Professional Documents
Culture Documents
An estimated 99 million Americans live with a chronic illness. The defining features of primary care (that is, continuity, coordi-
Meeting the needs of this population is one of the major chal- nation, and comprehensiveness) are well suited to care of chronic
lenges facing the U.S. health care system today and in the future. illness. A rapidly growing body of health services research points
Dozens of studies, surveys, and audits have revealed that sizable to the design of the care system, not the specialty of the physi-
proportions of chronically ill patients have not received effective cian, as the primary determinant of chronic care quality. The future
therapy and do not have optimal disease control. The consistent of primary care in the United States may depend on its ability to
findings of generally substandard care for many chronic conditions successfully redesign care systems that can meet the needs of a
have spurred proposals that care be shifted to specialists or dis- growing population of chronically ill patients.
ease management programs. Published evidence to date does not Ann Intern Med. 2003;138:256-261. www.annals.org
indicate any clear superiority of these alternatives to primary care. For author affiliations, see end of text.
with more than one chronic condition may benefit from specialty differences in preventive care is mixed. Some ev-
primary caregivers who have more general training and idence suggests that specialists are less likely than general-
clinical experience. Fourth, expertise in behavioral change ists to provide general preventive services (17, 18). Con-
and self-management support is central to successful care. versely, several studies have found that specialists are more
Primary care clinicians, especially more recent graduates, likely to perform preventive procedures related to their spe-
usually have more training in these areas than specialists. cialty; for example, obstetricians and gynecologists are
Arguments favor keeping primary care a principal fo- more likely to provide clinical breast examinations, mam-
cus for chronic disease management; however, current per- mography, and Papanicolaou smears than generalists (19 –
formance suggests otherwise. Although we know that a 21). Lafata and coworkers (18) found that diabetic patients
majority of Americans with major chronic illnesses are not cared for by an endocrinologist were more likely to receive
receiving appropriate or effective management (2), most diabetes-related preventive measures (for example, retinal
studies of the quality of chronic illness care have made no examinations) than patients seeing only a generalist but
distinctions regarding sources of care or the specialty of the were less likely to receive general preventive measures (for
primary clinician. The few available comparative studies of example, Papanicolaou smears).
primary and specialty care make it clear that the quality We were unable to identify any evidence comparing
chasm pertains to both. the performance of generalists and specialists in manage-
ment of comorbid conditions outside the focus of the spe-
cialty group. A Canadian study found that patients with
ALTERNATIVES TO PRIMARY CARE diabetes, emphysema, and severe mental disorders were less
Specialty Care likely than patients without these conditions to receive es-
Many articles and editorials in the specialty literature trogen replacement therapy, lipid-lowering medications, or
advocate shifting the care of chronically ill persons from treatment for arthritis (22). Although these data suggest
primary to specialty care. The empirical argument for such that there may be deficiencies in the care of comorbid
a shift can be found in the growing body of evidence dem- conditions, the study did not provide evidence about
onstrating that specialists are more knowledgeable about whether the specialty of the primary caregiver affected the
the management of conditions associated with their spe- results. Regarding costs, specialist care uses more resources
cialty, more aware of guidelines delineating such manage- and diagnostic tests and involves longer hospital stays than
ment, and more likely to use tests and medications in ac- generalist care (11).
cord with guidelines (11, 12). Evidence also suggests that Several commentators have suggested that shared care
specialists more quickly change practice to adjust to new between primary care physicians and specialists may pro-
developments. duce the best outcomes (23, 24). Katon and associates (25)
It has been more difficult for investigators to demon- tested a shared care model for the management of patients
strate differences in clinical and health status outcomes by with major depression. Alternating care between psychiatry
specialty. In their review of the literature on specialty dif- and primary care led to substantial increases in the propor-
ferences in care, Harrold and colleagues (11) found that tion of patients receiving appropriate therapy and in the
specialist-treated patients had better outcomes than gener- incidence of recovery from a major depressive episode.
