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Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 1 | CV NCD Management Dr. Cherian Varghese MD., Ph.D. Senior Medical Officer.

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Presentation on theme: "Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 1 | CV NCD Management Dr. Cherian Varghese MD., Ph.D. Senior Medical Officer."— Presentation transcript:

1 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 1 | CV NCD Management Dr. Cherian Varghese MD., Ph.D. Senior Medical Officer (NCD)

2 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 2 | CV NCD progression and implications for management Healthy Risk factors High risk NCD Complications Effectiveness Impact CHS DH National centres Resources -Preventive and promotive programmes

3 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 3 | CV Very cost effective interventions Tobacco use  Reduce affordability of tobacco products by increasing tobacco excise taxes;  Create by law completely smoke-free environments in all indoor workplaces, public places and public transport;  Warn people of the dangers of tobacco and tobacco smoke through effective health warnings and mass media campaigns;  Ban all forms of tobacco advertising, promotion and sponsorship Harmful alcohol use  Regulating commercial and public availability of alcohol  Restricting or banning alcohol advertising and promotions  Using pricing policies such as excise tax increases on alcoholic beverages Unhealthy diet and physical inactivity  Reduce salt intake  Replace trans-fats with unsaturated fats;  Implement public awareness programmes on diet and physical activity Cardiovascular disease and diabetes  Drug therapy (including glycaemic control for diabetes mellitus and control of hypertenstion using a total risk approach) and counselling to individuals who have had a heart attack or stroke, and to persons with high risk (≥ 30%) of a fatal and nonfatal CVD event in the next 10 years  Acetylsalicylic acid for acute myocardial infarction. Cancer  Prevention of liver cancer through hepatitis B immunization;  Prevention of cervical cancer through screening (visual inspection with acetic acid [VIA]) or Pap smear (cervical cytology), if very cost effective), linked with timely treatment of pre-cancerous lesions

4 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 4 | CV NCD management: Defined package, coverage, follow-up

5 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 5 | CV Primary health care Services A world of difference High resource settings Low resource settings

6 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 6 | CV ABSENT MINIMAL

7 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 7 | CV Screening Symptomatic disease Pre- symptomatic ‘healthy’ HEALTH SCREENING Treatment

8 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 8 | CV Screening for cervical cancer

9 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 9 | CV Screening programme Information Awareness Decision to participate Time, effort, resources and people Responsive health system Reliable results Communicated Counselling Abnormalities Treated adequately Satisfied client Cancer averted COMMUNITY INVOLVEMENT AND SUPPORT IS NEEDED AT ALL LEVELS

10 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 10 | CV Copyright ©1999 BMJ Publishing Group Ltd. Quinn, M. et al. BMJ 1999;318:904 Age standardized incidence of invasive cervical cancer and coverage of screening, England,

11 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 11 | CV Heart Disease (CVD) is a result of multiple risk factors- which co-exist in the same individual Prevent/ postpone end organ failure Heart/brain/ kidney/eyes

12 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 12 | CV Package of Essential NCD interventions - PEN CVD –Primary prevention of heart attacks and strokes –Acute Myocardial infarction –Secondary prevention (post MI) –Secondary prevention (post Stroke) –Secondary prevention (Rheumatic Heart Disease) Diabetes Mellitus –Type 1 Diabetes –Type 2 Diabetes –Prevention of foot complications through examination and monitoring –Prevention of onset and delay in progression of chronic kidney disease –Prevention of onset and delay progression of diabetic retinopathy –Prevention of onset and progression of neuropathy Chronic Obstructive Lung Diseases –Bronchial Asthma –Prevent exacerbation of COPD and disease progression Cancer –Early diagnosis

13 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 13 | CV Think differently Currently all doctors and all hospitals manage hypertension, DM and NCDs Are they optimal? –Is there a method to get better value for money? Can we save more lives? –Yes, if we can identify those at maximum risk, who benefits most from the interventions, reaching as many as possible, and helping them to prevent complications PEN helps you to do that There is no new treatment A package with proven interventions Risk scoring and integrated management of high risk subjects is one component

14 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 14 | CV

15 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 15 | CV Million Hearts- USA Million Hearts® will achieve its goal by emphasizing cardiovascular health across patients, providers, communities, and other stakeholders. promoting the "ABCS" of clinical prevention –appropriate a spirin therapy, –b lood pressure control, –c holesterol management, and –s moking cessation) –as well as healthier lifestyles and communities.

16 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 16 | CV WHO/ISH risk prediction chart Enables integrated risk assessment and risk prediction for management of CVD Uses easily measurable indicators of risk to quantify the 10-year cardiovascular risk. These include gender, systolic blood pressure, smoking status, type 2 diabetes mellitus and total serum cholesterol. Selects those who would benefit most from treatment, and guide the intensity and nature of drug treatment.

