Chronic disease management: a systems model relating outcomes, reporting, monitoring, interventions and satisfaction

摘要

In health care systems, chronic disease state outcomes are typically reported as one-time observations ('snap-shots'). A novel mathematical and systems model was developed to link such reported outcomes to desired normal values. The model describes a dependency of outcomes on the characteristics of the provider, the patient and on the relative frequency of such snap-shots, thus confirming conventional methods in the traditional, chronic disease, management paradigm. Additionally, an important prediction is afforded by the model whereby, under certain conditions, outcomes can approach normal while being largely independent of the particular characteristics of either patient or provider. Exploitation of this unexpected prediction in risk assessment and managed care should be considered by heath authorities.