A beacon to guide others: improving chronic disease management through targeted, evidence-based primary healthcare quality measures

The innovative research

Svendsen et al. in their recent paper [1], titled ‘Developing quality measures for non-pharmacological prevention and rehabilitation in primary health care for chronic conditions: a consensus study’, report on their development of quality measures (QMs) for generic non-pharmacological secondary prevention and rehabilitation for persons with chronic conditions in primary healthcare (PHC). This work explains how poor health-related behaviours cause many chronic diseases; however, high-quality PHC can decrease rates of poor health behaviours in the community. Effective implementation of the QMs outlined by Svendsen et al. can improve the quality of non-pharmacological secondary prevention and rehabilitation of persons with chronic diseases and, in this way, contribute to a reduction in chronic disease rates.

The Svendsen et al.’s study [1] was undertaken in a challenging environment. A context where there is limited evidence or reliable information, and few clinical guidelines to support generic non-pharmacological chronic disease management in PHC. This is a common situation, even for a country like Denmark that is recognized internationally for their PHC quality. In such contexts, QMs are generally focused on a single chronic disease or episode of care, as opposed to covering more complex patients and healthcare journeys. Where clinical guidelines are available, adherence is often suboptimal, resulting in poor outcomes [2, 3] which have been blamed partly on the inflexibility and lack of specificity of the available guidelines [4].

Svendsen et al. [1] used a consensus-based approach to develop their QMs, involving an interdisciplinary expert panel’s review of published evidence and guidelines. Their work has global relevance with the QMs produced requiring further testing, refinement, and implementation in other contexts. This can occur by broad stakeholder coalitions in PHC, with a focus on quality and patient safety improvements and outcomes. Beyond specific disease groups, there are broader suites of QMs for PHC that assesses structure, processes, and outcomes of healthcare [5]. Future work necessitates, irrespective of how valid any specific domain of QMs is, that ‘emphasis must be shifted from preoccupation with evaluating quality to concentration on understanding the medical process itself’ [6]. This fundamental principle underscored the novel approach implemented in this study.

Significance of the problem of chronic disease management

Effective and efficient chronic disease management is a global challenge that health stakeholders have found difficult to address [7, 8]. The global burden of chronic diseases accounts for the largest cause of death globally. Annually, there are ∼29 million deaths due to the four leading chronic diseases, i.e. cardiovascular disease, cancer, chronic respiratory disease, and diabetes [9]. Low- and middle-income countries account for ∼80% of deaths attributable to Noncommunicable disease [10].

Individuals with coexisting chronic diseases are often frequent users of healthcare [11], making enhanced chronic disease management a financial, ethical, as well as a social challenge. Population ageing and its association with chronic disease rates place further emphasis on the importance of developing new solutions with haste. Ensuring that PHC promotes healthy behaviours effectively through safe, high-quality service provision is a public health, health systems, and quality and safety priority.

Future directions

Population health policies and programmes are vital in reducing the increasing burden of chronic diseases, so too are the roles of PHC services and professionals. PHC is one of the foundations for achieving universal health coverage and the health-related Sustainable Development Goals [12]. However, quality and safety remain a somewhat neglected element of PHC. For these reasons, there is an urgent need to ensure that individual patients and whole communities, with chronic conditions, receive high-quality and safe PHC. The implementation of the evidence-based QMs shared in this study can assist in achieving this goal.

It is important for health systems and facilities to develop QMs and criterion that enables them to make a determination of the extent to which their outcomes are being achieved. Irrespective of whether an expert-led or normative approach to QM development is used, proponents should ensure that they are guided by, and holistically address, the eight dimensions of quality. As Svendsen et al.’s study findings elucidate, it remains important to recognize that a robust QM system can only be operationalized effectively in contexts with adequate health information infrastructure and reporting systems. Healthcare systems need to be capable of efficient utilization by PHC professionals in a frictionless manner so as not to produce excessive, additional workload.

Social determinants of health will continue to exert greater influence on individual’s and community’s health literacy and behaviours than any particular healthcare intervention. Nonetheless, to support population health and reduce the strain on acute healthcare services, PHC must maximize its contribution to addressing this global challenge by providing enhanced, high-quality, and safe care for individuals and communities with chronic diseases. The QMs developed in Svendsen et al.’s study provide an excellent template that PHC stakeholders in other nations can consider for local application. While their international generalizability still needs to be tested, the underlying approach of the investigators serves as a beacon to motivate PHC stakeholders to drive similar, innovative quality and safety initiatives in their own settings.

Conflicts of interest

None declared.

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