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Improving symptoms
and functional outcomes for patients with arthritis and other
chronic illnesses depends on changing health systems. This can
be accomplished through the implementation of research and evidence-based
clinical care directed at influencing practice
team behavior and the overall system of care. These innovations
may focus on a single intervention. For example, simply integrating
routine exercise into arthritis care programs -- that is, incorporating
a self-management component into routine clinical care -- alone
reduces disability and pain, in some cases by more than twenty-five
percent (Ettinger
et al., 1997; Hochberg
et al., 1995; Kovar
et al., 1992).
For care of many different chronic conditions (diabetes, depression,
asthma, arthritis, heart failure, etc.), there is evidence that
multi-faceted changes to health care systems yield more substantial
improvements in patient outcomes than the same interventions offered
singly (Katon
et al., 1996; McCulloch et
al., 2000; Criswell
et al., 1997; van
Jaarsveld et al., 2000; Mazzuca
et al., 1991; Grahame
et al., 1996; Bensen
et al., 1999; Strand
et al., 1999; Parr
et al., 1989; Tugwell
et al., 2000; Caldwell
et al., 1999; Maisiak
et al., 1996; Weinberger
et al., 1989).
For example, introducing
a guideline supported by physician reminders, patient education
interventions, specialty support and active follow-up to monitor
care and outcomes is likely to be more effective than any one
of these interventions individually (Wagner,
2000). This suggests that the paradigm of the clinical
trial, in which single active treatment is evaluated against a
placebo condition that controls for all other sources of variation
other than the "active ingredient," may be inadequate for the
evaluation of the health care system changes needed to improve
care of persons with chronic symptom conditions.
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