Medical and Social Significance of Diseases of the Musculoskeletal System and Connective Tissue in Population Health and an Organizational Model for Preventive Arthrology

The dissertation examines the medical and social significance of diseases of the musculoskeletal system and connective tissue in population health and develops an organizational model for their comprehensive prevention. The study is based on an analysis of epidemiological indicators, morbidity with temporary and persistent disability (disability), mortality, departmental features, external factors, and the territorial distribution of musculoskeletal pathology, comparing data from the Saratov Region with indicators for regions of the Russian Federation. Particular attention is paid to the organization and management of preventive, medical and public health, and medical-social care, as well as to the information and methodological support for these processes.

RELEVANCE OF THE PROBLEM

At the beginning of the 21st century, diseases of the musculoskeletal system and connective tissue constitute an urgent medical and social problem not only of national but also of global significance (138, 273). Effective organization of preventive and medical-rehabilitative care for patients with musculoskeletal disorders, aimed at reducing society's direct and indirect losses through lower morbidity and disability, is an important task for healthcare and social security services.

Diseases of the musculoskeletal system and connective tissue occupy one of the leading positions in the structure of primary and overall morbidity among the population worldwide (WHO, 1993). Musculoskeletal diseases, which include more than 100 diseases and syndromes, are the most common cause of prolonged pain and disability, affecting hundreds of millions of people worldwide (WHO, 2000).

Diseases of the musculoskeletal system and connective tissue give rise to complex multifactorial problems at the intersection of rheumatology, orthopedics, and neurology, as well as pediatrics, adolescent medicine, geriatrics, and family medicine. In global medicine and healthcare, diverse joint pathology, periarthritic tissue pathology, spinal pathology, systemic connective-tissue lesions, and rheumatic fever (rheumatism) are collectively termed “rheumatic diseases.” During the past several decades, Russia has undergone significant changes in the structure of rheumatic diseases, with the profile of rheumatologic morbidity shifting toward the predominance of joint diseases (11, 12, 207). Thanks to advances in benzylpenicillin-based prophylaxis and treatment, rheumatism has receded into the background. Thus, in Russia in 1990, rheumatism accounted for 6.5% of all registered patients, whereas in 2001 it accounted for only 2.4% (122, 202). Diseases of the musculoskeletal system constitute the overwhelming majority of rheumatology patients (97.6%); their number was 33 times greater than that of patients with all forms of rheumatism. Today, rheumatology is concerned primarily with diseases of the musculoskeletal system and connective tissue and, above all, arthrology.

Diseases of the musculoskeletal system and connective tissue are represented most fully in Class XIII of the International Classification of Diseases, Tenth Revision (ICD-10; WHO, Geneva, 1995).

Over the past decade, both in the Russian Federation and worldwide, a pronounced trend has been observed toward an increasing number of diseases of the musculoskeletal system and connective tissue; moreover, the growth rate of morbidity from these diseases substantially exceeds the growth rate of overall morbidity (all registered classes of diseases) (118, 121). Morbidity from these diseases among children and adolescents has increased sharply, causing considerable concern (31, 97).

At the same time, in Russia's prevailing socioeconomic conditions, the medical and social significance of these diseases is clearly underestimated: insufficient attention is paid to their prevention, the improvement of early diagnosis, restorative treatment, and rehabilitation, and the widespread growth of this pathology cannot be curbed.

At the current stage of healthcare development, scientifically grounded forms and methods for detecting and eliminating socio-hygienic, medical-biological, and other factors that adversely affect the occurrence of musculoskeletal-system and connective-tissue pathology have not been sufficiently developed. The scarcity of typological studies of these diseases in Russia, the inadequate use of information systems, or their low effectiveness hinder monitoring of the medical situation related to musculoskeletal pathology and the management of healthcare.

It is known that primary-level healthcare is the instrument through which population health can be influenced most effectively and at an early stage. However, the organization of work in outpatient and polyclinic medical and preventive institutions shows clearly insufficiently active use of preventive technologies. Accordingly, the development of comprehensive multifactorial primary-prevention programs for musculoskeletal pathology—especially among children and adolescents—should be regarded as a priority in the development of rheumatology and orthopedics, while determining the role and place of these diseases in population health and their objective medical and social assessment are necessary conditions for planning and financing medical care for patients with this pathology.

In the context of limited healthcare resources in Russia, preventive and medical-rehabilitative measures for patients with these diseases must be developed and improved on the basis of the rational use of available resources; this is impossible without an epidemiological study and an economic analysis of medical and social losses.

All of the above gives particular significance to expanding information support for these diseases in order to better guide efforts to improve the organization and management system of medical-social care for patients with bone and joint diseases. It defines the urgent need to concentrate work on priority areas of prevention, provides a basis for seeking new organizational forms of preventive arthrology and approaches to rehabilitation, and makes systemic analysis of these diseases methodologically important, including a mandatory macroeconomic study of social losses, correlational factor analysis of the causes of their persistent increase, and medical-geographical mapping based on GIS technology.