alist-treated patients for myocardial infarction, stroke, and Lafata and coworkers (18) examined the care of diabetes in
asthma but not for hypertension, diabetes, chronic obstruc- the Henry Ford Health System and found that diabetic
tive pulmonary disease, unstable angina, and low back patients who saw both a primary care clinician and an
pain. What might account for the variability in findings? endocrinologist were more likely to receive appropriate
The evidence regarding specialty differences in diabetes diabetes-related preventive care and general preventive care
care may be instructive. Two large studies found minimal services than those seeing either type of clinician alone.
differences between specialists and generalists when both Willison and colleagues (26) found that patients in health
were practicing in typical practice settings, such as health maintenance organizations who had acute myocardial in-
maintenance organizations or private practice (13, 14). farction and were cared for by generalists with cardiology
Conversely, endocrinologists practicing in specialized dia- consultation were more likely to receive guideline-directed
betes clinics with access to a full range of multidisciplinary care than patients treated by generalists alone. The efficient
resources provided substantially better care and achieved involvement of specialists on primary care teams may offer
far better disease control than did generalists in the same the optimal combination of knowledge and skills that
geographic area (15, 16). These differences suggest the im- chronically ill persons need.
portance of the practice environment or system in deter-
mining the nature of care and its consequences. Disease Management
Arguments opposing the shift of chronic illness care Disease management refers to discrete programs di-
from generalists to specialists include concerns about the rected at reducing costs and improving outcomes for pa-
receipt of preventive care, the care of comorbid conditions tients with particular conditions. In a recent review,
outside of the specialty focus, and cost. The evidence on Bodenheimer (27) estimated that there are now more than
www.annals.org 4 February 2003 Annals of Internal Medicine Volume 138 • Number 3 257
200 commercial disease management firms. Many health addition, more problems were addressed in the chronic
care organizations have added internal disease management illness visits than in the acute care visits. As a consequence,
activities as well. However, in California, a mature man- the care of chronic illnesses is often a poorly connected
aged care market, only half of the major health care orga- string of episodes determined by patient problems.
nizations are using any kind of interdisciplinary team for In contrast, high-quality chronic disease care ensures
case or disease management (28). Most often, these teams that patients have the confidence and skills to manage their
provide physician feedback and focused educational or case condition; the most appropriate treatments for optimal dis-
management services for patients with a given condition. ease control and prevention of complications; a mutually
Programs vary in the extent to which the primary care understood care plan; and careful, continuous follow-up.
practice team is informed and participates in decision mak- This requires a longitudinal and preventive orientation
ing. They range from highly integrated services operating manifested by well-designed, planned interactions between
in close collaboration with primary care to “carve-out” a practice team and a patient in which the important clin-
models that are separate, condition-specific delivery sys- ical and behavioral work of modern chronic illness care is
tems (29). Published evidence of the effectiveness of com- performed predictably.
mercial programs remains scant, but there is growing evi- What characterizes effective chronic illness care? Mem-
dence of the effectiveness of noncommercial clinical case bers of a primary care practice team organize and coordi-
management services that provide clinical management by nate patient care through a series of interactions during
protocol, self-management support, and close follow-up which they elicit and review data concerning patient per-
(30 –32). Therefore, disease management or, more specifi- spectives and other critical information about the course
cally, clinical case management services may play an im- and management of the condition or conditions, help pa-
portant part in improving care of chronically ill persons, tients set goals and solve problems for improved self-man-
especially if they reinforce rather than undermine continu- agement, adjust therapy to optimize disease control and
ity and coordination of care by the primary caregiver. patient well-being, and ensure follow-up.
Careful study of this issue is urgently needed.
