Optimization of Medical Care for Patients with Arterial Hypertension in the Republic of Sakha (Yakutia)

The dissertation is devoted to the problem of optimizing medical care for patients with arterial hypertension in the Republic of Sakha (Yakutia). The research is aimed at the scientific justification and development of pathways for improving the organization of therapeutic and preventive care for arterial hypertension, taking into account the natural-climatic, demographic, and socio-economic characteristics of the Far North region. The work examines trends in the incidence of arterial hypertension among the population of the Republic, analyzes the practice of organizing medical and preventive care, and the interaction of healthcare institutions within the framework of implementing the Republican Program "Prevention and Treatment of Arterial Hypertension in the Republic of Sakha (Yakutia) for 2001-2007." An organizational-functional model for the provision of primary, physician, and specialized care based on unified scientifically grounded protocols and the application of remote technologies and telemedicine is proposed.

In this work, for the first time on the territory of the Republic of Sakha (Yakutia), on the basis of a systemic approach, the main directions for the implementation of the program for the prevention and treatment of arterial hypertension were determined, with the active involvement of patients and the entire population under the patronage of medical personnel and centralized remote consultation. The practical significance lies in the creation of a Scientific-Methodological Cardiology Center within the structure of Yakutsk City Hospital No. 1, the development of methodological recommendations for physicians and mid-level medical personnel approved by the Ministry of Healthcare of the Republic of Sakha (Yakutia), and the organization of a structure for qualified consultative remote care using modern means of communication and telemedicine.

In previously conducted studies, considerable attention was devoted to the clinical and organizational aspects of improving medical care for diseases of the circulatory organs (Alekseeva V.P. et al., 1989; Argunova V.A., 1989; Makarov V.M., 1989; Buganova A.A., 1993, etc.). It was established that by the end of the twentieth century, the prevalence of circulatory system diseases in the Republic of Sakha (Yakutia) was 95 cases per 1,000 adult inhabitants, and mortality from circulatory system diseases increased by 14% compared with the previous decade. The principal problem in the development and formation of the medical and social consequences of cardiovascular pathology is arterial hypertension (Yagya N.S., 1980, 1984; Kardakov Yu.I. et al., 1983; Gapon L.I. et al., 1993; Khasnulin V.I., 1998, etc.). This situation is particularly relevant in the regions of the Far North (Babina Ya.A., 1997; Salamatina I.V., 1998, etc.). Thus, in the Republic of Sakha (Yakutia), the incidence of hypertension increased over the last decade by 20.9%, and the underdiagnosis of patients with the diagnosis "Arterial Hypertension" in the Republic reaches 83% (Ivanov K.I. et al., 1997).

The materials of the All-Russian Conference "Arterial Hypertension and Heart Failure" (2001) note that arterial hypertension is the greatest pandemic in the history of humankind, determining the structure of cardiovascular morbidity and mortality: a condition that begins as a functional disorder, following pathogenetic pathways, sequentially leads to specific organ damage, transforming from a risk factor into a disease (First Report of the Experts of the Scientific Society for the Study of Arterial Hypertension, the All-Russian Scientific Society of Cardiologists, and the Interdepartmental Council on Cardiovascular Diseases, DAG-1, 2002).

The Concept for Improving Healthcare in the Republic of Sakha (Yakutia) (approved by the Resolution of the Government of the Republic of Sakha (Yakutia) of 12.02.2000, No. 78) notes the necessity of developing a new strategy for public health protection that is adequate to established socio-economic conditions and of "maximizing the concentration of state efforts on preserving the health of healthy people, healthy offspring, and healthy society." Furthermore, the Concept notes the growing role of outpatient and polyclinic institutions and services, remote and brigade-based principles of serving the population, and emphasizes the importance of promoting a healthy lifestyle among the population, including through the development of self-preserving behavior.

The Republican Program "Prevention and Treatment of Arterial Hypertension in the Republic of Sakha (Yakutia) for 2001-2007" provides for the necessity of scientific research on the problems of improving the quality and optimizing the pathways of therapeutic and preventive care for arterial hypertension (AH). Until recently, no research on the aforementioned problems had been conducted in the Republic of Sakha (Yakutia), which served as the basis for the present dissertation research.

