Managing chronic conditions

Last updated: October 27, 2022

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Chronic conditions and diseases affect over 50% of adults. They are associated with ongoing medical care and/or impaired activities of daily living as well as increased morbidity, mortality, and health care costs. Studies have shown that patients have improved health outcomes if they are knowledgeable about their chronic condition as well as engaged and confident in managing the condition. Clinicians should provide tailored patient education and use shared decision-making when caring for patients with or at risk for chronic conditions. For patients who are struggling to adhere to recommended treatment, exploring and addressing specific patient-related and systemic barriers may increase engagement.

See also “Patient communication and counseling,” “Patient-centered approach,” “Motivational interviewing,” and “Preventive medicine.”

Prevalence in adults [1]

  • ≥ 1 chronic disease: 60%
  • ≥ 2 chronic diseases: 40%

Risk factors for developing chronic conditions [2][3]

Some conditions have disease-specific risk factors that are detailed in the respective articles (e.g., risk factors for COPD, risk factors for coronary artery disease). The following are general risk factors for chronic diseases.

Obesity and smoking are associated with the highest risk of developing a chronic condition. [2]

Risk factors for poor outcomes in chronic conditions [4]

The following social determinants of health are often associated with worse outcomes in patients with chronic conditions.

  • Low household income
  • Discrimination
  • Limited literacy skills [5]
  • No medical insurance or insufficient coverage

Social determinants of health affect the management of chronic conditions. Consider individual factors and systemic barriers to adherence when tailoring disease management.

Cost to the health care system

  • 90% of total health care expenditure ($3.8 trillion in 2019) in the US [1][6]
  • 81% (∼ $27.3 billion in 2017) of preventable hospitalization costs for adults [7]

Epidemiological data refers to the US, unless otherwise specified.

This section provides information on engaging patients in the self-management of their chronic condition(s) during both initial diagnosis and follow-up encounters.

General principles [5][8][9]

Try to ensure the following during each patient encounter:

  • Use a patient-centered approach.
    • Create an open, nonjudgmental atmosphere.
    • Use open-ended questions.
    • Ask the patient what they would like to address during the appointment.
    • Encourage patients to bring someone to appointments, e.g., a family member or friend.
    • Ensure a follow-up visit is scheduled before the patient leaves.
  • Promote health literacy.
    • Avoid medical jargon; explain any new terms being used.
    • Do not overload the patient with too much information.
    • Encourage patients to take notes and provide them with a copy of instructions ; when appropriate, offer to let them record the consultation. [10]
    • Set clearly defined goals together.

Patients who are knowledgeable about and confident in managing their condition have improved health outcomes and experience less negative daily impact from the disease. [9][11]

Initial diagnosis [5]

  • State how the diagnosis was made: e.g., the patient's clinical and diagnostic findings.
  • Establish a knowledge baseline.
    • Ask the patient to explain what they know about the condition.
    • Ask the patient if they have any questions and/or concerns.
  • Explain the basics.
    • Describe the condition in simple terms.
    • Recommend treatment options when indicated.
      • Observation versus interventions (e.g., medications, lifestyle modifications)
      • Purpose of the treatment plan
      • Manage expectations.
      • Explain how to use equipment and administer medications.
    • Assess the patient's understanding (e.g., summarize what they heard, teach-back method) after each step.
  • Engage the patient by asking if they have any:
  • Use shared decision-making to set goals and expectations. [9][12]
    • Be specific and start with small goals.
    • Link medical goals to the patient's social and emotional goals.
    • Tailor the treatment plan to patient goals and identified obstacles.
  • Arrange follow-up: Coordinate the next follow-up and topics that will be addressed.
  • See alsoCounseling for patients with chronic conditions.”

Provide succinct, specific, and actionable patient information: Inform the patient what the main problem is, what they should do about it, and why they need to do this.

