Team-Based Treatment Helps Those With Cluster of Chronic
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
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
"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
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
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."
The U.S. National Institute of Mental Health has more on
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