Medical-Social Aspects of Preserving Work Capacity in Patients with Arterial Hypertension

The dissertation is devoted to the medical-social aspects of preserving work capacity in working-age individuals with prolonged arterial hypertension. The research is conducted within the framework of the Federal Target Program "Prevention and Treatment of Arterial Hypertension in the Russian Federation" and is directed toward one of the most prevalent classes of diseases of the cardiovascular system – arterial hypertension, the prevalence of which is acquiring an epidemic character and substantially affecting the healthcare economy and the demographic situation in the country. The author sets the goal of scientifically substantiating recommendations for the improvement of the organization of medical care with the aim of long-term preservation of active work capacity and prevention of unfavorable outcomes of the disease.

The work comprehensively examines three key directions: the influence of the organization of medical care (timeliness of detection, adequacy of treatment, and rational employment) on the outcomes of arterial hypertension; the role of temporary disability as a factor of social protection and its impact on the course and outcome of the disease; and the interaction of physician and patient, including compliance, adherence to pharmacotherapy, and self-monitoring. The dissertation contains a comparative analysis of living conditions, satisfaction, and medical activity of patients with favorable and unfavorable outcomes of arterial hypertension, as well as practical recommendations for the improvement of the quality of medical care.

Relevance of the Problem

In the second half of the twentieth century and at the beginning of the twenty-first century, diseases of the cardiovascular system (DCS) represent one of the most important problems of scientific medicine and practical healthcare of all economically developed countries. The socio-hygienic significance of these diseases is determined by the progressive growth of prevalence, severity of course, and outcomes (R.G. Oganyan et al., 1996; E.A. Tishuk, 2001; O.P. Shchepin, 2001; Yu.P. Lisitsyn, 2002; A.I. Osadchikh, 2002; Yu.N. Belenkov, 2003).

Over the last 25 years, DCS in the structure of morbidity of the population of Russia and economically developed foreign countries have moved from 10th–11th place to 2nd place, accounting for 14–15%. The prevalence of DCS among the adult population of Russia increased from 121.7% in 1991 to 193.0% in 2002. Primary morbidity of DCS grew from 17.2% in 1997 to 22.3% in 2002 (V.A. Medik, 2001; E.A. Tishuk, 2001; Yu.P. Lisitsyn, 2002; data from the State Report for 2002).

The tense epidemiological situation is primarily associated with the growth of diseases characterized by elevated blood pressure, the prevalence of which is acquiring the character of an epidemic. The prevalence of arterial hypertension (AH) among the population aged 15 years and older is approximately 40% (Order of the Ministry of Health of the Russian Federation dated 24.01.03 No. 4). In the structure of first-identified morbidity among the adult population, the share of hypertensive disease (HD) increased from 12% in 1997 to 21.8% in 2002.

The prevalence of diseases of the cardiovascular system based on in-depth studies is 5–6 times higher than the indicators of official statistics. Attention is drawn to the significant rejuvenation of this pathology (I.V. Fomin, 2000; V.A. Medik, 2001).

The economic damage inflicted by DCS is caused by expenditures in the healthcare system, Social Insurance Funds, and losses of life potential due to temporary disability (TD), disability, and premature death of patients. According to World Bank calculations, one person-year of labor activity in Russia in 1998 alone generated gross product worth 5 thousand US dollars. The economic damage in Russia from AH, ischemic heart disease (IHD), and cerebrovascular diseases (CVD) alone amounts to approximately 30 billion rubles annually (V.A. Medik, 2001; A.I. Osadchikh, 2002).

In other countries, labor losses from DCS are also significant. In the United States, approximately 176 million working days are lost annually due to this class of diseases, causing economic losses of 30 billion dollars, including funds spent on medical care (L.E. Hopkins, 1989).

This pathology occupies a prominent place in hospitalized morbidity, requiring the most intensive methods of therapy, prolonged hospital stays. In Russia, according to statistics, in 2002 the average duration of stay of patients with DCS in hospital was 16.0 days. In the structure of morbidity with temporary disability, DCS account for 9.0% of cases and 11.1% of days (2002 data). In the last decade, attention has been drawn to the growth of the average duration of a single case of TD for this pathology. According to statistics, its duration in Russia was: in 1990 – 16.0 days; in 2001 – 17.2 days; in 2002 – 17.4 days.

In the last decade, disability in Russia has become an important medico-social problem indicating a critical level of public health. The number of disabled persons aged 16 and older registered with social protection agencies reached in 1999 716.9 per 10,000 population of the corresponding age. By 2000, more than 10 million disabled persons were registered, with a high proportion of persons with severe disability. According to domestic authors, DCS account for 43.3% to 55% of disability cases. Primary disability among working-age individuals continues to grow from 65.2 to 65.3 per 10,000 population of the corresponding age from 1999 to 2002 (I.A. Kamaev, 1999; V.A. Medik, 2001; E.A. Tishuk, 2001; A.I. Osadchikh, 2002; K.A. Sarkisov, 2002; S.N. Luzin, 2003; D.I. Lavrova, 2004).

