Medical Rationale: Active in chronic disease

One of the most important challenges to employee health is chronic diseases. Successful treatment of these diseases allows sick people to remain in the labor market.

Dr. Piotr Winciunas, chief physician of the Social Security Administration, reported that the average age of retirement is increasing, just 20 years ago it was 57, last year it was 60, indicating more effective treatment of diseases. - 20 years ago, the first cause of pensions was cardiovascular and heart diseases, while last year it was musculoskeletal diseases, he added.

Mateusz Oczkowski, deputy director of the Department of Drug Policy and Pharmacy at the Ministry of Health, noted that chronic diseases are a challenge for healthcare systems across Europe due to the large patient population, increasingly expensive therapies and the long time it takes to finance treatment. Poland leads the way when it comes to entering into risk-sharing instruments where the price is hidden. - Therapies are coming in late, but I hope the amendment to the reimbursement law can change this. Year-on-year, we are speeding up reimbursement processes. Compared to 2023, we have reduced the time for reimbursement decisions by 120 days, and companies have delayed the time for submitting reimbursement applications by 100 days. 96% of innovative therapies have met with a positive decision from the Minister of Health," he calculated.

The role of adherence in optimal management of chronic diseases

Half of those suffering from chronic diseases - hypertension, hypercholesterolemia, diabetes - do not treat themselves or do so incorrectly. Non-compliance with therapeutic recommendations is a silent crisis of European health systems, which should become one of the systemic priorities for public health in Poland and the EU.

Therefore, it is necessary to implement comprehensive and systemic solutions in the area of education in the training programs of medical, pharmaceutical and nursing students, as well as public education from the school level.

- An important thing for adherence would be for one of the subjects of medical and nursing studies to be the subject of communication with the patient," pointed out Dr. Michal Sutkowski, president-elect of the College of Family Physicians in Poland.

Prof. Artur Mamcarz, head of the Department of Internal Medicine and Cardiology at WUM, noted the importance of building a doctor-patient or therapeutic team relationship. - The language of conversation must be the language of benefit. The patient needs to know that LDL cholesterol levels, blood pressure levels, glycated hemoglobin levels or a certain BMI level are tools so that he or she can achieve the main goal of improving his or her quality of life, which will also determine and define the ability to keep or return to work, he pointed out.

Adherence to medical recommendations can also be improved by using e-health tools to monitor adherence and by strengthening the role of pharmacists as local health advisors. - There should be such a medical alert in operation, which would remind the patient by text message about taking a medication, recommended examinations, unfulfilled prescriptions, Dr. Michal Sutkowski recommended.

It is also important to simplify therapy by reimbursing combination formulations and longer-acting drugs, and to introduce systemic adherence indicators for monitoring healthcare quality and contracting services.

It is estimated that the annual cost of non-adherence to the Polish health care system is PLN 6 billion. Currently, the health care system is missing tens of billions of zlotys. Experts agree that the implementation of systemic solutions to improve adherence to therapeutic recommendations in the short and long term will generate savings. These funds will be able to be allocated to pressing health care needs.

Vocational and social activity of people with metabolic diseases

Prof. Margaret Mysliwiec, head of the Department of Pediatrics, Diabetology and Endocrinology at WUM, stressed that over the past few years there has been a breakthrough in the monitoring and treatment of diabetes, which will translate into the level of activity of patients.

- Therefore, we must strive to ensure that diabetics are very well treated. It is important to have correct diagnosis - including antibody and genetic testing to select the right therapy. It is also important to have access to modern medications and to involve patients in their own treatment, through glycemic monitoring systems. These should be available to anyone receiving insulin," she stressed.

She added that the glycemic monitoring system has an educational effect and the patient can engage in the therapeutic process, achieving very good glycemic levels. - As a result, there are fewer acute complications - ketoacidosis, hypoglycemia, which also results in a decrease in hospitalizations for cardiovascular sequelae. By monitoring diabetes well, we normalize blood pressure, body weight, prevent late complications that shorten life. And the patient's work and family activities are not affected," she mentioned.

She stressed that it is also important for these systems to be combined with insulin pumps. AOTMiT is evaluating reimbursement for insulin pumps over 26.

- A pump and a glycemic monitoring system can normalize blood sugar levels without much patient participation. And the cost of treating complications is more than 3 billion zlotys," she pointed out.

According to Prof. Leszek Czupryniak, head of the Department of Internal Medicine and Diabetology at WUM, every patient treated with insulin should have access to this equipment. - The most drastic thing we would like to eliminate is the loss of reimbursement for patients using the pumps up to the age of 26, who are very well balanced in terms of glycemia," he said.

- The pump is not just a device that administers insulin subcutaneously, but works closely with glycemic monitoring systems. There is evidence that pumps improve diabetes compensation, quality of life at any age, he pointed out.

More than 9 million people in Poland already suffer from obesity. The disease and its complications can significantly shorten the lives of Poles. According to OECD estimates, by an average of 3 years and 10 months. Overweight and obesity have and will continue to have not only serious health consequences, but also socio-economic ones.

- Meanwhile, we have a colossal breakthrough in the possibilities of pharmacological treatment of obesity," pointed out Prof. Leszek Czupryniak.

Until now, bariatric surgery was the only effective treatment. Prior to the introduction of the KOS-BAR program, 2,000 people in Poland were operated on annually for this reason, then the number rose to 10,000.

