Outpatient Management of

Study Selection: T w o reviewers used eligibility criteria to assess all
titles, abstracts, and full texts and resolved disagreements by discussion or by consulting a third reviewer.
Data Extraction: O ne review er did data abstractions and quality
assessments, w hich were confirm ed by a second reviewer.
Data Synthesis: From 29 54 studies, 18 w ere included. A ll studies
used a registered nurse o r equivalent w h o titrated m edications by
fo llo w in g a protocol. In a meta-analysis, hem oglobin A 1c level decreased by 0 .4 % (95% Cl, 0.1 % to 0 .7 % ) (n = 8); systolic and
diastolic blood pressure decreased by 3.68 m m Hg (Cl, 1.05 to
6.31 m m Hg) and 1.56 m m H g (Cl, 0.36 to 2.76 m m Hg),
respectively (n = 12); total cholesterol level decreased by 0.24
m m o l/L (9.37 m g/dL ) (Cl, 0 .5 4 -m m o l/L decrease to 0 .0 5 -m m o l/L
increase [2 0 .7 7 -m g /d L decrease to 2 .0 2 -m g /d L increase]) (n = 9);
and low -density-lipoprotein cholesterol level decreased by 0.31
m m o l/L (12.07 m g/dL ) (Cl, 0 .7 3 -m m o l/L decrease to 0 .1 1 -m m o l/L
increase [2 8 .2 7 -m g /d L decrease to 4 .1 3 -m g /d L increase]) (n = 6).
Limitation: Studies had lim ited descriptions o f the interventions and
protocols used.
Conclusion: A team approach th a t uses nurse-m anaged protocols
m ay have positive effects on the ou tpatie nt m anagem ent o f adults
w ith chronic conditions, such as diabetes, hypertension, and
hyperlipidem ia.
Primary Funding Source: U.S. D epartm ent o f Veterans Affairs.
Ann Intern Med. 2014;161:113-121. doi:10.7326/M13-2567 www.annals.org
For author affiliations, see end of text.
edical management of chronic illness consumes 75%
of every health care dollar spent in the United States
(1). Thus, provision of economical and accessible—yet
high-quality—care is a major concern. Diabetes mellitus,
hypertension, and hyperlipidemia are prime examples of
chronic diseases that cause substantial morbidity and mortality (2, 3) and require long-term medical management.
For each of these disorders, most care occurs in outpatient
settings where well-established clinical practice guidelines
are available (4—7). Despite the availability of these guidelines, there are important gaps between the care recommended and the care delivered (8-10). The shortage of
primary care clinicians has been identified as 1 barrier to
the provision of comprehensive care for chronic disease
(11, 12) and is an impetus to develop strategies for expanding the roles and responsibilities of other interdisciplinary
team members to help meet this increasing need.Outpatient Management of Adults With Chronic Conditions Essay
The patient-centered medical home concept was developed in an effort to serve more persons and improve
chronic disease care. It is a model of primary care transformation that builds on other efforts, such as the chronic
care model (13), and includes the following elements:
patient-centered orientation toward the whole person,
team-based care coordinated across the health care system
and community, enhanced access to care, and a systemsbased approach to quality and safety. Care teams may include nurses, primary care providers, pharmacists, and bewww.annals.org
havioral health specialists. An organizing principle for care
teams is to utilize personnel at the highest level of their skill
set, which is particularly relevant given the expected increase in demand for primary care services resulting from
the Patient Protection and Affordable Care Act.
With this increased demand, the largest health care
workforce, registered nurses (RNs), may be a valuable asset
alongside other nonphysician clinicians, including physician assistants, nurse practitioners, and clinical pharmacists, to serve more persons and improve chronic disease
care. Robust evidence supports the effectiveness of nurses
in providing patient education about chronic disease and
secondary prevention strategies (14-19). With clearly defined protocols and training, nurses may also be able to
order relevant diagnostic tests, adjust routine medications,
and appropriately refer patients.
Our purpose was to synthesize the current literature
describing the effects of nurse-managed protocols, includSee a lso :
E d ito ria l c o m m e n t……………………………………………………………153
W e b -O n ly
S u p p le m e n ts
C M E q u iz
15 July 2014 Annals of Internal Medicine I Volume 161 • Number 2 [ 113
R e v i e w Nurse-Managed Protocols in Managing Outpatients With Chronic Conditions
Figure 1. S u m m ary o f ev id en ce search and selectio n .
In c lu d e d (n = 2 0 )
U n iq u e s tu d ie s : 1 8
C o m p a n io n a rtic le s : 2 *
* Methods or follow-up articles.
ing medication adjustment, for the outpatient management of adults with common chronic conditions, namely
diabetes, hypertension, and hyperlipidemia.Outpatient Management of Adults With Chronic Conditions Essay
M e t h o d s
We followed a standard protocol for all steps of this
review. A technical report that fully details our methods
and presents results for all original research questions
is available at www.hsrd.research.va.gov/publications/esp
D a t a S o u rc e s a n d S e a rc h e s
In consultation with a master librarian, we searched
MEDLINE (via PubMed), Cochrane Central Register of
Controlled Trials, EMBASE, and CINAHL from 1 January 1980 through 31 January 2014 for English-language,
peer-reviewed publications evaluating interventions that
compared nurse-managed protocols with usual care in
studies targeting adults with chronic conditions (Supplement 1, available at www.annals.org).
