Investigators Call for an Overhaul of Current Treatment Guidelines

Internal Medicine World ReportJuly 2005

Investigators Call for an Overhaul of Current Treatment Guidelines

SEATTLE—With an aging population and an increasing incidence of chronic diseases,

physicians are facing overwhelming challenges, according to Duke University investigators,

who are calling for an overhaul of treatment guidelines and new approaches to

the care of patients with chronic disease (Ann Fam Med. 2005;3:209-214).

“Geriatric patients are the ones getting shortchanged because they are the ones

with more chronic diseases, so they need more time with the physician just to follow

the guidelines,” Kimberly Yarnall, MD, told IMWR. “The primary care system is at a crossroads.

We are estimating a physician shortage in the next 10 to 15 years, but the

demand for services continues to increase,” said Lloyd Michener, MD. “The status quo is not going to work much longer. It’s not working now.” The investigators examined the time constraints

attached to 10 chronic diseases— high cholesterol, high blood pressure, depression, asthma, diabetes, arthritis, anxiety, chronic obstructive pulmonary disease, osteoporosis, and coronary artery disease. To determine the time required for chronic disease care, a model primary care

practice was designed, in which 2500 virtual patients were assigned with appropriate

ages and age-specific diseases that matched those of the general population. In the

model, physicians adhered completely with available guidelines for every patient.

A total of 10 minutes per visit for each chronic disease patient was allowed, a conservative

estimate; other studies show that the average visit lasts 18 to 21 minutes. The

number of visits was dictated first by the average number of visits recommended by

practice guidelines. The results showed that chronic disease management would take 3.5 hours of the physician’s day, provided all patients were stable and their diseases were in good control.

When recalculated to allow for both controlled and uncontrolled disease, the amount

of time needed for chronic disease management almost tripled, to 10.6 hours per day.

“Our estimates are not based on how much time is currently spent on chronic

disease in practice, but on how much time is required to meet current guideline recommendations,” said Truls Ostbye, MD, PhD. “The time requirements implied by

the guidelines are overwhelming and cannot be met in a real-world practice.”

Dr Ostbye said that guidelines for chronic disease are usually written by specialists

and focus on 1 disease area, without regard to the time it takes to follow the guidelines

completely. Instead, expert panels should write guidelines collaboratively, and guidelines

should combine relevant diseases. “It’s a domino effect. We don’t have

enough time for prevention, which leads to chronic disease. We don’t have enough

time to manage chronic disease, which leads to acute care issues,” said Dr Yarnall.

The solution is a new health care model that uses a team of health care providers

who would take the lead in preventive care, patient education, and routine chronic disease management, she added.

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