Ogni antibiotico è efficace in relazione a un determinato gruppo di microrganismi comprare keflex senza ricettain caso di infezioni oculari vengono scelte gocce ed unguenti.
CONFERENCES WITH PATIENTS AND DOCTORS
A 63-Year-Old Man With Multiple
Cardiovascular Risk Factors
and Poor Adherence to Treatment Plans
Thomas Bodenheimer, MD, Discussant
Mr P has long-standing hypertension, obesity, and dia-
Mr P is a 63-year-old retired businessman
betes mellitus and has experienced life-threatening car-
who has been obese for much of his life, has had hyperten-
diovascular events. Mr P is receiving evidence-based clini-
sion and hyperlipidemia for at least 20 years, and was di-
cal care but has adhered to his medical regimen poorly and
agnosed as having diabetes about 10 years ago. He is mar-ried, with several children and grandchildren. He has
remains at considerable risk of future catastrophic cardio-
commercial health insurance and has sought care at hospital-
vascular events. Practicing evidence-based medicine should
based primary care practices in Boston.
be a 5-step process: research uncovers the evidence, cli-
He and his family note that he has been poorly adherent
nicians learn the evidence, clinicians use the evidence at
to various suggested medical regimens for more than 20 years.
every visit for every patient, clinicians make sure patients
In 1988, a stroke believed to be hypertensive in origin left
understand the evidence, and clinicians help patients in-
him without deficits. In 1996, he was hospitalized for cel-
corporate the evidence into their lives. Research demon-
lulitis of his foot. In 1998, he came to the hospital with cre-
strates, however, that clinicians do not use the evidence
scendo angina, which led to coronary artery bypass graft(CABG) surgery. He has not had chest pain since that time.
at every visit, patients may misunderstand what took place
The same year, Mr P had a pulmonary embolism, recover-
in the visit, and clinicians are not always effective in help-
ing uneventfully. He has had intermittent back pain. He cur-
ing patients incorporate the evidence into their lives. These
rently has disabling hip pain, associated with degenerative
failures reflect the difficulty faced by clinicians attempt-
joint disease, and he plans hip replacement surgery in the
ing to address multiple issues while providing sufficient
next few weeks. He has had severe erectile dysfunction for
information and engaging in collaborative decision mak-
about 8 years. Changes in his medications and a trial of silde-
ing during a brief clinical visit.
nafil did not improve sexual function.
Mr P was formerly a heavy user of tobacco but stopped in
1982. He now smokes an occasional cigar. He drinks little orno alcohol, at most 2 beers daily. Over the years he has had little
has varied from 245 lb to 280 lb. He has mild, nonprolifera-
exercise but, as he notes below, had been more active physi-
tive diabetic retinopathy but not hypertensive retinopathy.
cally in the past 2 years. There is a strong family history of obe-
No cardiac abnormalities or signs of congestive heart fail-
sity, arteriosclerotic cardiovascular disease, and hypertension.
ure were present. The lungs were clear, and examination
He has been prescribed many medications, including allopu-
of the abdomen revealed only abdominal obesity. Ankles
rinol, aspirin, atenolol, atorvastatin, amlodipine, furosemide,
demonstrated 2-plus pitting edema; peripheral pulses were
glyburide, insulin, ibuprofen, lisinopril, and metformin.
This conference took place
at the Medicine Grand Rounds at the Beth Israel Dea-
On recent examination his blood pressure was 162/94
coness Medical Center, Boston, Massachusetts, on March 1, 2007.
mm Hg supine at rest, with a large cuff. His pulse was 60/min
Dr Bodenheimer is Professor of Family and Community Medi-
and regular; he was not tachypneic. With a height of 70 in,
cine at the University of California, San Francisco.
Thomas Bodenheimer, MD, Bldg 80-83, San Francisco Gen-
he weighed 267 lb (120 kg); over the past 10 years his weight
eral Hospital, 1001 Potrero Ave, San Francisco, CA 94110 (tbodenheimer@fcm
Clinical Crossroads at Beth Israel Deaconess Medical Center
is produced and ed-
CME available online at www.jama.com
ited by Risa B. Burns, MD, Eileen E. Reynolds, MD, and Amy N. Ship, MD. Tom
Delbanco, MD, is series editor.
Clinical Crossroads Section Editor:
Margaret A. Winker, MD, Deputy Editor.
