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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, amednews 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.

Works well with doctor?
Getting everyone on the same page
Why women stop hormonal birth control
Hormones out of favor but birth control needs remain
Treatment tips
Research findings
Links
See related content

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.

51% of pregnancies among women in their 40s were unintended.

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."

The key to proper management is not to take over for patients but to make them integral players in their care, Dr. Scherger said.

This goal can be achieved in different ways and with different tools, he said. In a poor area of California, community health workers visit patients at home to educate them and make sure they are taking their medications. In Dr. Wagner's model, patients were contacted via the telephone. And he found that disease control soared from about 25% of patients to 75% and 80%.

Others may find success in group visits. Edward J. Shahady, MD, medical director for the diabetes master clinician program, an initiative of the Florida Academy of Family Physicians Foundation, conducts group visits and has trained many Florida physicians to do the same.

He believes such visits are the wave of the future. He chose diabetes as a kick-off for this approach because the disease is complex and could serve as the "poster child for other chronic diseases." Dr. Shahady shared some of his lessons learned with physicians at the conference.

75% of patients with depression go untreated.

Patients likely fall into one of three groups, he said. There are the exemplary patients who watch their diets, exercise and have their disease under good control. They probably don't need to come in for group visits -- although a few could serve as examples to the others. Other patients might lack transportation and would find it difficult to attend meetings. But there is a third group who are struggling with adequate control and could benefit from the additional contact with physician, staff and others who face the same challenges.

And patients do seem to benefit. "I won't feel alone with this condition," one patient told him. "I like the group visits because you learn so much from other people with diabetes," another said.

Charting these measures, whether with an electronic medical record or paper, is a good indicator of progress for physicians as well as patients, said Bruce Bagley, MD, AAFP's medical director for quality improvement.

The measures also could provide the evidence that a physician practices quality medicine, Dr. Bagley said.

ADDITIONAL INFORMATION:

Works well with doctor?

Patients can help track their satisfactory progress and see where they need improvement with report cards developed by Edward J. Shahady, MD, medical director for the diabetes master clinician program, an initiative of the Florida Academy of Family Physicians Foundation. Patients at group visits to his practice are given a personalized card, helping involve them in their own care.

Getting everyone on the same page

Group visits for patients with the same chronic condition can cover a lot of disease management basics efficiently. For diabetes, for example, sessions can focus on diet, exercise, hypertension or foot care. Edward J. Shahady, MD, medical director of a diabetes master clinician program, offered these tips:

Prepare your office staff and explain the group visit will replace some routine visits.
Plan for the session to last about 2½ hours.
Invite about 10 patients; family members welcome.
Set the date well in advance to avoid scheduling conflicts.
Schedule a meeting every one to three months.
Spend the first 15 to 30 minutes taking vital signs and completing questionnaires. Plan for staff to speak for about an hour and for the physician to join in the second hour. Take the last 15 to 30 minutes to complete paperwork.

Why women stop hormonal birth control

Some of the reasons given:

Side effects	37%
No further need	23%
Method difficulty	14%
Clinician recommended	9%
Other	17%
Total	100%

Source: The American Journal of Obstetrics and Gynecology, September 1998

Hormones out of favor but birth control needs remain

Hormone-based birth control should continue to be an important option for women older than 40 -- but all too often, it's not, said presenters at the American Academy of Family Physicians' annual scientific assembly.

The 2002 findings of the Women's Health Initiative cast a pall over the use of hormones. More recent controversies connecting Depo-Provera and bone loss as well as the Ortho Evra patch with thromboembolic events keep these medications in the headlines.

But there also has been an increase in the number of unintended pregnancies among women in this age group, said Jeffrey P. Levine, MD, MPH, associate professor and director of women's health programs at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School.

Women in their 40s still need contraception, he said. Fifty-one percent of pregnancies in this group are unintended, and 65% of these end in abortion.

This should spur discussions with patients about available hormonal contraceptives, Dr. Levine said. Options include oral estrogen/progestin, oral progestin, transdermal patch, intravaginal ring and injectable, intrauterine and implantable progestin.

To trim the time needed to counsel patients on which one and at what dose, Dr. Levine suggested asking about the patient's needs, performing a risk factor assessment, determining the acceptability and commitment to a method and planning a follow-up visit. He also recommends keeping up with the research in this fast-moving field.

