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  Vol. 9 No. 8, August 2000 TABLE OF CONTENTS
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Improvement of Outcomes in Chronic Illness

Arch Fam Med. 2000;9:709-711.

MODERN MEDICINE has made tremendous advances in developing efficacious pharmacological treatments for patients with chronic medical illness. Most randomized trials of these new medications are tested in highly selected patients who are monitored very intensively, with results compared with placebo. In the "real world" of primary care, patients are much more heterogeneous—often having more ambivalence about taking medications long-term, having other medical comorbidities, and being followed up much less closely.1 The resulting differences in adherence to self-management activities (taking medications, changing diet, increasing exercise) and disease outcomes between efficacy studies and naturalistic studies in primary care are often marked.1

Evidence suggests that a minority of primary care patients with chronic illnesses such as asthma,2 hypertension,3-4 diabetes,5-6 or depression7-8 are receiving guideline-level treatments, resulting in less than optimal management of their illness. For instance, rates of nonadherence in asthma range from 30% to 70%, whether adherence is measured as percentage of prescribed medication taken, serum theophylline levels, days of medication adherence, or percentage of patients who failed to reach a clinically estimated adherence minimum.2 Despite blood pressure being checked at virtually every primary care appointment, recognition and treatment of hypertension is still problematic. In a recent study of union employees treated in a large health maintenance organization, 409 patients were found on screening to have hypertension.3 Although 289 patients (71%) were aware of their condition, 201 (49%) had been treated, and only 51 (12%) had their blood pressure controlled at the recommended level (<140/90 mm Hg).3 In studies of major depression in primary care, approximately 50% of patients are accurately diagnosed and, of these, approximately 30% to 50% receive guideline-level antidepressant therapy and fewer than 10% receive evidence-based psychotherapies.7-8 Studies of usual primary care outcomes in patients with depression have shown that only approximately 40% of patients diagnosed as having major depression and initially prescribed antidepressant medications have significant improvement by 4 to 6 months by conservative criteria (ie, a decrease in depression symptoms of 50% or greater).8 Finally, in patients with diabetes, despite findings from recent trials demonstrating the importance of improved glycemic control on long-term outcomes, data from primary care systems of care suggest that 30% to 50% of patients have hemoglobin A1c levels above recommended levels.9

Wagner et al10-11 have described important system barriers to high-quality care of chronic illnesses, including medical care being organized around the 12- to 15-minute visit, sole reliance on the physician, limited access to timely expertise of medical specialists and mental health personnel, inadequate access to key clinical information to help monitor patient progress and adherence, and lack of incentives for chronic illness outcomes. In the past 5 to 10 years, multiple randomized trials have been carried out that have shown improved care and outcomes of patients with chronic medical illnesses.5-6,12-16 These trials have several components in common, including (1) providing enhanced support to help educate and motivate patients to become knowledgeable partners in the care of their illness, (2) providing allied health professionals as "care extenders" to help with patient support and education and to increase frequency of follow-up visits, (3) closely monitoring adherence and outcomes and providing feedback on these parameters of care to primary care physicians, and (4) facilitating referral to specialists for patients with adverse outcomes.10-11 To implement these changes in care, organizations will need to reorganize practices (eg, utilize nurses in chronic illness management rather than clinic flow and access to care activities); provide physicians with timely feedback on patient adherence and outcomes and on guideline adherence, which will require better information systems such as disease registers; and provide and facilitate access to specialists for more complex cases or those with adverse outcomes.

In their article "Efficacy of Nurse Telehealth Care and Peer Support in Augmenting Treatment of Depression in Primary Care" in this issue of the ARCHIVES, Hunkeler et al17 provide an excellent example of the development of an intervention to improve care of a chronic or recurrent illness. In their study, intervention patients with depression received a mean of 10.1 telephone calls from medical nurses lasting 5.6 minutes on the average. These calls were aimed at improving patient education, medication adherence, and providing brief support, counseling, and behavioral activation. Because the intervention used nurses already integrated into primary care, it was well accepted by patients and physicians. The intervention was associated with improved symptomatic and functional outcomes compared with usual primary care treatment. Interestingly, there were no significant differences between intervention and control patients in antidepressant medication adherence over time, suggesting that behavioral activation (scheduling positive activities) and the emotional support provided by nurses were the most helpful strategies. It is essential to emphasize that most primary care patients with major depression who are recognized and initally given antidepressant medication receive about 2 primary care visits in the first 8 to 10 weeks of treatment and 4 to 6 depression visits per year.7-8 Therefore, adding 10 telephone visits with a primary care nurse is a major increase in the contact and monitoring of outcome and support provided by the medical system.

The findings of this study are mirrored by similar findings from other researchers who have found that "care extenders" who provide education, social support for behavioral changes (such as diet, exercise, and taking medication regularly), and behavioral activation strategies improved outcomes for patients with asthma,13-14 diabetes,5-6 and congestive heart failure.15 Moreover, 2 other recently published studies16-17 have found that use of care extenders providing education, support, and monitoring adherence and outcomes improved adherence to antidepressant medication therapy and depressive and functional outcomes compared with usual care.