2048 JAMA, November 7, 2007—Vol 298, No. 17 (Reprinted)
2007 American Medical Association. All rights reserved.
full. He had hip tenderness and an antalgic gait while using
in a while. I'm never quite convinced he is taking his medi-
a cane. Neurologic examination results were normal, with
cine, although now that his wife has gotten more involved
no evidence of residual deficit following his stroke.
in his care, I'm more confident about that. And I really don't
In recent laboratory evaluations, his glucose control has
know how much he understands about his illness. His re-
been good, with a hemoglobin A1c level of 5.7%. Creatinine
sponses to me are a sentence, or just one syllable. And I'm
and serum urea nitrogen levels were normal but he did have
never quite sure what's going on in his head.
microalbuminuria and frequent glycosuria. His calculated
I had been saying it for a long time, "You've got to exer-
low-density lipoprotein cholesterol level was 46 mg/dL (1.19
cise. You've got to eat less. You've got to do this. You've got
mmol/L) and his uric acid level was 6.4 mg/dL. Thyroid func-
to do that." I went through the nutrition business and the
tion was normal, as were liver function test results, serum
behavioral modification business, the usual patter song of
calcium levels, and complete blood cell count.
an internist, and it never really took. And then suddenly hebegan going to the gym. And his weight melted away. His
blood pressure came down. His glycemic control was bet-
Most doctors, they make 5 appointments for 1 o'clock. You
ter. His lipid control was better, and I became a convert. It
can't see 5 people, so you are sitting and waiting and wait-
is very rare that we see people do that.
ing all the time. And that bugs me. And I know there's a lot
He hates waiting for me. He's figured out to come early
of people that are always late. I'm just the opposite. You don't
in the morning because that is the first appointment. But
mind waiting a few minutes, but when it is getting into the
he doesn't really take me on about it. I just kind of see it in
hour waiting for doctors, my blood pressure goes up. So then,
his face. I apologize and he kind of says, "It's fine." And I
when he takes it, it is sky high. And I just blame it on the
hear the "It's fine," and I know it is really not fine.
doctor. But I guess that is just the nature of the beast, being
He is not a patient that pushes back and says, "Why should
I do this?" or "Do I have to do this?" When he is pushing
Well, it's hard for me to do the right thing. And I try the
back, I think he does it without talking to me. It's kind of a
best I can. My favorite thing to do is eat. I don't drink. I don't
quiet resistance, and he's probably saying, "I think my doc
smoke. But I do eat. And it seems like I'm going to a ban-
is crazy to have me swallow all these things. And I'm not
quet 5 nights a week. That is what it feels like. And I was
sure I need them. I feel okay." But in the end, I think he
taught from my family that when you've got 13 mouths to
takes quite a lot of the stuff I throw at him and probably
feed, you eat everything on your plate. And that's wrong now.
gets sick from some of it, periodically. Right now his blood
I've got to push the plate back.
pressure is up, and I'm sure it's because he is taking too many
I started the gym because my doctor told me I had to lose
NSAIDs [nonsteroidal anti-inflammatory drugs]. He just
weight. And the gym turned out to be a good thing. I met
jacked that way up when he was away from me, couldn't
people there, and it became an everyday habit, a good habit.
talk to me, or felt he shouldn't talk to me.
I went for a whole year. I was down 60 lb, and the pills were
It's awfully hard to juggle a lot of medicines. It's maybe harder
going. And then, in January, a year ago, my hip started both-
to juggle a lot, rather than just a few, because you have to de-
ering me. And I couldn't do the exercise. I couldn't walk. I
velop a system. His wife is clearly the system by now. I don't
couldn't go to the gym. And if you don't go to the gym, you
think he has a real clue about what numbers he is carrying
start eating more and not losing the weight. And then I was
medically in the results column, but he has a sense of when
just back to where I was. So I hope after the operation I'm
things are awry and when things are okay. If I asked him to
having that I will be back to the gym. That was a big deal,
list his medicines, he would turn to his wife for help.
For a while he would see a nurse on our team, and that
helped. But it never really took. He wanted to see the doctor.
That was the way I think he was socialized, and that was the
He's had many doctors throughout our married life. I think
way he wants to behave. I never could make team care work
that doctors just need, for one thing, to look at the pa-
very well. But we will see what happens in the future.
tients, look them in the eye when they talk to them. A lotof times doctors are so busy, and I understand that they are.
You wait sometimes for 45 minutes, and you are in the of-
AT THE CROSSROADS:
fice for 10 minutes. You like them to look at you and take a
QUESTIONS FOR DR BODENHEIMER
moment to say, "Is everything okay with you?"
Has Mr P's care followed principles of evidence-based medi-cine? How do such principles relate to his course? If pa-
tients are not benefiting sufficiently from such care, who is
He usually comes to see me alone, and we have a few min-
responsible? How can primary care incorporate evidence-
utes together. And it's pretty hard to get him to really talk,
based medicine into patients' lives? How can primary care
particularly since I'm busy trying to figure out what's been
practices improve the care of patients with cardiovascular
going on since I last saw him. He misses appointments once
risk factors? How can we help Mr P do better?