When available, offer referral to patient support groups as they can improve adherence, quality of life, and clinical outcomes. [13]

Follow-up encounters

Try to prepare for follow-up encounters beforehand; see “Managing clinical time constraints.” During the visit, address the following:

  • Assess for changes since the last visit, such as:
  • Use validated scores when possible to objectively track:
  • Screen for comorbidities; treat and/or refer when indicated.
  • Reevaluate the treatment plan with the patient.
    • Discuss any new clinical and/or diagnostic findings.
    • Answer patient questions and/or concerns.
    • Assess the need for treatment adjustments.
    • Set goals and establish the next follow-up.

Reassure patients that setbacks (periods of poor adherence or medications that fail to work as anticipated) are a normal and expected part of chronic disease management.

Chronic conditions affect many aspects of patients' lives, such as work, social life, and mood.

Overview

  • Definition: the extent to which an individual follows recommendations from a health care professional.

  • Five dimensions of adherence (according to the WHO) [20]
    • Social and economic factors (e.g., social support, cultural context, access to transportation)
    • Health care team and system-related factors (e.g., time constraints, communication skills of provider, cost of care)
    • Therapy-related factors (e.g., complexity of treatment plans, adverse effects, dosage frequency)
    • Patient-related factors (e.g., self-efficacy, motivation, health literacy)
    • Condition-related factors (e.g., symptom burden, prognosis, comorbidities)

Physicians should identify potential barriers to treatment adherence and implement strategies to encourage adherence using a patient-centered approach.

Risk factors for poor adherence

Patient-related factors and interventions

Patient-related factors affecting adherence [21][22]
Factors Recommendations

Limited comprehension

  • Provide ≤ 3 takeaway points per visit; repeat and reinforce them. [23]
  • Provide written and verbal instructions that are at a 5th– 6th grade reading level. [24]
  • Utilize the teach-back method. [5][25]
  • Ask what helps the patient best learn and remember things.
  • Assess for and accommodate any hearing and/or visual impairments.
Health illiteracy
(including technological literacy)
  • Consider referral to a chronic disease self-management program (see “Tips and links”). [26]
  • Provide in-person instruction and/or online videos demonstrating how to navigate health systems (e.g., how to use patient portals).
  • Provide digital and/or printed patient health passports. [27]
Forgetfulness
  • For patients who unintentionally miss medication doses, consider the following:
    • Blister packs or weekly pillboxes
    • Alarms or app-based medication reminders [28]
    • Electronic pill monitoring
  • Consider dementia screening (e.g., MMSE) in older patients.
Lack of motivation
  • Recognize and encourage when patient actions directly lead to improved symptoms and/or diagnostic results.
  • Ask the patient to suggest solutions.
  • Remind the patient of the benefits of healthier habits.
  • Refer for motivational interviewing.
  • Screen for depression (e.g., PHQ-9) and refer if indicated.
  • Ensure a follow-up visit is scheduled before the patient leaves.

Limited accessibility

  • Consider using telehealth visits for follow-up encounters.
  • Utilize patient portals and/or telephone calls for patient updates.
  • Book tests at the end of the last visit.
Cultural differences
Lack of support, stigmatization
(especially amongst adolescents,
e.g., due to peer attitudes toward the illness and/or its treatment)
[30]
  • If patients give permission to have a support person present, include them in the conversations.
  • Peer-facilitated behavioral interventions to convey knowledge about the illness and social acceptance for its treatment [31][32]
    • Encourage patients with chronic illnesses to seek support from peers with the same chronic illness, e.g., through:
      • Community health projects
      • Local and online support groups
    • Encourage patients with chronic illnesses to familiarize their peers with their illness and its treatment.

