Disease Management Framework Research Articles

The Role of social care in health organizations for managing chronic Medical Conditions: A Comprehensive Review

This review examines the role of social care in managing chronic medical conditions within health organizations. Chronic diseases such as diabetes, hypertension, and cardiovascular conditions require comprehensive management strategies that extend beyond medical treatment to address the broader social determinants of health, including socioeconomic factors, social support systems, and community resources. The integration of social care into healthcare settings has emerged as a critical approach to improving patient outcomes and reducing healthcare costs. This review highlights the impact of social care models, such as Accountable Care Organizations (ACOs) and Health Homes, on chronic disease management. By analyzing current literature and case studies, the review explores how health organizations have successfully integrated social services to support patients with chronic conditions. Challenges such as funding, workforce development, and institutional barriers are also discussed. The findings suggest that a multidisciplinary approach combining medical care with social support can enhance care continuity, patient engagement, and long-term disease management. This review emphasizes the need for policy changes and innovative models to facilitate the effective integration of social care into chronic disease management frameworks.

One Health policy for combatting African trypanocide resistance

The rise of African trypanocide resistance (ATr) is influenced by various factors such as evolutionary changes in the pathogen, the presence of resistance genes in the population, poor policy decisions, limited private-public partnerships to engage local communities, and insufficient funding for the development of new drugs over the past sixty years. These challenges have been exacerbated by the inadequate implementation of drug liberalization policies in the mid 20th century, leading to poor pharmacovigilance practices for veterinary drugs in low and middle income countries (LMICs). One health (OH), a disease management framework, provides practical solutions for addressing ATr, drawing on its success in managing previous epidemics like avian influenza in 2004 and the recent COVID-19 pandemic, where institutional collaborations were rapidly established. To combat ATr, OH initiatives involving both international and local partners at the policy and grassroots levels are crucial to generate community interest. The importance of political commitment, media involvement, and nongovernmental organizations cannot be overstated, as they are essential for resource mobilization and long-term sustainability in LMICs.

Improving outcomes of type 2 diabetes mellitus patients in primary care with Chronic Care Model: A narrative review.

Designed and implemented over two decades ago, the Chronic Care Model is a well-established chronic disease management framework that has steered several healthcare systems in successfully improving the clinical outcomes of patients with type 2 diabetes mellitus. Research evidence cements the role of the Chronic Care Model (with its six key elements of organization of healthcare delivery system, self-management support, decision support, delivery system design, clinical information systems, and community resources and policies) as an integrated framework to revamp the type 2 diabetes mellitus-related clinical practice and care that betters the patient care and clinical outcomes. The current review is an evidence-lit summary of importance of use of Chronic Care Model in primary care and their impact on clinical outcomes for patients afflicted with one of the most debilitating metabolic diseases, type 2 diabetes mellitus.

Digital health integration for noncommunicable diseases: Comprehensive process mapping for full-life-cycle management.

To create a systematic digital health process mapping framework for full-life-cycle noncommunicable disease management grounded in key stakeholder engagement. A triphasic, qualitative methodology was employed to construct a process mapping framework for digital noncommunicable disease management in Shanghai, China. The first phase involved desk research to examine current guidance and practices. In the second phase, pivotal stakeholders participated in focus group discussions to identify prevalent digital touchpoints across lifetime noncommunicable disease management. In the final phase, the Delphi technique was used to refine the framework based on expert insights and obtain consensus. We identified 60 digital touchpoints across five essential stages of full-life-cycle noncommunicable disease management. Most experts acknowledged the rationality and feasibility of these touchpoints. This study led to the creation of a comprehensive digital health process mapping framework that encompasses the entire life cycle of noncommunicable disease management. The insights gained emphasize the importance of a systemic strategic, person-centered approach over a fragmented, purely technocentric approach. We recommend that healthcare professionals use this framework as a linchpin for efficient disease management and seamless technology incorporation in clinical practice.

Zoonotic implications of white-footed mice habitat selection and territoriality in fragmented landscapes.