2007 American Medical Association. All rights reserved.
(Reprinted) JAMA, November 7, 2007—Vol 298, No. 17 2049
During his 10 years caring for Mr P, Dr Z
apply evidence-based principles. In a national evaluation of
used evidence-based guidelines.1-3 He participated in diet and
physician performance on 439 process indicators for 30 medi-
exercise counseling and prescribed proper medications. How-
cal conditions plus preventive care, patients received only 55%
ever, Mr P was in serious trouble before he came to Dr Z, with
of recommended care.7 While outcome measures involve the
a history of smoking, hypertension, a poor lipid profile, and
actions of both physicians and patients, process indicators are
a stroke in his 40s. Since primary prevention had failed, Dr Z
more closely associated with physician performance.
was playing catch-up, performing secondary prevention.
Clinicians often fail to inform patients about the
Although Mr P was cared for using evidence-based medi-
evidence. A 2002 national survey found that 55% of patients
cine, it appears that for Mr P, evidence-based medicine failed.
with diabetes reported receiving diabetes education.8 In an au-
Mr P's blood pressure was uncontrolled during visits in 2001,
diotaped study of 336 medical encounters with 34 physi-
2003, 2004, and 2006. His body mass index hovered around
cians, the physicians devoted an average of 1.3 minutes to giv-
38, well above the obesity threshold of 30. Between 2004 and
ing information, although they estimated that they devoted
2006, his hemoglobin A1c level fluctuated between 5% and
an average of 8.9 minutes to this activity. Eighty-eight per-
8.8%. His total cholesterol level rose from 132 mg/dL (3.42
cent of the information was worded in technical language.9
mmol/L) in 2004 to 256 mg/dL (6.63 mmol/L) in 2005, de-
While physicians frequently attribute medication nonadher-
creasing to 118 mg/dL (3.06 mmol/L) in 2006. While Mr P
ence to patient behavior, in fact, 3 of 4 physicians in 1 study
was treated according to the evidence, it is clear that evidence-
failed to give patients clear instructions on how to take their
based medicine was not consistently successful in his case.
medications.10,11 Clinicians may not be spending the time ad-dressing patients' concerns, either. In a study of 264 audio-
Why Does Evidence-Based Medicine Often Fail?
taped visits to family physicians, patients making an initial state-
Mr P's experience is hardly unique. National studies show that
ment of their problem were interrupted after an average of 23
evidence-based guidelines for cardiovascular risk factor re-
seconds. In 25% of the visits, the physician never asked the
duction, which have been well-researched and widely dis-
patient for his or her concerns at all.12
seminated to the nation's physicians, often fail. Sixty-five per-
Three separate studies come to conclusions that can be
cent of people with hypertension have poor blood pressure
summarized as the "50% rule." One found that 50% of pa-
control,4 62% with elevated low-density lipoprotein choles-
tients leave an office visit not understanding what they were
terol levels have not attained lipid-lowering goals,5 and 63%
told by the physician.13 In another study, when physicians
with diabetes have a hemoglobin A1c level of more than 7%.6
asked patients to restate the physician's instructions, the pa-
For many clinicians, evidence-based medicine is a 2-step
tients responded incorrectly 47% of the time.14 A third study
process: research uncovers the evidence and clinicians learn
reported that 50% of patients, when asked to state how they
the evidence. For patients to benefit, however, clinicians must
were supposed to take a prescribed medication, did not un-
apply the evidence at multiple visits, patients must under-
derstand how the physician had prescribed the medica-
stand the recommendations, and patients must incorpo-
tion.15 Mr P, when asked to state what medications he was
rate the practices into their lives.
taking, was unable to do so. His wife, in contrast, under-
Practicing evidence-based medicine should be a 5-step
stood precisely how the medications were prescribed. For
the estimated 90 million adults with limited health literacy,
• Step 1: Research uncovers the evidence.
physicians need to take particular care in making their ad-
• Step 2: Clinicians learn the evidence.
• Step 3: Clinicians use the evidence at every visit for
Clinicians often do not assist and encourage pa-
tients to incorporate evidence-based advice into their lives. Ac-
• Step 4: Clinicians make sure that patients understand
cording to a study of more than 1000 audiotaped visits with
124 physicians, patients participated in medical decisions only
• Step 5: Clinicians assist and encourage patients to in-
9% of the time.17 While half of patients surveyed preferred to
corporate the evidence into their lives.
leave final decisions to their physician, 96% wanted to be of-
Once these things are done, the responsibility shifts to
fered choices and to be asked their opinion.18 Patients are more
the patient. But if we as clinicians stop after step 2 and do
likely to be active participants in their care when their phy-
not perform all 5 steps, we have failed, or the system in which
sicians encourage such participation.19
we practice has failed us and our patients.
