TodayÔÇÖs medical professional hardly goes a day without reading about or discussing the topic of 'disease managementÔÇÖ. While the term 'secondary preventionÔÇÖ has been around much longer, the newly emerging term refers to managing the chronic illness of large populations. The implications of this rapidly growing strategy are great for the future delivery of secondary prevention services to those with chronic cardiovascular disease. The Disease Management Association of America (DMAA) defines disease management as follows:
ÔÇ£Disease management is a system of coordinated healthcare interventions...in which patient self-care efforts are significant. Disease management:
- supports the physician or practitioner/patient relationship and plan of care,
- emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and
- evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.ÔÇØ
As the medical profession moves into the new paradigm of disease management, it is imperative that we examine why the old paradigm of primary and secondary prevention failed. There are those that would argue with the word 'failedÔÇÖ, but if we are being honest, the word 'failedÔÇÖ is entirely appropriate. Obesity and diabetes are at near epidemic proportions. Exercise habits have not increased with the scientific body of literature supporting exercise as a fundamental support structure in disease management, and depression, anxiety, and social support continue to be ignored factors influencing cardiovascular disease.
Every element of failure in the primary and secondary prevention paradigm involves changing human behavior. Medicine simply does not change behavior in a professional and efficient manner.The reason for failure is three-fold. First, we do not understand the psychology of changing human behavior. How many in our profession have read and understood the stages and processes of change outlined in the past 20 years? Second, changing human behavior is difficult. It involves patient self-care involvement, large amounts of patient education, and well-defined steps and processes of behavior and psychological and social measurements of patientÔÇÖs motivations. Third, changing behavior requires time (time that is not reimbursed and time that is in short supply).
If the new paradigm of disease management is to be effective,we must understand and address the failures of the old model. Can we begin to address weight control and eating behaviors? Do we have realistic reimbursement models to address these behaviors? Can we increase exercise behavior in a cost-effective manner that fits into our current reimbursement scheme? Can we begin to understand the psychological needs of patients in the new disease management paradigm?
There are many challenges with disease management. If we fail to re-examine our past failures, we are destined to repeat them in our new model. Disease management must incorporate pharmacological treatment but, if it becomes exclusionary to behavior change, we will not be successful in primary and secondary prevention. Ôûá