Am Fam Physician. 2005 Oct 15;72(8):1454-1456.
As the medical community becomes increasingly aware of the ubiquitous prevalence of chronic illness, more and more physicians are realizing that most decisions determining the outcome of a chronic condition are made not by the physician, but by the patient.
Self-management, the focus of the discussion by Drs. Coleman and Newton1 in this issue of AFP, is what patients with chronic conditions do every day: decide what to eat, whether to exercise, if and when they will take medications. All patients self-manage; the question is whether they make changes that improve their health-related behaviors and clinical outcomes. For patients to make daily decisions and choose actions that favor healthy behaviors, they need to be informed about their chronic condition and activated to take on the role of their own manager.
Self-management support is what health care professionals do to assist and encourage patients to become informed and activated. It involves:
• providing information about the patient’s chronic condition (assisting the patient to become informed), and
• working in partnership with patients to make medical decisions in a collaborative manner (encouraging the patient to become activated).
Primary care physicians cannot provide information and engage in collaborative decision making in the multiple-agenda visit. Given the demands of acute, chronic, and preventive services, the provision of consistent, high-quality, guideline-compliant care in a 15-minute visit is beyond the reach of most primary care physicians, however well trained and well intentioned they may be. In visits with multiple agendas, acute concerns always will crowd out chronic care management.
The current system, based on the 15-minute physician office visit, has a poor record in providing information and in fostering collaborative decision making. Several studies have shown the inadequacy of the 15-minute office visit for supplying patients with sufficient information. In a 1994 study,2 76 percent of patients with type 2 diabetes received limited or no diabetes education. As many as 50 percent of patients leave an office visit not understanding what they were told by the physician.3 In a study4 of 1,000 audiotape-recorded visits with 124 physicians, the patients were not involved in clinical decisions 91 percent of the time. Current practice is not producing informed and activated patients.
Self-management support will not happen without planned visits. Planned visits are encounters with one agenda: the management of the patient’s chronic condition(s).
For planned visits to be successful, patients must understand that these visits must be focused tightly on chronic care. To ensure that the multiple-agenda habit is broken, planned visits often are scheduled with a care manager (usually a nurse or pharmacist) rather than with the patient’s regular physician. Ideally, planned visits are not limited to patient education but include medication management, with the care manager prescribing medications using physician-written protocols or standing orders. Planned visits can be done individually or with groups of patients.
Ample evidence, particularly for diabetes, demonstrates that planned visits are associated with improved outcomes.5–9 In Kaiser Permanente’s trial5 of planned, nurseled group visits for patients with diabetes, group-visit participants had significantly reduced A1C levels and lowered hospital use compared with control patients. Peters and Davidson6 demonstrated that patients attending a nurse-led diabetes planned-visit clinic had improved A1C levels that were lower than those of patients receiving usual care. Aubert and colleagues7 came to similar conclusions. In another study8 comparing patients attending planned diabetes visits with patients receiving usual care, the intervention group had lower mortality rates and a lower incidence of adverse clinical events (myocardial infarct, angina, revascularization procedures, end-stage renal disease) after a median follow-up of seven years. In a Cochrane review,9 researchers found that planned visits improved glycemic control in eight of nine studies and concluded that nurses “can even replace physicians in delivering many aspects of diabetes care, if detailed management protocols are available, or if they receive training.”9
If primary care physicians are serious about offering patients self-management support, there must be a major effort to redesign practices to include planned visits for patients with chronic conditions. Primary care practices in large systems should have personnel available to lead planned visits. Hospitals, independent practice associations, and community organizations should provide nurses and pharmacists to organize planned visits for the chronic care patients of several small practices. Because they help patients become more informed and activated, planned visits are an effective way to improve clinical outcomes.
THOMAS BODENHEIMER, M.D., is professor of family and community medicine at the University of California, San Francisco, School of Medicine.
Address correspondence to Thomas Bodenheimer, M.D., Department of Family and Community Medicine, University of California, San Francisco, School of Medicine, Building 80–83, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110 (e-mail: TBodenheimer@medsch.ucsf. edu). Reprints are not available from the author.
1. Coleman MT, Newton KS. Supporting self-management in patients with chronic illness. Am Fam Physician. 2005;72:1503–10.
2. Clement S. Diabetes self-management education. Diabetes Care. 1995;18:1204–14.
3. Roter DL, Hall JA. Studies of doctor-patient interaction. Annu Rev Public Health. 1989;10:163–80.
4. Braddock CH III, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282:2313–20.
5. Sadur CN, Moline N, Costa M, Michalik D, Mendlowitz D, Roller S, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care. 1999;22:2011–7.
6. Peters AL, Davidson MB. Application of a diabetes managed care program. The feasibility of using nurses and a computer system to provide effective care. Diabetes Care. 1998;21:1037–43.
7. Aubert RE, Herman WH, Waters J, Moore W, Sutton D, Peterson BL, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann Intern Med. 1998;129:605–12.
8. So WY, Tong PC, Ko GT, Leung WY, Chow CC, Yeung VT, et al. Effects of protocol-driven care versus usual outpatient clinic care on survival rates in patients with type 2 diabetes. Am J Manag Care. 2003;9:606–15.
9. Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev. 2000;(4):CD001481.
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