A participatory relationship between patient and physi-
cian is one of the most successful factors promoting healthy
How Is the US Health Care System Performing
behaviors.20,21 In a study of 752 ethnically diverse patients,
on Steps 3, 4, and 5?
information giving and collaborative decision making were
Clinicians do not use the evidence at every visit for
associated with better adherence to medications, diet, and
every patient. In many cases, the unsatisfactory intermediate
exercise.22 In an intervention study, patients encouraged to
outcomes for patients with diabetes, hypertension, and hy-
participate more actively in the clinical visit reduced aver-
perlipidemia are related to physicians failing to consistently
age hemoglobin A1c levels from 10.6% to 9.1%, while he-
2050 JAMA, November 7, 2007—Vol 298, No. 17 (Reprinted)
2007 American Medical Association. All rights reserved.
moglobin A1c levels for controls increased from 10.3% to
Primary care practices in England with longer visit times
!.01).23 For patients with diabetes, significant as-
scored significantly better on quality indicators for diabe-
sociations exist among information giving, participatory de-
tes, asthma, and coronary heart disease than practices with
cision making, healthier behaviors, and better out-
shorter visit times.37,38 Shorter primary care visits in the
comes.24-26 A participatory relationship between patient and
United States provide fewer preventive services and health
physician appears to be the most important factor promot-
education and score lower on measures of patient satisfac-
ing medication adherence. The more actively the patient is
tion and patient-physician relationship.39,40
involved, the higher the level of adherence and the greater
British physicians do not necessarily spend more time with
the chance that the patient engages in healthy diet and ex-
patients (5-9 minutes scheduled on average) than US phy-
sicians (10-20 minutes),40 but British practices use nurses
It seems that Mr P did not agree with some clinical decisions
to perform preventive and chronic care functions, many vis-
made by Dr Z, even though those decisions were based on evi-
its are for prescription refills only, and sicker patients may
dence. Mr P clearly stated, "One of my goals is to get rid of all
be cared for at home. Two separate studies found that pa-
my pills." He understood that he needed the pills but he did
tients are less effective in information seeking during visits
not want them and, accordingly, did not take them regularly.
lasting less than 18 minutes.41,42 Length of the office visit isa major predictor of patient participation in clinical deci-
Why Is Evidence-Based Medicine Not Consistently
sion making43; 1 study found that visits need to be at least
Incorporated Into Patients' Lives?
20 minutes to involve patients effectively in decisions.44
Between 62% and 65% of patients in the United States with
In summary, the 15- to 18-minute physician visit and re-
hypertension, elevated cholesterol, and diabetes do not have
sulting lack of patient participation and education may be
these conditions under good control.4-6 Is this a patient prob-
a primary reason why more than 60% of patients with hy-
lem, a physician problem, or a system problem? The prob-
pertension, elevated cholesterol levels, and diabetes have poor
lem cannot be corrected without knowing.
control of their condition.
Poor disease control should not be attributed to patients
if physicians are failing—as the above discussion sug-
Incorporating Evidence-Based Medicine
gests—to practice evidence-based medicine at every visit for
Into Patients' Lives
every patient,7 to impart information in a manner that pa-
A new paradigm for care of patients with chronic condi-
tients can understand,10-15 and to make decisions collabo-
tions and risk factors has achieved broad acceptance among
ratively with patients who prefer this form of decision mak-
health care institutions in the United States and many other
ing.17,19 If not a patient problem, are these failings a physician
nations: the chronic care model.45 This model emphasizes
problem or a system problem? Many clinicians are work-
that good chronic care requires a "prepared, proactive prac-
ing in a rushed atmosphere permeated by competing de-
tice team interacting with an informed, activated patient."
mands; the greater the number of competing demands in
The chronic care model teaches that a fundamental chronic
visits with patients with diabetes, the poorer the glycemic
care task of the practice team is self-management support—
control.29 It is likely that these system problems are fre-
what health care givers do to assist and encourage patients
quent contributors to poor disease control.
to become informed and activated.46 The Institute of Medi-
Physicians may fail to use evidence-based guidelines at ev-
cine defines self-management support as "the systematic pro-
ery visit for every patient,7 to provide adequate information
vision of education and supportive interventions to in-
to patients,10-15 and to engage in collaborative decision mak-
crease patients' skills and confidence in managing their health
ing17,19 because they do not have time. Mrs P confirmed that
problems, including regular assessment of progress and prob-
lack of time was a factor in Mr P's care: " . . you wait some-
lems, goal setting, and problem-solving support."47
times for 45 minutes and you are in the office for 10 min-
I would include in self-management support a number
utes." The average duration of primary care physician visits
of activities that require a team to
by established patients is 16 to 18 minutes,30-32 and the tasks
• Give information.
primary care physicians must accomplish are expanding rap-
• Teach disease-specific skills.
idly. Caring for diabetes, for example, is far more complex and
• Negotiate healthy behavior change.
time-consuming than a decade ago.33 It has been estimated that
• Provide training in problem-solving skills.
