noncommunicable diseases & health promotion ncd management | march 2014 | 1 | cv ncd management...

Noncommunicable Diseases

& Health Promotion

NCD Management | March 2014 | 1 | CV

NCD Management

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

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NCD progression and implications for management

Healthy

Risk factors

High risk NCD

Complications

EffectivenessImpact

CHSDH

National centres

Resources

-Preventive and promotive programmes


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Very cost effective interventionsTobacco 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


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NCD management: Defined package, coverage, follow-up


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Primary health care ServicesA world of difference

High resource settings

High resource settings

Low resource settings


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ABSENTMINIMAL


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Screening

Symptomatic disease

Pre-symptomatic‘healthy’

HEALTH

SCREENING

Treatment


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Screening for cervical cancer


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Screening programme

InformationAwareness

Decision to participate

Time, effort,resources and people

Responsive health system

Reliable resultsCommunicated

Counselling

AbnormalitiesTreated

adequatelySatisfied clientCancer averted

COMMUNITY INVOLVEMENT AND SUPPORT IS NEEDED AT ALL LEVELS


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NCD Management | March 2014 | 10 | CVCopyright ©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, 1971-95


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Heart Disease (CVD) is a result of multiple risk factors- which co-exist in the same individual

Prevent/postpone end organ failureHeart/brain/kidney/eyes


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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


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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


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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.


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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.


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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.


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Changes neededPublic 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.


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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


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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

1st level

2nd level (District hospital)

Referral hospital


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Staff, equipment, drugs


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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 referralAIM: 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


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Primary Health Care CenterStaff 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

Protocol1 & 2


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Primary Health Care CenterMinimum Requirements


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District HospitalSecondary Services in CVD Cluster


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Patient notes


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NCD passbook

• Diet

• Physical activity

• Smoking cessation

• Medications

NAME:AGE:Risk:Target:

NAME:AGE:Risk:Target:


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ComplianceMaintaining 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.

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.


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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


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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

PILOTIntroduce PEN after

ensuring the minimum requirements in selected health

facilities

Introducing WHO PEN


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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

PHC

PHC

PHC

PHC

PHC

PHC

PHC

PHC

PHC

DISTRICT HOSPITAL

Tertiary level

hospital


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noncommunicable diseases & health promotion ncd management | march 2014 | 1 | cv ncd management...

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