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Team-Based Treatment Helps Those With Cluster of Chronic Illnesses
Date:12/30/2010

By Amanda Gardner
HealthDay Reporter

WEDNESDAY, Dec. 29 (HealthDay News) -- A treatment team headed by an experienced nurse improved the health of patients suffering from multiple chronic illnesses such as heart disease, diabetes and depression.

A study appearing in the Dec. 30 issue of the New England Journal of Medicine reports improvements in the four areas of blood sugar, blood pressure, cholesterol control and depression in middle-aged patients offered this treatment strategy.

"The results were great. All of the key parameters improved in the intervention group compared with the controls," said study author Dr. Wayne J. Katon. "And the intervention patients were less disabled at the end of one year, rated their quality of life as higher and were more satisfied with medical care."

People with chronic illnesses often don't get optimal care in primary-care settings, noted Katon, who is vice chairman of psychiatry and behavioral sciences at the University of Washington School of Medicine in Seattle.

"[In primary-care clinics], at least 50 percent of people with diabetes have blood sugars above guidelines and many people with high blood pressure don't get enough pills or aren't taking them," he said. "Similarly with depression, only about one-quarter of people get guideline-level care in primary care."

And people with three or more illnesses are expensive, accounting for 60 percent to 80 percent of Medicare costs, he added.

A team-based, "collaborative care" strategy has been shown to work in control of heart disease, of diabetes or with depression, but no one has yet looked at all three in tandem.

Depression, said Dr. Yeates Conwell, co-director of the Center for the Study and Prevention of Suicide at the University of Rochester Medical Center, "typically goes along with a lot of other medical conditions, tends to interact with those conditions, complicate treatment and worsen outcomes." Even death rates are higher among people who suffer depression along with another chronic illness, such as heart disease.

The researchers randomized 214 patients enrolled in the Group Health Cooperative, a health care system in Washington state, to receive "usual care" in a primary-care setting or to get the collaborative care approach, called TEAMcare.

Those in the TEAMcare group were assigned to a nurse trained in all three conditions who worked with a primary care physician to monitor medication and lifestyle changes.

At the end of 12 months, patients in the team group saw improved blood sugar control, better LDL ("bad") cholesterol levels, lower systolic blood pressure and improvement with their depression.

Although the trial didn't last long enough to track actual health outcomes, the authors pointed out that improving these four measures has been associated in the past with fewer complications and death.

The TEAMcare approach cost $1,224 per patient for the year and the authors are now in the process of analyzing whether this actually saved the system money. These patients, on average, cost health-care systems $10,000 per year.

As always, though, the devil is in the details. "Implementation is the catch here," said Simon A. Rego, director of psychology training at Montefiore Medical Center in New York City. "This requires a lot of steps that, at the moment, don't happen together: coordination of resources, an excellently trained nurse practitioner, a nephrologist [and other specialists], and it's in the context of an HMO [health management organization]."

"This is a difficult model to implement outside of a large group practice," added Conwell. "A lot of the care delivered in the United States is in small practitioners so this would be difficult in some respects."

More information

The U.S. National Institute of Mental Health has more on depression.

SOURCES: Wayne J. Katon, M.D., professor and vice chairman, department of psychiatry and behavioral sciences, University of Washington Medical School, Seattle; Yeates Conwell, M.D., professor and vice chairman, psychiatry, and co-director, Center for the Study and Prevention of Suicide, University of Rochester Medical Center, Rochester, N.Y.; Simon A. Rego, Psy.D., director, psychology training, Montefiore Medical Center, New York City; Dec. 30, 2010, New England Journal of Medicine


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