David Kersenobich
Director General
National Institute of Health Sciences and Nutrition Salvador Zubirán
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Expert Contributor

Perspectives in Chronic Non-Communicable Disease Care

By David Kersenobich | Wed, 06/02/2021 - 09:12

Chronic non-communicable diseases (NCDs) such as diabetes, cancer, cardiovascular and neurodegenerative conditions, arthritis and chronic renal failure, among others, are complex and difficult diseases, both for diagnosis and to understand their physiopathology; commonly they are difficult to treat.

These are diseases that not only involve the sick patient but affect their families. They tend to occur in older people and, more importantly, their frequency has risen, in particular as a result of a higher life expectancy.

NCDs are among the main causes of morbidity and mortality in Mexico, as well as compromising the quality of life of patients in a noticeable way. It is this affectation of quality of life that is one of the concerns we face.  

NCDs have also led to the rise of a new myth, establishing above any other characteristic the fact that they cannot be cured, introducing a perspective in medicine in which harmony and effectiveness are broken.

In Mexico and globally, one of the most significant features of NCDs is the lack of long-term patient adherence to therapeutic indications and the monitoring of these conditions. Much of the natural history of these conditions has been built around this circumstance. A fundamental aspect has to do with models of care. In the consultation system that prevails today, the lack of a comprehensive management plan for these patients that sets clear goals is notorious; it is commonly reactive care. This translates, for example, into the repeated recording of the medical history by different specialists, fragmented management of the patients, multipharmacy involvement, etc.

One of the main paradigms in the care of these diseases is that obtaining good results requires specialized care. It is clear that this involves more consideration of complications than their prevention and, more importantly, than the prevention of the disease itself. It is difficult to change this paradigm and yet it may have become impractical or unacceptable. A change in care provision at earlier stages of the disease by general practitioners is imperative in most communities in Mexico. Good results require lifestyle changes, but many times it seems rather a rhetorical affirmation, not without solemnity, which implies a rupture in the most immediate cultural context; there is no doubt that it is a notion that is difficult to change. Over time, these diseases may have durable and traumatic consequences. At the heart of this statement is the complicated topic of aging. Deep down, there is often neglect and confusion regarding all these dilemmas, which eventually manifests itself in marginalization, ignoring treatment and possibly depression.

Among the different characteristics that differentiate NCDs from other pathologies is the fact that they frequently affect more than one organ and, therefore, require an interdisciplinary approach.  An important part of healthcare focuses on the logic of consultation by specialized physicians, which has been considered the best strategy for more than 20 years, yet the incidence and prevalence of these diseases are increasing. It is necessary to return to basic concepts, which include information and education for the prevention of these diseases, to move attention away from the rhetoric and make it digestible. But far more challenging is to make the care of these patients accessible to most doctors and here I mean non-specialists. It is essential to build a comprehensive model of care that considers the knowledge of those affected and their uncertainties. Patients should be offered the possibility of taking the floor, knowing their truth and not having adherence imposed on them. Efforts should be made to promote the importance of this issue, which is relevant in the short, medium and long-term management of a chronic disease.

This type of guardianship is difficult to achieve in a strategy that fragments the care of the affected individuals by different specialists. At the center of the medical care of patients with NCDs is the need to incorporate general physicians, particularly for early and timely detection. To do this, several actions are necessary, such as offering them quality continuous medical training and education on these conditions, beyond the clinical guidelines that are often complex and inaccessible in their compliance. It is necessary to promote physician’s insight and interest, facilitate their activity and give them both economic and scientific recognition.

Patient-centered care is one of the dimensions of quality that allows us to design patient care precisely according to their needs. For example, in the management of a patient with diabetes mellitus, being able to perform in a single visit all interventions, such as that of the nutritionist, endocrinologist, dentist, ophthalmologist and physical therapist, reduces costs for both patients and the institution and promotes better attachment to treatment, as well as teamwork by health professionals , ensuring care that benefits patients, improving other dimensions of quality such as the effectiveness, efficiency and opportunity of treatments.  Only in this way can we transform the model of comprehensive care of these patients.

To tackle the difficulty of control that NCDs represent, it is essential to migrate from specialized to primary healthcare, fostering the concept of earlier detection and implementation of preventive medicine at different stages of the disease. 

Photo by:   David Kersenobich