We selected exemplary articles and used a Medical
Subject Heading analyzer to identify terms for “nurse protocols.” We added selected free-text terms and validated
search terms for randomized, controlled trials (RCTs) and
quasi-experimental studies, and we searched bibliographies
of exemplary studies and applicable systematic reviews for
missed publications (15, 17, 20-29). To assess for publication bias, we searched ClinicalTrials.gov to identify completed but unpublished studies meeting our eligibility
criteria.Outpatient Management of Adults With Chronic Conditions Essay
S tu d y S e le c tio n , D a t a E x tr a c tio n , a n d Q u a li t y
A s s e s s m e n t
Two reviewers used prespecified eligibility criteria to
assess all titles and abstracts (Supplement 2, available at
1 1 4 15 July 2014 Annals of Internal Medicine Volume 161 • Number 2
www.annals.org). Eligibility criteria included the involvement of an RN or a licensed practical nurse (LPN) functioning beyond the usual scope of practice, such as adjusting medications and conducting interventions based on a
written protocol. Potentially eligible articles were retrieved
for further evaluation. Disagreements on inclusion or exclusion were resolved by discussion or a third reviewer.
Studies excluded at full-text review are listed in Supplement 3 (available at www.annals.org). Abstraction and
quality assessment were done by 1 reviewer and confirmed
by a second. We piloted the abstraction forms, designed
specifically for this review, on a sample of included articles.
Key characteristics abstracted included patient descriptors,
setting, features of the intervention and comparator, match
between the sample and target populations, extent of the
nurse interventionist’s training, outcomes, and quality elements. Supplements 4 and 5 (available at www.annals.org)
summarize quality criteria and ratings, respectively.
Because many studies were done outside the United
States, we queried the authors of such studies about the
education and scope of practice of the nurse interventionists. Authors were e-mailed a table detailing the credentialing and scope of practice of various U.S. nurses and asked
to classify their nurse interventionist.
D a t a S y n th e s is a n d A n a ly s is
The primary outcomes were the effects of nursemanaged protocols on biophysical markers (for example,
glycosylated hemoglobin or hemoglobin Alc [HbAlc]), patient treatment adherence, nurse protocol adherence,
adverse effects, and resource use. When quantitative synthesis (that is, meta-analysis) was feasible, dichotomous
outcomes were combined using odds ratios and continuous
outcomes were combined using mean differences in
random-effects models. For studies with unique but conceptually similar outcomes, such as ordering a guidelineindicated laboratory test, we synthesized outcomes across
conditions if intervention effects were sufficiently homogeneous. We used the Knapp and Hartung method (30, 31)
to adjust the SEs of the estimated coefficients.
For categories with several potential outcomes (for example, biophysical markers) that may vary across chronic
conditions, we selected outcomes for each chronic condition a priori: HbAlc level for diabetes, blood pressure (BP)
for hypertension, and cholesterol level for hyperlipidemia.
In 1 example (32), we imputed missing SDs using estimates from similar studies.
We computed summary estimates of effect and evaluated statistical heterogeneity using the Cochran Q and I 2
statistics. We did subgroup analyses to examine potential
sources of heterogeneity, including where the study was
conducted and intervention content. Subgroup analyses involved indirect comparisons and were subject to confounding; thus, results were interpreted cautiously. Publication
bias was assessed using a ClinicalTrials.gov search and funw w w .an n als.org Outpatient Management of Adults With Chronic Conditions Essay
E x c lu d e d a t th e t it le /a b s t r a c t
le v e l (n = 2 6 1 5 )
E x c lu d e d (n = 3 1 9 )
N o t E n g lis h , w e s te r n iz e d c o u n try ,
o r f u ll p u b lic a tio n : 5 5
N o a d u lts w it h d is e a s e o f in te r e s t
o r c o n d u c te d in a n o u t p a t ie n t
m e d ic a l s e ttin g : 2 9
In e lig ib le s tu d y d e s ig n o r
c o m p a ra to r : 7 5
N o in te r v e n tio n o f in te r e s t: 1 5 3
N o o u tc o m e o f in te r e s t: 7
S e a rc h re s u lts o f
re fe re n c e s (n = 2 9 5 4 )
R e tr ie v e d fo r
f u l l- t e x t r e v ie w
(n = 3 3 9 )
Nurse-Managed Protocols in Managing Outpatients With Chronic Conditions R e v i e w
nel plots when at least 10 studies were included in the
When quantitative synthesis was not feasible, we analyzed data qualitatively. We gave more weight to evidence
from higher-quality studies with more precise estimates of
effect. The qualitative syntheses identified and documented
patterns in efficacy and safety of the intervention across
conditions and outcome categories. We analyzed potential
reasons for inconsistency in treatment effects across studies
by evaluating variables, such as differences in study population, intervention, comparator, and outcome definitions.
