Surveillance for chronic illnesses and their outcomes is critical to identifying needs and disparities, setting priorities for action, and assessing programmatic progress. The report recommends that surveillance be enhanced and that it be multilevel, multistage, and longitudinal. Levels are patient, health care system, population, and policy. Stages are the precursors of chronic illness, such as social determinants, biological risk factors, lifestyles, and receipt of evidence-based preventive interventions; illness occurrence and manifestations; and illness consequences, including physical, mental, and social. Longitudinal surveillance of chronically ill people will allow better assessment of both community-based and health care interventions, enabling more sophisticated analyses of what works. Supplementing current population surveys with information from electronic health records should produce more precise assessments of trends in improving quality of life for people living with chronic illness.
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.
and Robert B. Wallace, MD, MSc
Interventions,
