An evaluation of a chronic disease outreach program (CDOP) - a primary care and tertiary care kidney and cardiovascular prevention, detection and management program
Date
2011-02-01
Authors
Katz, Ivor Jonathan
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Abstract
Background: Chronic diseases have increased worldwide. Despite the significant advances in
medical science, the management of chronic diseases continues to be poor. To meet this
challenge, we need to try to implement existing chronic illness models of prevention, early
detection, and risk factor management. This is achievable in part by linking primary health care
clinicians, such as primary health care nurses (PHCNs) and hospital-based medical specialists.
This study evaluated a ‘real life’ chronic disease outreach program (CDOP), which assisted
PHCNs with the early detection and management of chronic illnesses known to cause chronic
kidney disease (CKD) and cardiovascular disease (CVD). PHCNs are critical in the management
of chronic illnesses but they require ongoing support of and links with specialists. This will
ensure that current guidelines reach the people receiving primary health care (PHC) and
detection of those needing referrals.
Aims: The study aimed to determine if CDOP was an effective method for the early detection
and management of diabetic and hypertensive patients at high risk for complications like stroke,
ischaemic heart disease and CKD. It also aimed to evaluate the PHCNs’ knowledge and
motivation, and to elucidate the challenges facing the current health system in the management
of patients with chronic conditions.
Methods: Patients at risk for complications were enrolled for increased monitoring and clinical
support and management, at 20 clinics in Soweto, South Africa (SA). CDOP used a paper-based
support and patient care system, modelled on the Wagner Chronic Illness Care Model (CICM).
The components for evaluation included: (i) Focus on monitoring functional and clinical
outcomes (ii) Health system interventions, such as increased ‘decision support’ and the
development of a ‘prepared motivated health care team’ and (iii) Enhancing PHCNs’ knowledge
and motivation. The evaluation followed the various elements of the Wagner CICM, as well as
drawing on the WHO Innovative Care for Chronic Conditions (ICCC) Framework. A cohort
analysis of functional and clinical outcomes in enrolled patients was conducted. PHCN
knowledge and motivation was assessed through self administered questionnaires. Health
worker knowledge was evaluated through the use of case scenarios and multiple choice
questions. On the theme of health worker motivation, Franco’s model, with Penn-Kekana’s
adaptation, was used to develop the questions and analyse diary recordings. Diary recordings of
PHCNs and meetings with regional and provincial health managers’ discussions were collected
by CDOP staff during follow-up focus groups and feedback meetings. Diaries were analysed
thematically. The CDOP evaluation is thus a triangulated analysis of clinical and functional
outcomes, diary recordings, and the self-administered questionnaire.
Results: The CDOP ran from 2003-2006, during which time 618 patients (61% females, 39%
males) deemed at risk of CKD or CVD were enrolled; 55% had uncontrolled hypertension (HTN),
45% DM with HT and/or proteinuria. Patients were followed for 2 years. In total, 108 patients
completed 2 years of follow up, most of whom were referred for specialist support (n=69, 11%),
more intensive medication regimes or because were not available in the PHC system. Most did
not require referral (515, 82%), 35 (6%) were referred but never arrived at the hospital and 6
(1%) died. Twelve percent had advanced CKD, 2% required dialysis, 6.9% required medications
not available to primary care clinics, and 1% died. As a tool to detect those needing referral, the
program was successful. The sensitivity and specificity for detecting those needing referral was
95% and 100%, respectively.. However, although PHCNs were able to detect high risk patients,
not all those referred arrived at the hospital. Hypertension, blood glucose, cholesterol and
proteinuria control significantly improved in those followed (p<0.01) over 2 years, but no
improvement was noted with weight control. Importantly, proteinuria and kidney function, in
patients with static stable renal function, measured by estimated GFR equations and urine
dipstick or albumin creatinine ratio (ACR), did not worsen significantly. Of the remaining 510
patient enrolled but not followed up, 213 (35%) were reabsorbed into the routine clinics, and a
further, 123 (20%) of patients enrolled were lost to follow up completely. The diary recording
thematic analysis revealed the problem of poor patient follow up, attributed to the poor existing
health system in the clinics, competing demands on PHCNs, staff shortages, high staff turnover,
and the low motivation and morale of clinicians. The analysis of the health worker questionnaire
showed improved motivation and statistically better knowledge in those PHCNs involved with
CDOP compared to those who were not exposed to the program (p<0.0034).
Conclusions: CDOP was successful in supporting PHCNs, detecting patients with advanced
disease and ensuring their early referral. Such programs are able to correctly detect people with
disease, but this is dependent on the health and program systems being intact. It also improved
patient risk factor control in the sub-set of referred patients and impacted on PHCNs’ existing
knowledge and motivation for caring for patients. Its weaknesses were related to the poor
existing health systems and infrastructure, and the poor integration of chronic illness care in the
region. The PHC clinics had poor follow up compared with that in the hospital setting. The study
also revealed an overworked, poorly supported, and frustrated primary health care team. This
was despite the fact that the PHCNs were willing and motivated to deliver a good service.
Description
PhD, Faculty of Health Sciences, University of the Witwatersrand
Keywords
chronic diseases, prevention, management, detection, primary care, tertiary care