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Current System for Handling Chronic Diseases is Crippling Primary Care, Study Finds

Posted on: Tuesday, 2 August 2005, 12:01 CDT

Primary care physicians, faced with an aging population and an increase in chronic diseases, are overwhelmed by the needs of patients with diseases such as high blood pressure, heart disease and diabetes, according to a Duke University Medical Center study. The researchers call for an overhaul of treatment guidelines and new approaches to the care and management of patients with chronic diseases.

"For the physician who thinks she is overwhelmed, and for the patient who feels like he hasn't had enough time with his doctor, we're here to say 'Youre right.' There's not enough time," says Kimberly Yarnall, M.D., associate professor of Duke's department of community and family medicine.

The study, published in the May/June 2005 issue of the Annals of Family Medicine, found that the growing strain of chronic diseases on the health care system leaves little time for preventive care, acute care or other medical concerns.

The researchers say the health care system should support appropriate alternatives to costly one-on-one sessions between patients and a doctor. Such new approaches should emphasize a team approach among caregivers and could include group classes on disease management, videos that educate patients about diseases and treatments, online support groups for the psychological and emotional toll that some diseases bring, providermonitored chat rooms for patients with questions, and print materials that patients could read in their homes. The researchers cite insurance reimbursement as a major barrier for enacting such practices.

"The primary care system is at a crossroads," says Lloyd Michener, M.D., chair of Duke's department of community and family medicine and senior author of the paper. "We are estimating a physician shortage in the next 10 to 15 years, but the demand for services continues to increase. The status quo is not going to work much longer-it's not working now?'

Michener says the bulk of chronic disease management falls to primary care physicians. Many patients have multiple chronic diseases and prefer not to visit separate specialists whose insurance co-pays are typically more expensive than those for primary care physicians.

Researchers studied the time constraints attached to 10 chronic diseases: high cholesterol, high blood pressure, depression, asthma, diabetes, arthritis, anxiety, chronic obstructive pulmonary disease, osteoporosis and coronary artery disease. They occur widely and are among the main causes of death and illness in the U.S. population. Measures of national prevalence and published clinical guidelines also exist for the diseases.

To study the time required for chronic care, the researchers modeled a representative primary care practice. Using 2001 Census Bureau data, they assigned 2,500 "virtual patients" with appropriate ages (including children) and age-specific occurrence of diseases that match those of the general population. In the model, the family physician adhered completely to available guidelines for every patient.

The researchers allowed 10 minutes per chronic disease per patient, a conservative estimate considering other studies showing the average office visit per patient lasting 18 to 21 minutes. The number of visits per patient was dictated first by the average number of visits recommended by guidelines for the follow-up of stable disease, and then by the follow-up required for uncontrolled disease.

The study showed that chronic disease management would take 3.5 hours out of the physicians day, provided all of the patients are stable and their diseases are in good control. When recalculated to allow for both controlled and uncontrolled disease, the amount of time the physician needed for chronic disease management almost tripled to 10.6 hours per day.

"Our estimates are not based on how much time is currently spent on chronic disease in practice, but on how much time is required to meet current guideline recommendations," says Truls Ostbye, M.D., professor of community and family medicine and lead author of the paper. "The time requirements implied by the guidelines are overwhelming and cannot be met in a realworld practice."

Ostbye notes that guidelines for chronic diseases are usually written by specialists and focus on one disease area without regard to the time it would take to complete the guidelines. Guidelines also rarely consider comorbidities, or diseases that often go hand- in-hand, such as diabetes and heart disease.

The researchers suggest that expert panels write guidelines collaboratively, and that the guidelines include diseases that are highly correlated

Michener says the solution to the problem of inadequate time for comprehensive patient care lies in creating a new health care model that uses a team of caregivers. The model would include nurse practitioners, physician's assistants, nutritionists and health educators, who would take the lead in preventive care, patient education and routine chronic disease management.

The researchers further suggest that more informed and proactive patients would also help ease time constraints.

"When disease was controlled, we saw the required physician time drop from 10.5 hours to 3.5 hours," Ostbye says." Patients are a vital part of the solution. They need to come to the doctor before they get seriously ill. They must come in for follow-up visits so their care stays on track. And they will benefit greatly from educating themselves about their disease, so they understand their care and know when something is wrong."

Copyright Health Forum Inc. Jul 2005

Source: Hospitals & Health Networks

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