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appropriate for the setting is established, what makes a
difference? Moving beyond the three Rs, what was the
key aspect of this complex intervention and how did it
work? Could the study effect sizes be explained simply
by the setting and reassessment of personalised, realis-
tic goals by practitioners? This is certainly congruent
with evidence from psychology. Were patients who
received the intervention more actively involved in
their care, more satisfied, and more likely to adhere to
medication than those in routine care? This would be
congruent with evidence from trials of patient centred
care.
10
Addressing these questions is challenging,
particularly in the context of a pragmatic trial in
primary care. Answers require precise measurement of
variables along the causal pathway, relating to patients,
practitioners, and the system.
11
These include knowl-
edge, beliefs, and behaviours such as diet, physical
activity, adherence to medication, and even participa-
tion in consultations. Application of approaches based
on greater understanding of these wider mechanisms
can be measured in terms of reduction in cardio-
vascular risk factors such as glycaemia and should not
be underestimated.
12
Simon J Griffin general practitioner, university lecturer
Department of Public Health and Primary Care, Institute of Public
Health, University of Cambridge, Cambridge CB2 2SR
(sjg49@medschl.cam.ac.uk)
1 Griffin S, Kinmonth AL. Systems for routine surveillance for people with
diabetes mellitus (Cochrane review). Cochrane Database Syst Rev
2000;2:CD000541.
2 Olivarius N de F, Beck-Nielsen H, Andreasen AH, Horder M, Pedersen
PA. Randomised controlled trial of structured personal care of type 2
diabetes mellitus. BMJ 2001;323:970-5.
3 Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk JThM van, Assendelft
WJJ. Interventions to improve the management of diabetes mellitus in
primary care, outpatient and community settings. Cochrane Database Syst
Rev 2001;1:CD001481.
4 Stratton I, Adler AG, Neil HA, Matthews DR, Manley SE, Cull C, et al.
Association of glycaemia with macrovascular and microvascular compli-
cations of type 2 diabetes (UKPDS 35): prospective observational study.
BMJ 2000;321:405-12.
5 Adler AG, Stratton I, Neil HAW, Yudkin J, Matthews DR, Cull C, et al.
Association of systolic blood pressure with macrovascular and micro-
vascular complications of type 2 diabetes (UKPDS 36): prospective
observational study. BMJ 2000;321:412-9.
6 Diabetes Control and Complications Trial Research Group. The effect of
intensive treatment of diabetes on the development and progression of
long-term complications in insulin-dependent diabetes mellitus. N Engl J
Med 1993;329:977-86.
7 Gaede P, Vedel P, Parving HH, Pedersen O. Intensified multifactorial
intervention in patients with type 2 diabetes mellitus and microalbumin-
uria: the Steno type 2 randomised study. Lancet 1999;353:617-22.
8 Audit Commission. Testing times. A review of diabetes services in England and
Wales. Northampton: Belmont Press, 2000.
9 Griffin SJ. Lost to follow-up: the problem of defaulters from diabetes clin-
ics. Diabetic Med 1998;15:s14-24.
10 Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ.
Randomised controlled trial of patient centred care of diabetes in general
practice: impact on current wellbeing and future disease risk. BMJ
1998;317:1202-8.
11 Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P,
Spiegelhalter DJ, et al. Framework for design and evaluation of complex
interventions to improve health. BMJ 2000;321:694-6.
12 Greenfield S, Kaplan SH, Ware JEJ, Yano EM, Frank HJ. Patients' partici-
pation in medical care: effects on blood sugar control and quality of life
in diabetes. J Gen Intern Med 1988;3:448-57.
The challenge of chronic conditions:
WHO responds
The sooner governments act, the better
C
hronic conditions are expected to become the
main cause of death and disability in the world
by 2020,
1
contributing around two thirds of the
global burden of disease with enormous healthcare
costs for societies and governments.
