Primary Care & Chronic Diseases
The Alma Ata Declaration, adopted during the International Conference on Primary Health Care in 1978 at Alma Ata, states: "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-determination".
Primary health care was accepted by the member countries of World Health Organisation as the key to achieving the goal of "Health for All". It has garnered a lot of attention recently; due in part to the fragmentation of medical care, with more and more specialisation occurring, and generalists are suddenly in severe shortage.
The first contact of a patient is usually to his/her family physician. The Family Physicians give holistic care to a patient from cradle to grave. Some of the services provided by our Primary Health Team are:
- Treatment of Acute Illnesses (non-emergency type)
- Chronic Disease Management
- Vaccination
- Travel Advice
- Health Screening
- Medical Checkups - Pre-employment, Statutory, Annual, Pre-marital etc.
What are Chronic Diseases?
These are diseases which are persistent and long-lasting (sometimes lifelong). Chronic diseases are among the most prevalent, costly, and preventable of all diseases. Chronic diseases, as a group, contribute most widely to death, illness and disability globally. They can be treated effectively, but need regular follow-up by doctors to monitor side effects caused by medication, changes in the medical condition, and any associated physical as well as physiological damage.
It is estimated that by 2020, non-communicable chronic diseases will exceed 65% of healthcare load globally. According to the World Health Organization (WHO), out of the 35 million people who died from chronic disease in 2005, half were under 70, with half being women.
The ParkwayHealth Primary Care Network is currently implementing three chronic disease management programmes - Diabetes, High Blood Pressure and High Blood Cholesterol. Other Chronic Diseases like Obesity, Asthma/Chronic Obstructive Airway Diseases etc will also be implemented in the near future.
Chronic Diseases may not harm a person straight away but they may lead on to sudden death or reduce a person’s quality of life significantly with debilitating illnesses like a stroke, heart attack and organ failure e.g., kidney, heart, etc and cancer.
Who is involved?
The Primary Care Physicians, and the ancillary team that consists of Dietitians, Podiatrists, Nurses and Educators.
Where are the services available?
In various clinics all around Singapore. A full list is available on the following website: http://www.parkwayshenton.com/cliniclisting.html
The Chronic Disease Programme
The Chronic Disease Programme implemented by Parkway Shenton aims to provide consistent and effective medical care for diseases, thereby lowering the costs for managing these conditions in the long run. At the same time, the quality of life for patients having these diseases will be better, and patients will require fewer expensive specialist interventions and treatments in hospitals.
A summary of the diseases dealt with in our programme is as follows:
Diabetes
Diabetes is a common condition that affects about 8.2% of the Singapore population. One in 10 deaths of an adult between the ages of 24 to 65 is due to this disease. It is one of the major causes of ill health and premature mortality worldwide. In Singapore, a person with diabetes has a three-fold increased chance of mortality, usually due to cardiovascular diseases.
Diabetes is a group of diseases characterized by high blood glucose level due to a lack of insulin secretion, resistance to insulin action, or both. Insulin is a hormone that is secreted by special cells in an important organ called the pancreas.
It is well recognized now that patients who are diagnosed to be diabetic are already having vascular damage to their body as early as five years prior to the onset of the symptomatic disease. This pre-diabetic state is medically classified into two groups – Impaired Glucose Tolerance and Impaired Fasting Glycaemia. Every year, between 2-5% of the patients in his group become diabetic. The current Ministry of Health (MOH) Clinical Practice Guidelines (CPG) classifies all diabetic patients as having cardiovascular risks similar to someone who has had either a stroke or a heart attack.
Complications from Diabetes can lead to cardiovascular diseases like stroke and heart attack. Diabetes is the commonest cause of blindness and kidney failure in Singapore. It is also one of the leading causes of amputations of the lower limbs. It is a disease that can lead on to frequent infections, skin problems, nervous disorder etc. In short, Diabetes is a multi-system disease.
Dyslipidaemia
Cardiovascular diseases, especially coronary heart disease, are the major cause of illness in Singapore. In terms of mortality, Dyslipidaemia is ranked second only to cancer.
Dyslipidaemia is a description of a group of biochemical disorders that include several lipid abnormalities i.e., Good Cholesterol (HDL) being too low, Bad Cholesterol (LDL) too high, and Triglycerides being too high.
Multiple clinical trials worldwide have consistently shown the reduction of cardiovascular diseases by lowering LDL and improving HDL.
The risk factor of each individual is determined by his/her lifestyle and diet, as well as his/her family history. Similarly, the target treatment level for each lipid molecule differs between individuals, and is influenced by other existing medical conditions or social habits, such as smoking or alcohol consumption.
Hypertension
Hypertension is a condition characterized by the persistent elevation of blood pressures.
