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NCD Management Dr. Cherian Varghese MD., Ph.D.

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Presentation on theme: "NCD Management Dr. Cherian Varghese MD., Ph.D."— Presentation transcript:

1 NCD Management Dr. Cherian Varghese MD., Ph.D.
Senior Medical Officer (NCD)

2 NCD progression and implications for management
Resources Healthy Effectiveness Impact Risk factors High risk NCD Complications CHS DH National centres -Preventive and promotive programmes

3 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 NCD management: Defined package, coverage, follow-up
What is good ? Desire for universal coverage Global push for universal health coverage Package of Essential NCD interventions-Generic drugs What are the limitations? NCD services not defined adequately in PHC System limitations-concept of chronic care, human resorce Market driven treatment Profit sector What is needed? NCD services to be defined and incorporated Increase resources in primary care-one additional nurse Protocol based management

5 Primary health care Services A world of difference
High resource settings Primary health care Services A world of difference Low resource settings


7 Screening Symptomatic disease Treatment Pre-symptomatic ‘healthy’

8 Screening for cervical cancer

Screening programme Information Awareness Time, effort, resources and people Responsive health system Decision to participate Abnormalities Treated adequately Reliable results Communicated Counselling Satisfied client Cancer averted COMMUNITY INVOLVEMENT AND SUPPORT IS NEEDED AT ALL LEVELS

10 Age standardized incidence of invasive cervical cancer
and coverage of screening, England, Quinn, M. et al. BMJ 1999;318:904 Copyright ©1999 BMJ Publishing Group Ltd. 10

11 postpone end organ failure
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 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 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


15 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 aspirin therapy, blood pressure control, cholesterol management, and smoking cessation) as well as healthier lifestyles and communities.

16 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 Professional associations, leading clinical specialists and doctors.
Health facilities strengthened Health managers agreeing to the approach National level decision to adapt PEN

18 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 Changes 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 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 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 NCD services at different levels
Specialized care Referral hospital Management 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 care 1st level

22 Staff, 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 Cuff PHC Measuring tape, Weighing scale, Sphygmomanometer/BP Cuff, Blood sugar, Urinalysis Strips, Stethoscope Basic Medications for NCD risk-factor modification Nurse practitioner or Medical Officer Not necessary, but desirable: Doctor. Permanent or Outreach from DH DH Measuring tape, Weighing scale, Sphygmomanometer, Blood Sugar, Urinalysis Strips, Stethoscope, Ophthalmoscope, Tuning Fork, Serum Creatinine, Lipids Drugs: Advanced chronic condition management and acute event management Physician, Surgeon, Nurse, Laboratory staff 1 Extra Doctor per DH (NCD Clinic and PHC Outreach) Staff trained in NCD strategies and protocols

23 Community Health Workers
Roles/ Respons-ibilities Functions Clinical Proforma Protocols 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 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 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 Primary Health Care Center Staff Team & Roles
Physician Nurse Others Receives NCD referrals from nurse Physically examines pt Prescribes meds & promotes adherence WHO Pocket Guidelines for Assessment & Mngmt of CY Risk 2007 Conduct risk assessment & screening Measure ht& wt, take VS Perform UA and blood sugars, if needed Healthy lifestyle counseling For revision W/O physician Dietitian Smoking cessation specialist Health educator PEN Protocol 1 & 2

25 Primary Health Care Center Minimum Requirements
Facilities/ Medical Equipment Exam room/ bed Stethoscope BP apparatus Weighing scales & tape measure Height chart Urinalysis strips Blood gluc meter Medications/ Lab Tests Aspirin Statin ACE inhibitor Beta-blocker Calcium-channel blocker Thiazide Metformin a sulfonylurea SC insulin (long- and short-acting) Clinical Proforma NCD High Risk Assessment (Facility Form) Patient’s Record Patient’s NCD Passbook PEN Protocol Action 4. Secondary Clinic Referral Criteria

26 District Hospital Secondary Services in CVD Cluster
Management of referred patients/and walk in patients Supervision and guidance to lower levels Referral care Initial Management & close monitoring in acute phase 24-hour staff trained in ALS + ACLS Equipment: ECG, direct cardiac monitoring, Cardiac defibrillator Drugs: Resuscitation/ Secondary prevention Meds Acute Coronary Syndrome Service Review pts with significant peripheral neuropathy or vascular disease Nursing staff trained in foot care and dressing of chronic lower extremity ulcers Diabetic Podiatry Review and control of blood sugar to limit progression of blindness Referrals to a laser coagulation service Diabetic Retinopathy Service

27 Patient notes

28 NAME: AGE: Risk: Target: NCD passbook Diet Physical activity
Smoking cessation Medications NAME: AGE: Risk: Target:

29 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 benefit Perceived 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 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 Analysis of the facility assessment survey from 3 facilities
Introducing WHO PEN 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 PILOT Introduce PEN after ensuring the minimum requirements in selected health facilities Sustain and expand with resources, additional training and close monitoring Training for WHO PEN: Health managers, staff from referral facilities, staff of facilities where PEN will be introduced and other relevant personnel

32 District health service
Tertiary level hospital PHC PHC 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 PHC PHC PHC PHC PHC PHC PHC


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