2–4
These conditions
include non-communicable diseases such as diabetes,
chest and heart disease, mental health disorders such as
depression, and certain communicable diseases such as
HIV infection and AIDS. Mental health problems
account for nearly a third of the chronic disability affect-
ing the world’s population now and comprise five of the
top 10 causes of disability.
5
Yet many healthcare provid-
ers are ill equipped to manage chronic conditions effec-
tively, and many governments cannot cope with the
escalating disease burden and costs.
What can healthcare workers do? Firstly they can
make better use of the resources already available, as
several papers in this issue of the BMJ show. Healthcare
providers can do more to engage patients in managing
their own conditions and to use treatments properly:
we know that most patients who do not adhere to
treatment have poorer health outcomes.
6
In developed
countries only around half of the people prescribed
treatments for chronic conditions actually take their
medicines.
7
For instance, hypertension affects 43-50
million adults in the United States, but only 51% of
those treated adhere to their prescribed treatment.
8–10
Adherence is worse in poorer countries
—
in one study
in the Gambia only 17% of people diagnosed as having
hypertension were even aware that they had the dis-
order, and 73% of those prescribed treatment had
stopped it.
11
The problem is so great that Haines et al
have suggested that increasing the effectiveness of
interventions to increase adherence to treatments may
Strategies to improve clinical care and
outcomes for chronic conditions
Develop health policies and legislation to support
comprehensive care
Reorganise healthcare finance to facilitate and support
evidence based care
Coordinate care across conditions, healthcare
providers, and settings
Enhance flow of knowledge and information between
patients and providers and across providers
Develop evidence based treatment plans and support
their provision in various settings
Educate and support patients to manage their own
conditions as much as possible
Help patients to adhere to treatment through effective
and widely available interventions
Link health care to other resources in the community
Monitor and evaluate the quality of services and
outcomes
These strategies are based on WHO’s review of innovative best
practice and affordable healthcare models
Editorials
Education and debate
p990
BMJ 2001;323:947–8
947BMJ VOLUME 323 27 OCTOBER 2001 bmj.com
have a far greater impact on health than further
improvement in biomedical treatment.
7
What should policymakers do? The real answer is
that they should help to transform health care, moving
away from systems focused on episodic care for acute
illness. Some governments and healthcare systems are
already making the switch. Cheah’s paper in this issue
describes how Singapore has recognised the growing
burden of chronic disease and has begun to redesign
its healthcare system to meet people’s long term needs
(p 990).
12
To help healthcare systems around the world
to innovate and change in this way, the World Health
Organization has launched a project
—
“Innovative
Care for Chronic Conditions”
—
to analyse and help to
disseminate examples of good, affordable care for
people with chronic conditions. The strategies arising
so far from WHO’s review (see box) will be developed
further and published soon, giving concrete recom-
mendations for governments and healthcare systems.
A wide range of the world’s healthcare leaders and
policymakers are being consulted by WHO as part of
this project, and we would be pleased to hear from BMJ
readers too. In the meantime, the policymakers and
healthcare leaders who met at WHO headquarters in
May 2001 have come to several conclusions. Firstly, it is
clear that no nation will escape the burden unless its
government and healthcare leaders decide to act: the
prevalences of all chronic conditions are growing
inexorably and are seriously challenging the capacity
and will of governments to provide coordinated
systems of care. Secondly, the burden of these
conditions falls most heavily on the poor. Thirdly, uni-
dimensional solutions will not solve this complex
problem: health status and quality of life will not be
improved solely by medication and technical advances;
and thus healthcare systems will have to move away
from a model of “find it and fix it.” Lastly, these
solutions cannot be delayed
—
the sooner governments
invest in care for chronic conditions, the better.
JoAnne Epping-Jordan scientist
(Eppingj@who.int)
Rafael Bengoa director
Rania Kawar technical officer
Eduardo Sabaté medical officer
Department of Management of Noncommunicable Diseases, World
Health Organization, CH-1221 Geneva 27, Switzerland
1 Murray CJL, Lopez AD. The global burden of disease. Boston: Harvard
School of Public Health, 1996.