A patient's recall rate decreases when ≥ 3 pieces of information are given in one visit; summarize information and ask the patient to repeat back the management plan. [33]

Care-related factors and interventions [21]

Care-related factors affecting adherence [21]
Factors Recommendations

Medical costs [34]

  • Medications
    • Review medications and stop any unnecessary prescriptions.
    • Order insurance companies' preferred drugs.
    • Offer 90-day supplies rather than 30-day supplies when possible.
    • Suggest discounted cash-pay medications.
  • Consider utilizing technology for patient follow-ups (e.g., portal, telephone, telehealth visits) rather than more expensive in-office visits.
  • Consider consultation with a social worker.
Polypharmacy,
complex and/or
inconvenient treatment plans
  • Simplify whenever possible.
    • Stop unnecessary medications.
    • Consider combination tablets to reduce the pill burden.
    • Use less frequent dosing. [35]
  • Group specialist appointments on the same day, if possible.
Adverse effects of medication
  • Discuss medication side effects.
  • Lower doses and/or split dosing. [35]
  • Ensure appropriate administration times. [36]
  • Avoid coadministration with medications that might potentiate side effects. [37]
  • In patients with severe or persistent side effects, swap to an alternative medication if possible.
Clinical time constraints
  • Maximize time with the patient. [38]
  • Before the appointment, ensure required diagnostic studies have been performed.
  • On the day of the appointment:
    • Use morning huddles to prepare.
    • Provide follow-up forms at check-in.
    • Pick a few things to address during the visit.
  • Automate tasks.
  • Develop individualized care plans.
  • Customize encounter templates.
  • Update the problem list.
  • Send automated reminders: Use patient portals, email reminder programs, and/or telephone calls to:
    • Send reminders about appointments
    • Reinforce education
    • Highlight treatment goals

Factors affecting treatment adherence are dynamic, complex, and manifold; engage empathetically with the patient and avoid blame or judgment.

Primary prevention [2][3]

Many chronic conditions can be prevented with the following preventive medicine interventions:

The US Preventive Services Task Force has a web-based and mobile app with recommended routine screening services (see “Tips and links”).

Disease-specific prevention

Examples

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.

