A prescription for healing health care

One of the most interesting and inspiring talks I attended at the recent ACR (American College of Rheumatology) / ARHP (Association of Rheumatology Health Professionals) meeting in San Diego was given by Dr. Robert Kane, of the University of Minnesota School of Public Health. Dr. Kane spoke of the need to overhaul contemporary health care systems, by moving their traditional focus on acute care to address the huge contemporary problems associated with chronic disease and chronic care management.

Dr. Kane noted that the problem was a universal 21st Century challenge and that one in six Americans has a chronic condition that inhibits daily life. His statistics were startling; he noted that in the USA, 69% of hospital admissions were for chronic conditions and comprised 80% of hospital days; 83% of medical prescriptions were written for chronic conditions and chronic complaints absorbed 66% of physician visits. Even in the Emergency Ward-----the epicentre one would imagine of acute care medicine---56% of visits were chronic in nature, and when medical spending as a whole is examined, chronic disease consumes 70% of all American medical spending and fully 95% of spending for that portion of the population over the age of 65. The latter statistic must give us all pause, as we contemplate the phenomenon of population ageing throughout the developed world.

Dr. Kane enunciated a number of defining characteristics attached to a chronic disease like arthritis: it could last a lifetime; its impact accumulates with age; it is generally progressive, although the clinical course could demonstrate remissions and exacerbations; it is “life-shaping,” and it can assume different meanings in different cultures.

Again citing arthritis as an example, Dr. Kane described the essential goals of chronic disease care as:

• Managing the disease as well as possible to reduce the extent and frequency of exacerbations.
• Preventing (or at least) minimising the transition from impairment to disability, and from disability to handicap.
• Encouraging the patient to play an active role in managing his/her disease but avoiding allowing the disease to become the dominant force in the person’s life. To these, he added as desirable goals the following:

Providing care in a culturally sensitive manner. Integrating medical care with other aspects of life without “medicalising” those aspects. In order to achieve the goals he outlined as essential for good chronic care, Dr. Kane said some new definitions and some new approaches to traditional medical practices were desperately needed. It was imperative, he said, to reshape patient-physician roles. The patient needed to be well informed about the disease and to actively share responsibility (and risks) for its management with the physician. Decision-making particularly, had to be shared, and communication between the two had to be far deeper, longer, and ongoing.

How could this be managed in the typical hectic practice? Dr Kane said it could be done if medical appointments were no longer approached as “brief encounters”, set down more or less automatically in the standard “see me again in three weeks” manner. Instead, the patient would request an appointment only when experiencing a “meaningful episode”, based on personal knowledge of significant symptomology, or perhaps after being given some pre-screening by a physiotherapist, a nurse practitioner, or a physician assistant--- (Dr. Kane strongly advocated the establishment of interdisciplinary care teams ---something which he felt was a critical feature of an improved chronic care model). These new-style medical appointments would be for significant periods of time---45 minutes to 1 hour---but because they would be far less frequent than the old reflexive “10-minutes in 3 weeks” model, they could be accommodated within the physician’s schedule without major difficulties.

According to Dr. Kane, good information systems to track the situation of the chronically ill patient were also crucial to success in building new models of chronic care. “Clinical Guidepaths” (CG’s) for each patient needed to be developed. Dr. Kane defined a “Clinical Guidepath” as a systematic way to observe one or more parameters of a patient’s condition on a regular basis, in order to be able to compare the observed state with the expected state. If the patient stays within the expected course, nothing need be done, but if the clinical course deviates, such a change should trigger immediate close attention or lead to intervention in a problem at an early stage. The creation of all encompassing clinical guidepaths, managed through computerised flow sheets capturing patient histories, status displays, records of treatment modalities, and universal drug information, requires new and comprehensive approaches to data management. Medical care providers needed to urgently come to grips with this challenge in information management. The patient, too, needs to understand the guidepath system and to function as a full partner in the ongoing monitoring of his or her symptoms within it, so that patient-driven intervention can occur early and when needed.

Dr. Kane concluded by observing that:

Chronic disease is here to stay and will grow in importance with the ageing population, Much more needs to be done to bring the health care system into alignment with this pressing reality, There is good scientific evidence to show that better care is achievable. In his final remarks, Dr. Kane noted that it is hard bringing change to medical systems that have grown rigid over time and accustomed to doing things in traditional ways. However, he also argued forcefully that there is a moral imperative to “heal health care” and to do so NOW.

“It is simply the right thing to do”, he said, “And we have it in us to do it”.

Readers interested in following up further on some of Dr. Kane’s ideas, or those of other health care providers interested in exchanging experiences and new approaches to chronic health care management and reform, may wish to check out the web site of PPECC (Professionals with Personal Experience in Chronic Care) at www.ppecc.org