Chronic disease management: what will it take to improve care for chronic illness?

M eeting the complex needs of patients with chronic illness or impairment is the single greatest challenge facing organized medical practice. Usual care is not doing the job; dozens of surveys and audits have revealed that sizable proportions of chronically ill patients are not receiving effective therapy, have poor disease con- trol, and are unhappy with their care (1). Results of randomized trials also show that effective disease management programs can achieve substantially better outcomes than usual care, the control intervention. These trials, along with the ideas and efforts for improvement discussed in this issue, show that we can improve care and outcomes. As the articles suggest, these improvements will not come easily. If we are to improve care for most patients with chronic illness, the evidence strongly suggests that we reshape our ambulatory care systems for this purpose. Pri- mary care practice was largely designed to provide ready access and care to patients with acute, varied problems, with an emphasis on triage and patient flow; short appointments; diagnosis and treatment of symptoms and signs; reliance on laborato- ry investigations and prescriptions; brief, didactic patient education; and patient- initiated follow-up. Patients and families struggling with chronic illness have differ- ent needs, and these needs are unlikely to be met by an acute care organization and culture. They require planned, regular interactions with their caregivers, with a focus on function and prevention of exacerbations and complications. This interac- tion includes systematic assessments, attention to treatment guidelines, and behav- iorally sophisticated support for the patient's role as self-manager. These interactions must be linked through time by clinically relevant information systems and continu- ing follow-up initiated by the medical practice. Comprehensive System Change