The research was carried out according to the plan of scientific research of the Department of Public Health and Healthcare with a Course in Economics of the Sechenov Moscow Medical Academy "Organizational-Economic and Social-Psychological Technologies in Public Health Protection and Healthcare Management" (State Registration No. 01.200.110512).

The goal of the research was the scientific justification and development of pathways for optimizing medical care for patients with arterial hypertension in the territory of the Republic of Sakha (Yakutia).

The tasks of the research were: to determine the main trends in the incidence of arterial hypertension among the population of the Republic of Sakha (Yakutia); to study the practice of organizing and providing medical and preventive care for patients with arterial hypertension, to generalize the experience of the functioning and interaction of healthcare institutions of the Republic in this area; to scientifically substantiate the principles of continuity and organizational interaction of healthcare departments and services of the Republic within the framework of implementing the targeted republican program "Prevention and Treatment of Arterial Hypertension"; to optimize the pathways of methodological and organizational-technical support for the implementation in the regions of the Republic of the targeted program "Prevention and Treatment of Arterial Hypertension" within the framework of an organizational-functional model based on the provision of qualified therapeutic, diagnostic, and consultative care using remote technologies; to develop methodological recommendations for physicians and mid-level medical personnel on the tactics of organizing therapeutic and preventive care for patients with arterial hypertension, taking into account the latest scientific achievements in the country and the recommendations of the WHO; to implement the results of the research in the practice of therapeutic and preventive healthcare institutions of the Republic of Sakha (Yakutia) using modern information-methodological materials, available means of communication, the Internet, electronic mail, and telemedicine.

Scientific novelty of the research

In this work, for the first time in the Republic of Sakha (Yakutia), on the basis of a systemic approach, the main directions of the organizational-structural and therapeutic-preventive implementation technology of the program for the prevention and treatment of arterial hypertension were determined through the active involvement of the patient and the entire population under the patronage of existing medical personnel on site and with the provision of accessible centralized qualified remote consultation;

the system for managing the process of monitoring the health status of the population and the complex of measures for the prevention and treatment of arterial hypertension was optimized;

the possibility of implementing the targeted republican program "Prevention and Treatment of Arterial Hypertension" within the allocated resources with minimal expenditure and with the assurance of the necessary volumes and quality of therapeutic and preventive care was scientifically substantiated;

the exclusive role and necessity of the allocation of a separate systemic functioning of the program for the treatment and prevention of arterial hypertension in the territory of the Republic of Sakha (Yakutia) in all uluses, up to and including the ethnic communities of indigenous small-numbered peoples, was demonstrated, making it possible to актуализировать the problem of the urgent provision of medical safety for the populations of the Far North regions and the implementation of logistical principles for its assurance.

Practical significance and implementation of research results

An organizational-methodological and technological framework was established and, for the first time across the entire territory of the Republic of Sakha (Yakutia), a rational model for the provision of pre-doctoral, primary medical, physician, and specialized care for patients with arterial hypertension based on unified scientifically grounded protocols for the management of patients with arterial hypertension, regardless of their location, in accordance with the recommendations of the WHO, the experts of the Scientific Society for the Study of Arterial Hypertension, the All-Russian Scientific Society of Cardiologists, and the Interdepartmental Council on Cardiovascular Diseases, with a coordinating role played by the specialized clinical center - the National Center of Medicine of the Republic.

On the basis of the present research, a Scientific-Methodological Cardiology Center was created within the structure of the basic therapeutic and preventive healthcare institution in this study (Yakutsk City Hospital No. 1) for the guidance and coordination of the execution of the Republican Program "Prevention and Treatment of Arterial Hypertension in the Republic of Sakha (Yakutia) for 2001-2007" to ensure and accelerate its implementation and the execution of relevant preventive, therapeutic-diagnostic, and rehabilitation measures by practical healthcare across the entire territory of the Republic of Sakha (Yakutia).

