Improving the management of chronic disease
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7405.12 (Published 03 July 2003) Cite this as: BMJ 2003;327:12All rapid responses
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Prof Kane makes a move in the right direction but could go further.
What is needed is to determine what causes those with chronic problems to
relapse. It may be that we need to look at health rather than disease.
What are the factors that cause deterioration?
Is drug usage implicated in illness - does medication interact or produce
adverse effects (for example dizziness) which lead to loss of welbeing.
Is the development of "illness" the only way that the elderly get
attention?
The sick model may be outmoded - we may need to concentrate on what
factors cause the change from just about coping to "ill" and intervene
before it is too late. Care staff rather than nursing staff may need the
training and the responsibility for this. They may also be able to supply
the solution in terms of more contact or encouragement or simple patient
advocacy!
Competing interests:
None declared
Competing interests: No competing interests
Dr. Kane has provided yet another splendid insight into American
Medical Care. Newer, organized systems of medical care focus on
transactions and episodes. This can only lead to heightened concern for
productivity and through-put. It is essential that we begin to consider
"career" costs and outcomes both for chronic and acute care.
Competing interests:
None declared
Competing interests: No competing interests
I applaud Dr Kanes initiative. Nursing homes make excellent
laboratories for new health services initiatives and research. Not only do
they have a mostly compliant patient base but also an in-house resident
staff that can provide a high level of surveillance, monitoring and
intervention. Having an advanced practice nurse or nurse practitioner who
can respond to episodic clinical need would seem to make intuitive sense
in the early management of a change in chronic disease state. Of course
the ability to effect significant change in clinical outcomes is based
partly on a higher mortality and shorter length of stay within the
nursing home population ( average length of stay was 2.1 years in the
Calgary region in 2001) . Our patients are coming in 'quicker and sicker'
as the popular aphorism goes. The more critical question to be addressed
is what are the individualized care and treatment wishes of our patients?
How will a specific treatment improve a patients quality of life and how
might it extend or diminish a patients remaining life? This of course is
not meant to imply clinical nihilism. We have witnessed many improvements
in clinical care in our nursing homes over the past 10 years for example
through more aggressive influenza outbreak policies , more critical anti-
psychotic use and a greater understanding of end of life dementia care.
The most pressing issues facing nursing homes today are those of
inadequate human resources across the sector, an aging workforce and a
cultural move away from facility based care. In other words the incentives
to work or reside in our facilities have changed. Long term care in many
ways is under siege and is now mostly the preserve of the most disabled
and the most needy. I would ask Dr Kane what the cost of his intervention
was in terms of staffing and staffing mix ( if presumably more intensive
care is required for that 50% who were not transferred) and where does the
clinical responsibility lie in regard to the attending physician staff and
the nurse practitioner? I would argue that we need greater physician
participation in this care not less to effect meaningful change for our
patients at the bedside and at the policy development level. As our
nursing home bed capacity grows at a slower rate than the population we
serve we are experiencing heavier personal and professional care needs and
even shorter lengths of stay. Avoiding hospital admission, therefore, is
increasingly a palliative choice not necessarily the result of earlier
clinical interventions from staff with advanced training or from in-house
medical staff.
My contention would be that chronic disease management needs to be
considered and initiated at an earlier age in the dementia and chronic
disease trajectory. I would suggest this occur in the community through
partnerships with community based nursing, enhanced specialist access,
decentralized clinics and through the leadership of family physicians and
general practitioners. In our demonstration projects in the Calgary region
we are using such models to provide support to family physicians where it
really
counts, in the community at the doctors offices. I propose that we
concentrate our efforts in this direction and look towards improving the
quality of life of our nursing home patients. Dr Rosalie Kane [1]
described parameters one might use to measure such quality of life in the
Gerontologist in 2001. She challenged the reader to consider quality of
life over quality of care in support of more meaningful patient based
care. In a climate of shrinking health care budgets and patient choice I
would advocate a greater emphasis on the dimensions of care she has
outlined i.e. dignity, privacy, autonomy, choice, meaningful activity,
relationships, comfort, enjoyment , individuality, functional competence,
sense of security, and spiritual well being. Furthermore I would suggest
that this may be preferred to a greater medicalization in the management
of chronic disease in the nursing home setting at the end of life.
[1] Kane RA. Long-term care and a good quality of life: bringing them
closer together. Gerontologist. 2001 Jun;41(3):293-304.
Dr Paddy Quail MB CCFP
Medical Director
Home Care
Calgary Health Region
403 221 4370
Competing interests:
None declared
Competing interests: No competing interests
Cost focus and clinical realities argue for such thoughts as
these. The excitement and heroism in acute care in the
vastly productive past century remain functionally poorly
schooled in chronic care management except in layering
pharmaceutical strategies. This simply isn't enough and is
often wrong-headed or only fractionally significant. The
genuine medical needs cost human time and attention. Less
gives a factory floor cold feeling to the process.
Competing interests:
None declared
Competing interests: No competing interests
not a case for private care
EDITOR- Richard Smith's News1 of Prof. Robert Kane's Evercare programme for the frail elderly needs to be examined critically.
In a closely related field, systems of care for psychiatric patients, often in sheltered accommodation, have been subject to controlled trials. Assertive Outreach2 is the latest of these, designed to support at home, to review regularly, and to avoid hospital admission by intensive home care when necessary. This has all been developed within the NHS, so that private healthcare is not necessary. Indeed, the PFI replacement of the Edinburgh Royal Infirmary3 has been so expensive that its early problems have affected the healthcare resources of the rest of Scotland4.
Another USA "Carve-out" program in Tennessee for psychotic patients5, designed to contain costs, led to a loss of the continuity of their antipsychotic therapy due to a lack of continuity of doctors and nurses employed by the programme, though other States may have done better.
Gareth H. Jones
retired consultant psychiatrist
Bryn Capel, Caerffili CF83 3DF.
gareth.jones1k@doctors.org.uk
1 Smith R. Improving the management of chronic disease.
BMJ 2003;327:12. (05 July.)
2 Burns T, Firn M. Assertive Outreach in Mental Health: a manual for
practitioners. Oxford: Oxford University Press, 2002.
3 Dunnigan M, Pollock A. Downsizing of acute inpatient beds
associated with private finance initiative.BMJ 2003;326: 905.
4 Black E. Inspection at new hospital reveals series of problems. The
Scotsman 2003: Mon 30 June.
5 Ray WA, Daugherty JR, Meador KG. Effect of a mental health "Carve-
out" program on the continuity of antipsychotic therapy. NEJM 2003;348:
1885-94.
Competing interests:
None declared
Competing interests: No competing interests