The End of the Disease Era

1. The End of the Disease Era Gero 302 Jan 2012

2. The Problem • We now need to abandon disease as the focus for medical care. • Clinical decisions should be made on the attainment of individual goals and the treatment of modifiable biological and non-biological factors, rather than the diagnosis and treatment of individual disease. • Today most clinical encounters are for chronic illness and non-disease specific complaints. Chronic disease has a poor correlation between clinical manifestation and underlying pathology.

3. Undertreatment • A reluctance to treat symptomatic patients who do not meet diagnostic criteria. • Many symptoms cannot be ascribed to a single disease and the interplay between physical and psychological factors. Some confusion still exists between what is a symptom, an impairment or a disease and this is an artifact of the disease model of medicine. All three should be seen as a health condition causing discomfort and adverse consequences resulting from multiple factors. • Treating only biological mechanisms rather than addressing all contributing factors results in lost opportunities to maximize health outcomes.

4. Over Treatment • The emphasis on diagnosing and treating individual diseases leads to an abundance of disease management guidelines. E.G. A 75 year old with diabetes, heart failure, MI, hypertension, and osteoporosis. The guidelines to treat would require 15 medications. Multiple meds increase costs, and set up adherence issues plus adverse drug effects.

5. Mis-treatment • Clinical decisions based on disease specific outcomes rather than patient preferences. • Everyone has different values on survival, comfort, and function. • We may successful treat an organ failure or an infection but cause physical or cognitive damage in doing so. (Iatrogenic Disease) • The holistic health care model is often only deployed for those with terminal illness receiving palliative care.

6. Solution • Align medical care with health needs. • Integrate existing knowledge with effective strategies • Invoke alternative strategies rather than just using the disease model. • Treatment should be based on patient goals. • Treatment should be holistic • Abandon the concept of individual disease. • Examine the “trade offs” that the patient is willing to make. Look at life-style changes, costs, side-effects and the use of medications. • How will clinical encounters be structured to be most effective.

7. Challenges and Barriers • Review Table two the Disease Oriented Model vs the Integrated Model and review different strategies • The integrated Model argues that resources would be better spent investigating and treating the underlying mechanisms through which both the biologic and non-biologic factors operate. Our current system is entrenched in the disease specific, episodic care model. • Change can come through “tipping points” • Factors which will limit traditional approach include-rationing, aging baby boomers, treatment of every disease, diverse and competing health priorities.