On the basis of the research materials, the following positions were prepared: on the outpatient preventive department for the treatment of arterial hypertension at Central Ulus Hospitals (CUH), and on the Scientific-Methodological Cardiology Center for the guidance and coordination of the execution of the program "Prevention and Treatment of Arterial Hypertension in the Republic of Sakha (Yakutia) for 2001-2007."

Methodological recommendations on the prevention, diagnosis, and treatment of arterial hypertension in the Republic of Sakha (Yakutia), 2003, were developed and published, and approved by the Ministry of Healthcare of the Republic of Sakha (Yakutia).

A structure for qualified consultative remote care has been created and is functioning, utilizing all available means of communication, the Internet, electronic mail, and telemedicine.

The results of the research are reflected in five publications and methodological recommendations and are used in teaching at the Departments of Public Health and Healthcare of the Sechenov Moscow Medical Academy and the Medical Institute of the Yakutsk State University. The main provisions to be defended are as follows:

1. The main directions for optimizing preventive and therapeutic work on arterial hypertension, taking into account the specifics of natural-climatic and demographic factors across the vast territory of the Republic of Sakha (Yakutia), through the active involvement of each patient and the entire population in the process of prevention and treatment, under the control, patronage, and consultation of healthcare authorities and institutions of all levels of governance of the Republic.

2. The possibility of ensuring the program for the treatment and prevention of arterial hypertension with minimal expenditure while maintaining the necessary volumes and quality of accessible primary and qualified therapeutic and preventive care through the implementation of vertical organizational-medical technologies with centralized coordination and quality control from a single scientific-methodological and treatment center.

3. The creation of a structure for qualified remote care for arterial hypertension using all information-methodological materials, available means of communication, the Internet, electronic mail, and telemedicine.

4. The organizational-methodological and technological support for the implementation across the entire territory of the Republic of Sakha (Yakutia) of an organizational-functional model for the provision of primary medical, general physician, and specialized care for patients with arterial hypertension based on unified scientifically grounded protocols for the management of patients with arterial hypertension, regardless of the patient's location, in accordance with the recommendations of the WHO, the experts of the Scientific Society for the Study of Arterial Hypertension, the All-Russian Scientific Society of Cardiologists, and the Interdepartmental Council on Cardiovascular Diseases, with a coordinating role played by a single specialized clinical center.

5. The creation, within the structure of the basic therapeutic and preventive healthcare institution in this study (Yakutsk City Hospital No. 1), of a Scientific-Methodological Cardiology Center to accelerate the introduction of modern scientific achievements in the prevention and treatment of arterial hypertension into practical healthcare, for the conduct of relevant preventive, therapeutic-diagnostic, and rehabilitation measures across the entire territory of the Republic of Sakha (Yakutia).

Verification of research results

The main provisions of the dissertation research were reported at:

- A scientific-practical conference on current issues of therapy for physicians of the primary level of the Republic of Sakha (Yakutia). - Yakutsk, May 30, 2000;

- A scientific-practical conference on "Current Issues of the Implementation of General Practitioner Family Practice." - Yakutsk, May 26, 2001;

- The Collegium of the Ministry of Healthcare of the Republic of Sakha (Yakutia) on "The State of the Therapeutic Service of the Republic and Measures for Its Improvement." - Yakutsk, November 27, 2001;

- A scientific-practical conference dedicated to the 200th anniversary of the Ministry of Health of Russia - Moscow, Polyclinic of the Ministry of Health, November 19, 2002;

- A scientific-practical conference dedicated to the 80th anniversary of the Department of Public Health and Healthcare with a Course in Economics - Sechenov Moscow Medical Academy, Moscow, December 9-10, 2002.

The research was verified at a joint meeting of the Department of Public Health and Healthcare with a Course in Economics of the Medical-Preventive Faculty, the Departments of Healthcare Management, Economics, and Sociology of Healthcare of the Faculty of Healthcare Management of the Sechenov Moscow Medical Academy.