Cardiovascular Risk Factors
and Poor Adherence to Treatment Plans
Thomas Bodenheimer, MD, Discussant
Mr P has long-standing hypertension, obesity, and dia-
DR DELBANCO: 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 Author Affiliation: 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.
Corresponding Author: 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 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.
CLINICAL CROSSROADS 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 CLINICAL CROSSROADS DR BODENHEIMER: 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.
Step 4. 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.
vice understandable.16 • Step 3: Clinicians use the evidence at every visit for Step 5. Clinicians often do not assist and encourage pa-
every patient.
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 the evidence.
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 Step 3. 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.
CLINICAL CROSSROADS moglobin A1c levels for controls increased from 10.3% to Primary care practices in England with longer visit times 10.6% (P!.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- the disease.
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- tient, 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 CLINICAL CROSSROADS 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 Self-management Support? 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.
CLINICAL CROSSROADS 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? DR DELBANCO: 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 DR BODENHEIMER: 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 CLINICAL CROSSROADS and could be done electronically—much faster, much more 10. 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. 1992;49(4):435-454.
11. 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. 1997;35(10):996-1007.
can do a lot of follow-up work on the computer. But some 12. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda.
people really need the face-to-face interaction with people.
13. Roter DL, Hal JA. Studies of doctor-patient interaction. Annu Rev Public Health.
You certainly need that part of the time. But some people 14. 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.
QUESTION: Does your self-management and patient acti-
15. Schillinger D, Machtinger E, Wang F, Rodriguez M, Bindman A. Preventing
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DR BODENHEIMER: We did a small study of behavior change
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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. 2003;26(3): ity provider? It depends a lot on who the other person on 26. Heisler M, Bouknight RR, Hayward RA, et al. The relative importance of phy-
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Financial Disclosures: None reported.
tion result in improved self-management behaviors? Health Serv Res. 2007;42 Funding/Support: This Clinical Crossroads is made possible in part by a grant from
the Florence and Richard Koplow Charitable Foundation.
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Role of the Sponsor: The funding organization did not participate in the collec-
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CLINICAL CROSSROADS 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.

La une et 24 (page 1)

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