Bethesda, MD -- Worldwide disease prevention programs and greater use of primary care reduce deaths, rates of illness, and costs associated with chronic illness, according to several studies in the December issue of the journal Health Affairs. The articles offer hope for the success of similar interventions from rural China to urban Chile, where the growth of chronic diseases such as heart disease, hypertension, and diabetes has tracked the similar deadly escalation of these conditions in the United States. Funding for the publication of the global articles is made possible by a grant from the Bill & Melinda Gates Foundation.
The most comprehensive data comes from Latin America, where chronic conditions and their risk factors are now the major causes of death and illness across the region. In a series of studies originally sponsored by the Inter-American Development Bank, researchers have demonstrated the following: One of the most effective approaches is to strengthen primary care.
- In Brazil, 45 percent of all deaths in 2005 were due to cardiovascular disease or cancer. James Macinko of New York University and colleagues examined an innovative initiative to strengthen the Brazilian national health system, called the Family Health Program. Teams consisting of at least one doctor, one nurse, a medical assistant, and four to six community health workers provided primary care, made home visits, and helped improve the health of the nearly 100 million people they serve. Meanwhile, from 1999 to 2007, hospitalizations in Brazil for ambulatory care-sensitive chronic diseases--including cardiovascular disease, stroke, and asthma--fell at almost twice the rate of hospitalizations for all other causes. The authors say these results suggest that the investment in primary care was responsible for some of this decline.
- Angelica Castro-Ríos at the Mexican Institute of Social Security, in Mexico City, and colleagues found that Mexico’s preventive care program for treating patients with pre-type 2 diabetes and prehypertension saves money over the long term. For each dollar invested in prevention, between $84 and $323 would be saved over a twenty-year period. The study compared preventive care and routine care, and found that preventive care often delayed the manifestations of the disease and the development of chronic complications.
- By 2025, according to the World Health Organization, 300 million people around the world will suffer from diabetes. Stephanie Stock of the University Hospital Cologne and colleagues report that a German program that paid doctors modest additional fees to manage care of their patients with diabetes led to significantly lower mortality rates and medical care cost for the patients, compared to those not in the program. The four-year study found a mortality rate of 2.3 percent for patients studied in the primary care model, which had more intensive physician involvement, compared to 4.7 percent mortality in the control group. The difference in overall costs between baseline and the evaluation four years later was $1,443.65 for the intervention group, compared to the control group’s $1,890.40.
Other articles that focus on efforts to reduce chronic disease around the world include:
- In Latin America, cardiovascular disease accounted for 35 percent of all deaths in 2004, compared to 10 percent of deaths caused by communicable diseases such as tuberculosis, HIV, and malaria, writes Amanda Glassman at the Center for Global Development, in Washington, D.C., and colleagues. The authors note that while deaths from cardiovascular disease and stroke declined by about 60 percent in the United States and Canada between 1970 and 2000, Latin America had much smaller reductions, of 25-40 percent for men and 20-50 percent for women. The smaller changes in Latin America were attributable to rapid lifestyle changes relating to diet and exercise, as well as more limited access to good health care than in the United States and Canada, the researchers wrote. Latin American countries also have fewer resources with which to respond to chronic conditions.
- Since 2000, public spending on health in Latin America as a whole has stagnated, increasing only to 3.6 percent of GDP in 2008 from 3.5 percent in 2000, reports Glassman. With limited public funds, and increases in the costs of treating chronic conditions, smart strategic choices are critically important. “In the context of stagnant public spending and increasing needs, governments will increasingly need to strengthen explicit priority-setting mechanisms based on cost-effectiveness criteria,’’ say Glassman and coauthors.
- A trio of Chilean researchers--Ricardo Bitrán of Bitrán y Asociados, in Santiago; Liliana Escobar, also of Bitrán y Asociados; and Patricia Gassibe of the Arturo López Pérez Cancer Foundation, in Santiago--examined Chile’s comprehensive 2005 health reform by looking at access to care, treatment outcomes, hospitalization rates, and medical leave rates for six chronic diseases. The authors produced previously unpublished and clear evidence of marked improvements in nearly all categories for the six diseases--hypertension, types 1 and 2 diabetes, depression, child epilepsy, and HIV/AIDS. The hospital case-fatality rates for these diseases have all dropped, in some cases to almost zero.
- In Colombia, researchers have long sought answers as to why people with type 2 diabetes often avoid beneficial preventive care. Using data from Colombians with diabetes, Antonio J. Trujillo of the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland, and colleagues investigated the question. They sought to know if the low level of compliance with prevention was due to the fact that patients assumed insurance coverage would pay for care later, when their condition worsened, or whether insurers were limiting coverage of preventive services because they did not yield a short-term financial return. Ultimately, the researchers found no evidence that insurance coverage reduced compliance with prevention, and recommend that behavioral reasons be explored to increase policy makers’ ability to nudge patients with diabetes into better preventive behavior.
- Since 2002, China’s central government has made it a priority to reduce the gap in health outcomes between rural and urban areas. Drawing on national survey data from 2003 and 2008, Weiyan Jian of Peking University and his colleagues report that 14.9 percent of Chinese in urban areas had a chronic disease in 2008, compared to 7.9 percent in rural areas. But prevalence of chronic disease in rural areas was increasing at a faster pace, up 71.7 percent in five years, compared to a 43.3 percent increase in urban areas. The authors found major improvements in insurance coverage and use of hospital services for residents with chronic diseases in urban and rural settings. But because of higher copayments required for insurance in rural areas, rural patients were more than twice as likely to drop out of treatment for financial reasons as were patients in urban areas.