Chronic diseases and health promotion

Part Three. What works: the evidence for action

Chapter Two. Review of effective interventions


Use of patient information systems

Well-designed, locally relevant and sustainable clinical information systems are essential if the goal of coordinated long-term care is to be achieved. They enable the organization of patient information, tracking and planning of patient care, provision of support for patient self-management, and scheduling of patient follow-up.

Clinical information systems are effective when they encourage communication between clinical team members and patients. They can take a variety of forms, and effective systems can be created even in very resource-poor settings. They may be paper-based, such as a chronic disease register kept in a notebook, and be linked to patient records, computerized, or a combination of the two.

Multidisciplinary health-care teams

One of the characteristics of most chronic diseases is that the care required for them cuts across several different health-care disciplines. Multidisciplinary health-care teams, centred on primary health care, are an effective means in all settings of achieving this goal and of improving health-care outcomes

Spotlight:Improving diabetes care in Mexico

The Secretariat of Health of Mexico has launched a “crusade for the quality of health services” to provide better health care to people with chronic diseases. A one-year pilot project was conducted in the State of Veracruz, with in-service training of primary care personnel and the implementation of a structured diabetes education programme. Primary health-care teams were trained to adopt a quality improvement methodology. Among the innovations in primary health centres were the organization of diabetes clinics, collective medical visits for self-support groups of people with diabetes, and training people with diabetes to be community health workers.

The number of people with diabetes and good control increased from 28% to 39% in the intervention group, while among those receiving usual care the proportion only increased from 21% to 28%. Documented foot care education increased to 76% of patients in the intervention group and only to 34% elsewhere. The proportion of patients using insulin increased among the intervention group from 3.5% to 7.1%, while it remained at 0.9% among those receiving usual care.

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