Self-monitoring, systems, and chronic disease
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《英国医生杂志》
We've all had patients who pay too much attention to their chronic conditions and breathlessly report every minor symptom or fluctuation. Others appear disconnected from their diseases and are genuinely surprised when informed that things aren't going well. In general, it seems desirable for patients to be actively involved in monitoring their health. But it turns out that if you have a chronic disease, sometimes it's a good idea to monitor yourself, and sometimes it may not be.
George Stergiou and colleagues (p 559) discuss home self-monitoring of blood pressure, which makes sense for several reasons. It can detect white coat hypertension, measure medication compliance, and serve as a check for treatment effectiveness. All of this assumes, of course, that the home measurements are accurate, which calls for training and proper equipment. But assuming good readings, home self-monitoring can yield valuable information.
This is not necessarily the case for blood glucose self-monitoring in patients with type 2 diabetes. Reynolds and Strachan (p 557) point out that there is little evidence that home blood glucose monitoring improves outcomes in these patients. There may even be negative effects associated with it, including increased distress and worry. Regular hemoglobin A1c levels may be more appropriate than daily finger sticks. In a commentary, Roach (p 558) asks whether patients (and their doctors) know what to do with home blood glucose monitoring results, stating that appropriate systems for interpreting results would help.
Improved systems of care for depression made a difference in the primary care practices studied by Allen Dietrich and associates (p 582). Integration of care managers and psychiatrists into primary care treatment of depressed patients resulted in improved treatment response and patient satisfaction. But as Michael Von Korff (p 585) asks in his commentary, how many disease-specific care systems can we have? And what do we do with patients who have more than one chronic disease, say renal disease and depression? Or diabetes and heart failure? These patients' problems aren't usually studied, and yet they are among the most difficult challenges primary care doctors face.
One of the secrets of primary care is that many things get better by themselves. Chronic diseases tend not be in that group. Benign neglect, by doctor or patient, is a recipe for failure in chronic illness. It takes a varying balance of patient involvement, good systems of care, and partnership with a skilled and experienced doctor to obtain optimal results.
George Stergiou and colleagues (p 559) discuss home self-monitoring of blood pressure, which makes sense for several reasons. It can detect white coat hypertension, measure medication compliance, and serve as a check for treatment effectiveness. All of this assumes, of course, that the home measurements are accurate, which calls for training and proper equipment. But assuming good readings, home self-monitoring can yield valuable information.
This is not necessarily the case for blood glucose self-monitoring in patients with type 2 diabetes. Reynolds and Strachan (p 557) point out that there is little evidence that home blood glucose monitoring improves outcomes in these patients. There may even be negative effects associated with it, including increased distress and worry. Regular hemoglobin A1c levels may be more appropriate than daily finger sticks. In a commentary, Roach (p 558) asks whether patients (and their doctors) know what to do with home blood glucose monitoring results, stating that appropriate systems for interpreting results would help.
Improved systems of care for depression made a difference in the primary care practices studied by Allen Dietrich and associates (p 582). Integration of care managers and psychiatrists into primary care treatment of depressed patients resulted in improved treatment response and patient satisfaction. But as Michael Von Korff (p 585) asks in his commentary, how many disease-specific care systems can we have? And what do we do with patients who have more than one chronic disease, say renal disease and depression? Or diabetes and heart failure? These patients' problems aren't usually studied, and yet they are among the most difficult challenges primary care doctors face.
One of the secrets of primary care is that many things get better by themselves. Chronic diseases tend not be in that group. Benign neglect, by doctor or patient, is a recipe for failure in chronic illness. It takes a varying balance of patient involvement, good systems of care, and partnership with a skilled and experienced doctor to obtain optimal results.