From chronic conditions to chronic diseases: a primary health care research agenda. Vikram Patel
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1 From chronic conditions to chronic diseases: a primary health care research agenda Vikram Patel London School of Hygiene & Tropical Medicine Sangath, Goa, India Public Health Foundation of India 1
2 The categorization of human health conditions Group 1 : communicable, perinatal and nutritional disorders Group 2 : non-communicable disorders Group 3 : injuries 2
3 NCD to chronic diseases Reflecting the need for classifications to be pragmatic and relevant to health service contexts.but, in reality, chronic diseases has become equivalent to cardiovascular diseases and metabolic syndromes and the most vivid health outcome of CVDinfarctions and strokes, are acute conditions 3
4 Whats missing from the agenda? Disabling consequences of CVD/diabetes Mental, neurological, substance use disorders Cancers Palliative care Chronic infectious diseases (notably HIV/AIDS) 4
5 What do they share? Co-morbidity due to shared risk factors, for e.g. alcohol and tobacco use Co-morbidity due to interactions, for e.g. depression and diabetes One condition affecting the course and outcome of another, for e.g. CVD and depression Co-morbid influences on household members, e.g. stroke in person leading to depression in caregiver 5
6 Most importantly Principles of management in primary care Proactive or opportunistic detection Complex interventions combing pharmacological and psychosocial treatments delivered in a tailored, stepped care manner Long-term monitoring and adherence support Active participation of patient in self-management Concern with clinical and social outcomes 6
7 Research agenda An integrated approach to delivery of care for people with chronic conditions or associated risk factors in primary care 7
8 Extremely cost effective interventions (<US$ 100 per DALY averted) Patel et al, Lancet Series on Universal Health Care in India, in preparation Treatment of stage I breast cancer Extensive breast cancer program Preventive drug treatment for high blood pressure Metformin and lifestyle interventions for diabetes Control of tobacco, alcohol use Dietary salt reduction programme Screening for refractory error and provision of glasses 8
9 Cost effective interventions (US$ 100-1,000 per DALY averted) Patel et al, Lancet Series on Universal Health Care in India, in preparation Treatment of acute MI with aspirin or streptokinase Treatment of post-acute MI with aspirin / ACE-inhibitors / beta-blockers / statins Treatment of post-acute ischaemic stroke with aspirin or statins or blood pressure reducing drugs Treatment of CHF with ACE-inhibitors or beta-blockers Extra-capsular cataract extraction using aphakic glasses Preventive drug treatment for high cholesterol Preventive combination therapy for high CVD risk Flu vaccination (aged 60+ years) and smoking cessation programs for persons with COPD Brief interventions for heavy alcohol users Depression treatment Screening for hearing loss and provision of hearing aids 9
10 10
11 Key primary health care research questions 1. How to improve detection through opportunistic and proactive case finding 2. How to improve initiation of evidence-based treatments, typically a combination of health education, generic drugs and counselling tailored to individual needs. 3. How to maximise optimal outcomes and reduce risk of acute events/relapses through proactive monitoring and adherence support 4. How to reduce disabilities and support affected family members through community based rehabilitation 5. How to involve the private and non-profit sector in a population based chronic condition health care program 11
12 Delivery in primary health care 12
13 Barriers to scaling up to PHC Weak human resource capacity and development Difficulties in integration in PHC; management focused on acute care, lack of time, weak impact of training medical practitioners etc (adapted from Saraceno et al, Lancet GMH series 2007) 13
14 Potential solutions Task-shifting Application of ICT methods 14
15 Task shifting to scale up chronic disease management 15
16 What is task-shifting Old wine in a new bottle! the strategy of rational redistribution of tasks among health workforce teams specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health. 16
17 17
18 The evidence for chronic conditions: examples from mental health care 18
19 Lay health workers delivering group Interpersonal therapy for depression in rural Uganda (Bolton et al, JAMA 2005, 2007) 19
20 Lady health visitors using CBT to treat postnatal depression in rural Pakistan (Rahman et al, Lancet 2008) 20
21 Community mental health workers delivering care for schizophrenia in rural India (Chatterjee et al, Br J Psych 2003) 21
22 Community health workers supporting caregivers of persons affected by dementia (Dias et al, PLoS One, 2008) 22
23 23
24 Application of ICT 24
25 ICT in Decision Support Systems Telemedicine Computerized DSS Stand-alone software on PDAs web enabled Mobile phone Technology 25
26 Mobile Phone Technology Ubiquitous Technology Launch of 3G/4G mobile Networks Support Higher bandwidth Faster Internet capabilities Cost of Smart phones/pda Two Way Communication 26
27 27
28 Potential of mobile phone technology in Chronic Diseases Improving Primary health care delivery through CHWs Screening: Risk factors, integrated physiological assessments Decision support algorithms Monitoring and surveillance Adherence support 28
29 An ICT system for detection and care Development and evaluation of an Information and Communications Technology (ICT) system for the early detection and management of a range of chronic diseases and their risk factors 29
30 From chronic diseases to chronic conditions in primary care A biomedically driven approach to CDs risks further verticalisation and fragmentation of primary health care systems; let us not repeat the mistakes in the fields of maternal, newborn and child health Chronic conditions are those which, irrespective of diagnosis, require a package of treatments with both facility and community based elements, tailored to the needs of the individual, and delivered over extended periods of time to achieve optimal health outcomes 30
31 Acknowledgements VS Ajay Andy Haines Shah Ebrahim D Prabhakar 31
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