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Clinical care: Noncommunicable diseases
Care for noncommunicable
diseases (NCDs): Time for a
paradigm-shift
JAN DE MAESENEER
HEAD DEPARTMENT OF FAMILY MEDICINE AND PRIMARY
HEALTH CARE, GHENT UNIVERSITY, BELGIUM
PAULINE BOECKXSTAENS
PHD STUDENT, DEPARTMENT OF FAMILY MEDICINE AND PRIMARY
HEALTH CARE, GHENT UNIVERSITY, BELGIUM
ABSTRACT: Noncommunicable diseases (NCDs) are on the rise and multi-morbidity becomes more and more the rule, no
longer the exception. For these patients, disease-management programs are having difficulty in realizing comprehensive
care. Therefore, a paradigm-shift from “problem-oriented” toward “goal-oriented” care is needed, reorienting the care
toward the goals formulated by the patient. By doing so, we will avoid care that may lead to “inequity by disease”.
Today we face an important demographic and
epidemiological transition, confronting us with the challenge
of noncommunicable diseases (NCDs), which occur more
and more in the context of multi-morbidity. In the next decade,
multi-morbidity will become the rule, no longer the exception.
Especially in developed countries, with increasing life expectancy,
NCDs are more and more a phenomenon, accompanied by a rise
in multi-morbidity: 50 percent of the 65+ have at least three
chronic conditions, whereas 20 percent of the 65+ have at least
five chronic conditions (Anderson and Horvath 2002). In the case
of Chronic Obstructive Pulmonary Disease (COPD) e.g. more than
half of the patients have at least one comorbid disease (Mannino
and al. 2008). Describing the rising prevalence of NCDs as a
“crisis” (Beaglehole et al. 2011) makes for good drama, but
misleads us into thinking that this problem is amenable to a quick
fix. NCDs represent a set of chronic conditions that will require a
sustained effort for many decades.
In this article we describe how patients with multi-morbidity are
approached today. We will argue for the need for a paradigm-shift
from problem-oriented to goal-oriented care, which requires new
types of evidence and research, and we try to integrate this
development into the perspective of quality and equity in health.
The care for patients with multi-morbidity today
In recent years, not only Western countries, but also developing
countries started with “chronic disease management-programs” in
order to improve care. Wagner has described the different
components of the Chronic Care Model (CCM) as developed in
the context of primary health care (Wagner 1998). The CCM has
inspired policymakers and providers all over the world and is
widely accepted in North America, Europe and Australia. The
design of disease management programs includes most
frequently: strategies for case-finding, protocols describing what
should be done and by whom, the importance of information and
empowerment of the patient and the definition of process- and
outcome-indicators that may contribute to the monitoring of care.
Finally, incentives have been defined in order to stimulate both
patients and providers to adhere to guidelines. This development
has led to spectacular results e.g. in process– and outcomeindicators
in the United Kingdom under the Quality and Outcomes
Framework (Gillam and Siriwardena 2011). Moreover, the “chronic
disease management” approach has led to an acceleration of the
implementation of the subsidiarity-principle in primary health care
with important task-shifting from physicians, to nurses, dieticians,
health educators, etc. In spite of some critical reflections with
respect to equity (Norbury et al. 2011; Boeckxstaens et al. 2011),
to the sustainability of the quality improvement, and
comprehensiveness versus reductionism (Heath 2009), in general,
these programs have received positive feedback from providers,
patients and politicians.
Taking into account the epidemiological transition, we are faced
with the question: “How will this approach work in a situation of
multi-morbidity?”
Let us illustrate this with a patient from our general practice, we
call her “Margaret”. In Box 1 we describe her case.
According to the actual guidelines, Margaret is faced with a lot
of tasks (Boyd et al. 2005): joint protection, aerobic exercise,
muscle strengthening, a range of motion exercising, selfmonitoring
of blood glucose, avoiding environmental exposure
that might exacerbate COPD, wearing appropriate foot wear,
limiting intake of alcohol, maintaining body weight. She has to
receive patient education regarding diabetes self-management,
foot care, osteoarthritis and COPD medication delivery system
training. Her medication schedule includes 11 different drugs, with
30 World Hospitals and Health Services Vol. 47 No. 4