Category Archives: Chronic disease management
CDC Study: Nurses, Physician Assistants More Likely to Provide Education in Chronic Disease Management than Doctors
Proper patient management of chronic diseases is increasingly important to the nation’s health care system, as the Baby Boom generation reaches the stage of life where such conditions are common. From diabetes, arthritis, and asthma to obesity, hypertension, and depression, the health care system is looking to train patients to take steps mapped out for them in discussions with their health care providers. A new study from the Centers for Disease Control and Prevention (CDC), however, finds that a minority of patients with chronic conditions receive education in managing their problems, and that some practitioners—nurses and physician assistants (PAs), in particular—are considerably more likely to provide such education than others.
“Disease self-management is an essential component of care for patients with most chronic conditions,” writes a team of researchers led by Tamara S. Ritsema, MPH, MMSc, PA-C. “Patients cannot perform daily self-management tasks if they have poor understanding of the disease process, medications used, or the practical tasks they need to accomplish to care for themselves. Health education is, therefore, a vital preventive element in the patient visit.”
The researchers examined five years of CDC data, accounting for more than 136,000 patients who had been diagnosed with asthma, chronic obstructive pulmonary disease (COPD), depression, diabetes, hyperlipidemia, hypertension, ischemic heart disease, or obesity. The records indicated whether the patients’ doctors, nurse practitioners (NPs), or PAs had provided education to the patients in the self-management of their conditions during each visit.
Ruchi S. Gupta, MD, MPH, is an alumna of the Robert Wood Johnson Foundation Physician Faculty Scholars program. She is an associate professor of pediatrics and director of the maternal and child healthcare program at the Northwestern University Feinberg School of Medicine, and an attending physician at the Ann & Robert H. Lurie Children's Hospital of Chicago. Learn more at www.ruchigupta.com.
This past spring, 12 students with asthma at James Hedges Elementary in Chicago’s Back of the Yards neighborhood took hundreds of pictures, filmed video Public Serve Announcements (PSAs), created a website, and rolled out a community intervention to improve asthma conditions. These activities were part of the Student Media-Based Asthma Research Team, or SMART program. We developed this program from a previous pilot program in Chicago’s Uptown neighborhood that empowered students to learn about their asthma and challenged them to create change in their own communities.
As the most common chronic condition in children and the most common cause of school absenteeism, asthma is responsible for 13 million days of school missed each year. Asthma disproportionately affects racial and ethnic minorities, as African Americans and Hispanics/Latino children have significantly higher asthma-related morbidity and mortality rates compared to White children. While evidence-based guidelines for asthma care have been available for 20 years, ethnic minorities have a lower likelihood of receiving or following proper asthma treatment. Across and within racial/ethnic groups, asthma care has been shown to be more effective when it is tailored to the individual community instead of one-size-fits-all intervention.
Keon L. Gilbert, DrPH, MA, MPA, is an assistant professor in the Department of Behavioral Science & Health Education at St. Louis University's College for Public Health and Social Justice. As a Robert Wood Johnson Foundation New Connections grantee, his research focuses on the social and economic conditions structuring disparities in the health of African American males. His work seeks to identify sources of individual, cultural, and organizational social capital to promote health behaviors, and health care access and utilization, to advance and improve the health and well-being of African American males. This is part of a series of posts looking at diversity in the health care workforce.
I became a public health professional because I recognized a need to find opportunities and strategies to prevent the chronic diseases I saw silently killing African Americans in the community where I grew up. I vividly recall as a child the whispers surrounding the deaths of community members about cancer, diabetes (or sugar-diabetes, as it is commonly referred to in many communities still today), heart attacks, and strokes. I knew there was stigma and fear, but never heard of programs, interventions, or opportunities to stop these trends.
My interest in addressing these problems led me to pursue summer programs and internships during high school that allowed me to witness amputations of uncontrolled diabetic patients who had a range of clinical and social co-morbid conditions. Many of these amputees were living in poverty, they had Medicare or Medicaid, and the majority happened to be African American. This experience raised the question about prevention: How could I prevent African American men and women from having amputations? I never heard this conversation around prevention in my community. Many people seemed to accept the reality of developing these chronic conditions as a fate that could not be controlled.