SYSTEM CHANGES THAT WOULD SUPPORT MORE
IMPROVING CHRONIC ILLNESS CARE IN PRIMARY CARE EFFECTIVE CHRONIC ILLNESS CARE
In our view, the extensive rhetoric and posturing on The literature suggests the need for multifaceted, in-
both sides of the generalist–specialist debate miss the point. terconnected changes to the organization and functioning
Care is subpar regardless of the specialty of the caregiver. Is of practice to ensure routine performance of the tasks that
the problem cognitive—that is, are many primary care are critical to chronic disease care. System changes that lead
practitioners simply unaware of effective interventions— or to improvements in the process and outcomes of chronic
does the root of the problem lie elsewhere? If unfamiliarity disease care are similar for most conditions. To illustrate,
with effective therapies were the principal explanation for consider care for diabetes and for depression, two seem-
poor quality, one might expect more bimodal distributions ingly different conditions that have been the subject of the
of quality ratings. Instead, the variation in chronic illness largest volume of quality improvement research in primary
care and outcomes from patient to patient within individ- care.
ual practices generally exceeds the variation from practice A recent Cochrane Collaboration review examined 41
to practice (33, 34). These findings strongly suggest that studies of interventions to improve diabetes performance
even knowledgeable practice teams have difficulty consis- in primary care (38). Most studies demonstrated some de-
tently providing optimal care to all of their patients. gree of improvement in care processes, such as hemoglobin
Although some of the variation is clearly patient re- A1c testing or the performance of retinal or foot examina-
lated, we believe that it is principally a function of the tions. A few studies showed significant improvements in
organization and orientation of practice. We (35) and oth- disease control, such as reduced hemoglobin A1c levels,
ers (3, 36) have speculated that primary care systems were blood pressure, or lipid levels. The interventions that re-
originally organized to react to acute illnesses and remain sulted in the largest positive changes tended to be complex
that way despite the increased prevalences of most major and involved four areas: activities directed at changing cli-
chronic diseases. In primary care, attention continues to nician behavior, changes to the organization of practice,
focus on defining the problem; excluding more serious di- information systems enhancements, and educational or
agnoses; and initiating treatment, usually in the form of supportive programs aimed at patients. The most success-
drug prescriptions. In a study of representative family phy- ful interventions addressed all four of these areas. Of par-
sician visits, Yawn and coworkers (37) found that while ticular interest, the only interventions that achieved im-
visits for diabetes and other chronic conditions included provements in such patient outcomes as glycemic control
slightly more time for lifestyle and medication counseling were those that had a strong patient-oriented component.
than did acute illness visits, total average visit lengths were No specific intervention, if used alone, led to major im-
10.5 to 11 minutes versus 9.7 minutes, respectively. In provements in the quality of chronic illness care. The im-
258 4 February 2003 Annals of Internal Medicine Volume 138 • Number 3 www.annals.org
portance of patient educational and supportive interven- proved care processes and better outcomes. The current
tions found in the Cochrane diabetes review is consistent chronic care model and evidence underlying its compo-
with the growing body of literature demonstrating the pos- nents have been discussed recently elsewhere (47– 49).
itive effect of systematic efforts to increase patients’ knowl- The chronic care model posits that better outcomes
edge, skills, and confidence in managing their conditions result from productive interaction with medical care, in
(39, 40). which patients routinely receive the assessments, support
Recent reviews of research to improve the care of de- for self-management, optimization of therapy, and
pression in primary care practice have come to conclusions follow-up that are associated with good outcomes. Interac-
remarkably similar to those for diabetes (41, 42). For ex- tions are likely to be more productive if patients and their
ample, Callahan concluded that “achieving guideline-level families are active, informed participants in care (39). To
therapy requires the substantial participation of an in- ensure effective clinical and behavioral management, prac-
formed and motivated patient working in concert with a tice teams must have the necessary expertise, information,
health care team and health care system designed to care and resources to act rather than simply react. The challenge
for chronic conditions” (41). On the basis of their reviews then is to create a delivery system that promotes productive
of the research, Callahan (41) and Von Korff and col- interactions.
