What is the recommended management approach for chronic conditions?

Management of Chronic Conditions

The recommended management approach for chronic conditions prioritizes a team-based care model that integrates patient education, lifestyle interventions, self-management support, and systematic medication optimization, with treatment decisions guided by patient preferences, prognosis, and functional goals rather than disease-specific guidelines alone. 1, 2

Core Management Framework

Patient-Centered Assessment and Goal Setting

• Elicit individual treatment goals focusing on functional outcomes (return to work, improved quality of life, resumption of activities) rather than purely disease-specific metrics 1
• Stratify management complexity based on number and severity of conditions, functional status, life expectancy (short-term <1 year, mid-term <5 years, long-term >5 years), and treatment feasibility 2
• Use validated patient-reported measures (e.g., Seattle Angina Questionnaire for coronary disease) to reliably quantify symptom burden, as clinicians frequently inaccurately estimate disease impact 1
• Conduct comprehensive psychosocial assessment including psychological trauma history, depression, anxiety, and sleep disorders, as these significantly impact chronic disease outcomes 1

Team-Based Multidisciplinary Care

A multidisciplinary team-based approach is essential and improves health outcomes, facilitates risk factor modification, reduces emergency department visits, and decreases healthcare costs compared to usual care 1, 2

The care team should include:

• Primary care clinicians and specialists 1, 2
• Pharmacists for medication therapy management 1, 2
• Nurses and advanced practice providers 1
• Mental health professionals 2
• Case managers for complex patients 1, 2
• Disease-specific educators (e.g., diabetes care and education specialists) 3

Maintain continuity through in-person or virtual modalities, with annual in-person evaluation supplemented by telehealth when appropriate 1

Lifestyle Interventions as Foundation

Physical Activity

• Recommend 30-60 minutes of moderate activity >5 days per week for most chronic conditions 1
• Prescribe at least 150 minutes per week of moderate-intensity aerobic plus resistance activity, emphasizing that any amount is beneficial 3
• Reduce sedentary time and engage in at least light activity throughout the day 1

Dietary Modifications

• Adopt Mediterranean diet high in vegetables, fruit, and wholegrains 1
• Limit saturated fat to <10% of total calorie intake 1
• Limit alcohol consumption to <100 g/week (≤1 drink/day for women, ≤2 drinks/day for men) 1, 3

Weight Management

• Target and maintain healthy weight (BMI 18.5-25 kg/m²) through recommended energy intake and increased physical activity 1
• Consider pharmacological or surgical interventions in selected patients who fail lifestyle modifications 1

Sleep and Environmental Factors

• Ensure adequate sleep (7-9 hours nightly) to improve insulin sensitivity and reduce inflammation 3
• Treat sleep-related breathing disorders, as they worsen insulin resistance, hypertension, and dyslipidemia 1, 3
• Avoid passive smoking, reduce environmental noise, and minimize air pollution exposure 1

Self-Management Support

Maximize use of nonpharmacologic therapies including cognitive-behavioral therapy (CBT), complementary and integrative health interventions, and aerobic exercise 1

• Implement self-management education programs tailored to individual learning styles to develop patient knowledge and skills for long-term outcomes 2
• Develop personal health plans with timelines for follow-up and monitor progress toward personal goals 1
• Provide education for improved health literacy and engage families/caregivers/support persons when available 1
• Create systematic tracking systems and effective reminders for chronic disease management 2

Evidence-Based Nonpharmacologic Interventions

For chronic multisymptom illness specifically:

• CBT with or without exercise demonstrates improvement in cognitive functioning and fatigue 1
• Tai chi shows superiority to aerobic exercise for fibromyalgia, with greater improvement with longer treatment duration 1
• Yoga improves IBS symptoms comparably to low FODMAP diet 1
• Manual acupuncture improves quality of life immediately after treatment and up to 3 months post-treatment 1

Medication Management

Systematic Medication Review

• Conduct ongoing comprehensive medication reviews to reduce polypharmacy and assess medication regimen complexity using tools like the Medication Regimen Complexity Index (MRCI) 2
• Ensure medication reconciliation at each visit to address treatment adherence issues 3
• Recognize that complex treatment regimens increase risk of nonadherence, adverse reactions, poorer quality of life, and greater economic burden 2

Risk Factor-Specific Pharmacotherapy

For cardiovascular risk reduction:

• Target LDL-C <1.4 mmol/L (55 mg/dL) with ≥50% reduction from baseline using statins as first-line therapy 1, 3
• Target systolic blood pressure 120-129 mmHg when well tolerated, using renin-angiotensin system blockers (ACE inhibitors or ARBs) when BP exceeds 140/90 mmHg 1, 3
• Target HbA1c <7.0% (53 mmol/mol) for diabetes management 1

For smoking cessation:

• Use pharmacological support (nicotine-replacement therapy, bupropion, or varenicline) in all smokers ready to quit, as these are effective and not linked to increased cardiovascular events 1
• Discourage e-cigarettes as they are not harm-free and cause negative changes in vascular endothelial function 1

Antianginal and Symptom-Specific Therapy

• Recognize that revascularization and antianginal medications primarily reduce symptoms rather than mortality in stable coronary disease 1
• The burden of ischemic symptoms before intervention is the strongest predictor of symptomatic improvement after revascularization 1

Monitoring and Follow-Up

Regular Assessment Parameters

• Monitor key health parameters including BMI, waist circumference, blood pressure, lipid profiles, and glucose levels regularly 3
• Assess for organ-specific complications using non-invasive tests (e.g., FIB-4 for liver involvement) with appropriate risk stratification 3
• Clinical follow-up evaluation at least annually is recommended and may be sufficient if the patient is stable on optimized therapy 1

Vaccination and Preventive Care

• Vaccinate against influenza, pneumococcal disease, and other widespread infections (e.g., COVID-19) 1
• Treat comorbid conditions definitively (posttraumatic stress disorder, depression, diabetes) as proper treatment improves symptoms and clarifies residual symptoms attributable to the primary chronic condition 1

Critical Considerations

Limitations of Single-Disease Guidelines

• Standard clinical practice guidelines focusing on single diseases may be cumulatively impractical, irrelevant, or even harmful for patients with multimorbidity 1, 2
• Older adults with multimorbidity are regularly excluded from trials, limiting applicability of standard guidelines 1, 2
• Review all chronic conditions present when formulating treatment plans, considering how management of one condition may impact others 2

Shared Decision-Making

• Use shared decision-making when initiating treatments, considering patient priorities, possible complications, and healthcare costs 1, 3
• Clearly explain that certain treatments alleviate symptoms while others reduce likelihood of ischemic events, helping patients understand treatment goals 1
• Provide clear explanations about potential benefits, harms, and uncertainties of treatments 2

Implementation Strategies

• Develop awareness of risks and benefits among patients and providers, educating staff and patients to reduce fears and misperceptions 2
• Implementation of remote, algorithmically driven disease management programs may provide useful adjunctive strategy to achieve treatment optimization 1
• Ensure episodic or acute care settings offer appropriate interventions or provide information on how to obtain them 2