Rethinking Healthcare Quality: Disease Management versus Health Promotion

Author: Jeffrey Wacks, MD

Disease Management versus Health Promotion

When people discuss healthcare quality, what they are really talking about is the degree to which health services optimize the management of the various chronic diseases in the individual and population. The American Academy of Family Physicians categorizes healthcare quality metrics into a few categories, such as structure, process, and outcome. Structure and process measures have to do with operational infrastructure and procedures behind how we perform disease management (i.e., using an electronic health record, staff-to-patient ratio, prescribing a certain medication for a given condition, appropriate diagnostic testing at the right intervals, etc.). Outcome measures are defined by the degree to which the various chronic diseases are pharmacologically managed. For example, you could look at the percentage of patients with hypertension, whose blood pressure is within the goal range. This is a function of the degree to which the patient is taking antihypertensive medications to lower it to the range. All of this, however, ultimately has to do with chronic disease management.

To be clear, chronic disease management is an important part of what healthcare providers do. We should optimize the efficiency of how we deliver services that alleviate symptom burden, lower the risk of cardiovascular disease, screen for cancers that can be better treated with early detection, etc. But if we only concentrate on disease management and pay no attention to health promotion, then as a society, we are running on a hamster wheel. We are working really hard, but getting nowhere. Because even if we become maximally efficient at managing chronic disease, if the overall chronic disease burden continues to increase, then we will never make any real progress. We need to also focus some of our attention on stopping and reversing the process by which chronic diseases develop in the first place. When looked at in this way, it seems absurd to discuss healthcare quality without including health promotion. 

Consider the following example. Imagine a healthcare provider sees a 40-year-old male patient for an annual physical. As part of the physical, screening bloodwork is done, which shows the patient is pre-diabetic, with a Hemoglobin A1c of 6.0%. What are we doing about this? The answer is... nothing. This level of hyperglycemia does not warrant pharmacologic treatment. The diagnosis of "pre-diabetes" is a type of subclinical dysfunction, it s a "warning sign." It would likely trigger the provider to watch the blood sugar more closely. But the patient asks, "Why is my blood sugar high and what do I do about it?" How we answer that question should be part of how we think about overall healthcare quality. But the reality is that the question is ignored or given a superficial response. "Eat less 'sugar,' exercise more, and lose some weight," they might say. But in reality, without a deeper dive into what that means, the patient is left without the education they need to make an actionable plan.

Why Health Promotion is Not Discussed

Patients who do not have experience with the healthcare system are often surprised by the lack of or superficial nature of this discussion. Many patients assume that a healthcare provider is holistically trained in the cause, prevention, and treatment of chronic disease, but the truth of the matter is that we are not. Healthcare providers are not formally trained in nutrition, exercise, or any other lifestyle factor that potentially could contribute to health promotion. It is fundamentally not part of what is included in 'healthcare services' and is not part of what healthcare providers feel like is in their purview. And herein lies the crux of the problem. We are spending all of our energy managing the downstream consequences of chronic diseases and we have completely ignored the structure, process, and outcomes related to alleviation of the chronic disease burden itself. 

Solutions

In our opinion, there are essentially two solutions to this problem. The first solution is that we accept our current roles as disease managers and commit to partnering with those who are better trained in health promotion. A simple step in the right direction for a primary care clinic might be to increase the frequency of referrals to nutritionists, personal trainers, health coaches, etc. While this may seem like a simple intervention, if one considers the amount of people with subclinical metabolic dysfunction, at scale, this practice would be quite substantive. Or alternatively (and in our opinion more ideally), the second solution is that healthcare providers themselves become better trained in health promotion. Imagine we lived in a world where primary care services routinely included in-depth nutrition analysis and counseling, monitoring of physical activity and fitness, analysis of metabolic function/rate, and a broader array of evidence-based health-promoting therapeutics. If we are truly committed to optimizing overall healthcare quality and we are being honest with ourselves about what that means, then it seems evident that this is the kind of system we would be aiming toward. Those who resist change will drag their feet, as introspection and change is always difficult. But at some point, we will simply have no choice but to make that paradigm shift as the imbalance between the chronic disease burden and the resources we have to manage its consequences continues to grow.