it would take a physician 7.4 hours per working day to pro-
• Assist with the emotional impact of having a chronic
vide all recommended preventive services to a typical patient
panel34 and an additional 10.6 hours per day to provide high-
• Provide regular and sustained follow-up.
quality chronic care.35 Wagner introduced the concept of "tyr-
• Encourage active participation in the management of
anny of the urgent." In visits with multiple agendas, acute con-
cerns crowd out chronic care management.36 Consistent
While this model focuses on the informed, activated pa-
guideline-compliant care provided in the standard visit is be-
, Mr P's informed, activated wife reminds us that for many
yond the reach of most primary care physicians.
patients the goal of chronic care management should be the
2007 American Medical Association. All rights reserved.
(Reprinted) JAMA, November 7, 2007—Vol 298, No. 17 2051
informed, activated family
. Mr P, who rarely asked ques-
ter hemoglobin A1c levels than patients without follow-
tions of his physician and who, for much of the time, placed
up.57 The benefits of self-management support for patients
his medical care near the bottom of his life's agenda, ap-
with diabetes diminish over time without regular follow-
peared to be an uninformed, passive patient. However, he
up, and the total time caregivers spend with patients cor-
became highly active and successful in managing his con-
relates with glycemic control.58 Similarly, regular fol-
dition through his exercise program at the gym, during which
low-up is necessary for hypertension management,49 and
time he lost substantial weight and brought his multiple risk
reviews of trials of patients with heart failure discharged from
factors under control. More recently, he was forced to con-
the hospital find that nurse-led follow-up is associated with
front a serious barrier: the incapacitating pain in his hip.
large reductions in heart failure readmissions and, in some
Patients with diabetes who have chronic pain have more dif-
cases, reductions in mortality.59,60
ficulty following a diet plan, engaging in physical activity,
Continuity of care and trust in the physician are also criti-
and regularly taking their medications.48 In addition, he may
cal factors in self-management support. A review of 41 ar-
be experiencing depression; patients like Mr P who have lost
ticles examining the association between continuity of care
motivation should be evaluated for possible depression.
and 81 care outcomes (including preventive and chronic care
As Mr P demonstrates, even if information giving is op-
outcomes, hospitalization rates, and quality of the patient-
timal, as presumably is the case for him, it is insufficient to
physician relationship) found that continuity was associ-
improve outcomes. A review of diabetes patient education
ated with improved outcomes in 51 of the 81 case out-
found that in 33 of 46 studies, education improved pa-
comes.61 Patient trust in the physician has been associated
tients' knowledge about their condition, but in only 18 of
with improved medication adherence, better health-
54 studies did patient education improve glycemic con-
related behaviors, and continuity of care.62
trol.21 Sixteen randomized controlled trials of patient edu-cation on hypertension found that education alone is not
How Can Primary Care Practices Offer
associated with reductions in blood pressure.49 A review of
12 asthma studies concluded that patient education alone
If primary care is truly centered on the 15- to 18-minute
neither improved asthma-related symptoms nor reduced
clinician visit, how is it possible to offer the time-
asthma-related emergency department visits.50 Nor does edu-
consuming components of self-management support, in-
cation by itself increase the extent to which patients take
cluding regular and sustained follow-up? Additional visits
with health educators, behavioral health counselors, and
Teaching disease-specific skills may be the most impor-
pharmacists would certainly help. But as Mr P reported, many
tant component of self-management support. For ex-
patients do not like to seek medical care both because of
ample, home glucose monitoring by itself does not appear
other priorities in their lives and because receiving medical
to improve glycemic control in patients with type 2 diabe-
care is not how most people want to spend their day. The
tes who are taking oral medications, and its efficacy is ques-
best time to reach patients is as part of their regular clinic
tionable in those treated with insulin.52 Measuring, record-
visit, expanding the 15-minute visit into a longer encoun-
ing, and reporting one's glucose levels are not sufficient: one
ter that allows patients like Mr P to benefit from self-
must understand the meaning of the glucose values and how
management support provided as "one-stop shopping."
to adjust diet, exercise, or medication doses in response to
Teams in larger primary care practices generally have sev-
those values. Patients with type 2 diabetes who learn to self-
eral clinicians; for instance, nurses, health educators, phar-
regulate insulin doses based on home glucose levels have
macists, social workers, medical assistants, and reception-
better glycemic control than those who do not self-regulate.53
ists. A "teamlet" is a small subset of this larger team. It consists
Healthy behavior change is a self-management support
of a clinician and 1 other person. The other person would
activity still searching for conclusive evidence. Some litera-
ideally be a nurse or health educator, but in most primary
ture suggests a benefit if patients choose a goal and agree
care practices the other half of the teamlet is more likely to
on a concrete action plan that moves toward the goal.54 A
be a medical assistant. To perform self-management sup-
review of 92 studies of diet behaviors found that goal set-
port, the medical assistant would need additional training
ting or action planning was associated with eating less fat,
in teaching disease-specific skills, working with patients on
and more fruits and vegetables.55 A separate review found
behavioral goals and action plans, and performing regular
32% of 28 studies supporting the use of goal setting or ac-
telephone or electronic follow-up.
