Chronic Disease Battle
Requires Better Tools
THE DOCTOR'S OFFICE
By BENJAMIN BREWER, M.D.
September 4, 2008
The lab results didn't look good. My 57-year-old patient's blood sugar was high. He was obese and already on cholesterol medication.
My diagnosis was metabolic syndrome, an assortment of risk factors that is often a precursor to heart disease and diabetes.
His was the third case I'd come across that week.
The chronic disease epidemic is upon us. Patients with health problems are younger and fatter. I had to buy a heavy-duty scale last year to replace the one I started in practice with a decade ago. I have more obese patients now and needed something accurate up to 400 lbs.
When I was growing up, nearly half the kids in this country walked or rode their bikes to school. By the early part of this decade, the figure had dropped to about 15%. Meanwhile, the proportion of kids who are seriously overweight has climbed, with 16% of kids in the 95th percentile or higher on a measure of body mass, according to the Centers for Disease Control and Prevention.
Certainly there is more we can do to help ourselves. We can be active with our kids. We can exercise more and eat less.
The biggest challenge in primary-care medicine is dealing with the complications of obesity, diabetes and hypertension.
We have drugs to treat the conditions. But we don't have potent enough public health measures, patient education and follow-up monitoring to avoid the heart attacks, strokes and chronic kidney problems that come with the modern disease territory.
At my office we use a disease registry to track our patients with diabetes, heart disease and high blood pressure. We use it to generate recall lists of people who are overdue for follow-up visits or lab tests. Most veterinary offices do that routinely, but not enough medical offices.
In an insurance-driven world where a high volume of office visits is the only practical way to earn a living, managing patients with multiple chronic diseases is a money loser. Seeing four patients over the course of an hour pays much better than helping a patient with complex problems for a full 60 minutes.
My office has invested heavily in an electronic medical record to track and monitor chronic conditions with little financial return.
Still, the system helped me notice that a patient's control of his diabetes had been slipping for a year. Repeating the mantra of diet and exercise wasn't getting us anywhere. He would promise to do better, yet the results never improved.
Adding more pills over the last year wasn't improving his blood sugar either. It was time for a radical lifestyle adjustment or the start of insulin. He wasn't happy about either option but reluctantly agreed to give insulin a go.
He has been coming into the office about four times a year. And his employer-based insurance was paying for his visits, but missing work to make appointments with me during normal business hours was costing him his attendance bonus and undermining my efforts to get tighter control of his diabetes.
We got around that by using email. He started sending me spreadsheets of his blood sugars every few days, and I gave him advice for adjusting his insulin and diet when he got off track. His blood sugar came down to near normal within two weeks.
Managing chronic diseases between visits is uncompensated work for doctors, yet the need for such care is huge.
The current financial disincentives to providing proper care for chronic disease are daunting, and the waste created by ignoring the problem is growing as the population ages.
Teaching patients to take care of themselves effectively should be paramount because it works. It's also cheap compared with a lifetime of drugs. Self-management makes all the difference in preventing long-term complications or avoiding a disease in the first place.
Most people have some gaps in their knowledge and lack confidence in managing aspect of their own care. Tools to help patients are scattered, incomplete and often lack relevant details.
Online sites, like WebMD and others, help with general information. But they only go so far. I've found patients need specific information tailored to their condition. How much weight should I lose to make a difference in my blood pressure? What exercise makes sense for me? What should my heart rate be? What foods should I buy at the store? How do I prepare those foods in a hurry?
A 15-minute office visit with me isn't enough time to deal with the sheer volume of important information. And in any event, patients don't often remember more than a few key items from any visit.
It's too easy for the doctor to just write a prescription and avoid the tougher work of digging deeper into the reasons why a patient isn't making progress. We need some new approaches to wellness and ways to align the incentives for patients and doctors to work together toward health.
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