Part Three. What works: the evidence for action
Chapter Two. Review of effective interventions
Disease management. Spotlight: South Africa
The previous sections of this chapter have shown that there are highly effective and cost-effective interventions to reduce the morbidity and mortality attributable to chronic diseases. Yet in many places, effective interventions for chronic diseases are poorly delivered or are not available at all. Specific reasons for poor or absent delivery of chronic disease interventions vary between countries and between regions within countries. In some settings, lack of human, physical and financial resources are the major constraining factors. In other settings, resources are available but are used in a fragmented and inefficient manner. Factors to take into account include the following:
- evidence-based decision support tools can improve the delivery of effective care for chronic diseases;
- effective clinical information systems, including patient registries, are an essential tool for proviing the continuity of care necessary for chronic diseases;
- the provision of multidisciplinary health-care teams can be a highly effective approach to improving chronic disease care;
- the support of patient self-management is a core element of effective chronic disease care.
Relevance for HIV/AIDS
These factors are also applicable to HIV/AIDS care. Health specialists are increasingly viewing HIV/AIDS as a chronic condition that requires comprehensive health services similar to those needed for heart disease and diabetes. Countries can obtain greater efficiency from their health systems by combining disease management for all chronic conditions.
Spotlight: Health-care quality improvement in the Russian Federation
Tula is an industrial town in the Russian Federation in which cardiovascular disease is a leading cause of death, accounting for 55% of adult mortality. High blood pressure prevalence is estimated at 27% and is considered to be a primary contributor to this mortality rate.
In 1998 the Central Public Health Research Institute of the Russian Ministry of Health and the Tula Oblast Health Authority, together with international partners, began an attempt to improve care for patients with high blood pressure. Five health-care facilities, each with a multidisciplinary team of staff, were involved in the decision-making and planning of the project. Goals included:
- promoting healthy behaviours to prevent the complications of high blood pressure;
- changing the delivery of care for high blood pressure to reflect the new guidelines;
- developing evidence-based guidelines for high blood pressure care at the primary care level;
- reallocation of financial and human resources to facilitate implementation of these services.
Positive outcomes included a sevenfold increase in the number of patients managed at primary care level. There was a 70% success rate in controlling high blood pressure, an 85% reduction in admissions for high blood pressure, and net savings for overall high blood pressure care costs of 23%. Other recent results from Russia, however, have not been so impressive (35).
The quality improvement project was expanded during Phase II (2000–2002) to all 289 general practitioner practices covering the whole population of the Tula region, and Phase III (national scale up) for integrated chronic disease prevention and control was launched in December 2002.