The rising tide of chronic non-communicable diseases (NCDs) is now killing 36 million people worldwide each year (World Health Organization 2012). There is an urgent need for effective and affordable delivery of health sector interventions for patients with NCDs, complementing implementation of the multisectoral policies aimed at decreasing population-level risks for NCDs (Maher & Ford 2011). Delivery of health interventions requires a focus on primary care, as ‘the route to greater efficiency and fairness in healthcare and greater security in the health sector and beyond’ (Chan 2009). Despite their huge burden of morbidity and mortality, chronic NCDs in low- and middle-income countries (LMICs) have often been neglected, with a largely unstructured primary care approach to their management and a lack of systematic follow-up and monitoring of care. A model of systematic evaluation of management of NCDs through cohort monitoring draws on experience of scaling up interventions for two chronic infectious diseases, tuberculosis and HIV (Harries et al. 2008). This model is a key element of a structured, programmatic framework for NCD management in primary care (Maher et al. 2009).
The two linked papers by Khader et al. (2012a,b) report on cohort monitoring for patients with hypertension and diabetes, respectively, in a primary health care clinic for Palestine refugees in Jordan. Cohort monitoring involves registering all the patients diagnosed with a certain condition within a particular catchment area over a period of time and reporting regularly on standard clinical outcomes. The purpose is to answer two deceptively simple questions: how many patients have been diagnosed and what happens to them? The authors describe how cohort monitoring provides information on the disease burden of hypertension and diabetes in primary care and on standard patient outcomes. Information on disease burden is valuable because knowing the number of patients in care informs planning in the clinic, for example, staffing requirements and forecasting of drugs and consumables. Also, comparing disease burden in the clinic with disease burden in the community can indicate trends in access to care and inform population-wide health care planning. Information on patient outcomes is valuable for quality improvement: outcomes, which may be classified as generic (death and loss to follow-up) and disease-specific (complications of hypertension and diabetes), are identified and recorded; when outcome trends are monitored and fed back to health programme and clinic staff, opportunities can be identified for improved programme performance; corrective actions are implemented, with re-evaluation to continue the quality cycle.
What are the key ingredients for successful use of cohort monitoring aimed at improved management of patients with NCDs? The authors highlight the importance of an electronic health information system (in this case E-Health). A paper-based system of cards and registers is time-consuming, distracts staff from clinical care and can be consigned to the waste paper basket. An electronic information system facilitates cohort analysis, improves on-the-spot care in the clinic by prompting clinicians to follow protocols and provides a platform for audit and operational research aimed at improved programme performance. The authors do not spell this out as an ingredient for success but reading between the lines it is apparent that a change management process that included the full range of stakeholders was important in successfully introducing the new system.
The benefits of cohort monitoring for patients with communicable diseases (e.g. tuberculosis and HIV infection) led to wide uptake into programme policy and practice. The use of cohort monitoring for patients with NCDs is at an earlier stage. The successful use of cohort monitoring in managing patients with diabetes has been reported in a central referral hospital in Malawi (Allain et al. 2011). The papers by Khader et al. (2012a,b) are a useful contribution to the literature on cohort monitoring for patients with chronic NCDs in primary care. The results should encourage more widespread use of cohort monitoring, with evaluation of the extent to which it may contribute to improved programme performance, patient outcomes and health status. As the same principles of cohort monitoring apply to patients with communicable diseases and patients with NCDs, this approach may facilitate integrated management of communicable diseases and NCDs (ensuring avoidance of nosocomial transmission of infections, especially airborne-transmitted infectious diseases such as tuberculosis).