The Burden of Chronic Disease

The Burden of Chronic Disease

What does it mean for an individual to be engaged in health care? Patient engagement in health care means not only preparing for and making the most of healthcare services, but also identifying behaviors that increase the risk of developing preventable diseases.

The importance of this second point, health promotion, is perhaps more important now than it has ever been. For example, at the turn of the 19th century infectious diseases; pneumonia/influenza, tuberculosis, and gastritis accounted for more than one third of all deaths.1 Over the next 50 years, however, advancements in microbiology, public sanitation, and the development of antibiotics increased the life expectancy of Americans by approximately 20 years.2 These efforts did not require the same kind of public participation as is needed today, and were relatively quick to take effect.

By allowing people to live longer these advancements changed the American landscape of disease by increasing the frequency of other illnesses, specifically chronic illnesses. Unlike infections, chronic illnesses are slow to develop and often result from years of unhealthy behavior which gradually damage the body’s critical organs. While they are developing, chronic illnesses do not produce symptoms, and as a result are far more abstract than other illnesses, which make individuals feel ill after only a day or two. Imagine if you had a serious flu with no symptoms and you continued to live your life unaware, its easy to imagine how this might take a serious toll on your body.

Because chronic illnesses are so slow to develop it wasn’t until after World War II that researchers began to work out what kinds of behaviors and conditions slowly damage your body and lead to chronic disease. Smoking received the most attention, partially because its association with chronic disease (lung cancer, stroke, and heart disease) threatened an industry that was “perceived to be invulnerable,”2 and partially because it is the number one cause of preventable death. Soon to follow was the association of elevated blood pressure, elevated lipids, smoking, sedentary lifestyle, obesity, and diabetes with heart disease. The association between behaviors and certain predisposing, measurable conditions within an individual are now referred to as risk factors.  For over 60 years researchers have been trying to convince the public that these conditions slowly lead to diseases which decrease the quality of life for effected individuals, and are preventable if these conditions are managed appropriately.

This effort on behalf of public health officials has been massive and vigorously sustained, because chronic illnesses are disproportionately expensive for both the individual and society. Sadly, despite these efforts 3 out of every 4 healthcare dollars are spent on chronic diseases.7

It is important to remember that chronic illnesses are multifactorial, a fancy word which means complicated. They are influenced by genetics, the environment, and individual behavior. Placing blame on individuals for acquiring chronic illnesses disregards the many causes of these diseases.

However, it is also important to acknowledge that a lot of chronic illness is without a doubt preventable. Unfortunately, there are many systems which support unhealthy behavior in America, and as a result unhealthy trends continue to get worse. For example, in the last twenty years the rate of obesity doubled in adults, nearly tripled in kids ages 2-11, and more than trippled in children who are 12-19.9  As a result of how unhealthy our society has become, today’s kids could represent the first generation in history to have a shorter lifespan than their parents.9

As a result of these trends, the phrases “exercise daily,” “eat healthy,” and “don’t smoke,” are almost as common in our society as televisions, soda machines, and convenience stores. Still, the past 60 years have established just how difficult it is to get people to care about health, and today many experts agree  “reducing morbidity (sickness) and mortality (death) may depend as much on motivating changes in behavior as on developing new treatments.”11

Perhaps more surprising, however, is that we even struggle to treat and or prevent chronic diseases when all that is required is to follow a prescription. According to the archives of internal medicine “the potential benefit of some of the most promising advances in medicine, such as medications to control blood pressure, lower cholesterol levels, and prevent stroke, has been stymied by poor adherence rates among patients.”5

To help us understand some of the potential causes and effects of poor adherence, let’s do a quick case study. In 1994 the interruption of hypertension medication in the first year of treatment cost $873 per patient.6 These extra costs were primarily associated with an increased rate of hospitalization.  However, by not taking their medications patients saved $281 on prescription costs, so we will take that off the total. The same study found that 86% of patients experience an interruption in their prescription regimen, “poor adherence.” If we extrapolate this information to the 56 million Americans with hypertension today, then failure to take hypertension medication as prescribed would cost 28.51 billion dollars ($0.86 x 56,000,000 x ($873 -$281: money saved on prescription costs = $28.51 billion). This calculation is only meant to be suggestive, however, research suggests that between $100 and $300 billion of medical spending are attributable to poor medication adherence in the US every year.1