White-footed mouse (Peromyscus leucopus) populations can thrive in fragmented suburban and urban parks and residential spaces and play a pivotal role in the spread and prevalence of tick-borne diseases. We collected spatial data on 58 individual mice living at the intersection of county park land and residential land in suburban Howard County, MD, U.S.A. We analyzed mouse density, home-range size and overlap, and a Bayesian mixed-effects model to identify the habitats where they were found relative to where they were caught, as well as a resource selection function for general habitat use. We found that as mouse density increased, home-range size decreased. The overlap indices and the resource selection function supported territoriality coupled with site-specific space use in these suburban mouse populations. While mice occurred in open areas, forest edge, and forest, they showed a strong preference for forested areas. Interestingly, mice captured only 30 to 40 m into the forest rarely used the nearby private yards or human structures and this has direct implications for the placement of rodent-targeted tick control treatments. Our study supports the need for zoonotic disease management frameworks that are based on site-specific land cover characteristics as well as specific management objectives.

Modelling the spread and mitigation of an emerging vector-borne pathogen: Citrus greening in the U.S.

Predictive models, based upon epidemiological principles and fitted to surveillance data, play an increasingly important role in shaping regulatory and operational policies for emerging outbreaks. Data for parameterising these strategically important models are often scarce when rapid actions are required to change the course of an epidemic invading a new region. We introduce and test a flexible epidemiological framework for landscape-scale disease management of an emerging vector-borne pathogen for use with endemic and invading vector populations. We use the framework to analyse and predict the spread of Huanglongbing disease or citrus greening in the U.S. We estimate epidemiological parameters using survey data from one region (Texas) and show how to transfer and test parameters to construct predictive spatio-temporal models for another region (California). The models are used to screen effective coordinated and reactive management strategies for different regions.

Mapping interventional components and behavior change techniques used to promote self-management in people with multimorbidity: a scoping review

ABSTRACT Ageing populations and improved survival, have contributed to a rise in the number of people living with multimorbidity, raising issues related to polypharmacy, treatment burden, competing priorities and poor coordination of care. Self-management programs are increasingly included as an essential component of interventions to improve outcomes in this population. However, an overview of how interventions supporting self-management in patients with multimorbidity is missing. This scoping review focused on mapping the literature on patient-centered interventions for people living with multimorbidity. We searched several databases, clinical registries, and grey literature for RCTs published between 1990–2019 describing interventions that supported self-management in people with multimorbidity. We included 72 studies that were found to be very heterogeneous when it comes to the population, delivery modes and modalities, intervention elements and facilitators. The results pointed to an extensive use of cognitive behavioral therapy as a basis for interventions, as well as behavior change theories and disease management frameworks. The most coded behavior change techniques stemmed from the categories Social Support, Feedback and monitoring and Goals and Planning. To allow for implementation of effective interventions in clinical practice, improved reporting of intervention mechanisms in RCTs is warranted.

Abstract P306: Life’s Essential 8 is Associated With All-Cause and Cardiovascular Disease Mortality Among Community Dwelling Older Men and Women in the InCHIANTI Study of Aging (1998-2020)

Introduction: The population of individuals aged 65 y and older has increased steeply over the past few years. Health factors including obesity, high cholesterol, blood pressure, and blood glucose levels, as well as adverse health behaviors such as smoking, poor diet, insufficient physical activity, and low sleep quality are risk factors for chronic disease development and mortality. Because both health factors and behaviors are critical for reducing the risk of chronic disease and mortality, we examined a score assessing overall cardiovascular health (CVH) based on American Heart Association’s (AHA) Life’s Essential 8, an update of the AHA’s former Life’s Simple 7 metric. This metric may provide a tenable framework for chronic disease management and prevention. Hypothesis: We hypothesized that in a cohort of participants aged 65 y and older, higher CVH scores based on Life’s Essential 8, indicating better CVH, at baseline, is inversely associated with risk of all-cause and CVD mortality. Methods: Overall cardiovascular health was assessed using 8 health factors and behaviors, scored 0 to 100, among 928 participants (55% female) aged 65 years and older within the InCHIANTI study of aging. Vitality status was ascertained using registry information. For analysis, CVH was modeled as a 1 Standard Deviation (SD) increase in the score. Cox proportional hazards models, adjusted for age and sex, were used to examine the associations between CVH and all-cause and cardiovascular disease mortality over a median follow-up of 14.6 y. Results: A 1 SD increase in the overall CVH score was inversely associated with all-cause (hazard ratio [HR] = 0.80, 95% confidence interval [CI] = [0.738, 0.873]) and CVD mortality (HR = 0.73, 95% CI = [0.632, 0.832]). Conclusion: Among older adults, overall CVH - assessed through the lens of the AHA's Life's Essential 8 - is associated with a lower risk of all-cause and CVD mortality. This relationship lends credence to the importance of prioritizing health factors and behaviors in preventing chronic disease development and promoting healthier lives among older individuals.

