F E AT U R E
SHRINKING the health care footprint
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s the nation struggles with the costs of an oppressively large health care footprint, many patients with chronic conditions face a health care footprint of their own that is ever-growing and never-ending. Beyond the expense, the burden of illness—symptoms, disability, and avoidance of activities to prevent symptoms— can significantly reduce patients’ independence, quality of life, and ability to care for loved ones and pursue goals and dreams. For the chronically ill, the goal often is not a cure, but rather controlling the condition and reducing the risk of long-term complications. There has been an explosion in chronic conditions, due in part to aging of the population; improvements in survival of previously lethal conditions; and, increasingly, defining conditions based on risk. Examples include diabetes (defined as blood sugar levels above which patients are at high risk of vision impairment or loss), hypertension (blood pressure levels above which treatment reduces the risk of stroke), and dyslipidemia (LDL cholesterol levels above which treatment reduces the risk of damage to the heart). As a result, many patients, particularly older ones, have multiple chronic conditions. Many of these people are fundamentally healthy—they have few symptoms and experience little illness—but receive a large amount of health care: Medicare patients with five or more chronic conditions account for almost 70 percent of health care expenditure. For them, the fundamental problem is not the burden of illness, but the burden of treatment.
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MINNESOTA HEALTH CARE NEWS SEPTEMBER 2011
A call for minimally disruptive medicine By Victor M. Montori, MD, MSc
To understand the role of treatment as a burden, we have to understand what modern health care requires of patients. Most of the recommended care comes from guidelines that focus on a single condition. These guidelines require tests to diagnose, prognosticate, monitor, and trigger referrals and treatment; indicate measures to ascertain the quality of care performed; and propose treatments, dictating the outcomes that need to be achieved. These guidelines are problematic for a number of reasons: • The research on which they are based is often corrupt. Consider, for example, reports of selective publication of studies favorable to antidepressants, with suppression of those not so favorable. • The guidelines’ writers are often specialists with narrow expertise and important financial relationships with corporations that stand to profit from adherence to the recommendations. • The recommendations fail to account for patient context—including what other conditions and treatments they have and take, but also patient circumstances. Attention to these circumstances has been minimal. To bring this into focus, let’s consider the case of John, a fictional patient who resembles an increasing number of my own patients. A case study John is a 55-year-old accountant, husband, and father of two. He has diabetes, for which he takes metformin and glipizide; abnormal blood lipid levels, for which he takes a statin; and high blood pressure, for which beta blockers were recently added to his diuretic because his office readings were above goal. After this addition, John experiences dizziness when he stands up. His weight seems parked at 238 pounds. He also has depression and chronic low back pain, as well as some nerve pain in both feet. To achieve guideline targets for patients with type 2 diabetes, John’s primary care clinician refers him for evaluation by specialists in podiatry, dietetics, diabetes education, and endocrinology. John must take time off work for each of these appointments. He emerges with advice to cut back on carbohydrates, fats, salt, and calories; to take his pills regularly; to check his blood sugars twice per day; to exercise; and to check his feet daily. John feels no one paid much attention to his back difficulties when advising exercise. Because of back stiffness and abdominal obesity, he will have to ask his wife to take a look at his feet regularly. Meanwhile, his complaints of pain and difficulty sleeping remain largely unaddressed. One reason John doesn’t sleep well is the situation at work. He used to be one of three accountants; through downsizing, he is now the only accountant. He takes work home regularly, feels pressure to perform, and is noting that the numbers are not adding up. He wor-