Finding common ground: patient-centeredness and evidence-based chronic illness care.

Health outcomes for patients with major chronic illnesses depend on the appropriate use of proven pharmaceuticals and other therapeutic technologies, and effective self-management by patients. Effective chronic illness care then bases clinical decisions on the best, rigorous scientific evidence, or evidence-based medicine. Effective support for patient self-management includes efforts to increase patient participation in care and collaborative goal-setting and planning of treatment. These interventions appear somewhat consistent with recent conceptualizations of patient-centered care. The consistent delivery of proven therapies and information and support for self-management requires practice systems organized for that purpose. The Chronic Care Model is a compilation of those practice system changes shown to improve chronic care. This paper explores the concept of patient-centeredness and its relationship to the Chronic Care Model. We conclude that the Model is both evidence-based and patient-centered and that these can be properties of health systems, and not just of individual practitioners.

[1]  D. Eddy.  Evidence-based medicine: a unified approach. , 2005, Health affairs.

[2]  M J Hensley,et al.  Self-management education and regular practitioner review for adults with asthma. , 2002, The Cochrane database of systematic reviews.

[3]  Kate Lorig,et al.  Patients as partners in managing chronic disease , 2000, BMJ : British Medical Journal.

[4]  P. Bower,et al.  Patient-centredness: a conceptual framework and review of the empirical literature. , 2000, Social science & medicine.

[5]  Edward H. Wagner,et al.  A Survey of Leading Chronic Disease Management Programs: Are They Consistent with the Literature? , 2002, Managed care quarterly.

[6]  J. Lynn,et al.  Quality improvements in end of life care: insights from two collaboratives. , 2000, The Joint Commission journal on quality improvement.

[7]  M. Stewart,et al.  The impact of patient-centered care on outcomes. , 2000, The Journal of family practice.

[8]  K. Lorig,et al.  Self-management education: History, definition, outcomes, and mechanisms , 2003, Annals of behavioral medicine : a publication of the Society of Behavioral Medicine.

[9]  J. Hibbard,et al.  Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. , 2004, Health services research.

[10]  R. M. Anderson.  Patient Empowerment and the Traditional Medical Model: A case of irreconcilable differences? , 1995, Diabetes Care.

[11]  Alastair Baker,et al.  Crossing the Quality Chasm: A New Health System for the 21st Century , 2001, BMJ : British Medical Journal.

[12]  E. Wagner,et al.  A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study. , 2004, Archives of pediatrics & adolescent medicine.

[13]  The role of self-treatment guidelines in self-management education for adult asthmatics. , 1998, Respiratory medicine.

[14]  S. Kaplan,et al.  Expanding patient involvement in care. Effects on patient outcomes. , 1985, Annals of internal medicine.

[15]  E. Deci,et al.  Supporting Autonomy to Motivate Patients With Diabetes for Glucose Control , 1998, Diabetes Care.

[16]  B. Korsch,et al.  Gaps in doctor-patient communication. 1. Doctor-patient interaction and patient satisfaction. , 1968, Pediatrics.

[17]  Brian T. Austin,et al.  Improving chronic illness care: translating evidence into action. , 2001, Health affairs.

[18]  B. Lo,et al.  Patient-centered communication , 2004, Journal of General Internal Medicine.

[19]  M. Funnell,et al.  Patient Empowerment: Results of a randomized controlled trial , 1995, Diabetes Care.

[20]  M. Stewart.  Effective physician-patient communication and health outcomes: a review. , 1995, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[21]  Thomas Bodenheimer,et al.  Improving primary care for patients with chronic illness: the chronic care model, Part 2. , 2002, JAMA.

[22]  J H Wasson,et al.  A Replicable and Customizable Approach To Improve Ambulatory Care and Research , 1997, The Journal of ambulatory care management.

[23]  J. Brown.  Patient-centred medicine: Transforming the clinical method , 1998 .

[24]  E. Taal,et al.  Patient education for adults with rheumatoid arthritis (Cochrane Review) , 2003 .

[25]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .

[26]  J. Schaefer,et al.  Collaborative Management of Chronic Illness , 1997, Annals of Internal Medicine.

[27]  Haya R Rubin,et al.  Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. , 2004, JAMA.

[28]  S. Norris,et al.  Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. , 2001, Diabetes care.

[29]  M. Stewart,et al.  Effect on Health-Related Outcomes of Interventions to Alter the Interaction Between Patients and Practitioners: A Systematic Review of Trials , 2004, The Annals of Family Medicine.

