The Pump Handle

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.

Comments

#1 Sultan of Nutrition
February 7, 2012

Smoking is definitely a cause f most major health problems. it leads to cancer, heart disease, etc. Alcohol is also a major problem in this country.

As far as poor nutrition goes, that is a factor as well, but let us discuss GMO foods and poison like aspartame in foods and sodium flouride in the water and aluminum nanoparticles and sulfur particles being sprayed into the atmosphere as well. Seems like government has a role in our poor nutrition and health as well. The we have laws that prohibit the use of raw milk and vegetables and even in some places people who grow their own food to get away from GMO foods and pesticides are being arrested and harrassed. Ths country has gone literally insane.

If one can get busted for selling raw milk then its time for regime change. Get rid of every polticians in office, disband every agency, and start all over new again. This control over the populace crap has to end somewhere. This is America, not north Korea. Let’s start acting like it.
#2 Liz
February 8, 2012

Smoking and alcohol are indeed major contributors to disease — but remember, the agencies you want to disband have done a great deal to reduce tobacco and alcohol use in this country.
#3 GregH
February 8, 2012

Sultan of Nonsense: you’re completely misguided about most of your complaints, but all that axe-grinding will keep you fit, and that should add some years to your life. Good show!
#4 david
February 8, 2012

I dont believe the IOM has the best interests of the public at heart- they seem to serve the occupational strategies of their colleagues in medicine and academia instead. In their report on pain- they offer no vision or plan for lowering the prevalence on chronic pain-and they clearly state they dont believe in cures. I guess its more profitable for them and their colleagues for chronic pain to continue to rise in prevalence-and they are unwilling to jump over the shadows in pain care to create the symbols of a new day.
The IOMs ideas are rigidified in predetermined ways that serve themselves and evolution is forbidden
#5 Art
February 8, 2012

It doesn’t help solve any of those problems but IMO those very common complaints are something of a monument to the effectiveness of overall public health, mainly clean food and water, but a god bit of actual medicine, in allowing the population to get old enough to experience those chronic conditions. ie: When miners and construction workers were more likely than not to get planted around 55 years of age there were far fewer chronic cases. Dead men don’t tell tails … or complain about their chronic arthritis.

You have to survive cancer to qualify for the long term consequences of any treatment to manifest.

We are all getting older and this is, in large part, a success story for public health, food, and environmental safety. Being commonly able to live into our nineties is a blessing but it isn’t a vertical light and sunshine. Getting old isn’t for wimps. It means we are exposed to consequences of all the rough handling, abuse and insults we experience over this much longer time. It isn’t pretty. Or comfortable. But it is real and it keeps the medical science and public health people off the streets and out of trouble by giving them something to work on. It’s all good.

As soon as someone mentions the dangers of Aspartame, fluoride, GMOs, or chemtrails I pretty much know I’m talking to that particularly dangerous form of self deluding and credulous idiot that thinks they know what is going on because Alex Jones told them. There just aren’t enough faces or palms to express how embarrassed I am for you.
#6 dave
February 8, 2012

Public health has failed people in pain- and that is why perhaps the IOM called for a public health approach to people in pain. The simple facts-which is mentioned in the June 2011 IOM report on pain is that chronic pain is expected to rise rapidly -much more rapidly then population growth. I dont consider that success but failuire. The lenght of life isnt considered the most important thing by many people- and why live a life of terrible suffering? Pain is considered a life ruining condition- a Lord more terrible then death. Its ashame there are people who for their own comfort and convenience wish to feel good about the sorry state of affairs in pain care- perhaps our Nation would be better served if they made a real effort to improve the sorry state of affairs rather then boast about the ever rising prevalence of suffering due to chronic pain-and poor medical care in our country
#7 rj
February 8, 2012

I’m glad they included chronic pain. Some diesases are relatively simple and straightforward to treat. But it is very hard to get good treatment for a condition that requires many different specialists to collaborate. Certain medical centers (Mayo, for example) claim to follow an “integrated approach” where teams of doctors treat a patient, but most medical practices are isolated and over-specialized.
#8 harold
February 9, 2012

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.

However, this does create a somewhat confusing situation.

Most of the conditions described here are symptom groups, not diseases. Furthermore, they are in many cases symptom groups that have massive diversity within them.

Arthritis, chronic pain, dementia, depression*, and “vision and hearing loss” are all symptom groups, descriptive of diverse situations and potentially caused by many different diseases. *Depression is the name of a primary disease, but it is defined purely by symptomology, and it can be secondary to many other diseases or conditions.

Schizophrenia, cancer, and trauma are medical conditions, not symptoms, but they are the names of groups of conditions, especially the latter two.

For full disclosure –

I very strongly support the idea that these symptoms and conditions deserve to be taken seriously and treated effectively.

