Patient Self-Management: A Key to Effectiveness and Efficiency in Care of Chronic Disease

Halsted Holman, MDa The present health care system is neither effective nor efficient. The dominant Kate Lorig RN DrPH3 reason for this is a contradiction between the principle problem confronting the system?chronic disease?and the system's methods of operating, which were designed for acute disease. Resolution of the contradiction requires a different practice of health care, with new roles for the patients, for physicians and other health professionals, and for health services. Until the middle of the last century, acute disease was the major health problem in the United States. Then chronic disease began to emerge as the central health care issue. Now, chronic disease is the major cause of disability, the principle reason why patients visit physicians, and the reason for 70% of health care expenditures.1,2 The present health care system, designed early in the last century to cope with acute disease, did not change when chronic disease became the major issue. As a consequence, discontinuity and fragmen tation of care are widespread. Technology is often applied unnecessarily. Com munity and home-based care are poorly developed. Costs mount without obvi ous commensurate benefits for patients. And a large segment of the population is unable to obtain appropriate health care. Why is this so? The answer begins to emerge when we examine the differ ences between acute and chronic disease, as outlined in Tables 1 and 2. Among the many differences, the most crucial are: There is no cure for chronic disease; instead, management over time is essential.