Characteristics of chronic disease management

The core feature of chronic disease management is essentially to break away from the traditional single-time diagnosis and treatment logic of "treat disease and recover" and shift to long-term health care that is patient-centered and covers all life scenarios. The core goal is not to "radically cure the disease", but to delay complications and improve the quality of life.

I worked in the chronic disease management team of a community health service center for half a year in the past two years. I met too many patients who had misunderstandings about chronic disease management. The most common one was to ask with the physical examination report, "Doctor, can you prescribe some special medicine for me? Will it be better if I take it?" I had to explain repeatedly that once chronic diseases such as hypertension, diabetes, and COPD are acquired, they will basically be with them for the rest of their lives. What we need to do is not to "get rid of" the disease, but to learn to coexist peacefully with it.

The one who impressed me the most was 62-year-old Uncle Zhang, who had a 12-year history of hypertension. He always thought that taking antihypertensive drugs on time would make everything fine. In the winter, he stayed up all night playing chess with his old friend. He had a stroke and was admitted to the ICU for three days in a row. After he was rescued, his left hand and legs became weak, so he obediently joined the chronic disease management team in the community. Don't tell me, in the management plan for him, medication only accounts for a small part, and more are trivial matters that cannot be broken down: playing chess no more than three times a week, and each session can last up to 2 hours; the salt in each dish when my wife cooks cannot exceed half the beer bottle cap; even when he quarreled with the neighbors downstairs and sulked, we had to specifically persuade him for half an hour during the follow-up, for fear that his blood pressure would spike due to emotion.

Interestingly, there is currently no unified conclusion on the core focus of chronic disease management in the academic community. Most experts from the hospital system prefer "medical treatment first" and believe that the core focus is on medication compliance and the compliance rate of various indicators. After all, the most dangerous aspects of chronic diseases are target organ damage and complications. Only by stabilizing hard indicators such as blood pressure, blood sugar, and blood lipids can risks be reduced to the greatest extent. However, most practitioners in public health and community services agree more with "life first". They say that the unstable indicators of many patients are not caused by the wrong medicine at all, but rather by eating pickles, staying up late playing mahjong, and secretly stopping anti-diabetic drugs to take health supplements. These habits cannot be changed. Simply adjusting the prescription is useless. Life intervention must be given a higher weight than prescribing medicine. The two ideas have been arguing for many years, and now when they are implemented, they basically take half, focusing on the indicators and daily habits.

What many people don’t know is that the individual differences in chronic disease management are so huge that there is no template that can be applied to everyone. A 28-year-old Internet practitioner who is also suffering from type 2 diabetes and is overweight. He drinks milk tea every day. The focus of management is to help him set a fitness plan three times a week and teach him how to order takeout with less sugar and salt. He even has to discuss with his company's executive whether afternoon tea can be served. Put more sugar-free drinks; if you were a 78-year-old grandmother with bad teeth and living alone, the focus would be to persuade her not to always eat leftovers that have been left for two or three days. She always carries candy cubes in her pocket to prevent hypoglycemia. Handrails should be installed on the toilet and bedside at home to avoid falling. If you stick to a unified guideline, you will definitely end up dissatisfied with both ends.

The "digital chronic disease management" that has been so popular in the past two years also has a lot of controversy. Teams from major manufacturers believe that smart bracelets, APP check-ins, and AI health consultants can significantly reduce management costs and make the data more accurate. However, what grassroots community doctors complain about the most is this: many elderly people over 70 years old cannot even scan their health codes. It is simply unrealistic for them to open the APP every day to upload their blood pressure and blood sugar values. Most areas now walk on two legs. Young people can use digital tools if they are willing to do so. Elderly people still rely on community doctors to come to their homes every week for measurements, and family members to help record. They do whatever is convenient for them. We never force everyone to use one set of tools.

After working in this industry for a long time, you will actually find that chronic disease management does not have so many high-level theories. In many cases, you have to understand the patient's living habits better than the patient himself: if you know that he likes to drink a few sips of wine, persuade him to drink less than half a liang at a time. Don't directly say that he is not allowed to drink to save him from the consequences. It's a secret; if you know that he cares about money, try to prescribe medicines that can be reimbursed by medical insurance, and don't add expensive imported medicines to increase his burden; if you encounter someone who is too stubborn to listen to advice, talk to him by an old friend who also has a chronic disease and can manage it well. Ten words from a doctor are more effective than a doctor's words.

After all, what we manage is never those indicators on paper, but real people.