  1. Paterick TE, Patel N, Tajik AJ, Chandrasekaran K. Improving health outcomes through patient education and partnerships with patients. Proc (Bayl Univ Med Cent). 2017; 30 (1): p.112-113. doi: 10.1080/08998280.2017.11929552 . | Open in Read by QxMD
  2. Greene J, Hibbard JH, Alvarez C, Overton V. Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels. Ann Fam Med. 2016; 14 (2): p.148-154. doi: 10.1370/afm.1904 . | Open in Read by QxMD
  3. Graham S, Brookey J. Do patients understand?. Perm J. undefined; 12 (3): p.67-9. doi: 10.7812/tpp/07-144 . | Open in Read by QxMD
  4. Barr PJ, Bonasia K, Verma K, et al. Audio-/Videorecording Clinic Visits for Patient’s Personal Use in the United States: Cross-Sectional Survey. J Med Internet Res. 2018; 20 (9): p.e11308. doi: 10.2196/11308 . | Open in Read by QxMD
  5. Gruber-Baldini AL, Velozo C, Romero S, Shulman LM. Validation of the PROMIS® measures of self-efficacy for managing chronic conditions. Quali Life Res. 2017; 26 (7): p.1915-1924. doi: 10.1007/s11136-017-1527-3 . | Open in Read by QxMD
  6. Lenzen SA, Daniëls R, van Bokhoven MA, van der Weijden T, Beurskens A. Setting goals in chronic care: Shared decision making as self-management support by the family physician. Eur J Gen Pract. 2014; 21 (2): p.1-7. doi: 10.3109/13814788.2014.973844 . | Open in Read by QxMD
  7. Shillington A, Ganjuli A, Clewell J. The impact of patient support programs on adherence, clinical, humanistic, and economic patient outcomes: a targeted systematic review. Patient Prefer Adherence. 2016 : p.711. doi: 10.2147/ppa.s101175 . | Open in Read by QxMD
  8. Li S-C. Factors affecting therapeutic compliance: A review from the patient’s perspective. Ther Clin Risk Manag. 2008; Volume 4 : p.269-286. doi: 10.2147/tcrm.s1458 . | Open in Read by QxMD
  9. Gupta N, Pinto LM, Morogan A, Bourbeau J. The COPD assessment test: a systematic review. Eur Respir J. 2014; 44 (4): p.873-884. doi: 10.1183/09031936.00025214 . | Open in Read by QxMD
  10. Jia CE, Zhang HP, Lv Y, et al. The Asthma Control Test and Asthma Control Questionnaire for assessing asthma control: Systematic review and meta-analysis. J Allergy Clin Immunol. 2013; 131 (3): p.695-703. doi: 10.1016/j.jaci.2012.08.023 . | Open in Read by QxMD
  11. Zhou Z, Zhou A, Zhao Y, Chen P. Evaluating the Clinical COPD Questionnaire: A systematic review. Respirology. 2017; 22 (2): p.251-262. doi: 10.1111/resp.12970 . | Open in Read by QxMD
  12. Schmitt A, Gahr A, Hermanns N, Kulzer B, Huber J, Haak T. The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health Qual Life Outcomes. 2013; 11 (1): p.138. doi: 10.1186/1477-7525-11-138 . | Open in Read by QxMD
  13. Katon WJ. Epidemiology and treatment of depression in patients with chronic medical illness. Dialogues Clin Neurosci. 2011; 13 (1): p.7-23. doi: 10.31887/dcns.2011.13.1/wkaton . | Open in Read by QxMD
  14. Buttorff C, Ruder T, Bauman M. Multiple Chronic Conditions in the United States. RAND Corporation ; 2017
  15. Adams ML, Grandpre J, Katz DL, Shenson D. The impact of key modifiable risk factors on leading chronic conditions. Prev Med. 2019; 120 : p.113-118. doi: 10.1016/j.ypmed.2019.01.006 . | Open in Read by QxMD
  16. Ng R, Sutradhar R, Yao Z, Wodchis WP, Rosella LC. Smoking, drinking, diet and physical activity—modifiable lifestyle risk factors and their associations with age to first chronic disease. Int J Epidemiol. 2019; 49 (1): p.113-130. doi: 10.1093/ije/dyz078 . | Open in Read by QxMD
  17. Cockerham WC, Hamby BW, Oates GR. The Social Determinants of Chronic Disease. Am J Prev Med. 2017; 52 (1S1): p.S5-S12. doi: 10.1016/j.amepre.2016.09.010 . | Open in Read by QxMD
  18. Press release: CMS Office of the Actuary Releases 2019 National Health Expenditures. https://web.archive.org/web/20220822175034/https://www.cms.gov/newsroom/press-releases/cms-office-actuary-releases-2019-national-health-expenditures#:~:text=The%20growth%20in%20total%20national,trillion%2C%20or%20%2411%2C129%20per%20person.. . Accessed: August 22, 2022.
