Managing chronic conditions

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Chronic conditions and diseases affect over 50% of adults. They are associated with ongoing medical care and/or impaired activities of daily living as well as increased morbidity, mortality, and health care costs. Studies have shown that patients have improved health outcomes if they are knowledgeable about their chronic condition as well as engaged and confident in managing the condition. Clinicians should provide tailored patient education and use shared decision-making when caring for patients with or at risk for chronic conditions. For patients who are struggling to adhere to recommended treatment, exploring and addressing specific patient-related and systemic barriers may increase engagement.

See also “Patient communication and counseling,” “Patient-centered approach,” “Motivational interviewing,” and “Preventive medicine.”

Prevalence in adults ^[2]

• ≥ 1 chronic disease: 60%
• ≥ 2 chronic diseases: 40%

Risk factors for developing chronic conditions ^[3][4]

Some conditions have disease-specific risk factors that are detailed in the respective articles (e.g., risk factors for COPD, risk factors for coronary artery disease). The following are general risk factors for chronic diseases.

• Modifiable risk factors
  • Obesity
  • Smoking and/or smoke exposure
  • Physical inactivity and poor diet (e.g., malnutrition)
  • Excessive alcohol intake
• Nonmodifiable risk factors
  • Age
  • Sex ^[2]
  • Genetics

Obesity and smoking are associated with the highest risk of developing a chronic condition. ^[3]

Risk factors for poor outcomes in chronic conditions ^[5]

The following social determinants of health are often associated with worse outcomes in patients with chronic conditions.

• Low household income
• Discrimination
• Limited literacy skills ^[6]
• No medical insurance or insufficient coverage

Social determinants of health affect the management of chronic conditions. Consider individual factors and systemic barriers to adherence when tailoring disease management.

Cost to the health care system

• 90% of total health care expenditure ($3.8 trillion in 2019) in the US ^[2][7]
• 81% (∼ $27.3 billion in 2017) of preventable hospitalization costs for adults ^[8]

Epidemiological data refers to the US, unless otherwise specified.

This section provides information on engaging patients in the self-management of their chronic condition(s) during both initial diagnosis and follow-up encounters.

General principles ^[6][9][10]

Try to ensure the following during each patient encounter:

• Use a patient-centered approach.
  • Create an open, nonjudgmental atmosphere.
  • Use open-ended questions.
  • Ask the patient what they would like to address during the appointment.
  • Encourage patients to bring someone to appointments, e.g., a family member or friend.
  • Ensure a follow-up visit is scheduled before the patient leaves.
• Promote health literacy.
  • Avoid medical jargon; explain any new terms being used.
  • Do not overload the patient with too much information.
  • Encourage patients to take notes and provide them with a copy of instructions ; when appropriate, offer to let them record the consultation. ^[11]
  • Set clearly defined goals together.

Patients who are knowledgeable about and confident in managing their condition have improved health outcomes and experience less negative daily impact from the disease. ^[10][12]

Initial diagnosis ^[6]

• State how the diagnosis was made: e.g., the patient's clinical and diagnostic findings.
• Establish a knowledge baseline.
  • Ask the patient to explain what they know about the condition.
  • Ask the patient if they have any questions and/or concerns.
• Explain the basics.
  • Describe the condition in simple terms.
  • Recommend treatment options when indicated.
    • Observation versus interventions (e.g., medications, lifestyle modifications)
    • Purpose of the treatment plan
    • Manage expectations.
    • Explain how to use equipment and administer medications.
  • Assess the patient's understanding (e.g., summarize what they heard, teach-back method) after each step.
• Engage the patient by asking if they have any:
  • Questions or concerns
  • Obstacles or risk factors for poor adherence that may impact management
• Use shared decision-making to set goals and expectations. ^[10][13]
  • Be specific and start with small goals.
  • Link medical goals to the patient's social and emotional goals.
  • Tailor the treatment plan to patient goals and identified obstacles.
• Arrange follow-up: Coordinate the next follow-up and topics that will be addressed.
• See also “Counseling for patients with chronic conditions.”

Provide succinct, specific, and actionable patient information: Inform the patient what the main problem is, what they should do about it, and why they need to do this.

When available, offer referral to patient support groups as they can improve adherence, quality of life, and clinical outcomes. ^[14]

Follow-up encounters

Try to prepare for follow-up encounters beforehand; see “Managing clinical time constraints.” During the visit, address the following:

• Assess for changes since the last visit, such as:
  • New medical and/or personal issues
  • Risk factors for poor adherence ^[15]
  • Successes and/or difficulties in meeting established goals
• Use validated scores when possible to objectively track:
  • Symptoms ^[16][17]
  • Disease impact on activities of daily living and quality of life ^[18]
  • Patient self-efficacy ^[12][19]
• Screen for comorbidities; treat and/or refer when indicated.
  • Age-appropriate screening recommendations for the general population; see “Preventive medicine” for details.
  • Disease-specific screening recommendations for known complications and/or associated conditions, e.g., depression ^[20]
• Reevaluate the treatment plan with the patient.
  • Discuss any new clinical and/or diagnostic findings.
  • Answer patient questions and/or concerns.
  • Assess the need for treatment adjustments.
  • Set goals and establish the next follow-up.

Reassure patients that setbacks (periods of poor adherence or medications that fail to work as anticipated) are a normal and expected part of chronic disease management.

Chronic conditions affect many aspects of patients' lives, such as work, social life, and mood.

Overview

• Definition: the extent to which an individual follows recommendations from a health care professional.

• Five dimensions of adherence (according to the WHO) ^[21]
  • Social and economic factors (e.g., social support, cultural context, access to transportation)
  • Health care team and system-related factors (e.g., time constraints, communication skills of provider, cost of care)
  • Therapy-related factors (e.g., complexity of treatment plans, adverse effects, dosage frequency)
  • Patient-related factors (e.g., self-efficacy, motivation, health literacy)
  • Condition-related factors (e.g., symptom burden, prognosis, comorbidities)

Physicians should identify potential barriers to treatment adherence and implement strategies to encourage adherence using a patient-centered approach.

Risk factors for poor adherence

Patient-related factors and interventions

A patient's recall rate decreases when ≥ 3 pieces of information are given in one visit; summarize information and ask the patient to repeat back the management plan. ^[34]

Care-related factors and interventions ^[22]

Factors affecting treatment adherence are dynamic, complex, and manifold; engage empathetically with the patient and avoid blame or judgment.

Primary prevention ^[3][4]

Many chronic conditions can be prevented with the following preventive medicine interventions:

• Encourage routine well-visits which include:
  • Health screenings, e.g.:
    • Screening recommendations for nonpregnant women by age
    • Screening recommendations for men by age
    • Preventive health care of transgender individuals
  • Immunization schedules
• Address modifiable risk factors, e.g.:
  • Counseling on smoking cessation
  • Counseling on weight and diet changes
  • Counseling on regular exercise
  • Counseling on alcohol use disorder

The US Preventive Services Task Force has a web-based and mobile app with recommended routine screening services (see “Tips and links”).

Disease-specific prevention

Examples

• Primary prevention of atherosclerotic cardiovascular disease
• Primary prevention of colorectal cancer
• Primary prevention of opportunistic infections in HIV

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