We followed the approach recommended by the
Agency for Healthcare Research and Quality (33) to evaluate the overall strength of the body of evidence. This
approach assesses the following 4 domains: risk of bias,
consistency, directness, and precision. These domains were
considered qualitatively, and a summary rating of high,
moderate, low, or insufficient evidence was assigned.
Role o f th e Funding Source
The Veterans Affairs Quality Enhancement Research
Initiative funded the research but did not participate in the
conduct of the study or the decision to submit the manuscript for publication.
R e s u l t s
Our electronic and manual searches identified 2954
unique citations (Figure 1). O f the 23 potentially eligible
studies, 4 were excluded because we could not verify
whether nurses had the authority to initiate or titrate medications and the author did not respond to our query for
clarification (34—37). We excluded a trial of older adults in
which we could not differentiate the target illnesses (38).Outpatient Management of Adults With Chronic Conditions Essay
Approximately two thirds of the authors we contacted for
missing data or clarification responded.
We included 18 unique studies (23 004 patients) that
focused on patients with elevated cardiovascular risk (Table) (32, 39-55). O f these, 16 were RCTs and 2 were
controlled before-and-after studies on diabetes (49, 53).
The comparator was usual care in all but 1 study, in which
a reverse-control design was used, and each intervention
served as the control for the other. Eleven studies were
done in Western Europe and 7 in the United States. Median age of participants was 58.3 years (range, 37.2 to 72.1
years) based on 16 studies. Approximately 47% of the participants were female. Race was not reported in 84% of the
studies. Supplement 5 gives detailed study characteristics.
No outstanding studies were identified through ClinicalTrials.gov. Supplement 6 provides funnel plots that assess
publication bias (available at www.annals.org).
Overall, these studies displayed moderate risk of bias.
Two studies were judged as having a high risk of bias
because of inadequate randomization (44, 53), 12 were
moderate risk (32, 39 -4 1 , 43, 47-52, 54), and 4 were low
risk (42, 45, 46, 55). Other design issues affecting risk-ofbias ratings were possible contamination from a concurrent
Table. Study and Patient Characteristics of Included
Diabetes, Hypertension, and Hyperlipidemia Studies
Characteristic Cardiovascular Risk
Studies, n (%)
Studies 18
Patients* 23 004
RCT 16 (89)
Non-RCT 2(11 )
United States 7(39 )
Western Europe 11 (61)
General medical hospital 12 (67)
Specialty hospital 3 (17)
Primary clinic and specialty hospital 2 (11 )
Telephone- and clinic-delivered care 1 (5.5)
Glucose 15 (83)
Blood pressure 11 (61)
Lipids 9 (5 0 )
Clinic visits 15 (83)
Primarily telephone 3 (17 )
6 mo 2 (11 )
12 mo 8 (44.5)
> 1 2 m o t 8 (44.5)
Nurse training
Specialist* 3(17 )
Received study-specific training 10 (55)
Case manager 1 (5.5)
Not described 4 (2 2 )
M edication initiation 11 (61)
Education or behavioral strategy
Education 16(89)
Specific behavioral strategy! 3 (17 )Outpatient Management of Adults With Chronic Conditions Essay
Self-management plan 9 (5 0 )
O utcom e
Hemoglobin A1c level 12 (67)
Blood pressure 14 (78)
Cholesterol level 15(83)
Performance measure 13 (72)
Behavioral adherence 4(22 )
Protocol adherence 1 (6)
Risk of bias/quality
Low/good 4 (22 )
M oderate/fair 12 (67)
H igh/poor 2 (11)
RCT — randomized, controlled trial.
* Number of patients represents the total mean of 22 839 and 23 170 because in
1 included study (30), hypertension and hyperlipidemia results were reported on 2
different but overlapping populations due to randomization,
t Range, 14-36 mo.
$ Clinical certification or diabetes nurse educator.
§ Motivational interviewing.
www.annals.org 15 July 2014 Annals of Internal Medicine Volume 161 •Number 2 115
R e v i e w Nurse-Managed Protocols in Managing Outpatients With Chronic Conditions
F ig u r e 2 . Effects of nurse-managed protocols on hemoglobin A1c level.
Study, Year (Reference) Nurse Protocols Total, n Usual Care Total, n
Mean (SD) Mean
A u be rteta l, 1998(40) 7.10 (1.33) 51 8.20
Bellary et al, 2008(42) 8.20 (1.74) 868 8.35
Houweling et al, 2009 (47) -1.50 (1.35) 46 -0.90
Houweling et al, 2011 (46) -0.09 (1.07) 102 0.03
MacMahon et al, 2009 (48) -0.34 (0.97) 94 0.12
O’Hare et al, 2004 (52) -0.23 (1.42) 182 -0.20
Taylor et al, 2003 (32) -1.14 (1.35) 61 -0.35
Wallymahmed et al, 2011 (54) 9.30 (1.40) 40 9.70
Summary (/2 = 69.8%)
Weighted Mean
(95% Cl), %
-1.10 (-1.62 t o -0.58)
-0.15 (-0.33 to 0.03)
-0.60 (-1.15 t o -0.05)
-0.12 (-0.43 to 0.19)
-0.46 (-0.74 t o -0.18)
-0.03 (-0.34 to 0.28)
-0.79 (-1.24 t o -0.34)
-0.40 (-0.99 to 0.19)
-0.40 (-0.70 t o -0.10)
intervention, unblinded outcome assessors, and incomplete
outcomes data.