According to official statistics, indicators of primary disability among the entire population of Russia per 10,000 population were: in 1998 – 76.5; in 2002 – 82.6 persons. Including due to DCS: in 1998 – 35.8 persons (46.8% of the overall structure); in 2002 – 40.0 persons (48.4% of the overall structure). Working-age individuals constitute up to 50% among those first recognized as disabled.

Since the 1990s and to the present day, Russia has had a complex demographic situation characterized by population depopulation. One of the causes of this situation is high population mortality (V.I. Krichagin, 1998; E.A. Tishuk, 2001; O.P. Shchepin, 2001; Yu.P. Lisitsyn, 2002). According to statistics, its indicators in 2002 were 1627.9 per 10,000 population and were the highest in Europe. Over 5 years, the mortality rate in Russia increased by 20%. This dynamics is determined by the growth of mortality among the working-age population. Compared to 1998, in 2002 the latter indicators increased by 28% and constituted 29% of the total number of deceased.

Diseases of the cardiovascular system occupy first place in the structure of causes of mortality of the Russian population, accounting for 55–56%. Over the period from 1990 to 2002, according to statistics, its indicators per 100,000 persons increased from 618.9 persons in 1990 to 913.0 in 2002. The mortality rate of the working-age population of Russia from DCS is 4.5 times higher than comparable indicators in the European Union, Japan, Canada, and the USA (D.M. Aronov, 1997; A.I. Osadchikh, 2002; D.I. Lavrova et al., 2004). According to official statistics, in recent years DCS in the structure of causes of mortality of working-age individuals yield only to accidents, injuries, and poisonings. Along with this class of causes of death, DCS currently determine the reduction of the overall life expectancy of the population of Russia. The average age of death among working-age men is 50 years. In 2001, the greatest growth in mortality from DCS was registered in the age group from 20 to 29 years. According to expert forecasts, mortality from DCS will continue to increase (R.G. Oganyan et al., 1996; E.A. Tishuk, 2001; O.P. Shchepin, 2001; D.D. Venediktov, 2002; Yu.P. Lisitsyn, 2002; A.I. Osadchikh, 2002; Yu.N. Belenkov, 2003).

The main causes forming a high level of disability and mortality from DCS are HD, IHD, and CVD.

The medico-social significance of the problems of DCS and arterial hypertension has placed their resolution among the main state tasks of all developed countries of the world. In accordance with the WHO Global Strategy for Health for All in the Twenty-First Century, the resolution of the WHO European Regional Office of September 1998, the Decree of the Government of the Russian Federation dated 17.07.2001 No. 540 "On the Federal Target Program 'Prevention and Treatment of Arterial Hypertension in the Russian Federation'", the conduct of scientific research on the study of methods of prevention, diagnosis, treatment, and rehabilitation of patients with AH with the development of methodological and informational materials, are priority scientific directions in current conditions (D.D. Venediktov, 2002).

Risk factors for the development of DCS are well studied (B.C. Volkov, 1989; A.L. Syrkina, 1991; R.G. Oganyan et al., 1996; E.I. Chazov, 1997; D.M. Aronov, 2000; G. Schlirf, 1980; W.B. Kannel, 1984; N.M. Kaplan, 1989; M. Caulfield, 1994; T.G. Allison, 1995; D. Cusi, 1997). The literature contains numerous epidemiological studies devoted to the study of the prevalence of this class of diseases as a whole and individual nosological forms entering its composition, their share in the structure of morbidity with temporary disability, disability, and mortality in various regions of Russia (S.G. Rozin, 1996; E.E. Gogin, 1997; G.S. Zhukovsky, 1997; V.V. Gafarov, 2000; A.A. Mozyer, 2003; I.A. Trubacheva, 2003; F.T. Ageev, 2004; V.K. Sitina, 2005; I.N. Stupakov, 2005). Studies devoted to the study of primary disability due to DCS of various categories of the Russian population can be found. Most often these are socio-hygienic studies of the contingent of disabled persons due to IHD (A.S. Isaeva, 1994; E.M. Kunavsky, 1995; Yu.A. Balashova, 1998; M.P. Bankovskaya, 1998).

Despite the great medico-social and scientific-practical significance of the problem, the questions of prevention of unfavorable outcomes of DCS, primarily AH, remain insufficiently studied. In the existing isolated works devoted to this question, the obtained data are often contradictory. The organizational and interpersonal relationships of physician and patient influencing the behavior of the patient are insufficiently studied.

As shown by the analysis of modern literature, the most relevant are the medico-social analyses of the following problems:

• the influence of the quality of medical care on the outcome of the most prevalent pathology from DCS – arterial hypertension;

• the study of patient behavior as a factor influencing the outcome of arterial hypertension (achieving compliance between physician and patient, patient adherence to preventive and therapeutic measures);

• the investigation of temporary disability as a factor of social protection in the event of deterioration of the patient's condition, influencing the course of the disease and its outcomes.