tion planning for diet and physical activity.56 The Ameri-
In this model, the 15-minute physician visit is expanded
can Diabetes Association, American Association of Diabe-
to a longer encounter in which the medical assistant would
tes Educators, and American Heart Association recommend
spend time post visit with the patient. In this visit, the up-
goal setting as a component of cardiovascular risk reduction.
graded medical assistant would make sure the patient
Sustained regular follow-up of lifestyle and medication
understands everything that took place in the visit, would
behaviors is necessary in self-management support. Pa-
teach and reinforce disease-specific skills, and would en-
tients with diabetes who have regular follow-up have bet-
gage the patient in behavioral goal setting and action plans.
2052 JAMA, November 7, 2007—Vol 298, No. 17 (Reprinted)
2007 American Medical Association. All rights reserved.
Between visits, the medical assistant would perform tele-
formed passive patient to an activated patient when he em-
phone or electronic follow-up to check on behavioral goals
braced physical activity in the gym, thereby incorporating
and medication use. Some primary care practices in the
evidence-based medicine into his life and improving his
United States have instituted elements of this model, though
weight, blood pressure, hemoglobin A1c, and cholesterol. The
no studies have yet been done to evaluate its effectiveness,
story of Mr P highlights that the activated patient is a ma-
and its widespread adoption would require reform of pri-
jor determinant of chronic disease outcomes. Finding what
mary care payment to reimburse self-management support
helped him motivate himself and trying to reproduce that
could help him regain a sense of control over his disease.
Was Mr P a Nonadherent Patient?
On being asked, "Why are so many of your hypertensive
Many patients do not achieve adequate control of cardio-
patients poorly controlled?" the average community phy-
vascular risk factors, in part because the systems in which
sician replies, "Because they're noncompliant."11 If one asks
many physicians work do not allow sufficient time for phy-
an academic physician the same question, the standard an-
sicians to provide evidence-based medicine at every visit for
swer is, "They are nonadherent." In fact, the definitions of
every patient, to make sure that patients understand the evi-
compliance and adherence are identical,64,65 and both con-
dence, and to assist and encourage patients to incorporate
cepts may be counterproductive.66 Are patients nonadher-
the evidence into their lives. To remedy this situation, pri-
ent if they are among the 50% who do not understand what
mary care practices need to be held responsible for per-
happened in the physician visit?13 Are patients nonadher-
forming these activities and reimbursed adequately to al-
ent if they are not engaged in decisions about their care16
low the practices to build care teams who can work with
and may not agree with what the physician ordered? More-
physicians to carry out this responsibility.
over, are patients nonadherent with an exercise program ifthey live in a neighborhood with a high homicide rate and
QUESTIONS AND COMMENT
nowhere to exercise?
Do you think computers in the future might
A helpful approach is simply to say, "This patient is not
be those "teamlet" members and have some role? And who's
taking his/her medications," and to probe for the reasons
going to pay for these teamlet players? Should we get the
why. Is it cost, medication discordance (the patient not un-
money from the cardiologists, the gastroenterologists, or from
derstanding how the medication should be taken15), ad-
President Bush? You're going to say it's not an incremental
verse effects, lack of belief that the medication will im-
cost, and I won't believe it.
prove one's life, or excessive numbers of pills with complex
There are a lot of barriers to doing team-
dosing schedules? Solving the problem is better served by
lets. One is that it means changing job descriptions, and
probing rather than by affixing the label of nonadherence.
changing job descriptions is not easy to do. It means train-
Evidence-based medicine did not fit well with Mr P's life
ing. But the reason that this teamlet project is not just a fig-
goals. Mr P worked hard, enjoyed life, liked to eat, and ab-
ment of my imagination is that there are people who are ac-
horred his pills. For most of his life he has chosen to be a pas-
tually doing large parts of it.
