Burden of treatment as a measure of healthcare quality: An innovative approach to addressing global inequities in multimorbidity

Global evidence shows that system quality failures are responsible for more deaths than those caused by HIV, tuberculosis, and malaria combined [1]. In low- and middle-income countries (LMICs), the effects of poor quality care are particularly profound. Nearly 60% of the 8 million preventable deaths that occur yearly in LMICs are due to quality deficits [2]. These span many sectors of healthcare, including primary care, where deficiencies in disease prevention, care coordination, and continuity of care result in inadequate management of both communicable and non-communicable diseases (NCDs) [2]. As the burden of NCDs rises, the push for quality is imperative [3]. The presence of multimorbidity, defined as the occurrence of two or more chronic conditions including those of infectious etiology, compounds this need. In this commentary, we argue that novel methods to evaluate the quality of primary healthcare, such as burden of treatment, must be developed and tailored for use in order for LMICs to achieve equitable outcomes in patients with multimorbidity.

Ideal tools to measure healthcare quality respond to patient expectations in ways that are meaningful to them while also improving their health. The use of patient-reported outcome measures (PROMs) is one way to do this. PROMs reflect patients’ experiences of care and can serve as footprints of patient-centered healthcare reforms. In high-income countries (HICs), their use has been shown to improve quality of care in a patient-centered fashion, and they are even included in some national registries [4, 5].

Despite their successful application in HICs, few PROMS have been effectively used in LMICs, preventing systematic improvement in primary healthcare delivery and perpetuating poor-quality management of chronic conditions. This pattern has led to increased strain on already resource-limited healthcare systems. The presence of both infectious and non-infectious chronic diseases only increases demands by further augmenting the need for long-term, integrated care amongst various specialties and necessitating prevention efforts addressing shared risk factors [6]. Moreover, because LMIC primary healthcare systems evolved to provide short-term, curative programs to treat acute illnesses, they do not contain the infrastructure or organization necessary to provide the multidisciplinary, integrated, and longitudinal care that is required for chronic disease management [3].

Unique epidemiological patterns in the development and distribution of NCDs has created only further challenges for LMIC healthcare systems [7]. This has resulted in NCD onset and mortality at a younger age than in HICs, meaning that healthcare systems must expend more resources over a longer period of time managing the complications of chronic conditions. NCDs also tend to cluster in those with lower socioeconomic status and less education, groups whose capacity to manage extra expenses incurred by chronic diseases is limited [8, 9]. When quality of care is poor, they must deal with the prolonged consequences of their uncontrolled chronic conditions, such as less time spent working or prohibitively high medication costs. This compounds financial losses, driving them, their households, and their communities deeper into poverty and augmenting strain on the healthcare system.