Meeting the challenge of chronic illness in general practice

Seven of every ten general practice encounters are for chronic conditions. Here I review three common, chronic conditions managed by GPs — depression, diabetes and asthma.1

Diabetes and asthma are National Health Priority Areas (NHPAs), and depression was chosen by all Australian health ministers as the focus for the mental health NHPA. Nomination as NHPAs reflects both their high prevalence, and the potential for significant health gains by improving outcomes for those with these conditions.2 The other NHPAs are cancer, cardiovascular health, injury prevention, and arthritis and musculoskeletal conditions.

The current burden of illness caused by depression is alarming. Annually, depression affects over 800 000 adults, and, by the year 2020, it is projected to be the second leading cause of premature death after cardiovascular disease.3 Heart disease, and alcohol and other substance misuse are the most frequent causes of death in people with depression.

The mental health NHPA was introduced in 1997. After the release of the NHPA report, a national action plan was developed jointly by federal, state and territory governments as well as community representatives. Key features of the depression program are the national depression initiative “beyondblue” and the “Better outcomes in mental health care initiative”. In the 2001–02 Australian budget, this second initiative was allocated $120 million over 4 years to strengthen the care of people with depression in general practice.4 The five key components of the initiative are given in Box 1.5

Regrettably, the current general practice care for people with mental health problems is suboptimal. Many patients who present with symptoms of anxiety and depression do not receive a psychological diagnosis or appropriate interventions.6 This may change with the wider use of self-report tools, (eg, the Depression Anxiety Stress Scale [www.criminology.unimelb.edu.au/victims/resources/assessment/affect/dass42.html], the Edinburgh Postnatal Depression Scale [www.wellmother.com/articles/edinburgh.htm], and the Geriatric Depression Scale [www.psychologynet.org/geriatric.html]), which have been shown to be effective in case finding for depression in general practice.7 However, even if effective treatment programs are provided for every person with depression, it is estimated that disability and premature mortality may only be reduced by 50%, because effective treatments are not always optimally delivered.8

While the new general practice-based initiatives for managing depression are welcomed by most in the profession, they demand that GPs spend additional time to refresh, upskill and register to deliver the 3 Step Mental Health Process to their patients. These demands are being applied to an already pressured GP workforce, who are working hard to keep abreast of multiple changes in the primary-care sector. Many wonder whether there is sufficient capacity in general practice for the additional time required for the longer consultations that comprise the 3 Step Mental Health Process. This is a particular concern in rural and urban fringe areas where GP : population ratios are unacceptably low, and where there are proportionately fewer female GPs, who tend to offer longer consultations than their male counterparts. Special incentives or assistance may be needed to bring the 3 Step Mental Health Process to areas of high need.

It will be especially important to evaluate the “Better outcomes in mental health care initiative”. There is already disquiet about the paucity of general practice-based research underpinning the educational programs on the effective management of depression. An additional concern is that few GPs have experience working in multidisciplinary teams or with a primary healthcare approach, yet both underpin this initiative. GPs need a strong community orientation, good collaboration with other healthcare sectors, and a desire to deliver an appropriate balance between health promotion, disease prevention and treatment.

The number of adults with diabetes has trebled since 1981, although perhaps half of all people with this condition remain undiagnosed. In 2000, it was estimated that 7.5% of the Australian population aged 25 years or more had type 2 diabetes.9

Diabetes has been a National Health priority area since 1996. As a high proportion of the population visit GPs, if appropriate screening measures are used, GPs have the opportunity to identify most people with undiagnosed diabetes. Recent research supports a two-step screening strategy — fasting plasma glucose estimation for people with diabetes symptoms or risk factors, followed by full oral glucose tolerance testing for those with equivocal test results (ie, plasma glucose levels 5.5–6.9 mmol/L).10 GPs are well placed to support lifestyle interventions (eg, regular exercise and dietary change) in people with risk factors who screen negative. It is in this group that such interventions can prevent diabetes.

In the 2001–02 Australian budget, over $43 million was allocated over 4 years for the National Integrated Diabetes Program (NIDP). Two of the four key components of the NIDP (outlined in Box 2) focus on general practice.11

The costs of enhanced care of people with diabetes are high and rising. Estimates derived from the Australian Coordinated Care Trials showed that the annual Medicare and Pharmaceutical Benefits Scheme costs ranged from $1900 to $3200 per patient.12 This is likely to be money well spent.

Evidence from the UK Prospective Diabetes Study suggests that intensive control of a patient’s blood glucose and blood pressure levels results in improved clinical outcomes and fewer diabetes-related complications.13

The CARDIAB database is an important Australian resource for the management of diabetes and cardiovascular disease in general practice.14 It is used by over 43 Divisions of General Practice nationally. CARDIAB provides a centralised register–recall system, enables identification of high-risk cardiovascular patients and all diabetes patients, and incorporates the National Diabetes Outcomes Quality Review Initiative (NDOQRIN) minimum data set (which reports the majority of the clinical indicators for the National Divisions Diabetes Program) and CVData (the cardiovascular minimum data set).

Pekarsky and other commentators have queried the capacity of the Australian healthcare system to cope with the pressure of more intensive management of diabetes.12 Furthermore, unexpected and unintended consequences may result from providing allied and specialist services to people with diabetes. Examples include expansion of waiting lists for elective surgery and inequitable access to services. Disadvantaged patients obtain allied health services from public hospitals and make up the vast majority of patients on waiting lists for surgery. Under this scenario, these patients, who cannot afford the high copayments required for treatment in the private sector, are more likely to miss out on needed services. It was also somewhat discouraging that the Australian Coordinated Care Trials were unable to show a cost saving from intensive management of patients with diabetes over two consecutive years. Clearly, health benefits that should accrue from good management of this chronic condition require longer timeframes and a long-term investment strategy.

Moderate to severe asthma affects at least one in 10 adults and is another recognised cause of preventable premature mortality and morbidity in Australia.15 Optimal management of asthma can reduce asthma-associated mortality and hospitalisations.16

In August 1999, asthma was added as a NHPA. In the 2001–02 Australian budget, almost $49 million was allocated over 4 years to improve asthma management in general practice.15 Box 3 gives the twin components of this asthma initiative.

Australian research focused in general practice has resulted in improved asthma management. Population-based surveys suggest that, without tailored interventions, asthma management plans were provided to about 33% of patients with asthma in 1996, and this proportion had declined from the previous year.17 There is evidence from a randomised controlled trial based in South Australia that either attending an asthma clinic run by a nurse educator and a GP, or regular review by a patient’s usual GP, increased the likelihood that people with asthma had a written action plan and were taking inhaled preventer medication.18

Thus, the proactive Asthma 3+ Visit Plan is underpinned by the most robust Australian research evidence of any of the three conditions covered in this article. Surprisingly, the initiative does not specifically encourage GPs to identify and support smokers with asthma to quit the habit.