Chronic conditions are expected to become the main cause of death and disability in the world by 2020,1 contributing around two thirds of the global burden of disease with enormous healthcare costs for societies and governments.2–4 These conditions include non-communicable diseases such as diabetes, chest and heart disease, mental health disorders such as depression, and certain communicable diseases such as HIV infection and AIDS. Mental health problems account for nearly a third of the chronic disability affecting the world's population now and comprise five of the top 10 causes of disability.5 Yet many healthcare providers are ill equipped to manage chronic conditions effectively, and many governments cannot cope with the escalating disease burden and costs.
Strategies to improve clinical care and outcomes for chronic conditions
Develop health policies and legislation to support comprehensive care
Reorganise healthcare finance to facilitate and support evidence based care
Coordinate care across conditions, healthcare providers, and settings
Enhance flow of knowledge and information between patients and providers and across providers
Develop evidence based treatment plans and support their provision in various settings
Educate and support patients to manage their own conditions as much as possible
Help patients to adhere to treatment through effective and widely available interventions
Link health care to other resources in the community
Monitor and evaluate the quality of services and outcomes
These strategies are based on WHO's review of innovative best practice and affordable healthcare models
What can healthcare workers do? Firstly they can make better use of the resources already available, as several papers in this issue of the BMJ show. Healthcare providers can do more to engage patients in managing their own conditions and to use treatments properly: we know that most patients who do not adhere to treatment have poorer health outcomes.6 In developed countries only around half of the people prescribed treatments for chronic conditions actually take their medicines.7 For instance, hypertension affects 43-50 million adults in the United States, but only 51% of those treated adhere to their prescribed treatment.8–10 Adherence is worse in poorer countries—in one study in the Gambia only 17% of people diagnosed as having hypertension were even aware that they had the disorder, and 73% of those prescribed treatment had stopped it.11 The problem is so great that Haines et al have suggested that increasing the effectiveness of interventions to increase adherence to treatments may have a far greater impact on health than further improvement in biomedical treatment.7
What should policymakers do? The real answer is that they should help to transform health care, moving away from systems focused on episodic care for acute illness. Some governments and healthcare systems are already making the switch. Cheah's paper in this issue describes how Singapore has recognised the growing burden of chronic disease and has begun to redesign its healthcare system to meet people's long term needs (p 990).12 To help healthcare systems around the world to innovate and change in this way, the World Health Organization has launched a project—“Innovative Care for Chronic Conditions”—to analyse and help to disseminate examples of good, affordable care for people with chronic conditions. The strategies arising so far from WHO's review (see box) will be developed further and published soon, giving concrete recommendations for governments and healthcare systems. A wide range of the world's healthcare leaders and policymakers are being consulted by WHO as part of this project, and we would be pleased to hear from BMJ readers too. In the meantime, the policymakers and healthcare leaders who met at WHO headquarters in May 2001 have come to several conclusions. Firstly, it is clear that no nation will escape the burden unless its government and healthcare leaders decide to act: the prevalences of all chronic conditions are growing inexorably and are seriously challenging the capacity and will of governments to provide coordinated systems of care. Secondly, the burden of these conditions falls most heavily on the poor. Thirdly, unidimensional solutions will not solve this complex problem: health status and quality of life will not be improved solely by medication and technical advances; and thus healthcare systems will have to move away from a model of “find it and fix it.” Lastly, these solutions cannot be delayed—the sooner governments invest in care for chronic conditions, the better.
Education and debate p 990
References
- 1.Murray CJL, Lopez AD. The global burden of disease. Boston: Harvard School of Public Health; 1996. [Google Scholar]
- 2.Henriksson F, Jönsson B. Diabetes: the cost of illness in Sweden. J Intern Med. 1998;244:461–468. [PubMed] [Google Scholar]
- 3.Sullivan SD, Ramsey SD, Lee TA. The economic burden of COPD. Chest. 2000;117:5–9s. doi: 10.1378/chest.117.2_suppl.5s. [DOI] [PubMed] [Google Scholar]
- 4.Rice DP, Miller LS. The economic burden of affective disorders. Br J Psychiatry. 1995;166:34–42. [PubMed] [Google Scholar]
- 5.World Health Organization. World health report 2001: mental health: New understanding, new hope. Geneva: WHO; 2001. [Google Scholar]
- 6.Dunbar-Jacob J, Erlen JA, Schlenk EA, Ryan CM, Sereika SM, Doswell WM. Adherence in chronic disease. Annu Rev Nurs Res. 2000;18:48–90. [PubMed] [Google Scholar]
- 7.Haynes RB, Montague P, Oliver T, McKibbon KA, Brouwers MC, Kanani R. Interventions for helping patients follow prescriptions for medicines. Cochrane Database Syst Rev 2000;(2):CD 000011. [DOI] [PubMed]
- 8.Critical overview of antihypertensive therapies: what is preventing us from getting there? Based on a presentation by Munger MA. Am J Manag Care. 2000;6:s211–21. [PubMed] [Google Scholar]
- 9.Mancia G, Grassi G. The role of angiotensin II inhibitors in arterial hypertension: clinical trials and guidelines. Ann Ital Med Int. 2000;15:92–95. [PubMed] [Google Scholar]
- 10.Graves JW. Management of difficult-to-control hypertension. Mayo Clin Proc. 2000;75:278–284. doi: 10.4065/75.3.278. [DOI] [PubMed] [Google Scholar]
- 11.Van der Sande MA, Milligan PJ, Nyan OA, Rowley JT, Banya WA, Ceesay SM, et al. Blood pressure patterns and cardiovascular risk factors in rural and urban Gambian communities. J Hum Hypertens. 2000;14:489–496. doi: 10.1038/sj.jhh.1001050. [DOI] [PubMed] [Google Scholar]
- 12.Cheah J. Chronic disease management: a Singapore perspective. BMJ 2001;990-3. [DOI] [PMC free article] [PubMed]