Lessons to learn from the analysis of routine health data from Moria Refugee Camp on Lesvos, Greece.

Refugees in humanitarian settings commonly experience many health needs and barriers to access healthcare; health data from these settings are infrequently reported, preventing effective healthcare provision. This report describes health needs of refugees in Moria Camp on Lesvos, Greece-Europe's largest refugee camp. A set of routinely collected service data of 18131 consultations of 11938 patients, attending a primary care clinic in the camp over 6months in 2019-20, was analysed retrospectively, focusing on chronic health conditions. The most frequent chronic conditions were musculoskeletal pain (25.1%), mental health (15.9%), cardiac (12.7%) and endocrine conditions (8.9%). In all, 70.4% of consultations were for acute health problems, with high rates of injuries and wounds (20.8%), respiratory infections (12.5%), gastroenteritis (10.7%) and skin problems (9.7%), particularly scabies. The prevalence of acute and chronic health problems is high in this setting, with some likely attributable to the deplorable living conditions in the camp. Despite its magnitude, the interpretability of routine health data is limited. A research agenda is identified, and a framework for chronic disease management in refugee camps is proposed.

Secreted in Xylem Genes: Drivers of Host Adaptation in Fusarium oxysporum.

Fusarium oxysporum (Fo) is a notorious pathogen that significantly contributes to yield losses in crops of high economic status. It is responsible for vascular wilt characterized by the browning of conductive tissue, wilting, and plant death. Individual strains of Fo are host specific (formae speciales), and approximately, 150 forms have been documented so far. The pathogen secretes small effector proteins in the xylem, termed as Secreted in Xylem (Six), that contribute to its virulence. Most of these proteins contain cysteine residues in even numbers. These proteins are encoded by SIX genes that reside on mobile pathogenicity chromosomes. So far, 14 proteins have been reported. However, formae speciales vary in SIX protein profile and their respective gene sequence. Thus, SIX genes have been employed as ideal markers for pathogen identification. Acquisition of SIX-encoding mobile pathogenicity chromosomes by non-pathogenic lines, through horizontal transfer, results in the evolution of new virulent lines. Recently, some SIX genes present on these pathogenicity chromosomes have been shown to be involved in defining variation in host specificity among formae speciales. Along these lines, the review entails the variability (formae speciales, races, and vegetative compatibility groups) and evolutionary relationships among members of F. oxysporum species complex (FOSC). It provides updated information on the diversity, structure, regulation, and (a)virulence functions of SIX genes. The improved understanding of roles of SIX in variability and virulence of Fo has significant implication in establishment of molecular framework and techniques for disease management. Finally, the review identifies the gaps in current knowledge and provides insights into potential research landscapes that can be explored to strengthen the understanding of functions of SIX genes.

Development and application of a new framework for infectious disease management at the early stage of new epidemics: Taking COVID-19 outbreak in China as an example.