High blood pressure levels are closely related to the risk of developing cardiovascular disease. It is one of the main causes of strokes, heart attacks, as well as heart and kidney failure.
While there are good levels of public awareness of hypertension, awareness of its complications is still lacking. This may very well reflect upon why 50% of patients who are treated for hypertension are actually well-controlled.
Blood pressure is the pressure of blood in the arteries. When it is high, it can cause strain to the blood vessels, which can in turn lead to damage of the vessel lining and eventually narrowing. The result is damage to the organs with these narrowed blood vessels supplying blood e.g. the heart, the brain and the kidney (the target organs).
As the target organs are under threat, it is important that doctors not only control a patient’s blood pressure, but also monitor for early signs of target organ damage.
Where we come in
The ParkwayHealth Primary Care Network is currently implementing a Chronic Disease Management Programme that helps patients and busy doctors to monitor and actively look out for complications associated with these chronic conditions. We are adopting the Clinical Quality Indicators (CQI) suggested by the Ministry of Health (Singapore). Clinical audits are done on a regular basis to fine-tune the system. We are also involving the ancillary team to provide support from all areas.
Our Health Screening doctors actively look out for patients with pre-diabetes, pre-hypertension, and other risk factors. These patients are offered counselling and lifestyle modifications to stop the progression into full-blown chronic illnesses.
Our ParkwayHealth Primary Care Network doctors will also use the Chronic Disease Management Programme to determine the risk of an individual in developing a cardiovascular outcome in ten years, based on his/her blood parameters and lifestyle profiling.
Our dedicated doctors and their ancillary team will work hand in hand to help patients reduce their likelihood of developing an adverse cardiovascular outcome.
The ParkwayHealth Primary Care Network Chronic Disease Management Programme has a well-designed method to allow our doctors to closely monitor their patients and treat them early on in the disease process. In many instances, earlier diagnosis and treatment would slow down – and even halt – the condition. Benefits would then include:
- Better quality of life with fewer symptoms
- Less medicines to be consumed
- Less number of investigations and tests required overall
- Fewer complications from the disease
- Significantly less chance of hospital stay and treatment
- Cheaper cost of treatment overall
- Cheaper insurance premiums
Attached below is a sample of the programme for Diabetes Care.
Screening
All patients over the age of 40, or patients (at any age) with other chronic diseases like hypertension and hyperlipidaemia, are advised to go for fasting blood glucose tests.
Clinical Consultations
All patients with Diabetes are followed-up with specially designed case notes that assist doctors to perform special monitoring tests. These tests are grouped into quarterly, half-yearly, and annual intervals. Referral for ancillary team care, like diabetic care education, foot care, vision checks and dietitian education, are also incorporated in the protocols, which follow international best-practice guidelines.
During every visit, each patient and their attending doctor will discuss and agree upon a goal to be achieved by the next visit. These goals are personalized, and may be something as simple as buying a pair of sports shoes to start a walking exercise programme.
Follow-up
All chronic care patients will be given follow-up appointment visits. Those patients who need to alter their appointment dates will have a caring Chronic Care Manager to schedule their appointment time. A system to remind patients of their subsequent visits is also implemented, and can be customised to either short message service (SMS), email or telephone calls.
ParkwayHealth Primary Care Network is closely integrated with ParkwayHealth hospitals, and a new information sharing system will allow patient records to be assessed by all authorised members in the care team.
Being aware of how diabetes is not only a condition that may affect the patient's physical well-being, we regularly screen patients for depression, as well as providing the patient with strategies to cope with stress and anxiety.
How we differ from the norm
Feedback from patients over the years has revealed a disorganized and inefficient management system for many patients with chronic diseases. Between company appointed doctors and the patient’s own family physician, there is often no leadership in the care. In many cases, care is often pushed from one party to another with no ownership of the management plan. Referrals for other medical investigations, such as foot-care or vision checks in the case of Diabetes, is often overlooked. Compliance of medication and diet is often lacking and the patient is not aware of its significance until the disease progresses to a more severe stage.
Our clinical programmes serve to prevent all these common shortfalls. It aims to prevent complications, and to improve patient’s quality of life. It is meant to empower our doctors with the tools necessary to take charge in the management of the patient’s medical condition. Through better doctor-patient contact, we also aim to impress on our clients that the outcome of one's illness or wellness is ultimately medicated through one's behaviour and motivation.
In summary, the strength of our programme is as follows:
- Comprehensive Population Identification Process
- Strong Clinical Protocols based on evidence-based medicine
- Multi-disciplinary Collaborative Practice Models
- Enhanced Patient Self-Management Education
- Detailed follow-up arrangements
We aim to be a global leader in Primary Heath Care by setting the standards in quality care to all patients in our community and beyond.