Despite the improvement in outcomes associated with the nurse telehealth intervention program, which was associated with a 50% or more decrease in symptoms in about 48% to 57% of intervention patients compared with approximately 38% of patients receiving usual care, that still leaves almost half of patients with significant depressive symptoms. Similarly, another recent intervention used a depression case manager who followed up patients by telephone and provided enhanced education and information to patients, scheduled follow-ups with primary care physicians for patients who were still symptomatic, and alerted physicians about these persistent symptoms, found that 55% of intervention patients compared with 40% of control patients had a decrease in symptoms of 50% or more.16 A major question for primary care systems will be how to improve care for patients with persistent symptoms even after enhanced support by a care extender. Our research group recently tested a stepped collaborative care intervention that added psychiatry visits to primary care management of patients with depression to improve pharmacological treatment of those persistently ill after 2 months of antidepressant treatment. This intervention was associated with improved symptom and functional outcomes at 6 months compared with patients receiving usual primary care.18 Given that specialty resources are relatively scarce in many organized systems of care, tracking primary care outcomes and providing specialty services for patients with adverse outcomes may be the most cost-effective way to utilize specialty medical services.

Randomized trials have now demonstrated methods in organized medical systems to improve the process and outcomes of care for patients with chronic medical illnesses. These will require systematic changes in roles of professionals as well as the development of information systems that facilitate monitoring of treatment adherence and outcomes. Many systems of care are currently implementing key components of these disease management mechanisms in a stepwise fashion. But in a competitive health care environment, few have the economic resources to systematically provide all the components of the effective programs described in the research trials. Economic incentives by health care insurers such as the Health Care Financing Administration for improving outcomes of chronic illness would likely dramatically speed up the process.


Corresponding author: Wayne J. Katon, MD, Department of Psychiatry and Behavioral Sciences, Box 356560, University of Washington Medical Center, 1959 NE Pacific, Seattle, WA 98195-6560 (e-mail: wkaton{at}u.washington.edu).

Wayne Katon, MD
Department of Psychiatry and Behavioral Sciences
University of Washington School of Medicine


1. Bridging Science and Service: A Report by the National Advisory Mental Health Council's Clinical Treatment and Services Workgroup. Bethesda, Md: National Institutes of Health; 1999:23-24. Publication 99-4353.
2. Bender B, Milgram H, Rand C. Nonadherence in asthmatic patients: is there a solution to the problem? Ann Allergy Asthma Immunol. 1997;79:177-186. ISI | PUBMED
3. Stockwell D, Madhavan S, Cohen H, Gibson G, Alderman M. The determinants of hypertension awareness treatment and control in an insured population. Am J Public Health. 1994;84:1768-1774. FREE FULL TEXT
4. Alexander M, Tekawa I, Hunkeler E, et al. Evaluating hypertension control in a managed care setting. Arch Intern Med. 1999;159:2673-2677. FREE FULL TEXT
5. Weinberger M, Kirkman S, Samsa G, et al. A nurse-coordinated intervention for primary care patients with non–insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. J Gen Intern Med. 1995;10:59-66. ISI | PUBMED
6. Aubert R, Herman W, Waters J, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: a randomized controlled trial. Ann Intern Med. 1998;129:605-612. FREE FULL TEXT
7. Schulberg H, Katon W, Simon G, Rush A. Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines. Arch Gen Psychiatry. 1998;55:1121-1137. FREE FULL TEXT
8. Katon W, Von Korff M, Lin E, et al. Population-based care of depression: effective disease management strategies to decrease prevalence. Gen Hosp Psychiatry. 1997;19:169-178. FULL TEXT | ISI | PUBMED
9. McCulloch D, Price M, Hirdmarsh M, Wagner E. A population-based approach to diabetes management in a primary care setting: early results and lessons learned. Eff Clin Pract. 1998;1:12-22. PUBMED
10. Wagner E. Managed care and chronic illness: health services research needs. Health Serv Res. 1997;32:702-714. ISI | PUBMED
11. Wagner E, Austin B, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74:511-543. ISI | PUBMED
12. Berg J, Dunbar-Jacob J, Sereika S. An evaluation of a self-management program for adults with asthma. Clin Nurs Res. 1997;6:225-238. FREE FULL TEXT
13. Kauppinen R, Sintonen H, Vikka V, Tukiainen H. Long-term (3-year) economic evaluation of intensive patient education for self-management during the first year in new asthmatics. Respir Med. 1999;93:283-289. FULL TEXT | ISI | PUBMED
14. Rich MW. Heart failure disease management: a critical review. J Card Fail. 1999;5:64-75. ISI | PUBMED
15. Simon G, Von Korff M, Rutter C, Wagner E. Randomized trial of monitoring, feedback and management of care by telephone to improve treatment of depression in primary care. BMJ. 2000;320:550-554. FREE FULL TEXT
16. Wells K, Sherbourne C, Sherbourne M, et al. Impact of disseminating quality improvement programs for depression in managed care primary care: a randomized controlled trial. JAMA. 2000;283:212-220. FREE FULL TEXT
17. Hunkeler EM, Meresman JF, Hargreaves WA, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med. 2000;9:700-708. FREE FULL TEXT
18. Katon W, Von Korff M, Lin E, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999;56:1109-1115. FREE FULL TEXT


Efficacy of Nurse Telehealth Care and Peer Support in Augmenting Treatment of Depression in Primary Care
Enid M. Hunkeler, Joel F. Meresman, William A. Hargreaves, Bruce Fireman, William H. Berman, Arlene J. Kirsch, Jennifer Groebe, Stephen W. Hurt, Patricia Braden, Michael Getzell, Paul A. Feigenbaum, Tiffany Peng, and Mark Salzer
Arch Fam Med. 2000;9(8):700-708.

© 2000 American Medical Association. All Rights Reserved.