PURPOSE Despite the availability of national practice guidelines, many patients fail to receive recommended chronic disease care. Physician time constraints in primary care are likely one cause. METHODSWe applied guideline recommendations for 10 common chronic diseases to a panel of 2,500 primary care patients with an age-sex distribution and chronic disease prevalences similar to those of the general population, and estimated the minimum physician time required to deliver high-quality care for these conditions. The result was compared with time available for patient care for the average primary care physician.RESULTS Eight hundred twenty-eight hours per year, or 3.5 hours a day, were required to provide care for the top 10 chronic diseases, provided the disease is stable and in good control. We recalculated this estimate based on increased time requirements for uncontrolled disease. Estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands increased to 2,484 hours, or 10.6 hours a day.CONCLUSIONS Current practice guidelines for only 10 chronic illnesses require more time than primary care physicians have available for patient care overall. Streamlined guidelines and alternative methods of service delivery are needed to meet recommended standards for quality health care. INTRODUCTION Many Americans are not receiving recommended health care services. Despite the existence of established clinical guidelines, which are expected to facilitate more consistent and effective medical practice and improve health outcomes, Americans receive only about one half of the applicable services for acute, preventive, and chronic disease care.1 Chronic disease care is of particular concern, as chronic diseases have become more widespread and are often poorly controlled.For instance, hypertension affects approximately 50 million Americans and will become more common as the population ages; however, only 34% of the population with hypertension has blood pressures in the recommended range.2 Control of diabetes mellitus is also elusive: only 37% of patients with diabetes have glycated hemoglobin (HbA 1c ) values at or below the recommended level.3 The human costs are substantial: poor blood pressure control contributes to more than 68,000 preventable deaths annually, 4 and strict blood glucose control can decrease the risk of complications in patients with diabetes by 25%. 5,6 Barriers to chronic care delivery include a limited orientation to disease monitoring and lack of offi ce systems for chronic disease care.7 Time constraints in primary care have been shown to limit the delivery of preventive services 8 and likely also limit the delivery of care for chronic disease. It is diffi cult, if not impossible, to measure the exact amount of time 210CHRONIC DISEASE MANAGEMENT a physician should spend managing chronic diseases because of variability among patients in their disease processes, responses to medication, and lifestyle and social issues. It is, however, possible to estim...
Background To investigate the prognostic importance of functional capacity and exercise behavior in patients with metastatic non-small cell lung cancer (NSCLC). Patients and methods Using a prospective design, 118 consecutive participants with histologically confirmed metastatic (inoperable) NSCLC and Eastern Cooperative Oncology group (ECOG) 0–3 completed a six-minute walk test to assess functional capacity and questionnaire that assessed self-reported exercise behavior. Cox proportional models were used to estimate the risk of all-cause mortality according to six-minute walk distance (6MWD) (<358.5 m, 358.5–450 m, ≥450 m) and exercise behavior (MET-hrs wk−1) categories with adjustment for important covariates. Results Median follow-up was 26.6 months; 77 deaths were reported during this period. Functional capacity was an independent predictor of survival (Ptrend = 0.003) and added incremental prognostic value beyond that provided by PS plus other traditional markers of prognosis (Ptrend = 0.025). Compared with patients achieving a 6MWD <358.5 m, the adjusted hazard ratio (HR) for all-cause mortality was 0.61 (95% CI, 0.34–1.07) for a 6MWD of 358.5–450 m, and 0.48 (95% CI, 0.24–0.93) for a 6MWD >450 m. In unadjusted analysis, there was a borderline significant effect of exercise behavior on survival (p = 0.052). Median survival was 12.89 months (95% CI, 9.11–21.05 months) for those reporting <9 MET-hrs wk−1 compared with 25.63 months (95% CI, 11.28 to ∞ months) for those reporting ≥9 MET-hrs wk−1. Conclusions Functional capacity is a strong independent predictor of survival in advanced NSCLC that adds to the prediction of survival beyond traditional risk factors. This parameter may improve risk stratification and prognostication in NSCLC.
Physicians have many barriers related to discussing weight loss with patients. Given the obesity epidemic, the need to understand how to have these discussions, when to have these discussions, and with whom to have these discussions becomes paramount to providing effective care for patients with obesity. Limited physician training in weight-loss counseling explains why physicians find it challenging to discuss obesity with patients.
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