All of the above determined the goal and objectives of the present research, which was conducted in accordance with the plan of NIR of the State Educational Institution of Higher Professional Education "Ryazan State Medical University named after Academician I.P. Pavlov" of the Federal Agency for Healthcare and Social Development (state registration number 012.002.02.320) within the framework of the Federal Target Program "Prevention and Treatment of Arterial Hypertension in the Russian Federation" approved by the Decree of the Government of the Russian Federation dated July 17, 2001 No. 540.

Goal of the research: on the basis of a comprehensive socio-hygienic study, to scientifically substantiate recommendations for the improvement of the organization of medical care for working-age individuals suffering from arterial hypertension, with the aim of long-term preservation of active work capacity and prevention of unfavorable outcomes of the disease.

Objectives of the research:

• Identify priority socio-hygienic factors influencing the preservation of work capacity in individuals with prolonged arterial hypertension;

• Study organizational factors of medical care influencing the preservation of work capacity in patients with arterial hypertension;

• Conduct a comparative analysis of temporary disability in patients with favorable and unfavorable outcomes of arterial hypertension;

• Conduct a comparative analysis of the interaction of physician and patient with favorable and unfavorable outcomes of arterial hypertension;

• Develop recommendations for the improvement of the quality of medical care for patients with arterial hypertension with the aim of increasing the period of active work capacity.

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

• the dependence of outcomes of arterial hypertension in working-age individuals on factors of organization of medical care was studied;

• temporary disability at early stages of the disease was investigated as a factor of a favorable outcome in arterial hypertension in working-age individuals;

• the role of patient-physician cooperation as a factor of preserving work capacity in arterial hypertension was studied.

Unlike previous works, the course and outcome of arterial hypertension in patients of working age with long-term retrospective observation were studied. For the first time, temporary disability of patients with arterial hypertension over a long period of observation was investigated.

Scientific and practical significance of the work.

The results of the research allowed:

• to identify factors of lifestyle influencing the course and outcome of arterial hypertension in working-age individuals;

• to identify factors of organization of medical care influencing the course and outcome of arterial hypertension in working-age individuals;

• to identify the role of temporary disability at early stages of the disease as a factor influencing the course and outcome of arterial hypertension in working-age individuals;

• to identify features of patient behavior with arterial hypertension influencing the course and outcome of the disease in working-age individuals;

• to develop recommendations for the improvement of the quality of medical care for working-age individuals suffering from arterial hypertension, for the prevention of unfavorable outcomes of the disease and the extension of the period of labor activity.

Main provisions to be defended:

1. The influence of the organization of medical care at early stages of the disease on the outcomes of arterial hypertension in working-age individuals.

2. Temporary disability at early stages of the disease as a factor of a favorable outcome in individuals with arterial hypertension.

3. Physician-patient cooperation as a factor of preserving active work capacity in patients with arterial hypertension.

Implementation of the results of the research in practice:

The materials of the research were used:

1. In the organizational and methodological work of the Medical Service of the Gorky Railway OJSC "RZD" (implementation act dated 17.05.05);

2. In the activities of the Administration of Murom District (implementation act dated 26.05.05);

3. In the activities of the Healthcare Institution "Branch Hospital at the Murom Station of the Gorky Railway OJSC "RZD" (implementation act dated 14.04.05);

4. In the activities of the Healthcare Institution "Branch Hospital at the Vladimir Station of the Gorky Railway OJSC "RZD" (implementation act dated 26.04.05);

5. In the activities of the Healthcare Institution "Branch Hospital at the Kirov Station of the Gorky Railway OJSC "RZD" (implementation act dated 11.08.05).

The materials are used in the educational process at the departments of the Ryazan State Medical University named after Academician I.P. Pavlov.

Presentation of the work. The main provisions and results of the work were discussed at:

– the sixth Republican scientific-practical conference with international participation, dedicated to the 80th anniversary of the State Sanitary-Epidemiological Service of the Russian Federation and the 40th anniversary of the Medical-Preventive Faculty of the Ryazan State Medical University named after Academician I.P. Pavlov "Socio-Hygienic Monitoring of Population Health" (Ryazan, 2002);

– the fourth International scientific-practical conference "Health and Education in the XXI Century" (Moscow, 2003);

– the conference dedicated to the 50th anniversary of the Department of Therapy MALS, "Actual Questions of Therapy in Medical-Preventive Organizations of the Healthcare System of the Russian Federation: Approaches to Reducing Morbidity and Mortality from Cardiovascular Diseases" (Moscow, 2004);

– the eighth Republican scientific-practical conference with international participation "Socio-Hygienic Monitoring of Population Health" (Ryazan, 2004);

– the ninth Republican scientific-practical conference with international participation "Socio-Hygienic Monitoring of Population Health" (Ryazan, 2005).

Nine scientific works have been published on the topic of the dissertation.

Volume and structure of the dissertation. The main content of the work is presented on 150 pages of typed text. The dissertation is illustrated with 12 tables and 44 figures. The work consists of an introduction, five chapters, a conclusion, conclusions, practical recommendations, a list of references consisting of 151 domestic and 40 foreign authors.