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A NEGLECTED DIMENSION OF HEALTH CARE

School of Medicine Case Western Reserve University Cleveland, OH 44106-4945

Meeting the Challenge of Chronic Illness, by Robert L. Kane, Reinhard Priester, and Annette M. Totten. Johns Hopkins University Press, Baltimore MD, 2005, 302 pp., $55.00 (cloth).

The U.S. health care system, evolving through a couple of centuries and dominated for many years by physicians, has contributed to enviable progress in individual health and biomedical research. In terms of public health and social medicine, however, we have failed to keep up with many other industrialized countries. Over the past two decades, in fact, numerous thoughtful physicians, including medical educators and editors, health care analysts, and practitioners at all levels, have begun to express frustration and even anger at a system that has become dysfunctional, fragmented, excessively expensive, and unavailable to many when they need it most.

At this point of crisis, as many see it, we are offered a dispassionate analysis of a neglected part of the health care problem: the care of chronic illness. As the authors of this new volume rightly point out, chronic illness is developing into the largest part of total heath care, fueled by dramatic aging of the population, with its inevitable burden of chronic illness and disability.

This book provides a "deliberately selective review" of the status of scholarly reporting on and innovative practices in caring for aging and chronically ill individuals in the United States, with a brief appendix on recent changes in Great Britain. All three authors are connected with the University of the Minnesota School of Public Health, Kane as a well-known professor, Priester as coordinator of health services research, and Totten as a recent graduate now at Boise State University.

Current efforts to cope with the growing burden of chronic illness in a population facing the tribulations attached to a longer life span have proved seriously deficient. The U.S. health care system, which evolved primarily as a means of coping with acute illness and injury, has not proved to be an appropriate method for dealing with the now-dominant challenge of chronic illness. Instead, the authors advocate a comprehensive approach that includes the patient's whole life, family, and social situation.

Although the title suggests a call to action, and the text repeatedly refers to problems that could best be managed at a national or at least a state-wide level, the authors do not seem to be alarmed or to be calling for fundamental change. Instead, they describe numerous barriers to reform and avoid endorsing any specific action. Even journalistic efforts, they point out (in an appendix), have failed to focus public attention on this problem in the absence of effective political or professional leadership. The way forward, they believe, must be gradual and incremental rather than revolutionary, and integrated and sustained as well. They defer judgment about desirable action because "which combinations of interventions and strategies are most likely to achieve best possible outcomes have yet to be determined" (p. 90).

On the other hand, in the second section "Opportunities for Change," the authors do call attention to some important innovations that could, if widely adopted, improve chronic illness care in the future. This is the most novel and interesting part of the book. A remarkable amount of experimentation with pilot programs has been going on at organizational and local levels, they find, and several new strategies for overcoming the most glaring deficiencies have been tried and tested. Noteworthy change agents include the Robert Wood Johnson Foundation and specific health-care organizations such as the Group Health Cooperative of Puget Sound and Kaiser Permanente. For years, these organizations have been developing and testing new approaches to the care of chronic illness. Examples of progress are most frequently found in organizations that provide comprehensive care to a large-enough population where changes can be introduced and evaluated throughout the system.

Another widespread improvement in care has been the introduction of uniform system-wide computerized medical records. This important change has already been made throughout the Veterans Administration hospitals and clinics and in other large systems. Although Kane, Priester, and Totten don't mention these exemplary reforms, they do describe, with approval, other more-limited information technology reforms.

Other promising innovations include the training of advance practice nurses, interdisciplinary group practice guided by evidence-based guidelines, innovative technology in addition to computerization of records, improved professional education, case management, particularly in geriatrics, and a commitment to basing care on the needs of the patient rather than the requirements of an inappropriate system.

The final section, "Prospects for Change," is disappointing. Changes recommended take the form of sweeping generalizations, such as to "create a demand" or to "improve professional education," or else they follow established patterns put forth by Kaiser Permanente and others.

The decision of the authors to provide "a deliberately selective review" has resulted in no or only passing references to some very important issues that are integral to the care of chronic illness. These include the status and cost of nursing homes, where more than a quarter of all those aged over 65 die, and the recognition and still unsatisfactory management of end-of-life problems such as pain control, hospice care, palliative care, and dementia.

How does the problem of chronic illness care relate to our dysfunctional health care system as a whole? The force of population change and the resulting burden of chronic illness and disability certainly deserve special attention. But can they be considered apart from such urgent matters as lack of insurance for one-seventh of our fellow citizens, our uniquely expensive profit-based method of payment, or the dominance of the pharmacological and insurance industries? What about the repeated unsuccessful efforts to reform health care in this country? Solving or even recognizing the special problems of chronic illness will surely engage us in dealing with the whole system of health care.

Finally, to whom should this book be recommended? The intended audience is not identified, but what is presented would seem to be most appealing to thoughtful academics, with the caveat that much more needs to be said. Care providers will find the account of the sad state of health care in the United States all too familiar, and ordinary citizens looking for a way out of the tangle of a dysfunctional health care system may find little hope for answers to the pressing needs of friends, relatives, and themselves as we all age.

Challenges offered by the increasing prevalence of chronic illness certainly need to be highlighted, but solutions probably cannot be found by focusing on an isolated part of a sick system.

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