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Clinical care: Noncommunicable diseases (glycemic control in diabetes type 2). There is a lot of evidence available on the treatment of COPD or the management of type 2 diabetes for patients younger than 75 years but there is little, if any, evidence about how to treat a 75-year old woman who has both or even additional disorders. This problem implies a need for research on the effectiveness of diagnostic and therapeutic interventions that take into account these aspects of patients in primary care. The challenge of multi-morbidity illustrates the lack of appropriate evidence. A basic assumption in the development of guidelines is that clinical research follows clinical relevance. In reality, a lot of research is driven by commercial interests (Bodenheimer 2000). A consequence is that the focus has shifted from “treat-the-patient” toward “treat-to-target”. And in achieving the “target” much more evidence is available for pharmacological treatments than on the effects of interventions aimed at changing health behaviors. So, the threat in evidence-based medicine is pursuing what is possible and available, rather than what is relevant. If we want to take the goals of the patient into account, we need a new type of evidence: contextual evidence, to assist doctors in addressing the challenge of how to treat a particular patient in a specific situation. Contextual evidence deals with the principles of good doctor-patient communication in order to create trust in the interpersonal relationships, the exchange of pertinent information, exploration of the goals of the patient, and negotiation of treatment-related decisions. We will have to look for research-tools and approaches that focus on subjective determinants of well-being, and not only at biomedical parameters. In the new research-designs, patients with multi-morbidity will be the rule (instead of an exclusion criterion) and complexity will be embraced instead of avoided (Heath 2009).The International Classification of Function (ICF) (WHO 2001) might become as important as the International Classification of Diseases (ICD), as it provides a conceptual framework in which different domains of human functioning are defined. These domains are classified from an eco-bio-psychosocial viewpoint by means of a list of body functions and structures, and a list of domains of activity and participation. As an individual’s functioning and disability involves a context, the ICF includes a list of environmental factors and the concept of personal factors in its framework. Finally, there is a need to enrich daily practice in primary care with more “policy evidence”, which entails efficiency and equity. The achievement of individual treatment benefits is in itself not the final argument for promotion of that treatment for all patients. In one of her last editorials “The hidden inequity in health care”, Barbara Starfield re-iterates that organ systems based medicine is becoming dysfunctional, because most illness nowadays is multimorbidity – cutting across diseases and types of diseases and organ systems. The information on health problems is collected disease by disease. Doing so masks the greater needs of people in different population subgroups, because they are more vulnerable to and suffer more different types of illness and combinations of illness. Disease-oriented medicine, whether through guidelines or through a focus on particular chronic diseases and their management, is thus highly inequitable as it cannot address the adequacy of interventions when people have many problems. Diseases are not unique entities; there are greater differences in resource needs within disease categories than across them. We need guidelines that are appropriate to personfocused care, not disease-focused care (De Maeseneer 2003). Therefore, health systems should be assessed in relation to their capacity to deal with multi-morbidity in an equitable way (Swanson et al. 2009). Conclusion Approaching a patient with multi-morbidity challenges both practitioners and researchers. It challenges institutions for health professionals' education to train providers that are not only “experts”, or excellent “professionals”, but that are also “change agents” (Frenk 2010) that continuously improve the health system and question the reality of knowledge and care. It requires fundamental reflection on the individual provider-patient interaction, on the need for a paradigm-shift from problemoriented to goal-oriented care, on the organisation of the health care services and the features of the health system. Most fundamentally, it will also require dialogue and communication methodologies between the health sector and persons in need of health care and with other stakeholders within society involved in health care at the practice, research and policy level, in order to guarantee the essential characteristics of an effective health system: relevance, equity, quality, cost-effectiveness, sustainability, people-centeredness and innovation. ❏ Professor Jan De Maeseneer is Director of the International Centre for Primary Health Care and Family Medicine – Ghent University, a WHO Collaborating Centre on PHC. He is the chairman of the European Forum for Primary Care (www.euprimarycare.org) and Secretary General of the Network: Towards Unity for Health (www.the-networktufh.org). Pauline Boeckxstaens MD is a general practitioner at community health care center Botermarkt Ledeberg and is currently working on a PhD thesis concerning multi-morbidity at the Department of Family medicine and Primary Health Care – Ghent University. References Anderson G., Horvath J., 2002. Chronic conditions: making the case for ongoing care. Baltimore, MD: Johns Hopkins University. Barreto M.L., Teixeira M.G., Bastos F.I., Ximenes R.A.A., Barata R.B., Rodrigues L.C., 2011. Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs. The Lancet 377: 1877–89. Beaglehole R., Bonita R., Horton R. et al., 2011. Priority actions for the noncommunicable diseases crisis. The Lancet 377(9775): 1438–47. Bodenheimer T, 2000. Uneasy alliance: clinical investigators and the pharmaceutical industry. N Engl J Med 342:1539-44. Boeckxstaens P., De Smedt D., De Maeseneer J., Annemans L., Willems S., 2011. The equity dimension in the Quality and Outcomes Framework. A systematic Review. BMC Health Services Research 11: 209. Boyd C.M., Darer J., Boult C., Fried L.P., Boult L., Wu A.W., 2005. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA 294:716-24. De Maeseneer J., Roberts R., Demarzo M. et al., 2011. Tackling NCDs: a different approach is needed. The Lancet. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61135-5/fulltext. De Maeseneer J., van Weel C., Egilman D., et al., 2008. Funding for primary health care in developing countries: money from disease specific projects could be used to strengthen primary care. BMJ 336: 518–19. De Maeseneer J.M., van Driel M.L., Green L.A., van Weel C., 2003. The need for research in primary care. The Lancet 362:1314-9. Frenk J., Chen L., Bhutta Z.A., et al., 2010. Health Professionals for a New Century: 32 World Hospitals and Health Services Vol. 47 No. 4
Clinical care: Noncommunicable diseases References continued Transforming Education to Strengthen Health Systems in an Interdependent World. The Lancet 376:1923-58. Gillam S., Siriwardena N., 2011. The quality and outcomes framework. QOF-transforming general practice. Oxford: Radcliffe. Heath I., Rubinstein A., van Driel M.L. et al., 2009. Quality in primary health care: a multidimensional approach to complexity. BMJ 338:911-3. Mannino D.M., Thorn D., Swensen A., Holguin F., 2008. Prevalence and outcomes of diabetes, hypertension and cardiovascular disease in COPD. Eur Respir J 32:962-9. Mold J.W., Blake G.H., Becker L.A., 1991. Goal-oriented medical care. Fam Med 23(1):46-51. Norbury M., Fawkes N., Guthrie B., 2011. Impact of the GP contract on inequalities associated with influenza immunisation: a retrospective population-database analysis. British Journal of General Practice 61(588):379-85 Rijken M., Bekkema N., 2011. Chronic Disease Management Matrix 2010: Results of a survey in ten European countries. Utrecht, NIVEL: Netherlands institute for health services research 2011. Starfield B, 2011. The hidden inequity in health care. Int Journal for Equity in Health 10: 15. Swanson R.C., Mosley H., Sanders D., et al,. 2009. Call for global health-systems impact assessments. The Lancet 374 :433-435. Wagner E.H., 1998. Chronic disease management. What will it take to improve care for chronic illness? Eff Clin Pract 1:2-4 World Health Organization, 2001. International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization. World Hospitals and Health Services Vol. 47 No. 4 33
Page 1 and 2: 2011 Volume 47 Number 4 www.ihf-fih
Page 3 and 4: Contents Contents volume 47 number
Page 5 and 6: Editorial Editorial ERIC DE ROODENB
Page 7 and 8: Imaging 2.0 - Sharing your vision.
Page 9 and 10: Policy: China Figure 1: Three eras
Page 11 and 12: Policy: China need to be closely mo
Page 13 and 14: Policy: Japan Figure 2: The disaste
Page 15 and 16: Policy: Egypt Public policy and med
Page 17 and 18: Policy: Egypt consider the potentia
Page 19 and 20: Policy: Democratic Republic of the
Page 21 and 22: Policy: Democratic Republic of the
Page 23 and 24: Management: Paediatric hospitals Th
Page 25 and 26: Management: Paediatric hospitals pa
Page 27 and 28: Management: Mongolia Table 1: Chara
Page 29 and 30: Management: Safety and efficiency I
Page 31 and 32: Management: Safety and efficiency F
Page 33: Clinical care: Noncommunicable dise
Page 37 and 38: Opinion matters Self: You think a s
Page 39 and 40: Reference World Hospitals and Healt
Page 41 and 42: Reference World Hospitals and Healt
Page 43 and 44: IHF corporate partners Meet IHF cor
Page 45 and 46: IHF corporate partners ROYAL PHILIP
Page 47 and 48: Inject Geography into Your Electron
Page 49 and 50: Reference IHF Events calendar 2012
Page 51 and 52: Healing Environment. Healthy Busine

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