Is this because medications are either too expensive or their side-effects too unpleasant? Surprisingly, when researchers asked their participants about their reasons for non-adherence, only 2% of patients with hypertension said the medicine was too expensive, 6% said the side-effects were too unpleasant, and 7% said they hate taking it. In contrast, 55% said they just forgot, and 14% didn’t believe it was necessary to take it all of the time. Other explanations included 7% of patients who didn’t like being dependent on medication, and 3% who said they didn’t like being told what to take.3

These results suggest that more than half of the billions of dollars wasted every year by not taking medications as prescribed, are wasted because of either disinterest or forgetfulness alone. Additional costs include years of life lost, a decreased quality of life for aging populations, and unsustainable health care spending. Here is a perfect example of how taking an interest in your health and your impact on the healthcare system has the potential to reduce waste, and should be considered a social cause with remarkable importance.

Feeling guilty doesn’t help, our goal is to figure out what does.

Goals for reducing the burden of chronic disease:

  1. Eat healthy, exercise, and don’t smoke (You are probably sick of hearing this, but doing so will make you more likely to live longer, and improve your quality of life in your later years.
  2. See your doctor regularly and work with her or him to figure out what your greatest risk factors are, and how you specifically can protect yourself from chronic disease (this is called personalized medicine and we will be talking more about this in future posts). Let your doctor know this is important to you!
  3. Commit to taking your prescriptions, as prescribed, every time, no excuses.
  4. Reducing cholesterol levels by as little as 10% could cut the incidence of heart disease by as much as 30%. This could save America $42.75 billion every year and significantly improve the quality of life for millions of Americans.
References
  1. Berg JS, Dischler J, Wagner DJ, Raia JJ, Palmer-Shevlin N. Medication compliance: a healthcare problem. Ann Pharmacother. 1993;27(9 Suppl):S1-24.
  2. Brownson, RC, Bright, FS. Chronic disease control in public health practice: Looking back and moving forward. Public Health Reports, 2004;119:230-238.
  3. Cheng JW, Kalis MM, Feifer S. Patient-reported adherence to guidelines of the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Pharmacotherapy. 2001;21:828–841.
  4. Goldstein MG, DePue J, Kazuira A. Models for provider-patient interaction (applications to health behavior change). The handbook of health behavior change. 2nd ed.. New York: Springer; 1998;p. 85–113
  5. Kripalani S, Yao X, Haynes B. Interventions to enhance medication adherence in chronic medical conditions.  Arch Intern Med. 2007;167(6):540-550.
  6. McCombs JS, Nichol MB, Stimmel GL, et al: Use patterns for antipsychotic medications in Medicaid patients with schizophrenia. Journal of Clinical Psychiatry. 1999;60(suppl 19):5—11.
  7. Centers for Disease Control and Prevention. Chronic Disease Overview: Costs of Chronic Disease. Centers for Disease Control and Prevention Web site. www.cdc.gov/nccdphp/overview.htm.
  8. National Governors Association. NGA Report on Healthy Living. Investing in America’s Health. Washington, DC: NGA. 2007. www.subnet.nga.org/healthy/facts/National.pdf. Accessed July 20, 2007.
  9. Centers for Disease Control and Prevention. Overweight and Obesity. Centers for Disease Control and Prevention. www.cdc.gov/nccdphp/dnpa/obesity/trend/index.htm.
  10. Olshansky J, Passaro D, Hershow R, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med. 2005; 352(11):1138-1144.
  11. Schroeder SA. We can do better—improving the health of the American people.  N Engl J Med. 2007;357(12):1221-1228.
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