According to the World Health Organization (WHO, 2002) definition; chronic diseases are diseases characterized by their permanency and their capacity of leaving residual disability. These diseases are caused by non-reversible pathological alteration and do require special training of the patient for proper rehabilitation, or may be expected to require a long period of supervision, observation or care. The Australian Institute of Health and Welfare (AIHW, 2001) lists twelve chronic diseases that have the greatest repercussions on the Australian health care system. They include coronary heart disease, stroke, lung cancer, colorectal cancer, depression, diabetes, asthma, chronic obstructive pulmonary disease, chronic kidney disease, oral diseases, arthritis and osteoporosis. Because of the increase of chronic disease cases there is an urgency to stop and reverse the ever rising threats of the ailments, another measure that needs to be embraced is the dismissal of the elongated misunderstandings about these diseases.
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A conceptual framework provided by the Chronic Care Model (CCM) is therefore useful for understanding the elements considered essential for the management of chronic disease and the interplay between the elements (Zwar, 2009). (wafula, 1999) However, not all of the elements of the Chronic Care Model can be assessed experimentally for their effectiveness or efficiency and this is illustrated by the lack of research evidence to support the role of health care organizations and community resources. Significant of the evidence presented in this critical analysis refers to the management of adults with type 2 diabetes, Chronic Kidney Disease (CKD) and may not be applicable to all chronic diseases. Therefore this paper is going to discuss the issue of chronic disease based on early detection and early treatment of a chronic disease based on the Australian government’s 2005 national chronic disease strategy. The paper will touch on the issues about prevention across the continuum, early detection and early treatment, integration and continuity of prevention and care and self management measures. it will then conclude by showing what needs to be embraced in trying to mitigate this diseases.
Prevention across the continuum
Significant gains can be made by focusing on the risk factors that underlie chronic disease in a systematic and well-integrated manner. The range of risk factors amenable to intervention can be broadly grouped into two categories, behavioral and social risk factors, and biomedical risk factors (NCDS, 2005).
Cancer, cardiovascular disease, chronic obstructive pulmonary disease and type 2 diabetes have common and modifiable risk factors, notably high blood pressure, high blood cholesterol and obesity/overweight. They are also linked by three related major behavioural risk factors, namely unhealthy diet, physical activity and tobacco use. Psychosocial health can also impact on chronic diseases, including for peoples capacity to maintain healthy lifestyle approaches. Making an early diagnosis is the key to optimizing prognosis. This is as per the National Chronic Disease Strategy which states that:
Australia’s health system must be able to respond in an appropriate and cost effective way to this challenge. Failure to prevent, detect and treat chronic disease at an optimal stage in its course impacts on affected individuals and their families and cares in terms of pain and suffering, and on the whole Australian community in productivity losses and high health care costs (National Health Priority Action Council 2006).
Early detection and early treatment
In Australia Not all chronic diseases are detected as early as possible. It is estimated for example, that only half of the people with Type 2 Diabetes are actually diagnosed and receiving treatment (AIHW, 2004). Furthermore, many chronic diseases are diagnosed at advanced stages of the disease which can compromise overall health outcomes of an individual.
According to NCDS (2005) undetected, undiagnosed and untreated chronic disease can reflect, Lack of knowledge or poor health literacy by consumers about the risks and/or symptoms of a chronic disease, lack of recognition and the appropriate follow up response by health care providers to the risk factors for chronic disease and the manifestation or symptoms of disease, and Poor access to, or use of, health care interventions (i.e. both diagnostic and treatment) at the asymptomatic and symptomatic stages. Early detection and early treatment, where appropriate, can offer significant benefits at both an individual and population level and is a critical area in which to identify practical approaches under the NCDS.
For instance, Timothy (2009) said that early detection of chronic kidney disease (CKD) followed by appropriate clinical management appears the only means by which the increasing burden on the health-care system and affected individuals will be reduced.
Governance structures are required to oversee the continuation of the Strategy and support the change-management required to reshape the health system in Queensland. This is to ensure that the work outlined under the Strategy that occurs within agreed timeframes, ongoing governance arrangements at the federal, state, regional and local levels are required to guide implementation (Queensland Strategy for Chronic Disease 2005-2015). This can be done through local partnership an integrated health service delivery involving the range of health service professionals, agencies and consumers in planning and developing local options. Additionally, with the Australian Government to shape national health policy and funding models for primary health care services, pharmaceutical benefits and aged care services need to be embraced.
