Effective Patient Management

Acute Intervention vs. Disease Management Evidence-Based Practice Multidisciplinary Approach

The Role of Technology

Computerized Dynamic Posturography

Balance Program Models

Evaluating Your Practice

Marketing Your Balance Program

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ACUTE INTERVENTION VS. DISEASE MANAGEMENT

Acute Intervention
Disease Management
Impairment-Based Treatment

Acute Intervention

The acute intervention model, which uses specialized services focused on localizing and treating specific pathology, has been an unquestionable success in combating potentially life-threatening medical conditions and has increased our average life expectancy over the past 50 years. The consequence of increased life expectancy, however, has been the growing incidence of chronic diseases, which now consume an estimated 70% of healthcare resources in the United States.1 Leading the list of chronic disorders are mobility impairments accounting for 39% of the total.¹

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Disease Management

In contrast to the acute model, which has not proven as effective in treating chronic disorders, the Managed Care Quarterly² describes the optimal care system for chronic disorders as one that uses multidisciplinary teams of primary, specialty and home care, involves the patient, and emphasizes function. The embodiment of the chronic disease management approach is the World Health Organization (WHO) and Nagi disablement frameworks.^3-5 Highlights of these frameworks include:

• Classification of patients based on pathology, impairments and functional limitations
• A long-term care plan based on accurate patient classification, which includes progress indicators and expected outcome
• Access to surgical, medical and rehabilitation treatments as appropriate

While the traditional acute intervention model relies almost exclusively on the localizing diagnosis of pathology to determine treatment, treatment planning for chronic disorders requires that patient classification be based not only on knowledge of the pathology, but also on quantification of the impairment(s) and functional limitations. A case in point is a 1999 study from the Baylor Schools of Public Health and Medicine⁶, which demonstrates the importance of impairment information in management of patients with chronic dizziness and balance disorders. After examining the value of the objective diagnostic technologies typically brought to bear on this diagnostic problem, the Baylor study concluded that the impairment information provided by computerized sensory/motor assessments has the greatest impact on treatment planning and outcome for this population.

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Impairment-Based Treatment

Impairment information is especially important in managing chronic balance disorders, because the typical balance disorder has multiple causes that cannot be isolated to a single pathological source. Even when a specific cause is identified, the resulting impairments can vary considerably from one patient to the next because of the brain's adaptive response. Thus, the most effective management plan for the individual patient requires an approach that focuses not only on mitigating the impact of pathology, but also on modifying the associated adaptive responses and impairments.

Research has shown that, when treatment is customized to target the individual patient's pathology and impairments, outcomes are significantly improved over those achieved with generic approaches based on performance and/or site of lesion tests only.⁷ Two outcome studies further exemplify the impairment-based approach to treatment planning. Comparing three groups of patients with chronic peripheral vestibular deficits, Black and colleagues⁸ found superior outcomes in the group receiving customized treatment based on functional impairments rather than pathology. Calder and Jacobson⁹ have demonstrated how patients with similar pathologies were managed to different outcomes based on differences in their associated impairments. The clear implication is that both impairment and pathology information are essential for effective treatment planning.

There is a real clinical need for improved management of patients with balance and mobility disorders. The acute intervention model falls short by focusing only on a specific medical event, rather than the underlying impairments. The disease management approach to patient care takes a more inclusive view of the patient by accurately identifying pathology, as well as the resultant impairments and functional limitations. This comprehensive approach to patient management is fundamental to the effective treatment of balance disorders.

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References:

1. Chronic Care in America: A 21st Century Challenge. The Robert Wood Johnson Foundation, Princeton, 1996.
2. Sandy LG, Gibson R (1996). Managed care and chronic care: challenges and opportunities. Managed Care Quarterly 4: 5 - 11.
3. World Health Organization (1999). ICDIH-2 International Classification of Function and Disability. Beta-2 draft. Short Version. Geneva, Switzerland.
4. World Health Organization (1997). International Classification of Disease, 9th rev. Clinical Modification. New York, NY.
5. Verbugge, L, Jette (1994). "A disablement process." Soc Sci Med. 38: 1-14.
6. Stewart MG, Chen AY, Wyatt JR, Favrot S, Beinart S, Coker NJ, Jenkins HA (1999). Cost-effectiveness of the diagnostic evaluation of vertigo. The Laryngoscope 109: 600 - 605.
7. Shepard NT, Telian SA (1996). Practical Management of the Balance Disorder Patient. Singular Publishing Group, Inc., San Diego, 221pp.
8. Black FO, Angel CR, Pesznecker SC, Gianna C (2000). Outcome analysis of individualized vestibular rehabilitation protocols. American J Otology 21:543-551.
9. Calder JH, Jacobson GP (2000). Acquired bilateral peripheral vestibular system impairment: rehabilitative options and potential outcomes. J American Academy Audiology 11:514-521.

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