leagues (42) each proposed multicomponent models for The chronic care model includes enhancements to the
depression care that include system changes directed at ac- organization and its practices that contribute to productive
tivating the care system, clinicians, and patients and fami- interactions between clinicians and patients. Effective self-
lies. Callahan’s proposed system depends on trained, multi- management support and links to patient-oriented services
disciplinary primary care teams directed by guidelines, (for example, exercise programs, hospital chronic disease
performance feedback, and other decision support. These resources, and support groups) in the community (com-
teams ensure that patients receive support for self-manage- munity resources) help patients and families cope with the
ment, monitoring, and outreach. Von Korff and colleagues challenges of managing chronic illness. Successful practice
propose the use of the quite similar chronic care model teams use planned interactions with patients to ensure
(42). appropriate clinical and behavioral management and
One of the current authors, along with colleagues, in- follow-up (delivery system design). Clinical decisions are
dependently arrived at the need for a model to guide efforts aided by clear protocols and sufficient expertise (decision
to improve diabetes care at Group Health Cooperative in support) and access to timely patient and practice informa-
Seattle, Washington (43, 44). On the basis of the litera- tion (clinical information system). Making the necessary
ture, interventions were initially tried in a variety of areas, changes in these areas is difficult, if not impossible, without
such as registries, guidelines, and patient education, but strong leadership, appropriate incentives, and effective im-
without an overall vision for the optimal care system. The provement strategies (health care organization).
process of care for Group Health Cooperative’s 18 000 Several hundred health care organizations have used
diabetic patients improved while costs decreased (45). We the chronic care model as a guide to practice change in
then tried to categorize the practice enhancements that im- collaborative quality improvement programs that have ad-
proved patient outcomes and organize them in a way that dressed diabetes, congestive heart failure, asthma, depres-
would help guide quality improvement. Our initial catego- sion, cardiovascular disease, and arthritis. The experience
rization, like that of the Cochrane diabetes review (38), and lessons learned in these activities to date have been
included interventions directed at the clinician (guidelines, reported elsewhere (50). Both primary care and specialty
expert systems), patient (patient education), organization practices have been involved in these quality improvement
of care (practice redesign), and information systems. efforts. Our experience suggests that motivated practices of
This preliminary scheme was reviewed by a group of all specialties, sizes, and financial arrangements can make
advisors and revised (46). Expert systems and guidelines an integrated set of system changes in accord with the
were combined with other interventions to improve clini- chronic care model and that most that have done so have
cian expertise under a new rubric: decision support. Patient experienced improvements in the process and outcomes of
education became self-management support, reflecting re- care. A rigorous evaluation of these collaborative efforts is
search that shows that information transfer alone was in- under way (51).
adequate. Resources in the surrounding community, which
are often important to improving care for chronically ill
patients, were added. Overarching organizational factors, THE CARE TEAM
such as leadership, incentives, and quality improvement Most successful chronic illness interventions include
strategies, have a major influence on the structure and major roles for nonphysicians, and our quality improve-
functioning of practices and care. Finally, many advisors ment experience confirms the importance of such persons.
viewed the original framework or model as incomplete be- The appropriate deployment and use of practice teams
cause it did not indicate how organizational characteristics seem to be far more important to improving chronic illness
and practice system enhancements translated into im- care than physician specialty (52). Delegating responsibil-
www.annals.org 4 February 2003 Annals of Internal Medicine Volume 138 • Number 3 259
ity for key tasks in chronic illness care to nonphysician Requests for Single Reprints: Jonathan A. Showstack, PhD, MPH,
team members (for example, ensuring the completion of University of California, San Francisco, 3333 California Street, Suite
265, San Francisco, CA 94118-1944.
disease severity questionnaires, ordering protocol-driven
laboratory procedures, or frequent patient follow-up) in-
Current author addresses are available at www.annals.org.
creases the likelihood of task completion. However, other
papers in this supplement point out that physicians have
little training or experience with effective team practice and
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