Chronic disease management: policy design based on service design methods.

Area of Science:

• Public Health
• Health Services Research
• Health Informatics

Background:

• Chronic diseases like hypertension and diabetes present substantial health system and community burdens.
• Effective management strategies are crucial for mitigating the impact of these conditions.

Purpose of the Study:

• To inform implementation-oriented public health strategies for chronic disease management.
• To identify gaps and propose improvements in chronic disease care pathways using a mixed-methods approach.

Main Methods:

• A mixed-methods design integrating administrative data (93,146 hypertension, 32,050 diabetes patients), patient surveys (n=518), and qualitative data (10 interviews, 19 focus groups).
• Analysis included descriptive statistics for care cascades (diagnosis, enrollment, management, treatment, control) and reflexive thematic analysis of qualitative data.
• Findings were synthesized through a service-design lens.

Main Results:

• Significant drop-offs were observed in care cascades, particularly in enrollment and standardized management.
• Patient journey analysis revealed limited process visibility, low perceived value of follow-up, and fragmented information flow.
• Stakeholders identified inadequate coordination among service providers as a key issue.

Conclusions:

• A three-layer service-design framework (users, service processes, service provision) is proposed for redesigning chronic disease management.
• Integrating administrative data with user experience insights enables more actionable, user-centered policy design for chronic disease care.