BackgroundThe outbreak of coronavirus disease 2019 (COVID‐19) rapidly spread across worldwide, posing a significant challenge to public health. Several shortcomings in the existing infectious disease management system were exposed during the pandemic, which hindered the control of the disease globally. To cope with this issue, we propose a window‐period framework to reveal the general rule of the progression of management of infectious diseases and to help with decision making at the early stage of epidemics with a focus on healthcare provisions.MethodsThe framework has two significant periods (dark‐window period and bright‐window period). Outbreak of COVID‐19 in China was used as an example for the application of the framework.ResultsThe framework could reflect the progression of the epidemic objectively. The spread increased slowly in the dark‐window period, but rocketed up in the bright‐window period. The beginning of the bright‐window period was the time when healthcare personnel were exposed to a substantially high risk of nosocomial infection. Additionally, proper and prompt preventive actions during the dark‐window and bright‐window periods were substantially important to reduce the future spreading of the disease.ConclusionsIt was recommended that when possible healthcare provisions should upgrade to the highest level of alert for the control of an unknown epidemic in the dark‐window period, while countermeasures in the bright‐window period could be accordingly adjusted with full exploration and considerations. The framework may provide some insights into how to accelerate the control of future epidemics promptly and effectively.

Treatment for systemic sclerosis-associated interstitial lung disease.

This review provides an overview of the current treatments for systemic sclerosis-interstitial lung disease (SSc-ILD) and proposes a conceptual framework for disease management with case scenarios. Broad treatment categories include traditional cytotoxic therapies, biologic disease-modifying rheumatic drugs, antifibrotic agents, autologous hematopoietic stem cell transplant, and lung transplantation. The optimal use of each option varies depending on SSc-ILD severity, progression, and comorbidities of individual patients. A high-quality randomized controlled trial demonstrated nintedanib's ability to retard decline of lung function in patients with limited and diffuse cutaneous disease, with established ILD. Tocilizumab, recently approved by the FDA, provides a unique intervention in those with early SSc associated with ILD with elevated acute-phase reactants: two well designed trials showed lung function preservation in phase 2 and phase 3 trials. Stratifying patients based on key SSc-ILD characteristics (e.g. severity, risk of progression, comorbid disease presentation) may provide a useful guide for practitioners treating SSc-ILD.

The extent and association of chickpea Fusarium wilt and root rot disease pressure with major biophysical factors in Ethiopia

Fusarium wilt and root rot complex are among the major challenges to chickpea production throughout Ethiopia. Previous studies have surveyed economically important chickpea diseases in Ethiopia, but were restricted to the major chickpea growing areas and thus were unable to provide a broad geographic view of disease pressure. In the present study, we focus on understanding the extent of wilt/root rot disease pressure and its correlation with local edaphic and agronomic factors. In 2015 and 2016, we conducted geo-referenced field surveys covering 51 districts representing 17 chickpea growing zones, revealing that diseases were widely distributed in all surveyed areas. Across all surveyed sites, Fusarium oxysporum f. sp. ciceris (Foc) was the predominant species encountered among fungi cultured from plant tissue, representing 69.4% of total isolates. The remaining 30.6% of isolates were other root rot pathogens including Rhizoctonia bataticola, Fusarium solani, Sclerotium rolfslii, Rhizoctonia solani and unidentified fungi. Fusarium wilt and root rot diseases incidence were significantly (P < 0.05) associated with clay soils (vertisols), Desi type chickpea, early planting, flowering and plant maturity. The highest mean percent diseases incidence per m2 (45.65%) was recorded in the Amhara region, West Gojam zone, where heavy clay soils (typical vertisols) predominate and chickpea production is regularly threatened by high diseases pressure. Taken together, the results of this survey highlight factors associated with chickpea wilt and root disease and in doing so provide a framework for integrated disease management, while also nominating agricultural environments where breeding strategies for disease resistance might have greatest impact.

Designing an integrated, nurse-driven and home-based digital intervention to improve insulin management in under-resourced settings.

