High quality care for people with chronic diseases

What patients with chronic conditions really need

What do patients with chronic conditions need? Worldwide, the straight answer must be a better life with freedom from poverty, hunger, and violence, and with the ability to read, work, and choose how many children to have. As for health, there is still much to do to prevent chronic disease through improving maternal and infant health, tackling infections, treating depression, cutting rates of smoking, and improving diet and levels of physical activity. These are big themes needing concerted responses, and all are debated regularly in the BMJ.

This week, however, the BMJ is homing in on the practicalities of what researchers, doctors, and nurses and—most importantly—patients can do to make living with chronic disease more rewarding. This is the fourth issue the BMJ has dedicated to the topic of managing chronic diseases (see http://bmj.com/misc/fcissues.shtml for previous issues). Why have we given so much space to this topic?

Firstly, chronic diseases are now the main cause of death and disability worldwide. According to the World Health Organization, non-communicable conditions, including cardiovascular diseases, diabetes, obesity, cancer, and respiratory diseases, now account for 59% of the 57 million deaths annually and 46% of the global burden of disease.1 Less developed countries now face a huge double burden of acute and chronic disease. For example, WHO estimates that the number of people with diabetes will have risen by 195% in India during 1995-2025 to reach 57.2 million, while Pakistan is expected to have about 14.5 million people with diabetes by 2025.^w1

Less developed countries are rising to this challenge, and the BMJ would like to publish much more evidence on managing chronic conditions in less developed countries. This week Ramaiya brings encouraging news on diabetes services in Tanzania,2 and Pruitt and Epping-Jordan discuss the essential changes to the training and practice of health workers that chronic disease care requires and which are already underway in countries such as Eritrea and Sudan.3 Tang, however, discussing hypertension and cardiovascular disease in China, brings a note of warning: what works in countries with well resourced health services may simply be too expensive.4

But there is also much more to be learned about coping with and managing these conditions in the richer world. Firstly, how can the quality of existing care for chronic diseases be improved? One strategy is to pay doctors for performing well in treating and monitoring chronic diseases, running well organised modern services, and involving patients in decisions in both planning and care. For the past 15 years British general practitioners have earned part of their pay through reaching certain clinical targets, and in the past year more than 20% of the previous primary care budget has been tied to providing high quality care for patients with the 10 most common and burdensome chronic conditions.^w2

The United States too is beginning to pay its doctors for better performance in managing chronic disease. A recent review identified 37 different programmes offering payment for high quality, sponsored principally by health insurance plans and employer coalitions.^w3 The Medicare programme for older people and those with disabilities is following suit.^w4

American programmes, as in the United Kingdom, mostly target both process and outcome measures, although only a minority include measures of patients' experiences of care. Programmes generally reward level of performance, not improvement in performance. What happens to less well performing practices, whose reimbursements may actually diminish, and their patients is worrisome. In most American programmes less than 5% of a doctor's total compensation is tied to performance, so the impacts may be less negative or, for that matter, less positive than feared. Almost nothing has been reported yet about the impact on patients of these pay-for-performance programmes. They do seem to be encouraging larger medical groups to invest in practice enhancements, however.^w5 This week DiPiero and Sanders go one step further and suggests paying by fee-for-condition, a more balanced approach to risk that adjusts the payment for the severity of the condition and rewards superior results.5

Articles in this week's BMJ look more closely at what comprises and sometimes compromises high quality care. Glaziou et al warn that although monitoring patients' clinical progress is an essential and major component of care for chronic illness, it can too easily become a ritual with the potential to mislead clinicians, contribute little to the patients' understanding of their illness, and waste everyone's time and resources.6 And what about the different roles that doctors and nurses play in managing chronic diseases? Three articles this week argue that professional skills are too often used ineffectively or inappropriately.7^–9

Most importantly, health professionals still have much to learn from patients about their needs.10 Four years ago the US Institute of Medicine called for healthcare systems that respect patients' values, preferences, and expressed needs; coordinate and integrate care across boundaries of the system; provide the information, communication, and education that people need and want; and guarantee physical comfort, emotional support, and the involvement of family and friends.^w6 There is still a lot of work to do to achieve these ideals.