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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 (NCD)
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 2 | CV
NCD progression and implications for management
Healthy
Risk factors
High risk NCD
Complications
EffectivenessImpact
CHSDH
National centres
Resources
-Preventive and promotive programmes
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 3 | CV
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
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 4 | CV
NCD management: Defined package, coverage, follow-up
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 5 | CV
Primary health care ServicesA world of difference
High resource settings
High resource settings
Low resource settings
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 6 | CV
ABSENTMINIMAL
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 7 | CV
Screening
Symptomatic disease
Pre-symptomatic‘healthy’
HEALTH
SCREENING
Treatment
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 8 | CV
Screening for cervical cancer
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 9 | CV
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
Noncommunicable Diseases
& Health Promotion
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
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 failureHeart/brain/kidney/eyes
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
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
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 14 | CV
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 aspirin therapy,
– blood pressure control,
– cholesterol management, and
– smoking cessation)
– as well as healthier lifestyles and communities.
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.
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 17 | CV
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.
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 19 | CV
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.
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
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
1st level
2nd level (District hospital)
Referral hospital
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 22 | CV
Staff, equipment, drugs
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 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
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 24 | CV
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
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 25 | CV
Primary Health Care CenterMinimum Requirements
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 26 | CV
District HospitalSecondary Services in CVD Cluster
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 27 | CV
Patient notes
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:
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 29 | CV
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.
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
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
PILOTIntroduce PEN after
ensuring the minimum requirements in selected health
facilities
Introducing WHO PEN
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
PHC
PHC
PHC
PHC
PHC
PHC
PHC
PHC
PHC
DISTRICT HOSPITAL
Tertiary level
hospital
Noncommunicable Diseases
& Health Promotion
NCD Management | March 2014 | 33 | CV