sive, uninformed patient. If his clinical team (1) made sure
An interesting example is the University of Utah health sys-
he understood the best evidence regarding his disease man-
tem, using medical assistants in an expanded role. Another or-
agement and (2) worked with him collaboratively to look for
ganization that's doing a lot of this type of primary care restruc-
areas of agreement on how to balance his life goals with clini-
turing is Health Partners Medical Group in Minnesota. They're
cal goals, then Mr P's failure to incorporate the evidence into
actually doing previsit, visit, postvisit, and between-visit care.63
his life is his responsibility, his choice. Most clinicians would
Regarding the costs of this model, let me give the example
label Mr P nonadherent; an alternative would be to say that
of Neighborhood Healthcare, a community health center in
his life priorities, and the ways in which he chooses to spend
San Diego. As a federally qualified health center, it receives
his time, differ from the goals of his clinical team. For Mr P,
an augmented rate for patients on Medicaid. The medical di-
like many patients with diabetes, dealing with his health prob-
rector, who also holds a master's of business administration,
lems could consume a couple of hours per day.67 Self-
found that if each physician sees 1 additional Medicaid pa-
management support—providing information, conducting
tient per day at this augmented payment rate, that pays for
skills training, negotiating action plans to encourage achiev-
the extra medical assistants needed.63 Each primary care prac-
able behavior change, assisting in problem-solving, address-
tice has to see whether there is a business case for doing a team-
ing the emotional burden of chronic disease, and providing
let-like model, and some people are finding there is. It's not
regular follow-up—assists and encourages patients to bring
an easy problem, though. It's a huge challenge.
their life priorities into closer approximation with their clini-
I think the computer could take the place of some self-
cian's goals. Sometimes it succeeds, sometimes not.
management support functions in many circumstances. Prob-
The fascinating thing about Mr P is that, for whatever rea-
ably 50% of visits to the physician are unnecessary. They're
son, he temporarily transformed himself from an unin-
unnecessary for the patient, unnecessary for the physician,
2007 American Medical Association. All rights reserved.
(Reprinted) JAMA, November 7, 2007—Vol 298, No. 17 2053
and could be done electronically—much faster, much more
O'Brien MK, Petrie K, Raeburn J. Adherence to medication regimens: updat-
convenient for the patient, and shorter for the physician.
ing a complex medical issue. Med Care Rev
Morris LA, Tabak ER, Gondek K. Counseling patients about prescribed medi-
You can do a lot of self-management support, and you
cation: 12-year trends. Med Care
can do a lot of follow-up work on the computer. But some
Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda.
people really need the face-to-face interaction with people.
Roter DL, Hal JA. Studies of doctor-patient interaction. Annu Rev Public Health
You certainly need that part of the time. But some people
Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician com-
are very comfortable doing things by computer.
munication with diabetic patients who have low health literacy. Arch Intern Med
Does your self-management and patient acti-
Schillinger D, Machtinger E, Wang F, Rodriguez M, Bindman A. Preventing
vation model work across the spectrum of literacy and edu-
medication errors in ambulatory care: the importance of establishing regimen
cation in patients?
concordance. In: Advances in Patient Safety: From Research to Implementation.
Vol 1. Rockville, MD: Agency for Healthcare Research and Quality; 2005.
We did a small study of behavior change
Institute of Medicine. Health Literacy: A Prescription to End Confusion.
action plans in 4 safety net and 4 private practices.54 We called
ington, DC: National Academies Press; 2004.
the patients after they had done action plans with their phy-
Braddock CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. In-
formed decision making in outpatient practice. JAMA
sician. This was all self-reported, so it's not gold standard
Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate
research. The percentage of people actually doing some be-
in decision making. J Gen Intern Med
Street RL, Gordon HS, Ward MM, Krupat E, Kravitz RL. Patient participation
havior change based on the action plan they had agreed on
in medical consultations. Med Care
with their physician was identical between the safety net and
Mead N, Bower P. Patient-centred consultations and outcomes in primary care:
a review of the literature. Patient Educ Couns
the private practices. We always think that people of lower
Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management train-
socioeconomic status and people with lower health lit-
ing in type 2 diabetes. Diabetes Care
Piette JD, Schillinger D, Potter MB, Heisler M. Dimensions of patient-
eracy can't do these things. They can.
provider communication and diabetes self-care in an ethnical y diverse population.
Discontinuity of care disrupts relationships.
J Gen Intern Med
Greenfield S, Kaplan SH, Ware JE, et al. Patients' participation in medical care.
How do you handle that?
J Gen Intern Med
The problem with continuity of care,
Williams GC, Freedman ZR, Deci EL. Supporting autonomy to motivate pa-
especially in an academic clinic, is that physicians are here
tients with diabetes for glucose control. Diabetes Care
Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA. How well do patients'
one day and gone the next. Could you have continuity with
assessments of their diabetes self-management correlate with actual glycemic con-
a teamlet, with patients seeing the teamlet as their continu-
trol and receipt of recommended diabetes services? Diabetes Care
ity provider? It depends a lot on who the other person on
Heisler M, Bouknight RR, Hayward RA, et al. The relative importance of phy-
the teamlet is. If you have nurses, that's perfect. But most
sician communication, participatory decision making, and patient understanding
in diabetes self-management. J Gen Intern Med
primary care practices can't afford nurses, so we're trying
Osterberg L, Blaschke T. Adherence to medication. N Engl J Med
different kinds of caregivers.
