Presentation on theme: "NCD Management Dr. Cherian Varghese MD., Ph.D."— Presentation transcript:
1NCD Management Dr. Cherian Varghese MD., Ph.D. Senior Medical Officer (NCD)
2NCD progression and implications for management ResourcesHealthyEffectivenessImpactRisk factorsHighriskNCDComplicationsCHSDHNational centres-Preventive and promotive programmes
3Very cost effective interventions Tobacco useReduce 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 sponsorshipHarmful alcohol useRegulating commercial and public availability of alcoholRestricting or banning alcohol advertising and promotionsUsing pricing policies such as excise tax increases on alcoholic beveragesUnhealthy diet and physical inactivityReduce salt intakeReplace trans-fats with unsaturated fats;Implement public awareness programmes on diet and physical activityCardiovascular disease and diabetesDrug 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 yearsAcetylsalicylic acid for acute myocardial infarction.CancerPrevention 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
4NCD management: Defined package, coverage, follow-up What is good ?Desire for universal coverageGlobal push for universal health coveragePackage of Essential NCD interventions-Generic drugsWhat are the limitations?NCD services not defined adequately in PHCSystem limitations-concept of chronic care, human resorceMarket driven treatmentProfit sectorWhat is needed?NCD services to be defined and incorporatedIncrease resources in primary care-one additional nurseProtocol based management
5Primary health care Services A world of difference High resource settingsPrimary health care Services A world of differenceLow resource settings
9COMMUNITY INVOLVEMENT AND SUPPORT IS NEEDED AT ALL LEVELS Screening programmeInformationAwarenessTime, effort,resourcesand peopleResponsivehealth systemDecision toparticipateAbnormalitiesTreatedadequatelyReliable resultsCommunicatedCounsellingSatisfied clientCancer avertedCOMMUNITY INVOLVEMENT AND SUPPORT IS NEEDED AT ALL LEVELS
11postpone end organ failure Heart Disease (CVD) is a result of multiple risk factors- which co-exist in the same individualPrevent/postpone end organ failureHeart/brain/kidney/eyes
12Package of Essential NCD interventions - PEN CVDPrimary prevention of heart attacks and strokesAcute Myocardial infarctionSecondary prevention (post MI)Secondary prevention (post Stroke)Secondary prevention (Rheumatic Heart Disease)Diabetes MellitusType 1 DiabetesType 2 DiabetesPrevention of foot complications through examination and monitoringPrevention of onset and delay in progression of chronic kidney diseasePrevention of onset and delay progression of diabetic retinopathyPrevention of onset and progression of neuropathyChronic Obstructive Lung DiseasesBronchial AsthmaPrevent exacerbation of COPD and disease progressionCancerEarly diagnosis
13Think differentlyCurrently all doctors and all hospitals manage hypertension, DM and NCDsAre 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 complicationsPEN helps you to do thatThere is no new treatmentA package with proven interventionsRisk scoring and integrated management of high risk subjects is one component
15Million Hearts- USAMillion Hearts® will achieve its goal by emphasizing cardiovascular health across patients, providers, communities, and other stakeholders.promoting the "ABCS" of clinical preventionappropriate aspirin therapy,blood pressure control,cholesterol management, andsmoking cessation)as well as healthier lifestyles and communities.
16WHO/ISH risk prediction chart Enables integrated risk assessment and risk prediction for management of CVDUses 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.
17Professional associations, leading clinical specialists and doctors. Health facilities strengthenedHealth managers agreeing to the approachNational level decision to adapt PEN
18How 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.
19Changes needed Public Perception Medical Education Facility 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 asymptomaticUse 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.