Characteristics of the Interventions
All 18 study interventions used a protocol and required the nurse to titrate medications; however, only 11
reported that the nurse was independently allowed to initiate new medications. All but 1 study (55) provided the
actual algorithm or citation. An RN (not an advanced
practice RN) was the interventionist in all U.S. studies; a
nurse with an equal scope of practice was the interventionist in the non-U.S. studies. Outpatient Management of Adults With Chronic Conditions Essay  No studies reported use of
LPNs. In 14 studies, interventions were delivered in a
nurse-led clinic (39-42, 44, 46-54). Supervisors were
nearly always physicians. O f the studies reporting nurses’
training, 3 used specialists (for example, diabetes-certified),
10 used RNs with study-specific training, and 1 used nurse
case managers with experience in coordinating long-term
Nurse protocols included additional components, such
as education or self-management, in 16 studies. Two studies (41, 47) did not report additional intervention. Baseline
characteristics showed that patients with diabetes had an
elevated HbAlc level of approximately 8.0% or greater.
Most patients with hypertension had moderate hypertension, and patients with hyperlipidemia had borderline high
lipid levels. Outcomes were assessed at 6 to 36 months,
with most studies reporting outcomes at 12 months or
Diabetes Outcomes
O f the 15 studies done in patients with diabetes, 10
RCTs (2633 patients) targeted glucose control. Figure 2
shows the forest plot of the random-effects meta-analysis
on HbAlc level. Compared with usual care, nurse-managed
protocols decreased HbAlc levels by 0.4% (95% Cl, 0.1%
to 0.7%) (n = 8) and effects varied substantially (Q =
23.19; I 2 = 70%). In the 2 non-RCTs (49, 53) not included in Figure 2, effects of the protocols on HbAlc level
1 1 6 15 July 2014 Annals of Internal Medicine Volume 161 • Number 2
were larger and in the same direction but had higher variability. Thus, nurse-managed protocols were associated
with a highly variable mean decrease in HbAlc level.
Other diabetes-related performance measures were
rarely reported (Supplement 6). In 1 controlled beforeand-after study (53), achieving target eye examination, urinary microalbumin-creatinine ratio, and foot examination
goals was reported to reach 80% to 100% using nursemanaged protocols. A second study (49) found a nonsignificant increase in intervention patients achieving eye and
foot examination goals compared with control participants.
Reduction in the proportion of patients with an HbAlc
level of 8.5% or greater was achieved in 1 study (odds
ratio, 1.69 [Cl, 1.25 to 2.29]) (49).
BP Outcomes
Fourteen studies reported BP outcomes: 13 RCTs
(10 362 patients) and 1 non-RCT (885 patients). Restricted to the 12 RCTs specifically addressing BP (10 224
patients), the intervention decreased systolic BP by 3.68
mm Hg (Cl, 1.05 to —6.31 mm Hg) and diastolic BP by
1.56 mm Hg (Cl, 0.36 to 2.76 mm Hg), with high variability (72 > 70%) (Figures 3 and 4). Funnel plots suggested possible publication bias with systolic but not diastolic BP (Supplement 6). Overall, nurse-managed
protocols were associated with a mean decrease in systolic
and diastolic BP.
Eleven of the 18 studies focused on achieving various
target BPs: 10 RCTs (9707 patients) and 1 non-RCT (885
patients). When the analysis was restricted to RCTs, nursemanaged protocols were more likely to achieve target BP
than control protocols (odds ratio, 1.41 [Cl, 0.98 to
2.02]), but these results could have been due to chance,
and treatment effects were highly variable (Q = 35.20;
/ 2 = 74%) (Supplement 7, available at www.annals.org).
Using the summary odds ratio and median event rate from
the control group of the trials that implemented nurse protocols, we estimated the absolute treatment effect as a risk Outpatient Management of Adults With Chronic Conditions Essay

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The Institute of Medicine concluded in 2001 that with regard to quality,
“between the health care we have and the care we could have lies not just a gap, but a
chasm.” In fact, the chasm is not only over quality. The lack of access, financial barriers,
high costs and workforce shortages are among the other dimensions of our health care
system that further expose the chasm between “what is” and “what should be.” These
deficiencies are particularly troubling for people with chronic conditions who, on
average, use the health care system more frequently, consume more health care
resources and are more likely to see multiple health care professionals and have longterm relationships with them. When the health care system fails, chronically ill patients
are often harmed the most. The foremost reason America’s health care system cannot
optimally provide the services needed by people with chronic conditions is that the
system remains based on an episodic, acute care medical model. In addition, care is
often fragmented and poorly coordinated, families’ and patients’ roles are too restricted,
information technology (IT) is not fully utilized, too few providers are adequately
trained in chronic care and economic incentives are at odds with quality care. This
paper explores these deficiencies and examines how they hinder the provision of
optimal chronic illness care.