The aim of the study was to develop, scientifically substantiate, and implement a comprehensive system for organizing medical and public health care and medical-social care and a model for preventing diseases of the musculoskeletal system and connective tissue.

In accordance with the aim of the study, the following tasks were formulated:

1. To study the epidemiological aspects of these diseases and the features of their structure.

2. To compare the main indicators in the official statistics for these diseases in the Russian Federation and the Saratov Region, taking external exposure factors into account.

3. On the basis of an assessment of the epidemiological aspects, medical and social burden, and economic burden of these diseases, to substantiate their significance for population health under contemporary conditions.

4. To analyze the current state of medical care for patients with these diseases at the stages of medical and public health care.

5. To substantiate contemporary requirements for organizing and managing medical-social care measures for patients with these diseases.

6. To scientifically substantiate and develop an organizational model for comprehensive prevention of these diseases.

The scientific novelty of the study lies in the fact that, for the first time:

- a detailed epidemiological characterization of these diseases has been provided for a large agroindustrial region of the Volga region (using the Saratov Region as an example);

- medical-geographical mapping and ranking of the region's territory by the severity of musculoskeletal pathology have been carried out;

- factor analysis of external determinant relationships determining the parameters of morbidity from these diseases has been conducted, yielding scientifically grounded approaches to improving the organization of medical care for patients with musculoskeletal-system and connective-tissue disorders and to forecasting the situation with these diseases in light of regional characteristics;

- the dynamics of disability associated with these diseases has been studied at the regional level, and a forecast of disability for the Russian Federation has been calculated;

- the current state of medical-social care for patients with these diseases has been critically analyzed, and instructional-methodological requirements for organizing and managing such care for patients with musculoskeletal-system and connective-tissue pathology have been substantiated and developed;

- an organizational model for comprehensive prevention of diseases of the musculoskeletal system and connective tissue has been developed.

PRACTICAL SIGNIFICANCE

The study materials make it possible to:

- use epidemiological data to organize and plan medical care for patients with these diseases, taking into account the characteristics of the evolution of the pathology in the Saratov Region in comparison with other regions of the Russian Federation;

- visualize the territorial distribution of musculoskeletal pathology on the basis of prepared medical-geographical cartograms and identify high-risk zones requiring priority measures to prevent musculoskeletal pathology;

- introduce contemporary informational, organizational, and managerial technologies for providing medical-social care to patients with these diseases into regional healthcare practice;

- introduce recommendations into healthcare practice for actively detecting musculoskeletal-joint disorders at early stages of the process among populations of different sex and age groups at high risk of these diseases and for developing appropriate preventive and rehabilitative health-improvement programs.

The main findings of the dissertation were incorporated into eight educational and methodological manuals on preventive and rehabilitative medicine; the management of patients with joint and spinal diseases in outpatient clinics; the assessment of temporary and permanent disability; and adolescent-age pathology and its correction. All of these manuals were approved by the All-Russian Educational-Scientific-Methodological Center for Continuous Medical and Pharmaceutical Education of the Russian Ministry of Health. They are intended for senior students and attendees of the postgraduate education faculty and have been implemented in the teaching process at the Department of Outpatient Therapy of Saratov State Medical University and at several other medical universities.

Some findings of the study were incorporated into the “Family Doctor's Handbook” (M.; EKSMODOOZ) and the “District Therapist's Handbook” (M., EKSMODOOZ). Methodological recommendations entitled “Medical and Social Aspects of Diseases of the Musculoskeletal System and Connective Tissue in the Saratov Region” (2003), intended for healthcare organizers, rheumatologists, therapists, and specialists in medical-social expert examination, were published.

The study made it possible to develop a number of proposals for the basic and postgraduate training program for physicians dealing with arthrology and rehabilitation of patients with musculoskeletal-joint pathology, concerning the determination of the level of knowledge, skills, and necessary competencies.

The dissertation materials were presented at the All-Russian Congress of Rheumatologists (May 2003, Saratov); the meeting of the Saratov Regional Scientific Society of Therapists (February 2004); the Scientific and Practical Conference “Social Aspects of Rheumatic Diseases” (Moscow–Zvenigorod, May 2004); conferences of the Volga Branch of the Central Research Institute for the Organization and Informatization of Healthcare (2002–2004); and the 8th International School “Innovative Management Technologies in the Sphere of Ecology and Health, Educational and Health-Improvement Programs” (Moscow, 2004).

The main provisions put forward for defense:

1. The medical and social significance of diseases of the musculoskeletal system and connective tissue under contemporary conditions.

2. Typological, sex-and-age-related, and occupational features of these diseases.

3. A scale of the most socially significant forms of these diseases.

4. Results of the forecast for growth in disability resulting from these diseases in Russia.

5. The principal elements of an information and methodological complex for ensuring the organization and management of medical-social care measures for patients with these diseases.

6. The development, scientific substantiation, and implementation of an organizational model for comprehensive prevention of these diseases.