Living Well with Chronic Illness A Call for Public Health Action (2012) / Chapter Skim
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1 Living Well with Chronic Illness
1 Living Well with Chronic Illness
Pages 27-50
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From page 27... ...
. Not only have chronic diseases emerged as leading causes of death; they also represent enormous and growing causes of impairment and disability (WHO, 2004)
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Addressing the toll of all chronic diseases, from a population health perspective, is the subject of this report. THE TIMELY RELEVANCE OF A PUSH TOWARD LIVING WELL WITH CHRONIC ILLNESS Chronic illnesses have always been a great burden not only to those living with them but also to their societies and cultures, taking a tremendous toll on welfare, economic productivity, social structures, and achievements.
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Some examples include deep vein thrombosis following joint replacement surgery for hip or knee arthritis; increases in type 2 diabetes during treatment with some common mental health medications; more cardiovascular events with intensive glucose lowering in some patients with diabetes; antibiotic resistant infections of kidney dialysis catheters; and increased risk of falls or fractures among frail elders treated with sedative-hypotic medications intended for improving sleep or reducing agitation. In addition, some population risk factors for chronic diseases are going in the wrong direction.
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Morbidity can be measured at the individual level or summed to reflect the aggregate health of a population. Chronic diseases cause considerable population morbidity, which is reflected in often striking statistics regarding the frequency of various complications and subsequent high levels of health care utilization, health care costs, and missed days of work due to illness or disability.
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It is also important to recognize that the degree of impairment or disability imposed by a particular chronic illness is subject to change over time, as the illness's course and the affected individual's coping responses evolve. Some chronic diseases, such as arthritis or type 2 diabetes, begin to impact quality of life even prior to their diagnosis, by causing psychological stress or physical symptoms.
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addressing chronic illness morbidity is to help each affected person and the population as a whole to live well, regardless of the illness in question or an individual's own current state of disablement. The committee adopted the concept of living well, as proposed previously by other chronic disease experts (Lorig et al., 2006)
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Moreover, it is intended also to heighten awareness that interventions and policies that promote function, reduce pain, remove obstacles for the disabled, or alleviate suffering at the end of life play an essential role in providing a more complete response for addressing chronic diseases in the United States today. DOING SOMETHING ABOUT IT In this report the committee elected to use the "living well framework" to inform the consideration of policies and the allocation of resources to solve important issues related to chronic diseases in a manner that is tied to a more complete understanding of the interactions among individual, behavioral, social, and environmental characteristics.
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Before introducing those concepts, however, it is important first to consider the evolution of American strategies designed to understand illness burden and how existing resources and strategies available to promote population health might help to guide the nature and scope of future living-well interventions. A Brief History The capacity of society to respond to health threats, chronic or otherwise, is influenced by the way in which it documents and interprets the magnitude and distribution of health outcomes.
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, and others, have used data from an evolving list of population health indicators to inform a variety of strategies by governmental public health entities, community-based nongovernmental organizations, and the health care system to address illness and promote health and function. Recently, the increasing burden of chronic diseases globally has expanded the attention of these efforts to focus well beyond simply prolonging life, with an increasing emphasis on wellness and function.
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. Although these initiatives are attempting to advance the capacity to understand the impact of chronic diseases and their risk factors on population health, practical considerations have led them to recommend only very brief metrics that are already being collected and are in the public domain.
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. Another common way to express the summative impact of chronic diseases for a population is through a cost of illness approach, which attempts to monetize the direct and indirect financial costs incurred by society for a particular chronic disease.
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For example, in a 2007 report, the Milken Institute examined treatment costs for seven common chronic diseases in the United States in 2003: cancers, diabetes, heart disease, hypertension, stroke, mental disorders, and pulmonary conditions. This report estimated direct treatment expenditures to be $277 billion across those seven conditions, corresponding to 16 percent of total 2003 national health expenditures of $1.7 trillion (DeVol and Bedroussian, 2007; Smith et al., 2005)
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. In 2009, arthritis and coronary heart disease affected African Americans slightly more than whites (CDC, 2010b)
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. Smoking is related to a wide range of chronic diseases, including chronic obstructive pulmonary disease, coronary heart disease, stroke, peripheral vascular disease, and peptic ulcer disease (Fagerström, 2002)
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but also in terms of their relative intensity to meet the needs of those who shoulder the greatest burden of nonfatal chronic illnesses. This framework is used in subsequent chapters to communicate the nature and Priority Pyramid Intervention Targets High-intensity interventions designed specifically to address the unequal burden of chronic disease in high-priority groups Intensive strategies aligning Refinement health care and non–health care guided by sectors to maximize quality of life coordinated and reduce complications surveillance of living well Community-wide strategies that link with health care to support outcome self-care, provide risk factor treat metrics ment, and prevent complications Environmental and population based policy interventions to support healthy living and primary prevention 1-3.eps FIGURE 1-3 Prioritization scheme for policies and other interventions to address the burden of nonfatal chronic diseases across the population.
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) as well as a shared sense of participation and accountability among individuals, groups, institutions, businesses, communities, and governments to preserve, protect, and advance population health at every level.
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, depicted in Figure 1-4, advances the perspective that care model elements bridge across health care and non–health care sectors and that an overarching goal of those bridging support structures and programs is to improve population health outcomes not only by impacting the health and behaviors of individual patients and their health care providers but also by activating communities and preparing community partners. Although integration frameworks, such as the Expanded Chronic Care Model, may prove helpful in coordinating care resources for persons with nonfatal chronic illnesses, much more work is needed not only to understand the best approaches for developing clinical-community linkages (Ackermann, 2010; Etz et al., 2008)
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New strategies for understanding and addressing this burden must give ample consideration to all chronic illnesses and all dimensions of suffering. Indeed, all chronic diseases have the potential to reduce population health not only by causing premature death but also by limiting people's capacity
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Because different chronic illnesses impact social participation and quality of life in varied ways, the committee also uses examples of different chronic diseases to illustrate key concepts. This, however, should not be viewed as an assertion that some diseases are more burdensome or more important than others.
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. Chronic Disease Prevention and Health Promotion.
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: Metrics, incentives, and partnerships for population health. Preventing Chronic Disease 7(4)
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. Chronic Diseases and Health Promotion.
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Geneva, Switzerland: World Health Organization. http://www.who.int/ healthinfo/global_burden_disease/global_health_risks/en/index.html (accessed October 4, 2011)
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