Chronic care toolkit (AAFP annual scientific assembly)

Logs of patient progress, support for self-care and connections to community resources can improve disease management.

By Susan J. Landers, AMNews staff. Nov. 20, 2006.

Reports from conferences important to physicians

Physicians' waiting rooms fill with patients who have chronic medical conditions -- diabetes, arthritis, heart disease, depression, pain. But today's medical system is geared up to treat acute conditions.

It's time for system change, said physicians at the American Academy of Family Physicians' annual scientific assembly held in Washington, D.C., Sept. 27 to Oct. 1.

Granted, doctors have been taking care of patients with chronic illnesses for a long time, said Theodore Ganiats, MD, professor of family and preventive medicine at the University of California, San Diego. "But the data show we aren't doing a very good job."

For example, only 27% of patients with hypertension are adequately controlled, and only 25% of those with depression are treated.

"It's not because we don't care, or aren't hard working or we don't know what we're doing, but it's that the systems we are functioning in are not the most efficient," he said.

A panel of physicians led by Dr. Ganiats discussed ways to bring those systems in line with the goal: chronic illness management. They used a model developed in 1998 by Edward Wagner, MD, MPH, director of the MacColl Institute for Healthcare Innovation in Seattle, as a framework to establish high-quality, patient-centered chronic disease care. The model weaves together the use of community resources, the reorganization of office systems and support for patients.

Chronic disease care is about what takes place between office visits, said Joseph Scherger, MD, MPH, professor of family and preventive medicine at the University of California, San Diego. "Patients with chronic illness live with chronic illness every day. And every day a diabetic patient makes several decisions about what they are going to do about their diabetes."