[30]  V. Entwistle,et al.  Interventions for providers to promote a patient-centred approach in clinical consultations (Review) , 2018 .

[31]  Sherrie H. Kaplan,et al.  Patients’ participation in medical care , 1988, Journal of General Internal Medicine.

[32]  Thomas Bodenheimer,et al.  Improving primary care for patients with chronic illness. , 2002, JAMA.

[33]  P. Cowan,et al.  A Randomized Trial of Group Outpatient Visits for Chronically Ill Older HMO Members: The Cooperative Health Care Clinic , 1997, Journal of the American Geriatrics Society.

[34]  J. Hibbard,et al.  Engaging Health Care Consumers to Improve the Quality of Care , 2003, Medical care.

[35]  A. Kramer,et al.  Effectiveness of a Group Outpatient Visit Model for Chronically Ill Older Health Maintenance Organization Members: A 2‐Year Randomized Trial of the Cooperative Health Care Clinic , 2004, Journal of the American Geriatrics Society.

[36]  E H Wagner,et al.  Quality improvement in chronic illness care: a collaborative approach. , 2001, The Joint Commission journal on quality improvement.

[37]  N. Clark,et al.  Educational interventions for asthma in children. , 2002, The Cochrane database of systematic reviews.

[38]  I. McWhinney,et al.  Why we need a new clinical method. , 1993, Scandinavian journal of primary health care.

[39]  W. Assendelft,et al.  Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. , 2001, Diabetes care.

[40]  T. Louis,et al.  Evaluation of a Quality Improvement Collaborative in Asthma Care: Does it Improve Processes and Outcomes of Care? , 2005, The Annals of Family Medicine.

[41]  Nicola Mead,et al.  The impact of general practitioners' patient-centredness on patients' post-consultation satisfaction and enablement. , 2002, Social science & medicine.

[42]  J. Bensing,et al.  Bridging the gap. The separate worlds of evidence-based medicine and patient-centered medicine. , 2000, Patient education and counseling.

[43]  E. Wagner,et al.  Chronic care clinics for diabetes in primary care: a system-wide randomized trial. , 2001, Diabetes care.

[44]  Russell E Glasgow,et al.  Translating what we have learned into practice. Principles and hypotheses for interventions addressing multiple behaviors in primary care. , 2004, American journal of preventive medicine.

[45]  M. Chin,et al.  Improving diabetes care in midwest community health centers with the health disparities collaborative. , 2004, Diabetes care.

[46]  Brian T. Austin,et al.  Organizing care for patients with chronic illness. , 1996, The Milbank quarterly.

[47]  E. Keeler,et al.  Differences in education, knowledge, self-management activities, and health outcomes for patients with heart failure cared for under the chronic disease model: the improving chronic illness care evaluation. , 2005, Journal of cardiac failure.

[48]  Brian T. Austin,et al.  Improving outcomes in chronic illness. , 1996, Managed care quarterly.

[49]  E H Wagner,et al.  Chronic disease management: what will it take to improve care for chronic illness? , 1998, Effective clinical practice : ECP.

[50]  Matthias Schonlau,et al.  Does the Collaborative Model Improve Care for Chronic Heart Failure? , 2005, Medical care.

[51]  M. Stewart.  Towards a global definition of patient centred care , 2001, BMJ : British Medical Journal.

[52]  Judith H Hibbard,et al.  Moving toward a more patient-centered health care delivery system. , 2004, Health affairs.

[53]  C. Caspersen,et al.  The effectiveness of disease and case management for people with diabetes. A systematic review. , 2002, American journal of preventive medicine.

[54]  T. Louis,et al.  Measuring the effectiveness of a collaborative for quality improvement in pediatric asthma care: does implementing the chronic care model improve processes and outcomes of care? , 2005, Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association.

[55]  E. Wagner,et al.  A state-level application of the chronic illness breakthrough series: results from two collaboratives on diabetes in Washington State. , 2004, Joint Commission journal on quality and safety.

[56]  T. Bodenheimer,et al.  Patient self-management of chronic disease in primary care. , 2002, JAMA.

[57]  John E. Ware,et al.  Expanding Patient Involvement in Care , 1985 .

[58]  E. Taal,et al.  Patient education for adults with rheumatoid arthritis. , 2003, The Cochrane database of systematic reviews.

[59]  E. Wagner.  The role of patient care teams in chronic disease management , 2000, BMJ : British Medical Journal.