- But we have 9 million obese patients. Recommendations in diabetology and metabolic medicine say to use pharmacotherapy before surgery," said Prof. Leszek Czupryniak.

He added that the drugs not only treat obesity, but also slow the progression of dementia and memory loss in the early stages of the disease, and will soon likely be drugs for addiction, including alcoholism. - The comment from people not at all familiar with the subject is that "all you have to do is tell fat people not to eat." This is not the case. Obesity is a severe, chronic disease with relapses, more difficult to treat than diabetes, he stressed.

He added that the results achieved by pharmacotherapy in most patients are sensational. - This is a loss of up to 20% of body weight, reduction or even withdrawal of insulin in diabetes, hypotensive drugs used in hyperlipidemia, postponement of vascular complications. Semaglutide reduces the risk of heart attacks and strokes by 20% over four years. So how can obese patients be denied such treatment? - he asked. He added that the health ministry and the National Health Service should start preparing a plan on how to make these drugs widely available.

Biological treatment in spondyloarthropathies

Prof. Brigid Kwiatkowska, national consultant in rheumatology, spoke about axial spondyloarthropathy affecting young people, sometimes just beginning their professional path, which translates into a significant limitation of their professional and social activity. She pointed out that the disease has an insidious onset in the form of mild back pain, and the patient usually ends up in rehabilitation either with a family doctor, who refers them to an orthopedist, or a neurologist, and wastes valuable time to get the treatment on the right level. - Meanwhile, with current treatment options, we can treat patients very effectively. We have access to treatment with all drugs that are registered for the treatment of spondyloarthropathies. It's a little worse in children, but after the change in the reimbursement law, as a consultant I will indicate which drugs, however, should be reimbursed for children," she pointed out.

Treatment with less effective therapies initially excludes patients from activity for a long time. European guidelines recommend the use of innovative therapies already in the first line of treatment. According to available data, about 30-50% of patients with rheumatic diseases lose their ability to work within 10 years of diagnosis - active biological treatment significantly delays this process.

Prof. Brigid Kwiatkowska added that a good solution is for the patient not to be tied to a center and receive the medicine there. The solution is to move some medications from the hospital to outpatient specialized care. - These are steps that make life easier for patients, so that chronic disease limits them as little as possible, so that fertility increases, because our patients want to have children. We work with gynecologists, we treat with drugs that allow them to get pregnant. So I think it's worth fighting for this group of young people, whom we have less and less of, and investing in making them economically active," she appealed.

Biologic treatment in spondyloarthropathies is crucial in keeping patients active. By reducing pain, improving mobility, lowering fatigue, and protecting against joint damage, patients can maintain work activity for longer periods of time.

Hepatitis, HCV and HIV

Dr. Pawel Grzesiowski, Chief Sanitary Inspector, presented the results of an observational study, almost a decade old, showing that vaccination against herpes zoster reduces the risk of ischemic and cardiovascular episodes, as well as delays the onset of dementia. - One of the most important elements that affect the rate of aging and the health consequences that follow is inflammation. Many diseases that appear or increase after age 60 have an inflammatory basis - diabetes, COPD, atherosclerosis, autoimmune diseases. Infection conquers inflammation often to levels not previously present, and this damages the vascular system. Therefore, prevention of infectious diseases at this age is particularly important and can have a broader impact on quality of life. And this is what, among other things, vaccination serves," he explained. - We have reimbursement for hemiplegia vaccination, and that's a 1,500 zloty savings for the patient. We have RSV vaccine for seniors at risk. Not to mention influenza and Covida," he enumerated. He added that the new My Health program includes an individual vaccination calendar as part of the benefit. - When we report to our family doctor, depending on our age, we should have a risk assessment after an initial examination and a proposed list of vaccinations that will be individually tailored for us, he informed.

Prof. Krzysztof Tomasiewicz, president of the Polish Society of Epidemiologists and Doctors of Infectious Diseases, pointed out that screening for HCV and HIV infection could be more effective thanks to programs implemented by PCPs.

- There is a lack of education both of the public itself and of family doctors, so that we can take advantage of this benefit provided by the My Health program," he lamented. - Besides, family doctors can simply earn money from these tests, so it's not only self-funding, but also provides some income. And thanks to this, millions of people will be able to be tested for anti-HCV," he added.

He pointed out that widespread testing in EDs and hospitals is lacking.

HCV still poses a threat to the Polish population due to the lack of vaccine prevention and the serious consequences of long-term infection - cirrhosis or hepatocellular carcinoma.

There are still more than 140,000 people actively suffering from hepatitis C, and about 70% live in ignorance of HCV infection. Thus, there is an urgent need to increase efforts in HCV diagnosis and subsequent treatment of hepatitis C.

Prof. Krzysztof Tomasiewicz also pointed to the problem of HIV testing.

- Statistics and our daily practice show that these patients are increasing. We have an increase of several tens of percent in the number of registrations to preventive and diagnostic clinics to start antiretroviral therapy. And patients are coming to us at a very late stage of infection," he lamented.

From the implementation of testing in 1985 until 2022, nearly 30,000 HIV infections have been identified in Polish citizens and people with other citizenship residing in Poland. Among the total registered infections were at least: 6457 infected through drug use, 2232 infected through heterosexual contact and 4818 through sexual contact between men. A total of 3979 AIDS cases were reported, 1465 patients died.