I wrote last month about the role of chronic diseases in healthcare-cost growth, so I was excited to see a new report from the Institute of Medicine called Living Well with Chronic Illness: A Call for Public Health Action.
When I think of chronic illness, diabetes and heart disease are what leap to my mind — in part because they’re so tied to the lifestyle factors of smoking, inadequate exercise, and poor nutrition, and in part because they cost our health system so much money. The IOM report notes that chronic illness represents 75% of the $2 trillion the US spends each year on healthcare, but it also emphasizes that the goal of addressing chronic diseases conditions isn’t just to slow the growth of healthcare costs, but to improve quality of life. The report is a response to a request by CDC and the Arthritis Foundation to “help identify ways to reduce disability and improve the function and quality of life for people living with chronic illness.”
Another refreshing aspect of this report is that it doesn’t just focus on the usual suspects of chronic disease (diabetes, heart disease, kidney disease, etc.). While the authors seek to assist health officials in prioritizing the use of limited healthcare dollars, they’re also careful to avoid ranking diseases by a single metric. The report highlights nine “clinical clusters” that together “encompass and flesh out the range of key issues that affect the quality of life of patients with the full spectrum of chronic illnesses.” Here’s my quick summary of the nine conditions, which I hope will encourage some of you check out the full report. (The diseases are described in Section 2 of the report, and the uncorrected proof is currently available for free downloading.)
- Arthritis: Arthritis is the leading cause of disability in the US, with approximately one in five adults having received an arthritis diagnosis. Osteoarthritis (the most common type) is more common in women and people who are obese, and in miners, construction workers, and agricultural workers. “In 2008, 29 million persons over age 18, 13 percent of all adults in the United States, had self-reported activity limitations attributable to arthritis.”
- Cancer survivorship: In 2007, nearly 12 million people living in the US had previously been diagnosed with cancer. While their survival represents a victory, the treatments often have lasting health consequences, from heart failure and lymphedema (collection of fluid in a body part) to problems with fatigue and psychological distress.
- Chronic pain: In the US, an estimated 116 million adults deal with chronic pain, and chronic pain’s prevalence on the rise worldwide. Racial and ethnic minorities are at greater risk of having undertreated pain. Disablement from chronic pain affects sufferers, their families, and their workplaces.
- Dementia: An estimated 5.4 million people in the US are affected by Alzheimers disease, and millions more have dementia from other causes. Complications from dementia place a heavy burden on caregivers; research suggests that these caregivers are at increased risk of coronary heart disease and depression.
- Depression: Major depression affects around 7% of the US population at any given time, and 17% of us can expect to experience major depression during our lifetimes. It is often a complicating factor for other chronic illnesses, including diabetes.
- Type 2 diabetes: An estimated 11.3% of US adults (25.6 million people) have diabetes, with 90-95% of diagnosed cases being type 2. The disease is the leading cause of end-stage renal disease and a major contributor to blindness, nervous system damage, and amputations. Self-management (monitoring blood glucose, taking medication, adhering to diet and lifestyle advice) takes a great deal of effort and resources. Those with multiple and severe complications are especially likely to experience reduced quality of life.
- Posttraumatic disabling conditions: This category encompasses the effects of traumatic injuries and includes knee meniscus injuries, traumatic brain injuries, severe burn injuries, and injuries from falls and fractures. Disabilities and activity restrictions are among the long-term consequences from traumatic injuries.
- Schizophrenia: This “severe, chronic, and disabling mental disorder” affects more than two million people in the US each year; while medications can relieve many of the symptoms (including hallucinations and disorganized speech and behavior), most sufferers experience some symptoms throughout their lives. Rates of alcohol abuse and homelessness are higher among schizophrenics than the general population. Families and caregivers face significant burdens from the disease, and these can be exacerbated by feelings of shame, guilt, or embarrassment.
- Vision and hearing loss: An estimated 15% of US adults have hearing difficulty, and 11% have trouble seeing even with the aid of corrective lenses. Visual impairment can interfere with sufferers’ ability to care for themselves, leading to dependence and worse emotional wellbeing. Research has found hearing loss to be associated with social isolation and depressive symptoms as well as impairment in walking and performing chores.
The IOM Committee gives 14 detailed recommendations for the Department of Health and Human Services (especially CDC), federal and state agencies, research funders, healthcare payors, and federal and state policymakers — including working in partnership with “organizations representing health care, public health, and patient advocacy.” The recommendations range from improving surveillance and pilot testing of interventions to adopting a “health in all policies” approach that evaluates the impacts of legislation and regulations on health-related quality of life.
A recurring theme in the report is the importance of focusing on the interactions between multiple chronic conditions. Since more than one-fourth of the US population has two or more chronic conditions and the prevalence of multiple chronic conditions increases with age, it’s important to get out of the habit of focusing narrowly on one condition at a time. Another recurring theme is the importance of addressing racial, ethnic, and socioeconomic disparaties in both the incidence and impact of chronic diseases.
Addressing chronic diseases in the US is a daunting challenge, but this IOM report represents a useful step forward in what will need to be a sustained and multi-faceted effort by a wide range of individuals, providers, communities, organizations, and government entities.