Helping patients improve their health-related behaviors: what system changes do we need?
Helping patients improve their health-related behaviors: what system changes do we need?
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DOI：
10.1089/dis.2005.8.319
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发表时间：
2005-10-01
影响因子：
--
通讯作者：
Bodenheimer, Thomas
中科院分区：
文献类型：
--
作者：
Bodenheimer, Thomas
慢性病患者的实际临床结果与最佳结果之间存在很大差距。这种差距可能是由于医生的问题（医生不知道实践指南），患者的问题（患者选择不遵循医疗建议）或系统问题（医生没有时间帮助患者管理他们的慢性病）。慢性病护理的一个目标是帮助慢性病患者成为知情的、活跃的患者。被告知和激活的患者（激活=参与健康相关决策）具有更好的健康相关行为和临床结局。初级保健通常在医生和患者之间进行15分钟的多议程访问。这种结构导致（1）患者不充分了解其慢性病状况，以及（2）患者是医疗建议的被动接受者，而不是医疗决定的积极参与者。其结果是，病人信息不灵通，消极被动。这是一个制度问题。三个重新设计的元素有可能解决这个系统的问题：（1）在临床访问之前预先激活患者似乎鼓励更多的积极患者和-在一项研究中-改善临床结果。(2)有计划的访问，与护理经理花时间与患者，单独或小组，提供教育和医疗管理，已被证明可以改善临床结果。(3)通过面对面的访问，电话或电子方式进行定期持续的随访与更健康的行为有关。并非所有通过重新设计的初级保健接受疾病管理的患者都会采取更健康的行为，因为医疗保健系统之外的许多因素会影响个人选择。然而，在医疗保健系统定期提供足够的信息并鼓励合作决策之前，将不健康行为的责任推给患者是不合适的。
A large gap separates actual clinical outcomes of patients with chronic disease from optimal outcomes. This gap may be attributable to physician problems (physicians unaware of practice guidelines), patient problems (patients who choose not to follow medical advice) or system problems (physicians lack time to assist patients in managing their chronic condition). A goal for chronic illness care is to assist people with chronic conditions to become informed, activated patients. Patients who are informed and activated (activated = participating in health-related decisions) have better health-related behaviors and clinical outcomes. Primary care is often conducted within a 15-minute, multi-agenda visit between physician and patient. Such a structure has led to (1) patients being inadequately informed about their chronic conditions and (2) patients being passive recipients of medical advice rather than active participants in medical decisions. The result has been poorly informed, passive patients. This situation constitutes a system problem. Three redesign elements have the potential to address this system problem: (1) Pre-activating patients prior to the clinical visit appears to encourage more active patients and--in one study--improved clinical outcomes. (2) Planned visits, with a care manager spending time with patients, individually or in groups, providing education and medical management, have been shown to improve clinical outcomes. (3) Regular sustained follow-up, by face-to-face visits, telephone, or electronic means, is associated with healthier behaviors. Not all patients receiving disease management through redesigned primary care will adopt healthier behaviors because many factors outside the medical care system influence personal choices. However, until the medical care system regularly offers adequate information and encourages collaborative decision-making, it is improper to place the responsibility for unhealthy behaviors onto patients.