In the current increasingly fragmented health care systems, older patients suffering from different chronic conditions consume a large range of medicines. The medicines which are given by one or several providers apply evidence-based medicine (EBM) without coordination; this in turn leads to potential adverse drug events (ADE) (Pierre, 2010).
Piere (2010) in this context, special attention must be given to better and standardized potentially inappropriate medication (PIM). A prescribing medication is potentially inappropriate if the risk of ADE outweighs the clinical benefit, particularly when a safer or more effective alternative therapy is readily available for the same condition.
Most prevalent co-morbidities in the population studied were vascular diseases (cerebrovascular disease 31%, ischaemic heart disease 10%); diabetes mellitus (14%); chronic pulmonary disease (13%); chronic kidney disease (13%), defined as serum creatinine > 150 µmol/l or estimated GFR < 50 ml/min; and congestive heart failure (12%) this is according to Cockcroft and Gault (19).
Self-management System (SMS)
Self management is a care model where the patient is actively engaged in and takes responsibility their healthcare. This model requires an informed, motivated and skilled patient with very good negotiation and communication skills to see them through the health system in sickness and in health (yes, possibly a bit like a marriage). Fundamentals to self-management are that, people with a chronic disease are able to undertake the health care actions that optimize their well-being. This means facilitating a situation where people have the knowledge, skills and confidence to identify their health needs and take action to address them in the most appropriate way. Importantly, self-management is not the sole responsibility of the person with the chronic disease. It is the role of the health professional to assist the person with a range of tasks that will promote effective self-management, based on the person’s goals, wishes and capacities.
To support self-management the health structure must provide ready access to appropriate systems of self-management support that are evidence based, and adequately resourced with trained staff. Staff must be culturally sensitive to the person’s needs and support the belief in the person’s ability to learn self-management skills (Brunson, 1995).
The aim of self-management support is to develop skills and confidence within patients and their families so that they can take responsibility for their own care (Wagner, 1996, and WHO, 2002). The self-management support strategies that were found to be most effective were those that developed self-efficacy in relation to specific behaviors such as diet, exercises physical and diabetes rather than those that were more general. Self efficacy theory underpins this process and this can only be interpreted and measured in regard to specific behaviours, such as diabetes self management or diet and exercise behaviors but not broadly in relation to a range of behaviours such as chronic diseases and self management in general (Bandura ,1977& Collins ,2005).
While the literature review did not identify any experimental evidence assessing the impact of self-management support in Indigenous communities, Collins (2005) reveals that in an evaluation report from the Eyre Peninsula suggests that chronic disease self management can be effectively delivered to Aboriginal populations by Aboriginal health workers.
Delivery system design (DSD)
Zwar and Abija (2006) asserted that among other management models the Delivery system design (DSD) is more effective in improving patient use of services, patient outcomes and health professional adherence to guidelines particularly for heart disease, diabetes and asthma. Zwar and Abija continued by showing that:
In combination with self-management support it was effective in improving physiological measures of disease, health and functional status and quality of life particularly for hypertension and diabetes. Nurses acting as case managers were effective in diabetes when combined with self-management support.
The delivery system design interventions that were found to be most effective included the development of multidisciplinary team care especially in the role of practice of nurses, use of patient reminders and proactive follow up which are central to the switch from acute to chronic care. The National Chronic Disease Strategy (NCDS) lists several recommendations that target delivery system design in primary care under the proposals for integration and continuity of care. These include risk stratification and case management where routine care planning and self management are insufficient. There is also a need to develop the funding structures to support multidisciplinary care and care planning more effectively to overcome the fragmented nature of the Australian healthcare system (NCDS, 2005).
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There is also another need for greater coordination between the services especially to improve the referral pathways between services. Delivery system design is of particular importance in Aboriginal health to overcome the problems of healthcare delivery in remote areas and barriers to access even in urban areas. With involvement of the whole community there have been improvements in patient outcomes associated with secondary prevention interventions such as dietary interventions in remote communities (Rowly,2000 and 2001). Much of the indigenous literature has been focused on interventions in remote communities and more research is required to support urban populations who also experience considerable morbidity and mortality.
