Clinical and Statistical Assessment of Risk Factors, Prevalence of Chronic Dermatoses, and Justification of Their Treatment System in Rural and Urban Areas

The research is devoted to the clinical and statistical study of risk factors, the prevalence of chronic dermatoses (atopic dermatitis, eczema, and psoriasis), and the justification of their treatment system in conditions of rural and urban areas. The work analyzes the influence of social and household and behavioral factors on the onset and exacerbation of chronic skin diseases, evaluates the quality of life of patients and the effectiveness of medical care at various stages — from pre-hospital to inpatient. Special attention is given to the comparative analysis of morbidity and prevalence of dermatoses among the rural and urban population, as well as to the development of organizational forms for the improvement of dermatological care.

Relevance of the Problem. Radical socio-economic transformations in Russia have led to changes in lifestyle and deterioration of health indicators of the population of the Russian Federation (Shchepin O.P., 1995; Ovcharov V.K., 1997; Minyaev V.A., Vishnyakov N.I., 1997; Denisov I.N., 1997; Yuryev V.K., 1999; Starodubov V.I., 2000; Vyalkov A.I., 2001; Orel V.I., 2002; Kucherenko V.Z., 2002; Gerasimenko N.F., 2002; Shevchenko Yu.L., 2003, et al.).

Chronic skin diseases have not exhibited a tendency toward decline over the last 10–15 years (Suvorova K.N., 1998; Skripkin Yu.K., 1999; Danilov S.I., 2001; Remes S.T., 1998, et al.).

In the structure of chronic dermatoses, from 50% to 80% are represented by atopic dermatitis, eczema, and psoriasis, which are characterized by a prolonged and often severe course with frequent relapses (Gorlanov I.A., 1996; Sokolsky E.V., 1999; Mordovtsev V.N., 1999; Monakhov K.N., 2000; Degtyar Yu.S., 2000; Kochergin N.G., 2001; Adasevich V.P., Mjadelec O.D., 2001; Fedenko E.S., 2001; Ballmer-Weber V.K., 1998; Leung D., 1999).

The onset and development of chronic dermatoses are largely determined by the peculiarities of living conditions and lifestyle of the individual (Shamov B.A., 1997; Gomburg M.A., Solovyov A.M., Akovbyan V.A., 1998; Bos J.O., Sillevis Smitt J.N., 1996). The determining role in the prevention of exacerbations and in the complex treatment of chronic dermatoses is possessed by the timeliness and adequacy of the provided medical care. However, to this day, many unresolved organizational problems remain regarding the qualitative pharmaceutical and medical-social provision of these patients. There is insufficient research on the prevalence of chronic dermatoses, especially among rural residents. The socio-hygienic peculiarities of the main types of activity and quality of life of patients with chronic dermatoses are not taken into account. There are virtually no studies with an analysis of risk factors for the onset and exacerbations of chronic dermatoses among the rural population, which constitutes 27.0% of the population of Russia. The modern concept of the development of health care and medical science provides for the necessity of improving the clinical-organizational forms of specialized dermatological care for the rural and urban population. The improvement of clinical-statistical methods for assessing the quality and effectiveness of therapeutic and preventive measures among patients with chronic dermatoses is an actual and practically necessary task.

The goal of the research is the clinical and statistical assessment of risk factors, the prevalence of chronic dermatoses, and the justification of their treatment system in rural and urban areas.

Research tasks: to determine the main medical-social risk factors for the onset and exacerbation of chronic dermatoses among the rural and urban population; to conduct a comparative clinical-statistical analysis of morbidity and prevalence of atopic dermatitis, eczema, and psoriasis among the rural and urban population; to assess the quality and effectiveness of treatment of chronic dermatoses among patients living in rural and urban areas at various stages of medical care; to conduct a medical-sociological study among patients with an assessment of the quality of inpatient medical care for patients with chronic dermatoses; to justify organizational forms of work of skin and venereal dispensaries for the optimization of the system of staged treatment and comprehensive prevention of exacerbations of chronic dermatoses among rural and urban residents.

The scientific novelty of the research lies in the fact that for the first time a comprehensive program of medical-social study of risk factors for the onset and exacerbation of chronic dermatoses among patients in rural and urban areas was developed. For the first time, a comparative clinical-statistical assessment of the prevalence of chronic skin diseases among the rural and urban population was presented. The morbidity of atopic dermatitis, eczema, and psoriasis among the population of rural and urban areas was studied over a 10-year dynamic. For the first time, a relationship between the level of morbidity and exacerbations of chronic dermatoses and risk factors of the main types of activity of the patient and his or her family was identified. For the first time, a characteristic of the quality of life of patients with chronic dermatoses in conditions of a rural administrative territory was given. For the first time, a medical-sociological survey of patients was conducted with an assessment of the accessibility, timeliness, quality, and effectiveness of staged dermatological care. Peculiarities of the diagnosis and treatment of chronic dermatoses in inpatient conditions were identified. For the first time, a justification of clinical-organizational forms for the improvement of specialized staged dermatological care, comprehensive treatment, and prevention of exacerbations of chronic dermatoses among rural and urban residents was presented.