A version of this paper will appear in Kane, R. L., Priester, R., & Totten, A. (in
press) Meeting the Challenge of Chronic Illness. Baltimore, MD: Johns Hopkins University.
Reinhard Priester, J.D., is a coordinator, Division of Health Services Research and
Policy, School of Public Health, University of Minnesota; Robert L. Kane, M.D., is a
professor and Minnesota Chair in Long-Term Care and Aging, School of Public Health,
University of Minnesota; and Annette M. Totten, Ph.D., is a research associate, Division
of Health Services Research and Policy, School of Public Health, University of
In its influential 2001 report, Crossing the Quality Chasm, A New Health System for Outpatient Management of Adults With Chronic Conditions Essay
the 21st Century, the Institute of Medicine’s Committee on the Quality of Health Care in
America found serious deficiencies in our health care system and concluded that
“between the health care we have and the care we could have lies not just a gap, but a
chasm” (Institute of Medicine, 2001). Although the IOM’s committee focused only on
the quality of health care, the chasm the committee identified is in fact much broader. In
addition to quality concerns, the lack of access for millions of Americans, financial
barriers, high costs, inadequately trained and too few health care professionals and
other dimensions of our health care system further expose the gap, or chasm, between
“what is” and “what should be.”
The deficiencies in the health care system are particularly troubling for people
with chronic conditions. On average, people with chronic conditions rely more heavily
on the health care system; they use the system more frequently, consume more health
care resources and are more likely to see multiple health care professionals and have
long-term relationships with them. Chronic illness care is the predominant challenge
facing America’s health care system. Nearly 125 million Americans, roughly half the
total population, report having at least one chronic condition and 60 million of them
have more than one chronic condition (Wolff, Starfield, & Anderson, 2002). By 2020, 157
million people in the United States are projected to have at least one chronic condition.
The cost of caring for people with chronic conditions will continue to increase as well,
from an estimated 75 percent of total health care expenditures in 2000 to nearly 80
percent in 2020 (Wu & Green, 2000).
Thus, when the health care system fails, chronically ill patients are often harmed
the most. Regarding chronic illness care, the deficiencies of our health care system can
be grouped into three categories: structure and function; payment; and personnel. This
paper explores some, but by no means all, of the deficiencies in each of these categories
and examines how they hinder the provision of optimal chronic illness care.
2. Structure and Function
The structure and function of the health care system refers to the way in which
hospitals, physician practices, clinics, rehabilitation centers, long-term care facilities,
health plans and the other components of the system are configured, both as
independent entities and as parts of a larger whole. It also refers to how those
components relate to and interact with one another. The “structure and function” of the
health care system thus encompasses both how the components of the system are put
together and how they, and the system as a whole, perform or do their jobs. Deficiencies
in the structure and function of the health care system that hinder optimal chronic
illness care include fragmented and poorly coordinated care, restricted roles for patients
and families, failure to practice evidence-based medicine (EBM) and inadequate use of
IT. But the fundamental failure of our health care system relative to chronic care is that
the conceptual model of care that lies at the system’s foundation does not support
optimal chronic illness care.
2.1 Wrong Model of Care
At its core, our health care system rests on a conceptual model. Conceptual
models are designed to make sense out of complex events in the world and to help
organize our responses. Micro-economics, for example, uses Adam Smith’s conceptual
model of a perfectly competitive market to both understand economic transactions and
shape policies to achieve desirable economic goals. In a similar fashion, the conceptual Outpatient Management of Adults With Chronic Conditions Essay
model that underlies our health care system constitutes the reference framework we use
to understand and treat health problems. The model helps, for example, determine
what counts as a “disease,” set the proper boundaries of health professionals’
responsibilities, establish the appropriate response of the health care system to those
who are “sick” and shape societal attitudes toward patients.
The conceptual model at the foundation of America’s health care system is the
acute care model. As a result, the system is structured first and foremost to prevent,
diagnose and treat acute medical conditions. The acute care model adopts a disease
orientation, is firmly grounded in science and is principally focused on the pathology
and pathophysiology of body functions and structure. In this model, diseases are
narrowly defined as abnormalities or deviations from what is normal. The language of
science (primarily the biological sciences) is used to establish both what is “normal” and
which deviations from the norm are sufficient to warrant the label “disease.” Thus the
model helps determine, for example, whether a child who is markedly shorter than his
peers can be said to have a disease, rather than being merely short. Short stature due to
a deficiency in human growth hormone is recognized as a disease, whereas short
stature due to no known natural causes (idiopathic short stature) typically is not. The
model also influences the response: treatment for a child with growth hormone
deficiency is accepted medical practice whereas medical interventions to increase the
height of a short child without a recognized disease are seen as inappropriate. Health
insurers typically pay for the former but not the latter.
