Michael Von Korff

Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.

CONTEXT: There is little information on the extent of persistent pain across cultures. Even though pain is a common reason for seeking health care, information on the frequency and impacts of persistent pain among primary care patients is inadequate. OBJECTIVE: To assess the prevalence and impact of persistent pain among primary care patients. DESIGN AND SETTING: Survey data were collected from representative samples of primary care patients as part of the World Health Organization Collaborative Study of Psychological Problems in General Health Care, conducted in 15 centers in Asia, Africa, Europe, and the Americas. PARTICIPANTS: Consecutive primary care attendees between the age of majority (typically 18 years) and 65 years were screened (n = 25 916) and stratified random samples interviewed (n = 5438). MAIN OUTCOME MEASURES: Persistent pain, defined as pain present most of the time for a period of 6 months or more during the prior year, and psychological illness were assessed by the Composite International Diagnostic Interview. Disability was assessed by the Groningen Social Disability Schedule and by activity-limitation days in the prior month. RESULTS: Across all 15 centers, 22% of primary care patients reported persistent pain, but there was wide variation in prevalence rates across centers (range, 5.5%-33.0%). Relative to patients without persistent pain, pain sufferers were more likely to have an anxiety or depressive disorder (adjusted odds ratio [OR], 4.14; 95% confidence interval [CI], 3.52-4.86), to experience significant activity limitations (adjusted OR, 1.63; 95% CI, 1.41 -1.89), and to have unfavorable health perceptions (adjusted OR, 1.26; 95% CI, 1.07-1.49). The relationship between psychological disorder and persistent pain was observed in every center, while the relationship between disability and persistent pain was inconsistent across centers. CONCLUSIONS: Persistent pain was a commonly reported health problem among primary care patients and was consistently associated with psychological illness across centers. Large variation in frequency and the inconsistent relationship between persistent pain and disability across centers suggests caution in drawing conclusions about the role of culture in shaping responses to persistent pain when comparisons are based on patient samples drawn from a limited number of health care settings in each culture.

In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families. Effective collaborative relationships with health care providers can help patients and families better handle self-care tasks. Collaborative management is care that strengthens and supports self-care in chronic illness while assuring that effective medical, preventive, and health maintenance interventions take place. In this paper, the following essential elements of collaborative management developed in light of behavioral principles and empirical evidence about effective care in chronic illness are discussed: 1) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; 2) targeting, goal setting, and planning, in which patients and providers focus on a specific problem, set realistic objectives, and develop an action plan for attaining those objectives in the context of patient preferences and readiness; 3) creation of a continuum of self-management training and support services, in which patients have access to services that teach skills needed to carry out medical regimens, guide health behavior changes, and provide emotional support; and 4) active and sustained follow-up, in which patients are contacted at specified intervals to monitor health status, identify potential complications, and check and reinforce progress in implementing the care plan. These elements make up a common core of services for chronic illness care that need not be reinvented for each disease.

STUDY DESIGN: An international group of back pain researchers considered recommendations for standardized measures in clinical outcomes research in patients with back pain. OBJECTIVES: To promote more standardization of outcome measurement in clinical trials and other types of outcomes research, including meta-analyses, cost-effectiveness analyses, and multicenter studies. SUMMARY OF BACKGROUND DATA: Better standardization of outcome measurement would facilitate comparison of results among studies, and more complete reporting of relevant outcomes. Because back pain is rarely fatal or completely cured, outcome assessment is complex and involves multiple dimensions. These include symptoms, function, general well-being, work disability, and satisfaction with care. METHODS: The panel considered several factors in recommending a standard battery of outcome measures. These included reliability, validity, responsiveness, and practicality of the measures. In addition, compatibility with widely used and promoted batteries such, as the American Academy of Orthopaedic Surgeons Lumbar Cluster were considered to minimize the need for changes when these instruments are used. RESULTS: First, a six-item set was proposed, which is sufficiently brief that it could be used in routine care settings for quality improvement and for research purposes. An expanded outcome set, which would provide more precise measurement for research purposes, includes measures of severity and frequency of symptoms, either the Roland or the Oswestry Disability Scale, either the SF-12 or the EuroQol measure of general health status, a question about satisfaction with symptoms, three types of "disability days," and an optional single item on overall satisfaction with medical care. CONCLUSION: Standardized measurement of outcomes would facilitate scientific advances in clinical care. A short, 6-item questionnaire and a somewhat expanded, more precise battery of questionnaires can be recommended. Although many considerations support such recommendations, more data on responsiveness and the minimally important change in scores are needed for most of the instruments.