It Never Rains but It Pours
Get one and you might end up with a whole set: welcome to complex chronic diseaseAn elderly woman shows up at the office of a palliative care doctor with complications from Type 2 diabetes. During her visit, she presents with swollen joints—the disease can cause a form of arthritis—and the medication is aggravating her kidneys, threatening renal failure. What’s more, her physical pain is taking a psychological toll, and she’s exhibiting symptoms of depression.
It’s a complex case for any medical practitioner, and it’s more common than you think. The worldwide explosion of chronic disease, defined as illnesses that last a year or more and require ongoing medical attention, has created a new phenomenon: complex chronic disease (also called multiple chronic disease, or in medical jargon, polypathology). It includes conditions like the one described above where one “index disease” triggers secondary complications as well as cases where two or more diseases co-exist.
“In pursuit of immortality we are living longer, but not better,” says Alejandro Jadad, Chief Innovator and Founder of the Centre for Global eHealth Innovation. “We’re living long enough to develop not just one or two of these chronic diseases, but three, four—sometimes even 10. And we’ve found ourselves unprepared.” It’s estimated that people with complex chronic disease may represent as many as 50 percent or more of the population living with chronic diseases, at least in high-income countries.
So far, knowledge about how and why chronic diseases cluster is patchy, mainly because in most disease management programs, research and clinical guidelines are still organized around the classic model in which a patient presents with a single disease. The rise of sedentary lifestyles and obesity is making them worse.
Drugs for different diseases are often prescribed by different doctors who don’t communicate with one another. This raises the possibility of harmful drug cocktails arising in the body, cocktails that can have new and unanticipated effects.
Patients with multiple chronic diseases account for most visits to general practitioners, most hospital admissions, and a growing proportion of healthcare costs. In the U.S., approximately 65 percent of total healthcare spending goes for patients with multiple chronic conditions.
Some healthcare providers are experimenting with improvements in at-home medical devices, giving patients more control over tracking and managing chronic conditions. In a joint pilot project by the Cleveland Clinic and Microsoft in 2008, more than 200 patients with chronic complex conditions were asked to use at-home medical devices specific to their diseases, such as heart-rate monitors, glucometers, pedometers and scales. Information from these devices was then uploaded to a Web-based data storage program, which all of their medical providers could access. This approach significantly increased the number of days between physician office visits for patients, particularly those with diabetes and hypertension.
“The need for chronic disease management services is overwhelming,” says C. Martin Harris, Chief Information Officer for the Cleveland Clinic. “The opportunity we see with this type of program is to reach out and engage patients in their own healthcare, and to deploy technology to deliver services to them on a continuous basis as needed—without office visits.”
Another interesting effort is Jadad’s Web site where healthcare providers can share innovative practices for complex chronic disease management. Called the Observatory of Innovative Practices for Complex Chronic Disease Management (www.opimec.org), the initiative has received over 300 contributions since its launch in 2007.
It’s this kind of collaborative effort, Jadad says, that will allow us to effectively stop what he calls the “tsunami” of complex chronic disease. “We’re still pretending that this problem does not exist, and working in a system that asks physicians to report diseases one by one,” he says. “We have to make changes based on best practices as soon as possible, because we are facing a crisis. We can do this, if we work together.” x