The acute care model has been enormously successful for understanding and
treating many medical conditions, resulting in remarkable achievements in identifying
the causes and mechanisms of disease and in developing effective treatments. This has
vastly reduced the incidence of infections diseases and ameliorated many other medical
problems. Although it is important to acknowledge the successes of this model in
improving treatment for acute conditions, the acute care model nonetheless is not a
sound framework for responding to chronic conditions.Outpatient Management of Adults With Chronic Conditions Essay
Chronic conditions differ from acute conditions on a variety of important
dimensions. Acute conditions generally have a sudden onset. They last for only a short
period of time and usually are stopped with the appropriate care or end spontaneously,
without requiring ongoing treatment. They usually end with cure but sometimes with
death. In general, an illness or condition is considered chronic if it has persistent or
recurring health consequences lasting for a substantial period of time (variously
identified as at least three months, six months, or longer), is not self-limiting, waxes and
wanes in terms of severity and typically cannot be cured. The essential aspect of a
chronic condition is its lengthy duration. (Chronic is derived from the Greek, khronos,
meaning “time.”) A chronic condition is enduring and not simply a series of
disconnected complaints.
In addition to differences in duration, the sudden onset of most acute conditions
contrasts with the progressive nature of many chronic conditions. People “come down”
with an acute illness, whereas they “develop” a chronic condition. Also in contrast to
acute conditions, chronic conditions tend to have multiple causes and can occur long
after the causative exposure or behavior. For example, a person’s exposure to
carcinogens such as asbestos fibers can lead to a chronic lung condition several decades
later. Acute and chronic conditions also differ markedly in their impact on a person’s
health and life. In acute conditions the threat to a person’s health is discrete and
relatively brief. In chronic conditions the threat is ongoing, long-lasting and global—
affecting the social, physical, psychological and economic aspects of the person’s life.
The acute care model leaves little if any room for the social, psychosocial and
behavioral dimensions of chronic illness (Tinetti & Fried, 2004). It does not provide for
the commitment to continuing care. It is also not broad enough to account for and aid
understanding of the types of human distress experienced by people with chronic
conditions. These include challenges to the “person’s self-image and sense of meaning
and purpose in life” (Jennings, Callahan, & Caplan, 1988) and the suffering that occurs
due to disruptions in the patient’s “extended system,” including their family, friends,
work associates and community (Cassell, 1991). Furthermore, the acute care model
undervalues the importance of a variety of other key facets of chronic illness care,
including the influence of lifestyle factors such as nutrition and exercise in preventing
or managing a chronic condition, the likelihood of depression or other mental health
issues accompanying a chronic condition, the vital role of families in supporting and
caring for a chronically ill family member and the influence of the environment in
understanding the causes of and developing appropriate responses to chronic
To paraphrase the IOM’s Committee on Quality, between the care encompassed
by the acute care model and the care needed by people with chronic conditions lies not
just a gap, but a chasm. Health care based on the acute care model focuses on treating
immediate presenting symptoms, and often discounts the sustained impairments that
threaten the health status and diminish the functioning of people with chronic
conditions. Similarly, acute care’s emphasis on cure seems misplaced when directed to
chronic conditions, most of which can never be resolved. The episodic nature of acute
care is also at odds with the long-term monitoring and continuous support and care
needed by people with chronic conditions to prevent exacerbations and maintain their
functional abilities.
Because America’s health care system is structured principally to respond to
acute conditions, it fails to effectively meet the needs of people with chronic conditions
(Tinetti & Fried, 2004). The predictable consequence of a system built on the acute care


model is the current chasm between the reality of having to respond to chronic illness in
our society and the way our health care system actually deals with chronic illness.
While the system does not ignore chronic conditions themselves, it continues to respond
to them as if they were acute and episodic, treating symptoms as they occur. The care Outpatient Management of Adults With Chronic Conditions Essay
for persons with chronic conditions is often a “poorly connected string” of clinicianpatient encounters (Rothman & Wagner, 2003). Consequently, the system ignores the
fundamentally different approach that is needed to care for people with chronic
conditions, that is, managing the conditions long-term and responding to the myriad
ways they impact peoples’ lives. The problem is not that people with chronic conditions
do not receive care in our health care system; rather, the problem is that their care is
provided in a system principally designed to treat a wholly different type of condition
and thus ill-equipped to adequately respond to chronic conditions.
In sum, the distance between “what is” and “what should be” for chronic illness
care persists as the health care system continues to emphasize acute care—in the
provision of services, the education of health care professionals, the research and
development of new technologies and the system’s financing. The foremost reason why
America’s current health care system cannot optimally provide the full complement of
services needed by people with chronic conditions is that the system remains based on
an episodic, acute care medical model.
2.2 Fragmented, Poorly Coordinated Care
In the current system, care for people is often fragmented and poorly
coordinated. While this may jeopardize health care quality and efficiency for any
patient, it is particularly troublesome for those with more than one chronic condition.
To meet their complex needs, patients with chronic conditions often receive care from
multiple clinicians, who may work independently from each other. Each of the
clinicians may provide one or more of the services that comprise the full spectrum of
care the patient needs, such as medical, mental health, rehabilitation, prevention and
supportive services. Yet the clinicians rarely communicate with each other about the
patient’s care. By functioning in separate “silos,” the clinicians (and the clinics and
health care organizations where they practice) often do not have complete information
about the patient’s condition or treatment history, a major source of medical errors.