17 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 17 | CV

18 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 18 | CV How to advance the programme? Get the support of leading clinicians in the country. NCD programme managers are likely to be public health experts and may not be comfortable with clinical interventions. Work with hospital management systems and health service providers. Health service staff are more likely to listen to national clinical experts rather than programme managers. Need clinical champions.

19 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 19 | CV Changes needed Public PerceptionMedical EducationFacility Provision Involve patient in notes: awareness of their risk. Public education of risk. Use of proforma. Importance of long- term notekeeping. Publishing and Provision of a notekeeping proforma, national ID register and database. Regular Checkups needed even if asymptomatic. Existence and correct use of algorithm. Monitor asymptomatic patients. Provide nationalised/Endorse international algorithm for management. Importance of taking medicines even when asymptomatic Use of cheaper medicines in low- resource setting likely to have better outcome than “gold- standards” Formation and guaranteed provision of formulary of cheap medicines for algorithm.

20 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 20 | CV NCD services NCD services defined as part of overall service (not based on the interest of staff) Adequate human resources (one NCD nurse for 10,000 population?) Equipment and drugs to support protocols Simple monitoring NCD card/passport for patients Periodic review and skill building

21 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 21 | CV NCD services at different levels Behavioural risk identification, counselling, referral, follow up care, palliative care Management of DM and HTN, CVD risk assessment and management, Cancer diagnosis (pathology), management of early cancer and pre cancer (surgical and medical) Specialized care 1 st level 2 nd level (District hospital) Referral hospital

22 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 22 | CV Staff, equipment, drugs

23 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 23 | CV Community Health Workers Promote healthy lifestyle Risk Factor Awareness + Educ Risk Factor Assessment (Smoking, Alcohol Intake, Diet, Physical Activity) Baseline BP and VS Give referral card to PHC Identify people with RF for PHC referral AIM: Review all popu >40 yrs old Refer clients WITH risk to PHC Advocate for NCD prevention & healthy lifestyle EQUIPMENT Stethoscope BP measuring device Measuring tape CLINICAL FORMS NCD High Risk Assessment (Community Case Finding Form)> PENToolkit Annex6 Referral Card Guidelines on Healthy Diet > PEN Toolkit Annex 2 WHO PEN Protocol 2 – Health for ALL

24 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 24 | CV Primary Health Care Center Staff Team & Roles Receives NCD referrals from nurse Physically examines pt Prescribes meds & promotes adherence Conduct risk assessment & screening Measure ht& wt, take VS Perform UA and blood sugars, if needed Healthy lifestyle counseling WHO Pocket Guidelines for Assessment & Mngmt of CY Risk 2007 Dietitian Smoking cessation specialist Health educator PEN Protocol 1 & 2

25 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 25 | CV Primary Health Care Center Minimum Requirements

26 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 26 | CV District Hospital Secondary Services in CVD Cluster

27 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 27 | CV Patient notes

28 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 28 | CV NCD passbook Diet Physical activity Smoking cessation Medications NAME: AGE: Risk: Target: NAME: AGE: Risk: Target:

29 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 29 | CV Compliance Maintaining compliance with medical advice is key to effective medical management, particularly in chronic conditions. Many factors may cause patients to fail to comply with medicines: No perceived benefitPerceived harm Cost Unpleasant side-effects These factors will also cause failure to follow advised dietary/lifestyle measures. Ongoing education at every level of healthcare provision is as essential to a successful NCD service as the medications and protocols themselves. Maintaining compliance with medical advice is key to effective medical management, particularly in chronic conditions. Many factors may cause patients to fail to comply with medicines: No perceived benefitPerceived harm Cost Unpleasant side-effects These factors will also cause failure to follow advised dietary/lifestyle measures. Ongoing education at every level of healthcare provision is as essential to a successful NCD service as the medications and protocols themselves.

30 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 30 | CV Continuing Care in the Community (Volunteers linked to health system) Emotional support Basic nursing Diabetic foot care Follow up Linking up with the professional team Social support to the affected family by way of –Helping with transport to hospital –Linking with other support groups –Helping to get benefits from various sources –Rehabilitation

31 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 31 | CV Selected district/province with identified health facilities which can introduce WHO PEN Sample of facilities-for facility assessment survey Analysis of the facility assessment survey from 3 facilities Training for WHO PEN: Health managers, staff from referral facilities, staff of facilities where PEN will be introduced and other relevant personnel Sustain and expand with resources, additional training and close monitoring PILOT Introduce PEN after ensuring the minimum requirements in selected health facilities Introducing WHO PEN

32 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 32 | CV District health service Model district Population 100,000 District hospital for 100,000 population One PHC for 10,000 population (n=10) One health volunteer for 2000 people (n-50) PHC DISTRICT HOSPITAL DISTRICT HOSPITAL Tertiary level hospital

33 Noncommunicable Diseases & Health Promotion NCD Management | March 2014 | 33 | CV


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