I understand that authors’ rationale for dealing with broad symptom groups and don’t disagree with it. I am commenting only for clarity.

However, for effective treatment, the actual underlying cause in the individual patient usually needs to be determined.
#9 Cennetevi
February 9, 2012

Thank you…Arthritis, chronic pain, dementia, depression*, and “vision and hearing loss” are all symptom groups, descriptive of diverse situations and potentially caused by many different diseases. *Depression is the name of a primary disease, but it is defined purely by symptomology, and it can be secondary to many other diseases or conditions.

Schizophrenia, cancer, and trauma are medical conditions, not symptoms, but they are the names of groups of conditions, especially the latter two.
#10 rj
February 10, 2012

reply to harold #7

Your statement that the underlying cause usually needs to be determined for effective treatment is not true.

In many cases no cause is identified for these conditions — they are idiopathic. Or else the diagnosis is complicated and unreliable, or there are multiple interacting causes and syndromes that interact. Or the underlying cause is not treatable.

Still, there are often treatments for these conditions, just not “cures”.
#11 harold
February 10, 2012

RJ said –

Your statement that the underlying cause usually needs to be determined for effective treatment is not true.

I don’t have any serious disagreement with what you say here, but note that I said “usually”; therefore, what I said is actually likely to be true.

In many cases no cause is identified for these conditions — they are idiopathic. Or else the diagnosis is complicated and unreliable, or there are multiple interacting causes and syndromes that interact. Or the underlying cause is not treatable.

This is correct.

Still, there are often treatments for these conditions, just not “cures”.

Also correct.

Allow me to clarify.

I did not object to the lumping done here, but I do think it is worthwhile to make the clarification I did.

Some of the terms used above are symptoms (“chronic pain” – there are many, many types of chronic pain, but it is a symptpom); others are names of disease groups that have many associated symptoms (“schizophrenia”, and there are also multiple types of schizophrenia, but it is a family of diseases).

When symptoms are present, if an underlying etiology can be determined, treatment and evaluation of prognosis are more likely to be successful. For example, if a patient has fever, coughing, and severe shortness of breath, and the etiology is correctly determined to be community acquired pneumonia, caused by an organism that is resistant to some antibiotics but sensitive to other antibiotics that the patient can tolerate, a sufficient course of correct antibiotics, accompanied by whatever supportive therapy may be needed, is very likely to eliminate all the symptoms. An alternate, but less rational approach, would be to try to address the symptoms without making any investigation of the etiology. You might be able to support the patient through a prolonged bout of pneumonia, but the patient might die of pneumonia or due to spread of the infection. I realize that this is a very simple example and that real life is often (although by no means always) more complicated; I am merely using a simple example to make my point very clear.

I already said, and emphasized in bold, that “I very strongly support the idea that these symptoms and conditions deserve to be taken seriously and treated effectively.”

Clearly, I am not at all suggesting that patients with such symptoms as chronic pain or dementia be denied support and treatment. Of course such patients deserve support and relief, even if an underlying etiology is difficult to establish, or is is a poorly understood one.

Nevertheless, when symptoms are present, it is overwhelmingly best to seek an underlying etiology. That is not mutually exclusive with treatment.
#12 dave
February 10, 2012

To say there is no cause or pain is idiopathic is scientific mumbo jumbo- trees fall in the woods without scientists being there to witness them. We know that science is less then concerned with people in pain. NIH spends less then 2% of budget on chronic pain research- even though pain effects more then 140 million people per year. A few years ago Senator Specter found that NIH was putting barriers to curative treatment. In A Call to Revolutionize pain care in america- doctors indicated pain has been “tragically overlooked”- when it comes to pain care the fault isnt in the stars- but in morally and mentally doctors, researchers, and government
#13 Jeremy Engdahl-Johnson
February 19, 2012

What is the economic burden of diabetes? Proper management and control could save 49,000 lives and $196 million annually. http://www.healthcaretownhall.com/?p=2699
#14 Witch
February 26, 2012

Health care costs will continue to escalate and send both governments and individuals broke. The orthodox approach to health care is flawed and unsustainable. We need true healthcare, not disease management; we need preventative care, not resuscitation. We need to teach our children to take responsibility for their health, rather than teach them to defer to higher authorities. Such a paradigm shift in healthcare would encourages approaches that are compatible with our bodies and our environment – i.e. sustainable healthcare.
#15 Liz
February 27, 2012

We absolutely need more prevention and care that goes beyond addressing the most immediate symptoms. Even if we start implementing that now, though, it’ll be many years before it starts to pay off in reduced burden of chronic diseases. So we need both a short-term and long-term approach to chronic diseases, while also addressing the overall misaligned incentives in our current system.