The scientific and practical significance of the work is determined by the results of the research, which have made it possible to use the identified medical-social patterns for the improvement of the organizational-clinical activity of regional and city skin and venereal dispensaries. The presented materials clarify and supplement information on the prevalence and morbidity of chronic dermatoses among rural and urban residents. The identified medical-social risk factors for the onset and exacerbation of chronic dermatoses allow skin and venereal dispensaries and central district hospitals to organize and purposefully conduct complex therapeutic and preventive measures among patients. The data of the medical-sociological analysis and subjective patient assessments can be used by medical workers for the optimization of treatment at the pre-hospital and inpatient stages. The practical significance is possessed by the data on the quality of life of patients with chronic dermatoses in the dynamics of treatment in conditions of residence in rural and urban areas.

The use of the proposed methods of multivariate analysis, calculation of risk zone boundaries, and prediction of the risk of exacerbation of chronic dermatoses allows dermatologists, general practitioners, and specialists of ambulatory-polyclinic institutions to optimize the system of accounting and dynamic observation of patients.

The materials of the dissertation research have been introduced into the practical activity of health care bodies and institutions (the Committee on Health Care of the Government of the Leningrad Region and the Committee on Health Care of the Administration of Saint Petersburg, the regional and city skin and venereal dispensaries, district dispensaries), presented in methodological recommendations and informational letters approved at the regional level (2000–2002), included in two textbooks of the Department of Public Health and Health Care, approved by the Accreditation Methodological Center of the Ministry of Health of the Russian Federation, and used in the training of students at the departments of dermatovenereology and public health and health care of Saint Petersburg State Medical Academy named after I.I. Mechnikov. The main provisions and conclusions of the research have been published in 25 scientific works, including, in central journals — 4, in a monograph, in textbooks — 2, in methodological documents — 3.

Validation of the Research Materials. The main results of the research were presented and discussed at:

• the Russian Scientific Conference of Staff and Students of Saint Petersburg State Medical Academy named after I.I. Mechnikov (Saint Petersburg, 1998, 2001, 2002);

• the III International Conference "Ecology and Development of the North-West of Russia" (Saint Petersburg, 1998);

• the Republican Scientific Conference of Young Scientists of Medical Universities of Russia (Samara, 1999);

• the International Conference "Regional Problems of Preventive Medicine" (Veliky Novgorod, 1999);

• the Scientific and Practical Conference dedicated to the 15th anniversary of the hospital of the Main Administration of Internal Affairs of Saint Petersburg and JIO "Actual Problems of Practical Medicine" (Saint Petersburg, 2000);

• the Regional Scientific and Practical Conference "Social Pediatrics — Problems, Searches, Solutions" at Saint Petersburg State Pediatric Medical Academy (Saint Petersburg, 2000);

• the Regional Scientific and Practical Conference "Environment and Health" at Saint Petersburg State Medical University named after academician I.P. Pavlov (Saint Petersburg, 2001);

• the VI International Conference "Ecology and Development of the North-West of Russia" (Saint Petersburg, 2001);

• the Regional Scientific and Practical Conference dedicated to the 300th anniversary of Saint Petersburg and the 100th anniversary of the brother of Peter the Great (Saint Petersburg, 2003).

Personal Contribution of the Author. The author developed the program and conducted the medical-social and clinical-statistical research. The collection of scientific information was carried out by extracting data from primary medical documentation of the regional, city, and district skin and venereal dispensaries. A medical-sociological survey of the rural and urban population and screening questionnaire survey was conducted (personal participation — 100.0%). A clinical-statistical analysis of the quality and effectiveness of treatment of patients with chronic dermatoses was carried out. The author carried out planning, compilation, and mathematical-statistical analysis of the research results with computer data processing (participation share more than 80.0%).

Main Propositions to Be Defended:

1. Medical-social and clinical-statistical characteristics of risk factors for the onset and exacerbations of chronic dermatoses. The prevalence of risk factors and chronic dermatoses among rural residents occurs more frequently and is largely determined by the living conditions of family members. Over a 10-year dynamic, an increase in morbidity indicators is noted. An integrated assessment of prognostically significant risk factors is presented.

2. Quality of life indicators of patients with chronic dermatoses. The dermatological quality of life index of rural residents is 1.8 times more negative by the DSQL scale than among urban patients.

3. Quality and effectiveness indicators of medical care for patients with chronic dermatoses in rural and urban health care institutions. The effectiveness of inpatient treatment is largely determined by the severity of the disease at admission, timeliness and regularity of physician visits, comprehensiveness and regularity of use of modern treatment and prevention methods, and its indicators are better among urban residents.

4. Proposals for the optimization of organizational forms, staged treatment, and comprehensive prevention of exacerbations of chronic dermatoses. The system and quality of staged treatment, post-hospital dynamic accounting and observation, and the improvement of quality of life of the afflicted (especially in rural administrative territories) require improvement.

Structure and Volume of the Dissertation. The dissertation consists of an introduction, a literature review, a research program, methodology, and organization of the research, 3 chapters, a conclusion, conclusions, practical recommendations, a list of references, appendices and documents confirming the introduction of the research results into practice. The dissertation is presented across 139 pages of typed text, illustrated by 33 tables and 11 figures. The bibliographic index contains 174 domestic and 108 foreign sources.