This “silo-based” approach to care is a hallmark of our fragmented system,
hampering the “coordinated, seamless care across settings and clinicians and over time”
that is needed to effectively meet the needs of people with chronic conditions (Institute
of Medicine, 2001). It also results in inefficiencies since discrete health care providers
will often duplicate laboratory and radiological investigations and other diagnostic
services, especially if medical records and other patient care information are not shared.
Compounding the complexity and inefficiency, each of these segments of care may have
its own distinct management information system, payment structure, financial
incentives and quality oversight. Patients find this complicated, uncoordinated ‘system’
extremely confusing and a “nightmare to navigate” (Picker Institute, 1996).
The fragmented system hampers the follow-through and coordination of care
across the entire spectrum of care processes. Information about a patient’s health and
treatments is rarely centralized, well-organized or easily retrievable, “making it nearly
impossible to manage many forms of chronic illness that require frequent monitoring
and ongoing patient support” (Institute of Medicine, 2001). Coordination of care for a
chronically ill patient is particularly important when many different individuals—
including various health care professionals as well as the patient, family members and
other informal caregivers—are involved in managing the patient’s conditions. The
discrete, yet interconnected tasks performed by these individuals, often in disparate
areas of the health care system as well as in the patient’s home, must be linked and
coordinated in order to ensure that desired outcomes are achieved efficiently.
But the coordination of care for chronically ill patients, including the integration
of medical with non-medical services, is often overlooked. Rarely in a fragmented,
poorly coordinated health care system is a single health care professional or entity
responsible for a patient’s overall care. Instead, clinicians and other health care
professionals may feel responsible only for the care and services they themselves
provide, and neglect or overlook integrating and coordinating all of the care their
individual patients receive. Even when a clinician strives to stay abreast of his patient’s
overall care, the system’s fragmentation may thwart such efforts. Imprecise clinician
responsibility increases the chance that some services may conflict with others (e.g.,
medications prescribed by different clinicians may interact and harm a patient) and that
still other needed services may not be provided at all.
Patients with chronic conditions suffer from fragmented services in another
sense—when they are treated not as persons but instead are segmented or
compartmentalized into discrete organs or body systems. If health care professionals
treat a malfunctioning system of the body rather than the person as a whole (i.e., treat
disease in the patient rather than treat the patient with disease), treatment can become a
series of medical interventions that target only the disease and ignore the ill person.
Such a disease-centered—as opposed to a person-centered—approach risks providing
care that the person may not want. By treating a patient’s diabetes, for example, rather
than treating the patient who has diabetes, a clinician may focus narrowly on using
intensive monitoring, aggressive follow-up and systematic assessments to control blood
sugar levels and other aspects of the disease, thereby reducing the risks of future
complications. Even if the patient shares the goal of reducing the chance of blindness or
other complications of diabetes, a singular focus on such narrow medical goals may
ignore the patient’s interest in keeping the management of the disease from
overwhelming other aspects of his or her life (Wolpert & Anderson, 2001).
2.3 Restricted Roles for Patients and Families
For chronically ill patients, the condition and its consequences “interact to create
illness patterns requiring continuous and complex management” (Holman & Lorig,
2000). Effectively managing chronic conditions requires intimate understanding of these
illness patterns. Patients, not their clinicians, are best positioned to accurately detect and
characterize such patterns. Only they can provide the personal information regarding
the impact of the condition on their health and well-being that is necessary for effective
management. Effective chronic illness care must therefore allow and encourage patients
to be more engaged in their own care. “Self-management” refers to a variety of activities
individuals undertake with the intention of limiting the effects of their illness. These
include participating in decisions about treatment and sharing responsibility for them
by, for example, monitoring their health status, reporting changes or unexpected events
and adhering to agreed-upon treatment. “Unlike much acute care, effective care of the
chronically ill is a collaborative process, involving the definition of clinical problems in
terms that both patients and providers understand; joint development of a care plan
with goals, targets and implementation strategies; provision of self-management
training and support services; and active, sustained follow-up” (Von Korff et al., 1997).Outpatient Management of Adults With Chronic Conditions Essay
Generally, people with chronic conditions have better health outcomes and are
more satisfied with their care if they participate actively in the management of their
health and health care (Leveille et al., 1998; Lorig et al., 1999). Yet many patients do not
have the needed skills and competencies for this role. Some patients desire a more
passive approach to their health and health care or may be uncomfortable managing
their own care and thus may not seek to acquire such skills and competencies. For
patients who want to become more actively engaged, however, health care providers
and health plans often fail to prescribe, provide, or reimburse the necessary educational
materials and empowerment tools to build self-efficacyand self-management skills or to
support their efforts to manage their own care. Even when patient education services
are provided, they are often sporadic, unplanned and superficial, given the lack of
coordination among providers. In addition, the current system often fails to
acknowledge and address the impact of a person’s chronic illness on other family
members, both as caregivers and as family members.
