual, acute care model and address the care of older people with chronic, and often multiple, diseases. This strategy must address the issue of care gaps, ie, the differences between best care and usual care. It should also embrace broad partnerships in which providers may be a cross-disciplinary team of nurses, physicians and pharmacists; the patient partners may include all patients in the community with a disease or group of diseases; and the system managers should work with all to seek improved long-term care and share the governance of interventions and resources. This partnership is activated by repeated and widely communicated measurements of actual practices and outcomes, facilitating rapid knowledge gain and translation, including unmasking the invisible wait list of unmeasured care gaps. It drives continuous improvement in practices and outcomes. The time is right for such care models. There is increasing evidence of their clinical and financial benefits. There is a clear and immediate opportunity to evaluate them as part of a health strategy for effective chronic care in our aging society. Things can be better.

Figure 1)

The continuum of medical therapy, from basic science discovery, to proof of efficacy in randomized clinical trials, to use in the real world. Care gaps occur when best care, as defined in efficacy trials, is not rapidly and widely applied to whole populations of patients. The primary consequence of care gaps is a missed opportunity; patients who can benefit from efficacious therapies do not. Reproduced with permission from reference 1

Figure 2)

The chronic care model of disease management. The community, provider and system partners act together to achieve overarching goals. The arrows represent activating and sustaining communication, including measurement and communication of practices, outcomes and other relevant knowledge, to all partners

Figure 3)

Temporal changes in prescription patterns of proven efficacious medical therapies for all patients with acute heart attacks admitted to hospital in Nova Scotia from 1997 to 2002 (by second and fourth quarters [2Q and 4Q, respectively]), during the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) disease management project. The principal intervention was the measurement and feedback of care practices to all partners. ACEi Angiotensin-converting enzyme inhibitors; AP Antiplatelets; ARB Angiotensin receptor blockers; BB Beta-blockers. Reproduced with permission from reference 10

Figure 4)

Comparison of traditional academic, or Mode 1, knowledge production with the less rigid Mode 2 knowledge creation and production typical of community and needs-based disease management partnerships. Partnership-measurement disease management projects provide a practical bridge in which the two knowledge production modes complement each other