20NCD servicesNCD 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 protocolsSimple monitoringNCD card/passport for patientsPeriodic review and skill building
21NCD services at different levels Specialized careReferral hospitalManagement of DM and HTN, CVD risk assessment and management, Cancer diagnosis (pathology), management of early cancer and pre cancer (surgical and medical)2nd level(District hospital)Behavioural risk identification, counselling,referral, follow up care, palliative care1st level
22Staff, equipment, drugs CHW PHC DH Measuring tape, Weighing scales, BMI Charts Public information materials package. Pre-prepared referral materials for at-risk patients.Not necessary, but desirable: Automated BP CuffPHCMeasuring tape, Weighing scale, Sphygmomanometer/BP Cuff, Blood sugar, Urinalysis Strips, Stethoscope Basic Medications for NCD risk-factor modificationNurse practitioner or Medical OfficerNot necessary, but desirable: Doctor. Permanent or Outreach from DHDHMeasuring tape, Weighing scale, Sphygmomanometer, Blood Sugar, Urinalysis Strips, Stethoscope, Ophthalmoscope, Tuning Fork, Serum Creatinine, LipidsDrugs: Advanced chronic condition management and acute event managementPhysician, Surgeon, Nurse, Laboratory staff 1 Extra Doctor per DH (NCD Clinic and PHC Outreach) Staff trained in NCD strategies and protocols
23Community Health Workers Roles/ Respons-ibilitiesFunctionsClinical ProformaProtocolsIdentify people with RF for PHC referralAIM: Review all popu >40 yrs oldRefer clients WITH risk to PHCAdvocate for NCD prevention & healthy lifestylePromote healthy lifestyleRisk Factor Awareness + EducRisk Factor Assessment (Smoking, Alcohol Intake, Diet, Physical Activity)Baseline BP and VSGive referral card to PHCEQUIPMENTStethoscopeBP measuring deviceMeasuring tapeCLINICAL FORMSNCD High Risk Assessment (Community Case Finding Form)> PENToolkit Annex6Referral CardGuidelines on Healthy Diet > PEN Toolkit Annex 2WHO PEN Protocol 2 – Health for ALL
24Primary Health Care Center Staff Team & Roles PhysicianNurseOthersReceives NCD referrals from nursePhysically examines ptPrescribes meds & promotes adherenceWHO Pocket Guidelines for Assessment & Mngmt of CY Risk 2007Conduct risk assessment & screeningMeasure ht& wt, take VSPerform UA and blood sugars, if neededHealthy lifestyle counselingFor revision W/O physicianDietitianSmoking cessation specialistHealth educatorPEN Protocol1 & 2
25Primary Health Care Center Minimum Requirements Facilities/ Medical EquipmentExam room/ bedStethoscopeBP apparatusWeighing scales & tape measureHeight chartUrinalysis stripsBlood gluc meterMedications/ Lab TestsAspirinStatinACE inhibitorBeta-blockerCalcium-channel blockerThiazideMetformina sulfonylureaSC insulin (long- and short-acting)Clinical ProformaNCD High Risk Assessment (Facility Form)Patient’s RecordPatient’s NCD PassbookPEN Protocol Action 4. Secondary Clinic Referral Criteria
26District Hospital Secondary Services in CVD Cluster Management of referred patients/and walk in patientsSupervision and guidance to lower levelsReferral careInitial Management & close monitoring in acute phase24-hour staff trained in ALS + ACLSEquipment: ECG, direct cardiac monitoring, Cardiac defibrillatorDrugs: Resuscitation/ Secondary prevention MedsAcute Coronary Syndrome ServiceReview pts with significant peripheral neuropathy or vascular diseaseNursing staff trained in foot care and dressing of chronic lower extremity ulcersDiabetic PodiatryReview and control of blood sugar to limit progression of blindnessReferrals to a laser coagulation serviceDiabetic Retinopathy Service
29ComplianceMaintaining 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 benefit Perceived harmCost Unpleasant side-effectsThese 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.
30Continuing Care in the Community (Volunteers linked to health system) Emotional supportBasic nursingDiabetic foot careFollow upLinking up with the professional teamSocial support to the affected family by way ofHelping with transport to hospitalLinking with other support groupsHelping to get benefits from various sourcesRehabilitation
31Analysis of the facility assessment survey from 3 facilities Introducing WHO PENSelected district/province with identified health facilities which can introduce WHO PENSample of facilities-for facility assessment surveyAnalysis of the facility assessment survey from 3 facilitiesPILOTIntroduce PEN after ensuring the minimum requirements in selected health facilitiesSustain and expand with resources, additional training and close monitoringTraining for WHO PEN: Health managers, staff from referral facilities, staff of facilities where PEN will be introduced and other relevant personnel
32District health service Tertiary level hospitalPHCPHCModel districtPopulation 100,000District hospital for 100,000 populationOne PHC for 10,000 population (n=10)One health volunteer for 2000 people (n-50)PHCDISTRICTHOSPITALPHCPHCPHCPHCPHCPHCPHC