An important factor to weigh in is research showing women older than 35 who smoke have a significantly higher risk of myocardial infarction from oral contraceptives than do nonsmokers, said Cheryl Lambing, MD, assistant clinical professor of family medicine at the University of California, Los Angeles. She co-presented with Dr. Levine at the assembly. The risks appear to be the same for the other routes of hormone administration. The bottom line is to tell women to stop smoking, Dr. Lambing said in an interview.

Research also shows that while the risk of venous thromboembolism increases with use of oral contraceptives -- 15 cases per 100,000 users compared with four per 100,000 nonusers -- pregnancy carries an even greater risk of 60 cases per 100,000.

Women who are more likely to be satisfied with hormonal contraceptives tend to be more satisfied with their physicians, have used the same or a similar method and experienced few side effects, are aware of transient side effects and are aware of noncontraceptive benefits, Dr. Levine said.

These benefits can include menstrual regulation and suppression and reduction of pain from fibroids and polyps, he noted. Hormones also might help with premenstrual symptoms that are exacerbated during perimenopause.

In addition, vaginal atrophy can occur even during the premenopausal years, he said. This, and sexual dysfunction, also can be helped hormonally.

Treatment tips

Here are some treatment tips from the meeting:

Heart disease predictors. Since half of all ischemic heart disease occurs in patients with low LDL, physicians could consider ordering additional tests to pinpoint who is vulnerable and requires treatment. Some potentially useful tests include high-sensitivity C-reactive protein, homocysteine and apolipoprotein B, said John Holman, MD, MPH, a U.S. Navy captain in the Camp Pendleton, Calif., Dept. of Family Medicine, during the meeting's lecture series.

Allergy woes. The allergy march begins in infancy, said Leonard Fromer, MD, assistant clinical professor of family medicine at the University of California, Los Angeles. Up to 40% of daily visits to primary care physicians are from patients with allergic symptoms and physicians should be ready to administer tests for triggers, he said.

Osteoporosis risk. Testing for low bone mineral density is still an underused diagnostic tool despite the fact that 10 million Americans have osteoporosis, said Cheryl Lambing, MD, assistant clinical professor of family medicine at the University of California, Los Angeles.

Doctors were cautioned that dual-energy x-ray absorptiometry scans should be checked to ensure the spine was well-centered, vertebrate correctly labeled and hips rotated properly.

Treating patients with disabilities. Nearly all people with developmental disabilities have at least one medical condition, said Robert Baldor, MD, professor of family medicine and community health at the University of Massachusetts Medical School. Common co-morbidities include seizure, movement disorders, visual and auditory impairments, and constipation.

Research findings: Natural therapies for menopause; detecting postpartum depression

A review of more than 100 studies and related guidelines regarding the multitude of "natural" therapies taken by postmenopausal women revealed little evidence that any of them work to suppress a chief complaint -- hot flashes.

Walter L. Larimore, MD, assistant clinical professor of family medicine at the University of Colorado's Health Sciences Center, reviewed the material available and concluded that no therapy is more effective than conventional hormones. However, since many women are reluctant to take hormones, physicians are left scrambling for other ways to help.

Dr. Larimore presented his findings during the American Academy of Family Physicians' annual scientific assembly.

Lifestyle modifications that include daily exercise, healthy diet and smoking cessation can provide some relief, said Dr. Larimore. Phytoestrogens -- isoflavones, lignans or coumestans -- are the most frequently used natural therapies. Although they are likely safe for most women, patients with risk factors for breast cancer should be cautioned to avoid concentrated supplements and excessive consumption of foods that contain this product. Patients on warfarin should also be cautious about adding soy to their diets, he said.

Meanwhile, in a prize-winning paper, Kyla Carney, DO, and Jessica Yoakam, MD, both residents at the Mercy/Mayo Family Medicine Residency Program in Des Moines, examined postpartum depression programs offered in Iowa hospitals.

The physicians found about 3% of hospitals had a standard screening tool for new mothers, although postpartum depression occurs in 10% to 15% of this population.

In another session, Theodore G. Ganiats, MD, professor of family and preventive medicine at the University of California, San Diego, presented the highlights of new heart failure guidelines that portray the disease as a complex, progressive illness.

The guidelines, released last year by the American Heart Assn. and the American College of Cardiology, indicate that heart failure moves along a spectrum from asymptomatic in its first two stages to symptomatic in its last two stages. Family physicians were advised to intervene early. During the first stage, recommendations for weight loss, smoking cessation and moderation of alcohol intake are important. The second stage could be treated with an ACE inhibitor, beta-blockers or angiotensin receptor blockers.