The purpose and significance of chronic disease management

The core purpose of chronic disease management has never been to "radically cure" irreversible chronic diseases such as hypertension and diabetes. Rather, it is to delay disease progression and reduce complications as much as possible through long-term, dynamic full-cycle intervention. Ultimately, while improving patients' quality of life, it also reduces unnecessary consumption of medical resources and achieves a win-win situation for individuals, the medical system, and public health.

Let me tell you a real story that I encountered when I was working at a community health service center two years ago: 62-year-old Uncle Zhang has a 12-year history of hypertension. He refused to take medicine before, thinking that "if he is not dizzy, he is not sick." Last winter, he suffered a cerebral infarction and paralyzed half of his side. His wife had to take care of him and he didn't even have time to buy groceries. His grandson, who had just entered elementary school, didn't even open the door after school. Later, he was included in the community chronic disease management ledger. The family doctor came to check his blood pressure once a week and helped him adjust his medication plan. He also specially taught his wife how to cook with less oil and salt. Now, more than half a year later, Uncle Zhang can go downstairs to buy cigarettes on his own using crutches, and pick up his grandson from school.

Interestingly, there are still obvious school differences in the assessment orientation of chronic disease management in the industry. One group is the "indicator group" who prefers evidence-based guidelines. They believe that patients' core indicators such as blood pressure, blood sugar, and blood lipids must be strictly controlled within the range recommended by the guidelines. Even if medications are adjusted and strict dietary restrictions are met, the standards must be met. This group is supported by a large amount of clinical data - the higher the indicator compliance rate, the lower the risk of complications. The other faction is the "quality of life faction" that has become more and more popular in recent years. Most of these practitioners are grassroots public health and geriatricians. They believe that for the elderly over 80 years old and with multiple underlying diseases, the death index may bring risks: for example, if the systolic blood pressure of the elderly is lowered too low, it will easily induce orthostatic hypotension and falls and fractures. Compared with the good-looking indicators, the first priority is to enable the elderly to eat, walk, and not suffer. But no matter how different the differences between the two groups are, everyone's underlying goal is the same: Don't let a minor illness turn into a serious one, and don't let an illness that could have been controlled become a burden that drags down the whole family.

When I first started working in public health, I also felt that chronic disease management was a "thankless job" - chasing the elderly every day to ask whether they had taken medicine or checked their blood pressure. Many people found you annoying and even thought you were here to sell health care products. It wasn't until I met Uncle Zhang that I changed my mind. Think about it, hospitalization for a cerebral infarction costs at least tens of thousands, and the money for subsequent recovery is even more bottomless. If it had been included in chronic disease management three to five years earlier, and spent a few cents a day on antihypertensive drugs, how could it have happened?

Don’t underestimate these trivial follow-up tasks, they actually “reduce the burden” on the entire medical system. I had dinner with the director of the cardiology department of a tertiary hospital. He complained that one-third of his half-day expert appointments were old patients who came to be prescribed antihypertensive drugs. Their conditions were very stable and they could get medicines for follow-up in the community. However, he had to squeeze into the tertiary hospital. Instead, severe patients who needed coronary angiography and treatment for refractory hypertension were not able to get registered. Good chronic disease management means keeping these mild and stable patients at the grassroots level and leaving high-quality medical resources to those who really need them.

It is even more cost-effective when calculated from public health accounts: public data from the National Medical Insurance Administration in 2023 show that medical expenditures related to chronic diseases accounted for 58% of total medical insurance expenditures, of which 80% was spent on the treatment of complications. Some estimates show that if the target compliance rate for my country's chronically ill people can be increased by 15%, nearly 100 billion in medical insurance expenditures related to complications can be reduced every year. The money saved will be much more cost-effective, whether it is used to expand the reimbursement scope of serious illness insurance or to vaccinate children with more free vaccines.

Nowadays, chronic disease management in many communities is no longer the rigid model of filling out forms and making phone calls. I have seen a chronic disease administrator in a community in Hangzhou organize a square dance group for hypertensive patients in the area. He distributes one-minute science tips to the group every day, and also conducts check-in activities. If he measures his blood pressure on time and uploads it for a week in a row, he can receive 10 eggs. The participation rate of the uncles and aunts is very high. The compliance rate last month increased by more than 20% compared with before.

A few days ago, I went back to the community where I was staying for a follow-up visit. I happened to see Uncle Zhang and a few old guys sitting in the pavilion of the community. They were holding a small book to record blood pressure and were giving the salt control spoons given to Lao Li Anli from the community next to him. He said, "I didn't listen to the advice before, but now I know that eating half a spoonful of salt every day is better than any tonic." You see, this is the most practical meaning of chronic disease management - it is never a lofty medical concept, it just helps you live a more practical life, be able to spend a few more years with your family, be able to take a few bites of what you want, and be able to go downstairs when you want to take a walk. That is enough.