I knew there had to be another way.
Ashok Reddy, MD, is a Robert Wood Johnson Foundation (RWJF) Clinical Scholar in residence at the University of Pennsylvania and a senior fellow at the Leonard Davis Institute of Health Economics. This is part of a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.
With the debate about the fiscal cliff and the sequester hanging so heavily over Washington, it was no surprise that congressional staffers at the AcademyHealth National Health Policy Conference seemed so exclusively focused on cutting health care spending. Some estimated that 30 percent of the $2.5 trillion spent on health care may provide little value; finding interventions that provide high-value care is a top priority that tends to obscure any other possibilities.
In this prevailing atmosphere of stark fiscal reality and gridlocked politics it can be hard to gain traction for the idea that investing in programs that prevent chronic diseases would ultimately decrease the costly long-term expenditures driven by those diseases. But that’s where traction is needed.
Take diabetes for instance. One estimate has the medical treatments for people with diabetes costing 2.4 times more than expenditures that would be incurred by the same group in the absence of diabetes. By preventing the development of diabetes in an individual you decrease the risk of heart attack, kidney failure and amputated extremities.
It is true that, so far, research in cost-effectiveness analyses has not shown that prevention reduces medical costs. Besides childhood vaccination and flu shots for the elderly, few health care services ‘save money.’ A 2010 Health Affairs article calculated that if 90 percent of the U.S. population used proven preventive services, it would save only 0.2 percent of health care spending.
Andrea Wallace, PhD, RN, is an assistant professor at the University of Iowa College of Nursing and a Robert Wood Johnson Foundation Nurse Faculty Scholar.
Patients live in communities that offer support and include influences that are outside the walls of clinical settings. While this is not a new revelation, I have often had to remind myself and the students I teach that, as health care providers, we witness only a very small part of patients’ lives, generally at a time when they are most removed from their experience of daily living.
"I cringe to think of how many of my adult patients I’ve asked to adopt a complex medication schedule for their diabetes, all the while suspecting they may have limited literacy skills"
We must remain continually aware of patients’ personal and financial resources when planning care. But it was not until recently that I became incredibly taken with the idea that, for many patients living with chronic illness, it’s those who help patients care for themselves—the daughter picking up medications, the neighbor driving to appointments, the spouse doing shopping – who may make the difference between successfully and unsuccessfully coping with what can be incredibly complex self-management regimens.
In late January, the nation’s second-largest health insurer announced a new initiative designed to improve care and reduce costs by raising reimbursements for primary care. WellPoint will provide additional revenue to primary care providers for “non-visit” services that it does not currently reimburse, such as preparing care plans for patients with multiple and complex conditions. The new program is designed to build and expand on WellPoint’s existing medical home program.
“Primary care physicians who are committed to expanding access, to coordinating care for their patients and being accountable for the quality of care and the health outcomes of those patients, will get paid more than they do today, and we’re committed to helping them achieve these quality and cost goals,” Dr. Harlan Levine, WellPoint executive vice president, Comprehensive Health Solutions, said in a statement. “Primary care is the foundation of medicine, and it can and should be the foundation of our members’ health.”
WellPoint predicts the program will reduce overall medical costs by as much as 20 percent by 2015. The program will launch in select markets later this year.
New Study Points the Way to Better Care, Improved Outcomes and Lower Costs for Homeless People with Chronic Conditions
By Laura Sadowski, MD, MPH, and Romina Kee, MD, Robert Wood Johnson Foundation (RWJF) Clinical Scholar alumnae
Becoming homeless is distressing for anyone, and it is especially challenging for people with chronic health problems who need ongoing care.