Background:In South Africa, initiating insulin for people with type 2 diabetes and subsequent titration is a major challenge for the resource-constrained healthcare system. Inadequate support systems in primary care, including not being able to access blood glucose monitors and test strips for self-monitoring of blood glucose, results in patients with type 2 diabetes being referred to higher levels of care. In primary care, initiation of insulin may be delayed due to a shortage of healthcare workers. The delayed initiation of insulin is also exacerbated by the reported resistance of both healthcare providers and people with type 2 diabetes to start insulin. In South Africa, telehealth provides an opportunity to overcome these challenges and manage insulin therapy in primary care.Methods:We describe the development of a digital health intervention including the framework used, the theoretical approach and subsequent implementation strategies.Results:This intervention is an innovative, nurse-driven and app-enabled intervention called ‘the Tshwane Insulin Project intervention’. The Tshwane Insulin Project intervention was designed and evaluated using the framework recommended by the Medical Research Council for complex interventions. The Tshwane Insulin Project intervention was developed in four sequential phases: planning, design, implementation and evaluation. The Tshwane Insulin Project intervention followed the Integrated Chronic Disease Management framework to facilitate implementation and acceptability. The Tshwane Insulin Project comprises a facility-level intervention, where nurses evaluate patients and initiate insulin, an individual-level intervention where community healthcare workers visit patients at their homes to follow-up and provide educational information, while using telehealth to enable physician-directed insulin titration if needed, and a community-level intervention aimed at empowering community healthcare workers to support people living with diabetes and raise awareness of diabetes.Conclusion:The technological advancements in digital health and telemedicine present an opportunity to improve diabetes care in resource-limited countries. This work can inform those intending to develop and implement complex interventions in primary healthcare in developing countries.

Multiple Disease Hotspot Mining for Public Health Informatics in Resource Starved Settings: Study of Communicable Diseases in Punjab, Pakistan

Communicable diseases remain a significant challenge for public health management. In particular, for resource scarce settings, it is important to understand the linkages and dynamics of multiple diseases that share common resources, space or time. We develop a framework, called Multiple Disease Management Framework (MDMF) based on machine learning approach for managing multiple diseases occurring in close space and time to identify locations that experience high disease burden rates. We use 8 water related disease incidence data in Punjab, Pakistan from year 2013 to 2019 to investigate interactions among hotspots of different diseases. However, the model is scalable and can be applied to any number of diseases. The hotspot analysis involves multi-level clustering and tagging of individual disease incidence streams that generates a distance based graph over a geographical area and is then integrated into a single stream in the framework to identify final sensitive locations called cluster alarms. The initial individual disease clustering yielded number of clusters as high as 24 clusters for each disease with up to 16 neighboring clusters of other diseases of similar sizes. The cluster tagging and multi-level clustering process was able to identify as low as 19 locations of cluster alarms across the whole province of 38 districts. The identification of high disease hotspots and their dynamics with the neighboring hotspots of multiple diseases allows identification of locations with higher need of related public health resources. This identification is very critical for national health agencies for optimal allocation of resources and devising an effective intervention programs.

PARTNER: a service delivery model to implement optimal primary care management of people with knee osteoarthritis: description of development

ObjectiveImplementation strategies, such as new models of service delivery, are needed to address evidence practice gaps. This paper describes the process of developing and operationalising a new model of service...

Mitigating The Burden Of Diabetes In Sub-Saharan Africa Through An Integrated Diagonal Health Systems Approach.

Diabetes is a chronic non-communicable disease (NCD) presenting growing health and economic burdens in sub-Saharan Africa (SSA). Diabetes is unique due to its cross-cutting nature, impacting multiple organ systems and increasing the risk for other communicable and non-communicable diseases. Unfortunately, the quality of care for diabetes in SSA is poor, largely due to a weak disease management framework and fragmented health systems in most sub-Saharan African countries. We argue that by synergizing disease-specific vertical programs with system-specific horizontal programs through an integrated disease-system diagonal approach, we can improve access, quality, and safety of diabetes care programs while also supporting other chronic diseases. We recommend utilizing the six World Health Organization (WHO) health system building blocks – 1) leadership and governance, 2) financing, 3) health workforce, 4) health information systems, 5) supply chains, and 6) service delivery – as a framework to design a diagonal approach with a focus on health system strengthening and integration to implement and scale quality diabetes care. We discuss the successes and challenges of this approach, outline opportunities for future care programming and research, and highlight how this approach can lead to the improvement in the quality of care for diabetes and other chronic diseases across SSA.