Hibbard JH, Mahoney ER, Stock R, Tusler M. Do increases in patient activa-
tion result in improved self-management behaviors? Health Serv Res
This Clinical Crossroads is made possible in part by a grant from
the Florence and Richard Koplow Charitable Foundation.
Parchman ML, Pugh JA, Romero RL, Bowers KW. Competing demands or clini-
Role of the Sponsor:
The funding organization did not participate in the collec-
cal inertia: the case of elevated glycosylated hemoglobin. Ann Fam Med
tion, analysis, and interpretation of the data or in the preparation, review, or ap-
proval of the manuscript.
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sician getting shorter? N Engl J Med
We thank the patient and his wife for sharing their story.
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A 57-Year-Old Man With Osteoarthritis of the Knee
ruary 2003,1 Jess H. Lonner, MD, discussed the epide-
2 or 3 times a week, and that really helped a lot. Shortly af-
miology, treatment options, and potential complica-
ter that, I was walking on crutches. Afterward, I went to an-
tions of osteoarthritis of the knee. The discussion focused
other therapist and she helped me a great deal.
on Mr V, a 57-year-old athlete with a history of persistent
I just got back to riding in late April, after I had a bicycle
knee pain spanning 30 years. Mr V was an avid long-
accident and fractured my neck, which put me on the side-
distance cyclist, estimating his annual cycling distance to
lines for a long time. All things considered, I'm riding pretty
be approximately 7000 miles. His pain had escalated gradu-
well, but a limited amount. I would say in an average week,
ally until it became difficult for him to stand for long peri-
I bike anywhere between 150 and 175 miles. Most of the
ods or bend down to garden. His pain was controlled with
time, I don't think about my replacement knee, it's just part
500 mg/d of naproxen. Radiographs of the left knee in 1999
of me. Obviously, I don't push the left leg as hard as I push
revealed marked tricompartmental osteoarthritis with promi-
the other leg. There are certain movements where I know
nent osteophyte formation and severe joint space narrow-
my limitations, like bending my knee all the way—I can't
ing. Mr V received disparate therapeutic recommendations
do that anymore. But it works well. I've been hiking some
ranging from ongoing physical therapy to total knee re-
technical terrain, and I know how far I can push it.
placement. At the conference, Mr V wondered if he should
In general, my health is very good now. Some time ago,
continue long-distance cycling and also questioned whether
I was diagnosed with osteoporosis and I developed some ar-
and when he should have total knee replacement surgery.
thritis in my right knee. According to my doctor, it is noth-ing to be concerned about right now. I was uncomfortable
for a few weeks, and then it went away, and now I don't have
I decided to have the replacement in my left knee. The sur-
any more pain.
gery went very well and my recovery was relatively quick. I
I'm taking Fosamax [alendronate], 70 mg/wk, and a mul-
had the surgery at the end of August 2003 and I was back
to bicycling the following summer. Obviously, I was per-forming far below my full physical capacity, but I was out
and about. The December following the operation, I was al-
ready hiking, with my physician's permission.
while we as clinicians advise patients regarding what we per-
2007 American Medical Association. All rights reserved.
(Reprinted) JAMA, November 7, 2007—Vol 298, No. 17 2055
Sessione straordinaria 2013 Prima prova scritta Ministero dell'Istruzione, dell' Università e della Ricerca P000 - ESAMI DI STATO CONCLUSIVI DEI CORSI DI STUDIO DI ISTRUZIONE SECONDARIA SUPERIORE PROVA DI ITALIANO (per tutti gli indirizzi: di ordinamento e sperimentali) Svolgi la prova, scegliendo una delle quattro tipologie qui proposte.
Horizons nSAHARA OCCIDENTAL MILITAIRES DE L'ALPS DANS LES TERRITOIRES DIMANCHE 24 AVRIL 2016 - 16 RADJEB 1437 - N° 5790 - PRIX 10 DA l Le projet sera livré Leprojet de la grande mosquée d'Alger est solide, parasismique et sera livré dans les délais, a affir- mé, hier, le ministre de l'Habitat, de l'Urbanisme etde la Ville, Abdelmadjid Tebboune, démentant ainsiles allégations mettant en cause la solidité de ceprojet. Lors d'une visite d'inspection du chantier dela grande mosquée d'Alger, le ministre a assuréque le projet sera achevé à la fin de cette année,ou, au plus tard, le premier trimestre 2017.«Depuis qu'il a été lancé, le projet a ses partisanset ses opposants. Quand il était dans sa phased'étude, personne n'en parlait, ni le contestait.Maintenant que la mosquée prend forme, que sastructure prend forme, elle est attaquée par despersonnes qui veulent casser tout ce qui est beaudans ce pays», affirme-t-il. LIRE EN PAGE 3