Chronic disease management revisited

David VK Chao 周偉強

HK Pract 2013;35:1-2The proportion of elderly population in Hong Kong rose from 11% in 2001 to 13% in 2011, and the rising trend is anticipated to continue according to the Census and Statistics Department.¹ In fact, the proportion of the population aged 65 and over is predicted to rise from 13% in 2011 to 30% in 2041.

Population aging can have many profound effects on the society, and increase in health care burden is one of them. As people are living longer, they would be more likely to suffer from various chronic diseases. People with chronic illnesses are more likely to consult their doctors, more prone to become inpatients, and hence more likely to occupy more hospital bed days than those without such conditions.² To complicate matters further, many elderly patients have co-morbidities and are living with more than one chronic disease, making the care plan even more challenging to formulate. Therefore, as the population ages, increasingly the health care planning will be focused on the management of long-term conditions.

In the Hong Kong primary care morbidity survey 2007 – 2008, Lo et al concluded that Family doctors in Hong Kong are looking after patients with a diversity of health problems and the care of patients with chronic illnesses constitutes a substantial proportion of their daily clinical workload.³ They also reckoned that patients with hypertension, diabetes and the lipid disorder are frequent encounters in the community setting and the primary care physicians should take up more health promotion, disease prevention and chronic disease care.

The Wagner model of chronic disease management is an example of systematic approach towards managing long-term conditions.⁴ In order to be successful in managing chronic diseases, Wagner et al emphasised the need for enhancing community resources and policies, health care organisation, self-management support, delivery system design, decision support and clinical information systems support.

To improve chronic care outcome, clinicians can build up a partnership with community-based resources such as exercise programmes and self-help groups.⁴ Once the health care programmes are successfully set up in the community, the local partners can continue to run them making the programmes self sustainable in the long run. At the same time, the health care providers need to consider chronic care as a priority to allow change and innovations in care to flourish, establishing new approaches to chronic disease management.⁴ Patients with chronic conditions and their carers will become experts in their own care. They can be empowered to acquire the relevant knowledge and skills to better manage their chronic conditions and become the principal caregivers for themselves.⁴ The way chronic care is delivered can have important bearings on the disease outcome. A more efficient and effective care delivery model can be considered in streamlining and redesigning the roles of health care staffs involved in the multidisciplinary team.⁴ To facilitate decision support, up to date evidence-based national and local clinical guidelines should be easily accessible to provide quality standards for optimal patient care.⁴ The Primary Care Office has recently issued reference frameworks on diabetes, hypertension, preventive care for children and older adults in primary care settings.⁵ Last but not least, the support of clinical information systems is very important.⁴ Electronic clinical data will definitely enhance the efficacy and efficiency of chronic care management. Hopefully, the electronic health record (eHR) system being developed by the government will be proven to be useful in enhancing the chronic disease management in the near future.⁶