4 Acute and Chronic Disease Management
It has been prepared by Prof. C Lionis and Dr. E.A Mechili
1 Chronic and acute morbidity in Primary Care/General Practice
A chronic disease or a chronic medical condition (CMC) is one condition that has been (or is likely to be) present for six months or longer. For example, the prevalence of chronic illness based on GP consultation data varies per setting. Data from UK classify the chronic illness upon from frequency as follow asthma, hypertension, backache, osteoarthritis, ischemic heart diseases, COPD, diabetes mellitus, cardiovascular diseases, epilepsy, alcohol related disorders, schizophrenia and multiple sclerosis (Table 1).1 A recent Cretan study that is still unpublished reports a slight different list (Table 2).
Table 1. Common chronic illness categorized by responsiveness to treatment
| Difficult to treat | Treatable – one stop | Treatable continuous |
| Asthma | Coronary atheroma | Addison’s disease |
| Chronic obstructive pulmonary disease | Hypodiroidism | Cataract of eye |
| Diabetes mellitus | Osteoarthritis of hip/knees | Depression |
| Hypertension | Peptic ulceration | Epilepsy |
| Inflammatory bowel disease | Prostate hypertrophy | |
| Multiple sclerosis | Idiopathic atrial fibrillation | |
| Osteoarthritis | Manic-depressive psychosis Myasthenia gravis | |
| Parkinson’s disease | Pernicious anemia | |
| Rheumatoid arthritis | ||
| Schizophrenia |
From: Stephenson A. A textbook of general practice. Third Edition. 2011; CRC Press, London
Table 2. Frequencies of most frequently reported chronic illness in a Cretan sample of 3160 persons
| Entire Cohort (n=3,160) (%) | Females
(n=1,831) (%) |
Males
(n=1,329) (%) |
||
| Hypertension | (68.2%) | (70.0%) | (65.6%) | |
| Dyslipidemia | (45.4%) | (49.3%) | (40.2%) | |
| Type-II diabetes | (25.0%) | (24.9%) | (25.2%) | |
| Osteoporosisa | (19.4%) | (32.1%) | (2.0%) | |
| GERD | (17.7%) | (18.7%) | (16.5%) | |
| CHDb | (16.6%) | (12.3%) | (22.6%) | |
| Depressionc | (12.3%) | (15.5%) | (8.0%) | |
| Arthritisd | (11.1%) | (14.4%) | (6.6%) | |
| BPH e | – | (24.9%) | ||
| Vertigo | (10.1%) | (12.1%) | (7.4%) | |
| Hypothyroidismf | (9.3%) | (13.7%) | (3.2%) | |
| COPD | (9.4%) | (5.8%) | (14.3%) | |
| Arrhythmiag | (9.0%) | (9.6%) | (8.3%) | |
| Hyperuricemia | 258 (8.2%) | 99 (5.4%) | 159 (12.0%) | |
| Peptic Ulcerh | 216 (6.9%) | 135 (7.4%) | 81 (6.1%) | |
| Glaucoma | 196 (6.2%) | 96 (5.3%) | 100 (7.6%) | |
| Anemiai | 175 (5.6%) | 109 (6.0%) | 66 (5.0%) | |
| Dementia | 126 (4.0%) | 83 (4.6%) | 43 (3.3%) | |
| Anxiety | 128 (4.1%) | 86 (4.7%) | 42 (3.2%) |
Source: Thalis project
The rising prevalence of chronic non-communicable diseases (NCDs) in refugees’ regions of origin suggests that chronic conditions may be increasingly common among recent refugees and underscores the need for a greater understanding of NCDs in this population. The global rise in chronic NCDs has dramatically increased the likelihood that adults from low- and middle-income nations arrive in Europe.2,3 Due to the increasing burden of chronic disease, it is essential to provide a broad framework and set of principles for how care should be organized and delivered on these vulnerable populations. In this context, providing evidence-based care, coordinating that care across a range of health care settings, and promoting self-management is of high importance. In addition, further policy and program development as well as capacity building in the health care workforce must be embedded. As a conclusion of the aforementioned, primary health care has an essential role in chronic disease management (CDM), as increasingly general practitioners and other primary health care professionals are managing people with chronic disease, often in collaborative arrangements with specialized services.4 CDM can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.5 In general, self-management interventions are effective in improving both processes of care and patient outcomes. In order to embed self-management in primary health care, the personnel working in PHC must be educated and trained to enable them to provide effective self-management support. The role of practice nurses must be emphasized.4 However, the CDM items are designed for patients who require a structured approach and to enable GPs to plan and coordinate the care of patients with complex conditions requiring ongoing care from a multidisciplinary team.