A Semantic-Based Framework for Rice Plant Disease Management

Rice plant diseases can cause damages and yield losses. To reduce the productivity losses, farmers need to observe and decide suitable treatments for the diseases recognized from the abnormal characteristics appeared in their farms. Traditionally, farmers identify potential diseases from their experiences or by consulting other experts. However, this approach has certain disadvantages due to varying knowledge, and at times unreliable experience and perception of different farmers. Externalization of knowledge from existing reliable sources and utilization of multiple farmer’s observations can overcome such problems. Thus, this study presents the design and development of RiceMan, a semantic-based framework in agriculture for rice plant disease management using multiple observations. The framework not only manages observations within a single farm, but also integrates with neighborhood observations to cope with spreadable rice diseases. In addition, with proper design of Rice Diseases Ontology (RiceDO) and Treatment Ontology (TreatO), the framework can identify possible diseases and give early warnings to farmers for their appropriate actions. Based on realistic situations, the paper also illustrates how the proposed framework can help farmers to better: (1) identify rice diseases, (2) prepare for the early warnings, and (3) obtain recommended treatments.

A Systematic Evaluation of Measures Against Highly Pathogenic Avian Influenza (HPAI) in Indonesia.

Over the past years, many different control measures have been implemented to prevent HPAI infection. The national plan with numerous measures lead to problems in terms of prioritization and budget allocation. Our study objectives are to (i) establish an inventory of measures on HPAI control in Indonesia since the first actions were taken in 2004, (ii) evaluate preferences for different HPAI control measures applied in the West Java province at the district level during 2013–2017, and (iii) establish a basis for further qualitative and quantitative research to improve control for an endemic HPAI in Indonesia. This research was carried out according to the following five steps (i) development of an HPAI management framework for an endemic state, (ii) inventorization of measures directed at HPAI and description of the development of HPAI in Indonesia, (iii) development of a questionnaire for the experts involved, (iv) systematic evaluation of preferences for short- and long-term HPAI strategies and measures applied in the West Java Province based on expert opinion, and (v) data analysis. The study systematically evaluated in total 27 measures. The results of this study show that the animal disease management framework is helpful as a systematic structure to distinguish and evaluate strategies and measures. In our framework, we defined the following strategies: prevention, monitoring, control, mitigation, eradication, and human protection. The findings of our research show that the primary aims of the government were to safeguard humans from HPAI transmission by mitigating HPAI disease in livestock. The measures with the highest priority were preventive vaccination of poultry, biosecurity, and stamping-out infected flocks. This showed that the government predominantly chose a vaccination-based HPAI mitigation strategy. However, the chosen strategy has a low implementation feasibility. A collaboration between the responsible stakeholders farmers may increase the feasibility of the chosen strategy in the future. Furthermore, our findings provide a basis for research into the motivation of farmers to implement different measures as well as into the expected impact of different measures to develop an effective and efficient mitigation approach.

Diabetes management in a Primary Care Network (PCN) of private general practitioners in Singapore: An observational study.

A Primary Care Network (PCN) is a virtual network of general practitioners (GPs), sharing common resources and common clinical governance framework for effective chronic disease management. In this study, we analyzed the frequency of assessment as well as control of HbA1c, blood pressure (BP), and low-density lipoprotein (LDL) over time among adult patients with diabetes managed by a group of private GPs under PCN.Data, including clinical measurements of HbA1c, BP, and LDL from 2012 to 2015, of 943 subjects at 9 GP clinics that piloted PCN in Singapore in 2012 was obtained from the chronic disease register for this analysis.The total number of PCN patients increased from 371 in 2012 to 911 in 2015. The average HbA1c decreased from 7.5% in 2012 to 7.3% in 2015, with a significant yearly improving trend of -0.11% (P < .001). The trends in change for systolic BP and LDL were not statistically significant during the same follow-up period. Regular assessment of HbA1c decreased from 80% in 2012 to 55% in 2015. Such decreases were also found in BP and LDL assessments. We also found that receiving government subsidies under a national scheme was a major determinant for maintaining regular assessment, with patients so covered 3 to 20 times more likely to have regular assessments.The PCN model can help improve care and clinical outcomes in adult patients with diabetes in the private primary care sector. Investing greater financial and human resources to augment service capacity and expanding subsidy coverage may be important to ensure the effectiveness, scalability, and sustainability of such a model of care.