2.4 Failure to Practice Evidence-Based Medicine
EBM is defined as “the conscientious, explicit, and judicious use of current best
evidence in making clinical decisions about the care of individual patients” (Sackett et
al., 1996). In a nutshell, EBM is designed to take the best available scientific information
and help clinicians apply the results in clinical practice. All too often, innovations in
clinical practice have had little impact beyond a few leading medical groups and
In theory, EBM will improve the quality of care by closing the gap between the
treatment recommended on the basis of clinical evidence and the treatment actually
provided—between knowing and doing. Examples of this so-called “treatment gap,”
i.e., the differences between the treatment recommended on the basis of clinical
evidence and the treatment actually provided, include the failure to prescribe the most
effective medications, inadequate follow-up and monitoring and many examples where
the care provided failed to follow widely accepted practice guidelines, resulting in the
underuse, overuse and misuse of services in the care of patients. Such problems have
been well-documented for patients with chronic conditions throughout the health care
system (Institute of Medicine, 2001; McGlynn et al., 2003). For example:
• The Diabetes Quality Improvement Project recommends routine monitoring
of HgbAlc protein, a marker for glucose. Only 29 percent of diabetic patients
reported having this test during the previous year (Saadine et al., 2002).
• 24 percent of patients with unstable angina who were “ideal” candidates for
treatment with aspirin during hospitalizations did not receive aspirin during
their hospital stay (Simpson et al., 1997).
• Less than 25 percent of Americans with major depressive disorders are
receiving adequate treatment (Kessler et al., 2003).
• Overall, even when evidence-based guidelines exist, a chronically ill patient
has just a 56 percent chance of receiving the recommended care (McGlynn et
al., 2003).
Efforts to promote EBM include the identification and dissemination of research
findings about effective clinical practice, the development of innumerable (sometimes
competing) practice guidelines and assessments of the safety and effectiveness of
existing and emerging health care technologies. The common aim of these activities is to
find out what works in health care and what does not, and to promote the appropriate
use of those interventions that work and minimize the use of those that do not.
However, EBM has several limitations. The base of evidence about the safety,
effectiveness and cost-effectiveness of health care interventions is not as great as some
believe, certainly not evidence derived from well-executed scientific studies.Outpatient Management of Adults With Chronic Conditions Essay  When such
evidence does exist, it may be restricted to carefully defined instances that do not
directly relate to actual practice, especially when patients’ chronic conditions are made
more complex by the interactions of other diseases. In many instances, scientific
evidence to support EBM has had to be supplemented by professional consensus. Still,
even where good scientific evidence does exist, clinicians unfortunately may not use it.
2.5 Failure to Optimize Information Technology
IT is critical for delivering good chronic care. In the context of health care, IT
encompasses all forms of technology used to create, store, exchange and use
information to support the delivery and processes of health care. IT includes single task
systems, such as computerized patient health records, as well as complex, integrated
systems that can meld together multiple tasks such as ordering medications and lab
tests, billing and patient records. The IT toolbox in health care includes discrete devices,
such as PCs and handheld computers, as well as e-mail and Web-based technologies
that allow health care providers to communicate with patients and monitor patient care
Health IT can play several crucial roles, including:
1. Providing clinical decision support
2. Collecting and sharing clinical information
3. Reducing medical errors
4. Enhancing patient/clinician interactions
5. Educating and informing patients.
Many believe that IT has significant untapped potential for improving chronic
illness care. IT is expected to improve the flow of information and improve the quality
of decisions by getting the right data to the right people at the right time—when
decisions need to be made—and thereby producing better care and providing care more
efficiently. Nevertheless, the rate of adoption of IT in health care has been slow, relative
to many other industries. Despite its promise, there has been great reluctance within
health care to invest heavily in IT, outside of financial accounting and billing. As a
result, “the U.S. health care system remains mired in a morass of paper records and
bills, fax transmittals and unreturned phone calls” (Goldsmith, Blumenthal, & Rishel,
3. Personnel
3.1 Workforce Shortages
Patients with chronic conditions will continue to receive care from a wide range
of health care practitioners. While projecting the future demand and supply of health
care professionals in chronic illness care is imprecise at best, the consensus is that
without significant changes in health professional education, there will be too few
practitioners trained to deal with the manifold needs of patients with chronic
conditions. One concern is the decline in the number of primary care clinicians
(Grumbach & Bodenheimer, 2002). Since primary care is the foundation for most
chronic illness care, this decline is troubling, especially in light of the projected increase
in demand for chronic care services.
Another concern is the number of clinicians who care for particular
subpopulations of chronically ill patients, such as elderly patients with multiple chronic
conditions. Because of their special training in aging and age-related disease,
maintaining and improving functional status and managing chronic conditions,
geriatricians are often the most qualified to treat such patients. There are, however,
relatively few practicing geriatricians and their number is expected to decline in the
near future as practicing geriatricians retire at a faster rate than new trainees enter
practice (Warshaw & Bragg, 2003). Beyond the shortage of geriatricians is the
inadequate training for medical students who do not specialize in geriatrics. Although
most physicians will see elderly patients at some point in their practice regardless of
their specialty, few receive much formal training in the specific needs of this
population.  Outpatient Management of Adults With Chronic Conditions Essay

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