Advantages of the Management of Chronic Disease in Primary Health Care

compared to Specialised Medical Care Units

Nikhil Bhatt
IX Semester
TMA

The World Health Organization has declared chronic disease an epidemic with a large economic
impact: currently, chronic diseases are the leading cause of death in the world. Adults with multiple
chronic diseases tend to be high users of health care services and account for more than two-thirds of
health care spending. Since the prevalence of multimorbidity increases with age, effectively managing
patients with multiple chronic diseases in primary care is critical. Part of effective chronic disease
management is adherence to clinical practice guidelines.

Marked success in reducing deaths from acute illnesses in the past half century has resulted in a new
emphasis on chronic diseases. As premature death from acute illness is reduced, the prevalence of
conditions that accumulate over time rises, particularly in a world in which greater exposure to
unnatural environments increases long term vulnerability to ill health.

Primary healthcare (PHC) refers to "essential health care" that is based on scientifically sound and
socially acceptable methods and technology, which make universal health care accessible to all
individuals and families in a community. The ultimate goal of primary health care is better health for all
(1). According to “Understanding What Is Most Important to Individuals with Multiple Chronic
Conditions: A Qualitative Study of Patients’ Perspectives” six domains of what patients described as
most important for their well-being and health: principles, relationships, emotions, activities, abilities,
and possessions. (2)

Depression may exist without any concurrent disorder or may coexist with other physical or mental
problems, often present in patients with chronic disease, including the disabilities of old age. It is very
common in the advanced stages of cancer. One of the reasons why depression is missed in
Specialist care is that patients are not usually overtly depressed. They are often smiling when they
first enter. Those with more severe forms of depression, however, will usually strike the physician as
being unhappy, and the first cue may be the feeling “this patient makes me feel depressed.” It may
need a question like “And how are you doing?” to allow them to express their pain. The most common
diagnostic error noted in doctors is the failure to ask the most sensitive and specific question of all:
“Do you feel depressed, low in spirits, down in the dumps?” Instead of asking this question, doctors
will often ask much less sensitive and specific questions about appetite, constipation, and weight loss,
which leave them uncertain about whether or not the patient is depressed.

Very short-term relationships with physicians are associated with poor outcomes. For example,
veterans with a chronic disease who did not have a previous relationship with a primary care
physician were randomized to receive an intervention of increased follow-up by a newly assigned
nurse and a primary care physician after they were discharged from the hospital. Rehospitalisation
rates six months later were higher in this intervention group, thus indicating that relationships over
time are an important component of primary care. At least two years of a relationship (and as many as
five) are generally required for patients and practitioners to get to know each other well enough to
provide optimal person-focused care. A freely chosen primary care practitioner provides better
assurance of a good relationship than does assigning a practitioner. The evidence is strong regarding
the benefits of an ongoing relationship with a particular provider rather than with a particular place or
no place at all. People with no source of primary care are more likely to be hospitalized, to delay
seeking needed and timely preventive care, to receive care in emergency departments, and to have
higher subsequent mortality and higher health care costs, and they are less likely to see a physician
in the presence of symptoms. (3)

Studies conducted in the international setting have assessed how emphasis on primary care quality
may impact health outcomes, and whether specialists or PCPs provide better quality of care for
chronic conditions. In a US study that focused on diabetes disease management, the results showed
that patients in the intervention group had significantly greater improvement in A1C level than the
control group that received no additional disease management support. In a study in Petropolis,
showed that patients who had better primary care experiences were more likely to report better
health, even after adjusting for other salient characteristics such as their age, whether or not they had
a chronic illness or a recent illness, household wealth, educational level, and the type of facility in
which they received their care (3). Research in Taiwan has found that patients with a PCP, experience
superior primary care quality, including better access, coordination, family centeredness, continuity,
and cultural competence (4).

The Chronic Care Model (CCM) is an organizational approach to caring for people with chronic
disease in a primary care setting. The system is population-based and creates practical, supportive,
evidence-based interactions between an informed, activated patient and a prepared, proactive
practice team. It identifies essential elements of a health care system that encourage high-quality
chronic disease care: the community; the health system; self-management support; delivery system
design; decision support, and clinical information systems. Within each of these elements, there are
specific concepts that teams use to direct their improvement efforts. Change concepts are the
principles by which care redesign processes are guided which are not seen in specialist care (5).

Effective chronic illness programmes in primary care tend to exploit the varied skills of the team by
using the following strategies (6):
 Population based care
 Treatment planning
 Evidence based clinical management
 Self-management support
 More effective consultations
 Sustained follow up

While in Specialist care, there are deficiencies in the system by which effective care is not provided to
the patients

 Rushed doctors not following established practice guidelines

 Lack of care coordination and planned care
 Lack of active follow-up to ensure the best outcomes
 Patients inadequately trained to manage their illnesses

Primary care providers deliver a disproportionate share of ambulatory care to disadvantaged

populations. Improved access to primary care was associated with reduced mortality rates, better
health outcomes, and lower costs. A higher proportion of PCPs in a given area has also been shown
to lead to lower spending on healthcare. Additionally, an increase of one primary care physician per a
population of 10,000 is associated with a reduction of 1.44 deaths.
Patient care teams in primary care improve the quality of care for patients with chronic illness
because the roles of team members are clearly defined and explicitly delegated and team members
are trained for their roles. By appropriate training and effective teamwork, primary care teams make it
possible to manage complex chronic illnesses intensively without losing the benefits of
comprehensive, continuous primary care. (6)

REFERENCES:

(1) http://www.wpro.who.int/topics/primary_health_care/en/
(2) https://rd.springer.com/article/10.1007%2Fs11606-017-4154-3#citeas
(3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/
(4) https://www.hindawi.com/journals/scientifica/2012/432892/
(5) http://www.med.uottawa.ca/sim/data/models/Wagner_chronic_disease_model.htm
(6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117605/