Management of Type 2 diabetes requires adhering to multiple lifestyle and medical surveillance self-care behaviors to achieve and sustain optimal glycemic control and behaviors that are inherently modifiable. Individuals are expected to quickly integrate these behaviors, which are the cornerstones of treatment and often the most difficult components of self-management. Of these major lifestyle changes, one of the most difficult behaviors is adhering to increased exercise (Pierre, 2010). Exercise has significant physiological and psychological benefits for individuals with diabetes. For example, exercise significantly decreases hemoglobin A1C, an index of blood glucose control.
Ganny (2010) pointed out that in addition to improving cardiovascular risk factors, joint flexibility and quality of life despite the obvious benefits of exercise, many individuals with diabetes failed to initiate and/or adhere to a regular exercise program. An estimated 37-60% of individuals with diabetes do not exercise and more often than not the majority of individuals who do exercises discontinue the program within 3-6 months (Willis, 1992).
The management of Type 2 diabetes requires a considerable amount of effort to achieve and sustain optimal glycemic control. Individuals living with diabetes must assume responsibility for their management, which is achieved through self-care behaviors, including medical surveillance (i.e. taking needed medications and maintaining proper foot care), blood glucose testing, adherence to a healthful diet, embracing routine exercises and increased physical activity.
The various state Governments in Australia, through, have identified the prevention and management of chronic diseases as one of its major strategic priorities for the coming decade. In Queensland for instance ,cardiovascular disease (coronary heart disease, heart failure and stroke), chronic respiratory disease (chronic obstructive pulmonary disease (COPD) and asthma), type 2 diabetes mellitus, and renal disease account for a significant proportion of morbidity experienced by the population and for more than one-third of all deaths in the state. Depression as a co-morbidity to these chronic diseases also affects the functioning and quality of life of affected people. Poor nutrition, physical inactivity, tobacco smoking and alcohol misuse are four common underlying risk factors associated with these diseases. The Strategy will manage the current and growing pressures on the health care system both now and in the future, and address the impact of chronic diseases and risk factors on individuals, families and communities in Queensland from 2005 to 2015. A significant priority is to better manage the care for people who already have chronic diseases and avoid hospitalization wherever possible. Concurrent investment is also required around the strategies to achieve longer-term outcomes of reduced prevalence and incidence.
According Lee (2009) “80% of chronic disease deaths occur in low and middle income countries and these deaths happen in equal numbers among men and women; the threat is growing; the number of people, families and communities afflicted is increasing”. “This growing threat is an under-appreciated cause of poverty and hinders the economic development of many countries; Interventions to reduce risk and prevent disease are working in many countries; Governments need to provide leadership to address chronic diseases (Lee, 2009). A sequence of low cost actions can be put in practice in a stepwise approach to mitigate this issue.
High level of cooperation is therefore necessitated through funds pooling and strategic planning between federal government and the state or territory governments are required. In addition, training and support to health care professionals, sitting targeted goals, and collaboration between practitioners and their patients are key elements to a successful. A research carried out by Bluff (2005) on chronic diseases shows the following:
Chronic diseases such as heart disease, diabetes, high blood pressure, high cholesterol and obesity are the leading cause of pain, suffering and death in many countries today. In Australia alone an estimated number of more than ten million Australians live with a chronic condition. Studies reveal again that 60% of all deaths are to chronic diseases. Financially again these diseases are the primary cause of our escalating health costs which account for more than seventy five percent of the country’s overall medical costs. Research all over the globe has shown that healthy lifestyle modifications can ultimately reverse the progression of chronic diseases. In Australia a large study found that in about 6 weeks of healthy eating, increasing physical activities levels and reducing levels of stress, high blood pressure dropped to normal ranges. Additional benefits including weight loss, increased energy and an increased sense of well being were realized. Healthy lifestyle modifications affect the body, mind and the spirit, increasing a person’s well being.
Therefore as shown in this paper, each nation, despite the consequences of its resources, has the prospective of making a considerable improvement in the preventing and curbing of chronic diseases. Better achievements as far as chronic diseases are concerned can be achieved with good leadership, embracing healthy practices, being strict on medication, seeking health advise and services, getting involved in exercises and governments low cost intervention measures.
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