1. Chronic non-communicable disease care in an atypical refugee setting: Syrian refugees in Lebanon
*Philippa Boulle1, Gustavo Fernandez1, Maria Lightowler2
1Médecins Sans Frontières (MSF), Geneva, Switzerland;
2MSF, Beirut, Lebanon
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

2. Lebanon Population 5,882,562 (July 2014)
- Palestinian refugees 650,000
Syrian refugees 1,180,755
MSF
emergency intervention
- Tripoli, Bekaa, (Saida)
Aarsal
Majdal Anjaar
Highly privatised, specialised medical system, strong pharma lobby
High prevalence of non-communicable diseases (NCDs)
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

3. Aim
Rationale: Limited MSF experience in non-communicable disease (NCD) management
open refugee setting, middle-income context
Objectives: to understand -
feasibility of a model of care utilising task-shifting, simplified protocols, limited use of investigations
feasibility/impact of home glucose monitoring
reasons for defaulting

4. Philippa Boulle, MSF. CNCD care in an atypical refugee setting.
Methods
Descriptive study
Retrospective review of programme data
Monitoring through field-designed aggregate data tables
Met MSF Ethics Review Board criteria for exemption from ethics review
met the criteria of the MSF Ethics Review Board for exemption from ethics review
recording patient numbers, diagnoses, and status
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

5. Developing an adapted response
Guidelines
evidence-based, simplified algorithms
essential drug list
rationalised investigations
Model of care – patient circuit
integrated in primary health centre (PHC)
task-shifting: nurses, community health workers (CHW)
Support to teams with guideline implementation
in-country workshop
in-field expert
Key diseases: unstable diseases with high untreated mortality and morbidity
Type 1 diabetes
Type 2 diabetes
Hypertension/cardiovascular disease
Asthma/COPD
Epilepsy
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

6. Philippa Boulle, MSF. CNCD care in an atypical refugee setting.
Standardized approaches for diagnosis, treatment and follow-up
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

7. Simplified drug regimens, utilization of generics where possible
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

8. Philippa Boulle, MSF. CNCD care in an atypical refugee setting.
Home glucose monitoring A real diabetic outcome improvement or an educational & motivational instrument?
Concept: provision of glucometers and strips to select patients, with specific instructions on times for testing Objective: improved glucose control through more targeted insulin adjustment Admission criteria: unstable patients on insulin, 3 months’ minimum follow-up in clinic; pregnant women with diabetes Outcome measures: HbA1c, qualitative questionnaires (clinicians and patients)
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

9. Results – cohort analysis
Active patients Cumulative patients
Tripoli
Bekaa
Total
Bekaa – 113,583 consultations → 21% NCD related
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

10. Philippa Boulle, MSF. CNCD care in an atypical refugee setting.
Bekaa – data analysis
Parameter
Definition
End 2014
Cumulative patients
Total patients seen
5458
One visit
Not seen after first visit
1358
25%
Admitted to cohort
≥2 visits
3820
70%
Newly admitted 2014
2312
33%
Readmission
300
67%
Defaulters
3 month absence in admitted patients
1258
Active patients
= admitted - defaulters
2562
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

11. Bekaa – patient breakdown
Age
1-9yo 5%
20-39yo 11%
40-49yo 21%
50-59yo 30%
60-69yo 22%
≥70yo 11%
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

12. Results - Defaulter tracing (Bekaa)
Total
Aarsal
Majdal
Baalbek
Hermel
Not contactable
221
179
138 26
564
91%
Total contacted 18 15 17 6 64
10%
Changed location 38 29 20 7 94
39%
within Lebanon 35 74
31%
returned to Syria 3 11 5 1 8%
Changed provider 2 55
23%
Travel constraints
Deaths 4 7%
Discontinued medications 6%
Concerns with waiting times 14
Not specified 5%
Not a defaulter 3%
Total follow up
239
194
155 32
620
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

13. Defaulter tracing (Tripoli)
Conclusions: - improvements in clinic organisation decreased defaulting rates - more patient education required (hypertension/diabetes most common defaulters) - home visit system for specific patients
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

14. Home glucose monitoring
End 2014: 85 patients enrolled (8.5% of diabetes mellitus cohort)
Admission HbA1c range % (mean 10.28%)
5 follow-up HbA1c – all decreased (average 1.84% in 3 months)
61% patients self-adjusting (not intended)
File review – 88% adjustment of insulin using results
Cost - $28/patient/month
One patient decreases from 11.4% to 7.6%
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

15. Philippa Boulle, MSF. CNCD care in an atypical refugee setting.
Conclusions (1)
Defaulter tracing
Some reasons for defaulting can be addressed
Ongoing defaulter tracing useful for patient support and programme adaptation
Home glucose monitoring
Limited results suggest that home glucometer use facilitates patient support and medication adjustment
Needs more systematic implementation and closer follow-up
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

16. Philippa Boulle, MSF. CNCD care in an atypical refugee setting.
Conclusions (2)
Lessons learned:
simplified protocols & expert support enable task-shifting, GP-based model of care, cost rationalisation
appointment system, dedicated patient files, defaulter tracing and patient circuit allow improved patient follow-up
Limitations:
poor data tools, inconsistent tools and methodology between projects (for data collection, home glucose monitoring, defaulter tracing)
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

17. Conclusions (3) Ongoing work:
improvement of adapted patient education models and tools
research into simplifying medication administration (fixed-dose combination pills for secondary prevention of cardiovascular disease)
Components now being utilised by MSF in other settings (Iraq, Syria, Ukraine, South Sudan).
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

18. Philippa Boulle, MSF. CNCD care in an atypical refugee setting.
Acknowledgments
Thanks to:
the field teams for their hard work and initiatives in this programme, and to
the Innovation Unit of OCG for support in tool development.
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.

19. Philippa Boulle, MSF. CNCD care in an atypical refugee setting.
Questions?
Philippa Boulle, MSF. CNCD care in an atypical refugee setting.