The Institute of Medicine’s New Report on Living Well With Chronic Illness
Jeffrey R. Harris, MD, MPH, MBA; Robert B. Wallace, MD, MSc
Suggested citation for this article: Harris JR, Wallace RB. The Institute of Medicine’s New Report on Living Well With Chronic Illness. Prev Chronic Dis 2012;9:120126. DOI: http://dx.doi.org/10.5888/pcd9.120126.In the United States, chronic illnesses such as heart disease, cancer, diabetes, stroke, and chronic lung disease account for 70% of deaths and 75% of health care costs (1,2) and have received attention in the professional and lay literature. Although efforts in managing chronic illness typically originate in the health care system, governmental and community-based public health organizations play an important role in helping people with chronic illness maintain optimal health. To help advance the chronic illness programs and policies of public health organizations, the Institute of Medicine (IOM), with the sponsorship of the Arthritis Foundation and the Centers for Disease Control and Prevention (CDC), has produced a new report, “Living Well With Chronic Illness: A Call for Public Health Action” (3). In this essay, we highlight findings from the report related to the consequences of chronic illness, the need for enhanced surveillance, the state of interventions and policies to decrease the effects of chronic illness, and the need for coordinated action in both health care and community-based settings. We close with a discussion of the report’s implications for public health organizations.
The IOM report highlights 9 chronic illnesses — arthritis, cancer survivorship, chronic pain, dementia, depression, diabetes, posttraumatic disabling conditions, schizophrenia, and vision and hearing loss. This list is not intended to indicate the most important chronic illnesses but is a means of illustrating their diverse sequelae, including emotional distress, sleep and pain symptoms, physical impairments, and age-related degenerative problems, all of which detract from living well. The report indicates that illnesses tend to cluster: among older adults, 43% have 3 or more illnesses (5) and 23% have more than 5 (6). The report also notes the disparities in chronic illness occurrence and care use according to race/ethnicity, income, and geography. For example, African Americans are twice as likely as whites to be diagnosed with diabetes (7).
The intervention section of the report reinforces the preventive needs of people with chronic illnesses. In general, people who are chronically ill need all of the preventive services recommended for people who are not chronically ill, such as disease screening, immunizations, and lifestyle interventions to promote healthful eating, physical activity, smoking cessation, and weight maintenance. Preventive interventions for certain illnesses are paramount: for example, physical activity is important for people with arthritis to maximize their mobility and diminish disabling symptoms. Among lifestyle interventions, the benefits of physical activity for people with chronic illness are best documented. The IOM report cites physical activity trials that have shown decreased symptoms, improved functioning, or both in people with arthritis, cancer, depression, and diabetes (3), and more research is needed.
Public health programs and health systems need to promote community-based care, including chronic illness self-management and professionally driven disease management (eg, nurse help lines), cognitive training, and complementary and alternative medicine. There are promising reports for all of the community-based care methods, but more research is needed on how to adapt them to illnesses while meeting broad community goals cost-effectively.
Given the availability of both effective preventive interventions and effective community-based care, the next challenge is scaling up so that effective interventions reach all people in need, especially disadvantaged populations disproportionately affected by chronic illness. The IOM report calls for public health programs to be evaluated for their ability to reach people with chronic illness and deliver effective community-based interventions to them.
Public policies are critical to optimizing function and independence of the chronically ill, particularly those who are most disadvantaged in terms of income and disability. The report outlines decades of social policies and programs that lay a foundation on which to build, including support for income, medical care, and social services for the disabled, elderly, and vulnerable. One example is the Americans with Disabilities Act, which mandates accommodations for and nondiscrimination against people with disabilities. The Affordable Care Act (ACA), a more recent example, has broad implications for the chronically ill. For example, the ACA broadens health insurance coverage through Medicaid expansion, limits the impact of preexisting conditions on care costs, and promotes both coordination of care and preventive care. The report recommends a “health in all policies” approach that evaluates the effect on health and chronic illnesses of major policies in nonhealth sectors, such as agriculture, transportation, and housing. The report also calls for improved methods for economic evaluation of community interventions by both public health organizations and health care organizations.
Author Affiliation: Robert B. Wallace, University of Iowa, Iowa City, Iowa.
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