The face of America’s homeless population is changing. When the job market collapsed a few years ago, millions of families were forced out of their homes. A 2009 national survey of organizations providing services to the homeless found that an estimated 10 to 19 percent had become homeless in the past year due to foreclosure. Nearly one percent of the U.S. population experiences homelessness each year.
Previous research on the health/medical, legal, housing and social services costs accrued by people who are homeless has focused on subsets of the population—those with mental illnesses, substance abuse problems, or the “chronic homeless” (those who have been without stable housing for 24 or more months). But they comprise a small portion of America’s homeless population. The chronic homeless, for instance, represent just 18 percent.
So how do we ensure that all homeless patients – regardless of their individual circumstances – get the care they need, while reducing costs?
In our study published in a special edition of Health Services Research: Bridging the Gap Between Research and Health Policy, we looked at a novel, broader sample: homeless adults with chronic conditions. Unlike previous studies, the majority of our study subjects were not mentally ill, substance abusers, HIV infected, veterans, or frequent users of the health care system.
As we head into 2012, the Human Capital Blog asked Robert Wood Johnson Foundation (RWJF) staff, program directors, scholars and grantees to share their New Year’s resolutions for our health care system, and what they think should be the priorities for action in the New Year. This post is by Laura Brennaman, MSN, RN, CEN, a fellow at the RWJF Nursing and Health Policy Collaborative at the University of New Mexico.
As we enter 2012, my resolution and wish for the U.S. health care system is a fundamental and transformative shift from a focus on disease management to one of health promotion. As Americans and health professionals, we must recognize that even the most advanced and best interventions to remedy diseases do not improve the overall health status of our country. Only preventing epidemics of chronic problems like metabolic syndromes, heart disease, and lung disease that plague our population can have significant wellness and economic benefits.
The Affordable Care Act offers a mechanism to foster such a change in emphasis with the establishment of the National Council for Prevention, Health Promotion, and Public Health that intertwines the governance of 17 executive agencies. Leadership from diverse arenas such as transportation, trade, agriculture and labor concentrating on health promotion strategies from within and across domains provides opportunities to affect many of the determinants of poor health and transform them into positive scenarios to improve health status of all Americans.
Actualizing new health promotion strategies through shifting spending from direct care provision to prevention mechanisms of social programs like job training, housing supports, public transportation systems, and childcare services has greater potential to improve health outcomes for Americans than new technology or pharmaceuticals for disease management.
In this coming election year, the candidates for office will propose a bevy of ideas concerning health care. However, we must pay heed to all programs they propose to enhance or curtail through a lens of health outcomes. Proposals dealing with environment, energy and economic issues will affect our health as surely as any health care reform plan.
Hence, my resolution for our health care system is holistic and comprehensive consideration of the health impact of every policy. Through such integrated deliberation, we will achieve improvement in health outcomes and reductions in health disparities for all Americans.
As we head into 2012, the Human Capital Blog asked Robert Wood Johnson Foundation (RWJF) staff, program directors, scholars and grantees to share their New Year’s resolutions for our health care system, and what they think should be the priorities for action in the New Year. This post is by Alexander Tsai, MD, PHD, RWJF Health & Society Scholar, Harvard University.
In the absence of addressing long-term drivers of population health in the U.S., changes in the health care delivery system may be within reach in the near term.
Management of care for chronic conditions remains notoriously poor, even among insured persons for whom out-of-pocket costs are not the primary barrier. Only one in two Americans with chronic conditions such as depression, diabetes and hypertension receives guideline-concordant care.
Poor chronic care management is often associated with systems-level failures such as lack of electronic data sharing among practitioners, or lack of care coordination for patients for multiple chronic conditions who struggle to adhere to complex medication regimens.
Further opportunities for cost containment are lost with regards to secondary prevention (e.g., readmissions for congestive heart failure), where better management could result in lower lifetime costs.
Reducing the costs for medical care in the United States without sacrificing health is among the highest priorities for the U.S. As our country continues to go through the demographic transition of becoming an aging society, we must consider ways to contain medical care costs and simultaneously increase healthy life expectancy.