The health care model of the future will have to deal with treating a whole lot more chronic disease. There are several reasons why this is so. The first one is obvious, the second two may well surprise you.
1. First is what we all know… the average American is living longer. By having a longer life, it is stands to reason that more of one’s lifetime could be spent with a chronic disease. With the advancement of our medical care, many acute illnesses which might have killed people in the past can now be successfully treated and managed. Most acute complications of chronic disease can similarly be managed with today’s medical care. Remember when pneumonia was considered the old man’s best friend? Thus, the conditions that typically lead to the demise of the patient in the past, are today not as big of an issue. The net result is nowadays, people will be living longer with established disease than ever before simply because they are living longer. But the increase in chronic conditions is due to other factors as well.
2. Because of lifestyle changes, particularly dietary habits, sedentary lifestyles and obesity, we are now starting to see chronic diseases emerge at an earlier stage in life. Many studies have shown that morbid obesity can add 20 years onto the chronological life of the patient. Obese patients are much more likely to develop degenerative osteoarthritis and other chronic conditions at a much earlier age. The demographics of diabetes have changed sharply over the last 50 years. When I was in medical school, Type II diabetes was defined as non-insulin dependent diabetes in a person over the age of forty. Now the pediatricians tell us that is commonplace to manage Type II diabetes in morbidly obese patients in their routine pediatric practice. The net result of these lifestyle issues is that patients will now have to deal with the chronic complications of these diseases at an earlier age. So not only are Americans living longer, but the onset of chronic disease for some will be earlier in their lives.
3. Many childhood diseases that previously resulted in premature deaths in the pediatric arena have now had great improvements in management and treatment, and many of these patients are living well into adulthood. Cystic fibrosis is a great example of this. In training I was taught that most of these patients never lived past early adolescence. I was proud in my residency to help deliver a baby from a patient who had cystic fibosis…. a wonderful event that would never have occurred even a few years ago!! Other childhood illnesses such as congenital heart disease and cerebral palsy have had similar improved results. Thus, in many cases that never would have made it into adulthood, the patient is now dealing with long term chronic conditions. Many internists until recently, for example, have never had to take care of patients with cystic fibrosis, cerebral palsy or congenital heart disease. This enlarges the pool of patients with established chronic disease.
The bottom line is that we are going to see much more chronic disease in our practices than we ever anticipated. Yes, Americans are living longer and by that very nature, there will be more time to live with chronic disease. But there are two other issues that are contributing to the increased prevalence of chronic disease: Lifestyle issues are bringing these chronic issues earlier into the timeline of the patient, and the ability to take better care of childhood diseases that used to result in premature death, will both result in more patients alive with chronic disease. Therefore, chronic disease starts earlier in the lifespan and the lifespan is increasing. The length of chronic illness is doubly prolonged, and the overall prevalence of chronic conditions will rise proportionately.
As care givers, we need to look at the impact of chronic disease on the health care infrastructure and assume we will be taking care of more than we had thought. Adult care in the future will be largely in the realm of the management of chronic conditions. And you pediatricians, thanks to the wonderful advances you have been doing, will also have to adjust to the greater management of chronic illness.
