Chronic disease management: what will it take to improve care for chronic illness?
Chronic disease management: what will it take to improve care for chronic illness?
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发表时间：
1998-08
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通讯作者：
E. Wagner
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作者：
E. Wagner
满足慢性病或残障患者的复杂需求是有组织的医疗实践面临的最大挑战。常规护理不起作用；数十项调查和审计显示，相当大比例的慢性病患者没有接受有效的治疗，疾病控制不佳，对他们的护理不满意(1)。随机试验的结果还表明，有效的疾病管理方案可以取得比常规护理、对照干预更好的结果。这些试验，以及本期讨论的改善想法和努力，表明我们可以改善护理和结果。正如这些文章所暗示的那样，这些改进来之不易。如果我们要改善对大多数慢性病患者的护理，证据有力地表明，我们应该为此目的重塑我们的门诊护理系统。PRI-Mary护理实践在很大程度上是为了向有各种急性问题的患者提供现成的接触和护理，重点是分流和病人流动；短期预约；症状和体征的诊断和治疗；依赖实验室调查和处方；简短、教化的患者教育；以及患者主动的随访。患有慢性病的患者和家庭有不同的需求，而这些需求不太可能由急性护理组织和文化来满足。他们需要有计划的定期与照顾者互动，重点放在功能和预防病情恶化和并发症上。这种互动包括系统的评估，对治疗指南的关注，以及对患者作为自我管理者的角色的行为复杂支持。这些相互作用必须通过临床相关的信息系统和由医疗实践发起的持续跟踪来随着时间的推移而联系起来。全面的体制变革
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