Acute illnesses are those that are of short duration. These kind of illnesses may be minor or serious. Upper respiratory tract infections or skin rashes are some of the most common minor illnesses presented in primary health services. Major acute illnesses may present as an acute exacerbation of an underlying chronic illness, such as a myocardial infarction, acute cerebrovascular episode, acute metabolic condition (stroke, epilepsy), acute abdomen, severe acute infection and acute emotional or psychological problem as severe depression. All the above acute major conditions should be identified through the triage phase (see flowchart below) where the first aid is provided and then needed to be transferred to the emergency room. Refugees and migrants bring symptoms that are often partially developed (and sometimes difficult to describe) at an early stage in the evolution of illness, long before a firmer diagnosis has resulted in a hospital outpatient referral. It is strongly suggested the primary care providers to use standardized symptoms scales to measure the degree of severity of the identified symptoms. Examples of such scales are listed below. A third category of common illness that could be prevented in the hotspot or at transition centres include specific minor conditions (Table 3)6. Usually, all the below minor conditions are self-learning and can be managed at the refugees’ consultation room. However they derive the attention of primary care providers to check carefully if any serious or major condition is behind including acute cerebrovascular episode, severe chest infection, acute abdomen and severe depression.
Table 3. Specific minor conditions presenting to general practice
| CONDITION | PERCENTAGE OF PRACTICE POPULATION CONSULTING IN ONE YEAR | NUMBER OF CASES SEEN BY AVERAGE GP IN ONE YEAR |
| Acute throat infection | 8 | 160 |
| Psycho-emotional | 7 | 140 |
| Backache | 6 | 120 |
| Eczema | 5 | 100 |
| Acute otitis media | 5 | 100 |
| External ear problems | 4 | 80 |
| Hay fever | 3 | 60 |
| Dyspepsia | 2 | 40 |
| Headache | 2 | 40 |
| Dizzy spells | 1,5 | 30 |
| Constipation | 1 | 20 |
| Piles | 1 | 20 |
| Varicose veins | 0,9 | 18 |
From: Stephenson A. A textbook of general practice. Third Edition. 2011; CRC Press, London Created by: McCormick A, Fleming D, Charlton J. Morbidity statistics from general practice: fourth national study, 1991–92. Series MB5 no 3. London: HMSO; 1995.
2 Guidance on how acute or chronic morbidity could be managed at the refugees arrival on the transit centres
Sometimes is difficult for refugees and migrants to describe their problem and to give a precise name. Due to this, primary health care personnel is important to recognize some very common symptoms in order to manage these cases. Except the diagnostic skills, the PHC team needs to emphasize on good communication skills, a mutual understanding of the problem and its probable causes and solutions, negotiated management, and clear instructions to the patient about follow-up. All of these need to be clearly documented in the refugees/migrant record. Chest pain due to myocardial infarction, hemiparesis due to stroke and hypovolemic collapse due to vascular compromise following gastrointestinal hemorrhage are some of the most common symptoms of patients with acute serious illness. In these cases a referral to secondary health services is urgent. For more information see the link below:
The primary care practitioners need to consider always the flow of actions deployed in the Fig. 1 (for more information about triage please see the presentation prepared by Dr. P. Aggouridaki in the context of training the PHC in Greece). The primary care practitioners accountable for the refugees’ health care needs assessment and first aid provision are guided to follow the guidance that is existing in their national settings. However, published European guidelines by major professional organizations including European Society of Cardiology, European Respiratory Society, European Society for the Study of Diabetes etc. could support their decision in terms of the chronic or acute illness recognition and management (Table 4).
Table 4. Selected European guidelines of the most common chronic conditions
Figure 1. Prepared by UoC team in the context of EUR-HUMAN project