Isn’t it Time to Embrace ‘Chronic Disease Management’?

Just wanted to share with you some thoughts around 'Chronic Disease Management', since most physicians are at their wit’s end figuring out how to sustain better clinical outcomes in their chronic disease patients for a lifetime. Thought you might be interested in it since progressive countries of the world like India & China are becoming havens for chronic metabolic diseases like Diabetes, Dyslipidemia & Hypertension and many of us would be treating many patients with these disorders every day.

Chronic disease like Diabetes is a disease for a lifetime. Though ‘Diabetes’ has the dubious distinction of being known as a ‘Silent killer’, Diabetes by itself, as we know, does not kill. It’s the complications of diabetes that kill, Cardio-Vascular Disease (CVD) being one of the biggest culprits. Just 2 decades ago, people in their 40s were being diagnosed to have diabetes with/without CVD and its now a fact that the age of onset and complications has gone back 20yrs and people in their early 20s are falling prey to this epidemic. No wonder, industrialisation & affluence combined with sedentary work environments form the backbone of this juggernaut.

During the 1800s, communicable (infectious) diseases like cholera attributed to 15 million deaths in India. Between 1900 and 2000, the maximum deaths in India resulted from diseases such as plague, cholera, typhoid, malaria, and tuberculosis.  A recent survey in 2010 reports Cardio Vascular Disease (CVD) is India’s number 1 killer. Thesefindings are part of the Million Death Study that is following the lives and deaths of 1.1 million households throughout India until 2014, whichindicates that ‘lifestyle’ diseases have overtaken ‘communicable’ diseases in India’s mortality numbers (number of deaths). As if that weren’t enough, the facts below leave us in splits:

1. International Diabetes Federation (IDF) estimates that Diabetes, CVD and Stroke alone shall cost India Rs 1.7 Lakh Crores by 2015
2. Price Water Coopers (PWC) and Assocham estimate that about 53% of all deaths happening in India are due to Chronic diseases
3. India shall spend Rs 160,000 Crores (USD 32 billion) to manage Diabetes alone in 2010 (dyslipidemia-elevated blood cholesterol, hypertension-high blood pressure, obesity & overweight, not included). 98% of our patients are spending from their own pocket/savings - no medical insurance, no other source of financial support to pay for these disease management. Many patients also take loans to pay for these (Ref: Study published in Aug 2010)

This shift in trend should not come as a surprise to us. Scientists have found that South Asians are genetically prone to heart disease. 1 in 25 Indians carry a mutated gene that causes heart failure. Add to it the stressful jobs, poor eating habits, and sedentary lifestyle. Though one may assume these factors to exist only in cities, with ‘urbanisation’ of rural India, the rural population is also facing similar problems.

Only 1%-40% of all Indian patients with chronic diseases have access to medical care and the remaining live in the shadow of these silent killers without even knowing that they have it. Even those that receive treatment have no better health outcomes. Figure them from the facts below:

1. ~50% of newly detected diabetics have cardiac disease
2. ~50% of those undergoing cardiac-stenting are diabetics
3. ~65% of diabetics die of cardiac disease
4. ~70% of kidney failure patients are diabetics
5. ~90% of stroke patients are diabetics
6. ~90% of stroke patients either die or get permanently disabled
7. ~50% of foot amputations cases are due to diabetic foot
8. ~60% of these foot amputated patients die over next 5 years

As chronic care physicians, all of us face common challenges in chronic disease patient management, which I have tried to summarise below:

1.) Treatment in chronic diseases is ‘Episodic’ since patients generally go back to doctors only when they have a problem, but not otherwise. However, periodic medical follow-up is the cornerstone to keeping these diseases in control.

2.) Adherence to ‘Diet & Exercise’ is a major challenge since most patients are averse to diet and exercise counselling as they feel not motivated enough to follow them.

3.) Self monitoring of blood glucose is an alien concept.....like a stationary cycle that gets used to dry clothes, Glucometers and HbA1c kits seldom get used, again due to lack of motivation.

4.) Societal factors tend to offer a variety of advices to the patient leaving him with a mix of information, not necessarily helping him/her make informed decisions that may benefit better health outcomes

5.) Patient attrition thus ensues

6.) Considering the chronic nature of the disease, maintaining long term patient motivation is the only answer to 'Improving Health Outcomes' in chronic care patients. However, this is not easy.

We all know that metabolic diseases like Diabetes, Dyslipidemia or Hypertension are not curable and hence the only answer lies in keeping them under ‘optimal clinical control’. However, it’s the ‘chronic nature’ of these diseases itself that poses the biggest challenge in management & hence the patient needs lifelong motivation to keep these diseases under control. Any loss of interest or negligent attitude of the patient towards managing them may cost him/her dear. That’s where 'Chronic Disease Management' comes to the rescue in being able to support these patients for a lifetime. In countries like US, Canada, EU, AU & NZ where governments pay for healthcare, it is in the interest of governments to invest in Chronic Disease Management so that more patients stay in control and hence spend less money to manage disease. These healthcare interventions are what constitute Health Economics in those countries.

But, India is a 100% self-pay market. Every patient has to pay from their own pocket for healthcare. With a disease burden of over 50 million diabetics, countries like ours need Disease Management as much as the other evolved countries. A report published in The Times of India in August 2010 states that India shall spend Rs 160,000 Crores (USD 32 billion) to manage Diabetes alone in 2010 (Dyslipidemia & Hypertension, not included). 98% of our patients are spending from their own pocket/savings - no medical insurance, no other source of financial support to pay for managing these diseases. Many patients also take loans to pay for these.

So, do we need a structured & organised ‘Chronic Disease Management’ infrastructure in out clinics & hospitals? Without batting an eyelid, the answer is YES. However, who will pay for Chronic Disease Management in India? Well, there is a way that Disease Management could be offered to every Indian Diabetic , Dyslipidemic & Hypertensive patient without the patient incurring any extra cost.