  19. Characteristics and Costs of Potentially Preventable Inpatient Stays, 2017. HCUP Statistical Brief #259.. https://web.archive.org/web/20210713145739/https://www.hcup-us.ahrq.gov/reports/statbriefs/sb259-Potentially-Preventable-Hospitalizations-2017.pdf. Updated: June 1, 2020. Accessed: December 1, 2021.
  20. ANONIMO, de la santé Om, Organization WH, Who WH. Adherence to Long-term Therapies. World Health Organization ; 2003
  21. Kardas P, Lewek P, Matyjaszczyk M. Determinants of patient adherence: a review of systematic reviews. Front Pharmacol. 2013; 4 . doi: 10.3389/fphar.2013.00091 . | Open in Read by QxMD
  22. Stevenson FA et al.. A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance. Health Expectations. 2004; 7 (3): p.235-245. doi: 10.1111/j.1369-7625.2004.00281.x . | Open in Read by QxMD
  23. R. P C Kessels. Patients' memory for medical information. JRSM. 2003; 96 (5): p.219-222. doi: 10.1258/jrsm.96.5.219 . | Open in Read by QxMD
  24. Cotugna N, Vickery CE, Carpenter-Haefele KM. Evaluation of Literacy Level of Patient Education Pages in Health-related journals. J Community Health. 2005; 30 (3): p.213-219. doi: 10.1007/s10900-004-1959-x . | Open in Read by QxMD
  25. Use the Teach-Back Method: Tool #5. https://www.ahrq.gov/health-literacy/improve/precautions/tool5.html. Updated: September 1, 2020. Accessed: October 29, 2021.
  26. Brady TJ, Murphy L, O’Colmain BJ, et al. A Meta-Analysis of Health Status, Health Behaviors, and Health Care Utilization Outcomes of the Chronic Disease Self-Management Program. Prev Chronic Dis. 2013; 10 . doi: 10.5888/pcd10.120112 . | Open in Read by QxMD
  27. Stamm-Balderjahn S, Faliniski R, Rossek S, Spyra K. Development and evaluation of a patient passport to promote self-management in patients with heart diseases. BMC Health Serv Res. 2019; 19 (1). doi: 10.1186/s12913-019-4565-4 . | Open in Read by QxMD
  28. Al-Arkee S, Mason J, Lane DA, et al. Mobile Apps to Improve Medication Adherence in Cardiovascular Disease: Systematic Review and Meta-analysis.. J Med Internet Res. 2021; 23 (5): p.e24190. doi: 10.2196/24190 . | Open in Read by QxMD
  29. Jacobs B, Ryan AM, Henrichs KS, Weiss BD. Medical Interpreters in Outpatient Practice. Ann Fam Med. 2018; 16 (1): p.70-76. doi: 10.1370/afm.2154 . | Open in Read by QxMD
  30. Hanghøj S, Boisen KA. Self-Reported Barriers to Medication Adherence Among Chronically Ill Adolescents: A Systematic Review. Journal of Adolescent Health. 2014; 54 (2): p.121-138. doi: 10.1016/j.jadohealth.2013.08.009 . | Open in Read by QxMD
  31. Enriquez M, Conn VS. Peers as Facilitators of Medication Adherence Interventions: A Review.. Journal of primary care & community health. 2016; 7 (1): p.44-55. doi: 10.1177/2150131915601794 . | Open in Read by QxMD
  32. Pai AL, McGrady M. Systematic review and meta-analysis of psychological interventions to promote treatment adherence in children, adolescents, and young adults with chronic illness. J Pediatr Psychol. 2014; 39 (8): p.918-31. doi: 10.1093/jpepsy/jsu038 . | Open in Read by QxMD
  33. Polona Selic, Igor Svab, Marija Repolusk, Nena K Gucek. What factors affect patients' recall of general practitioners' advice?. BMC Fam Pract. 2011; 12 (1). doi: 10.1186/1471-2296-12-141 . | Open in Read by QxMD
  34. Fiscella K, Venci J, Sanders M, Lanigan A, Fortuna R. A Practical Approach to Reducing Patients' Prescription Costs.. Fam Pract Manag. undefined; 26 (3): p.5-9.
  35. Ingersoll KS, Cohen J. The impact of medication regimen factors on adherence to chronic treatment: a review of literature. J Behav Med. 2008; 31 (3): p.213-224. doi: 10.1007/s10865-007-9147-y . | Open in Read by QxMD
  36. Oelke M, De Wachter S, Drake MJ, et al. A practical approach to the management of nocturia. Int J Clin Pract. 2017; 71 (11): p.e13027. doi: 10.1111/ijcp.13027 . | Open in Read by QxMD
  37. Coleman JJ, Pontefract SK. Adverse drug reactions. Clin Med (Northfield Il). 2016; 16 (5): p.481-485. doi: 10.7861/clinmedicine.16-5-481 . | Open in Read by QxMD
  38. Sinsky CA, Sinsky TA, Rajcevich E. Putting Pre-Visit Planning Into Practice.. Fam Pract Manag. 2015; 22 (6): p.34-8.

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