2 Henriksson F, Jönsson B. Diabetes: the cost of illness in Sweden. J Intern
Med 1998;244:461-8.
3 Sullivan SD, Ramsey SD, Lee TA. The economic burden of COPD. Chest
2000;117:5-9s.
4 Rice DP, Miller LS. The economic burden of affective disorders. BrJPsy-
chiatry 1995;166:34-42.
5 World Health Organization. World health report 2001: mental health: New
understanding, new hope. Geneva: WHO, 2001.
6 Dunbar-Jacob J, Erlen JA, Schlenk EA, Ryan CM, Sereika SM, Doswell
WM. Adherence in chronic disease. Annu Rev Nurs Res 2000;18:48-90.
7 Haynes RB, Montague P, Oliver T, McKibbon KA, Brouwers MC, Kanani
R. Interventions for helping patients follow prescriptions for medicines.
Cochrane Database Syst Rev 2000;(2):CD 000011.
8 Critical overview of antihypertensive therapies: what is preventing us
from getting there? Based on a presentation by Munger MA. Am J Manag
Care 2000;6:s211-21.
9 Mancia G, Grassi G. The role of angiotensin II inhibitors in arterial
hypertension: clinical trials and guidelines. Ann Ital Med Int 2000;15:92-5.
10 Graves JW. Management of difficult-to-control hypertension. Mayo Clin
Proc 2000;75:278-84.
11 Van der Sande MA, Milligan PJ, Nyan OA, Rowley JT, Banya WA, Ceesay
SM, et al. Blood pressure patterns and cardiovascular risk factors in rural
and urban Gambian communities. J Hum Hypertens 2000;14:489-96.
12 Cheah J. Chronic disease management: a Singapore perspective. BMJ
2001;990-3.
Improving outcomes in depression
The whole process of care needs to be enhanced
A
round 450 million people worldwide have
mental or psychosocial problems, but most of
those who turn to health services for help will
not be correctly diagnosed or will not get the right
treatment.
1
Even those whose problems are recognised
may not receive adequate care. In a World Health
Organization study of psychological disorders in
general health care carried out in 14 countries around
the world patients with major depression were as likely
to be treated with sedatives as with antidepressants,
although antidepressants were associated with more
favourable outcomes at three month follow up. This
benefit had dissipated by follow up at 12 months; but
patients had only been taking drug treatment for a
mean of 11 weeks, with a quarter of them doing so for
less than a month.
2
About two thirds of patients whose
illnesses were recognised and treated with drugs still
had a diagnosis of mental illness at follow up one year
later, and in nearly a half the diagnosis was still major
depression. Indeed, there are no observational studies
of routine care for patients with major depression in
the United Kingdom or in the United States that have
found most patients to be receiving care consistent
with evidence based guidelines.
Improving outcomes for patients with major
depression is not as simple as prescribing a new treat-
ment: the whole process of care needs to be enhanced.
This requires changes in the organisation and function
of healthcare teams, like those already being used to
improve outcomes in other chronic diseases.
3
Respon-
sibility for active follow up should be taken by a case
manager (for example, a practice nurse); adherence to
treatment and patient outcomes should be monitored;
treatment plans should be adjusted when patients do
not improve; and the case manager and primary care
physician should be able to consult and refer to a psy-
chiatrist when necessary.
45
Change is hard work for overtaxed healthcare
teams, and many might be tempted to adopt quality
improvement strategies that are quick and easy. Such
strategies do not usually work, however, as single initia-
tives. Ineffective interventions include distribution of
guidelines;
6
education for doctors and nurses that does
not increase their skills or change how the healthcare
team works; feedback reports on indicators of quality
of care; and stand alone screening programmes. Each
of these steps might be useful as part of a comprehen-
sive programme to change the management of
References cited in
the table appear on
the BMJ’s website
Editorials
BMJ 2001;323:948–9
948 BMJ VOLUME 323 27 OCTOBER 2001 bmj.com
