Approaches to NCD Prevention and Management APHA 2018 Mark A. - - PowerPoint PPT Presentation

Community-based Approaches to NCD Prevention and Management

APHA 2018 Mark A. Strand, PhD, CPH North Dakota State University

Objectives

• 1. Contribution of non-communicable

diseases to the global burden of disease

• 2. Prevention and management of NCDs and

the role of trained Community Health Workers: China case study

• 3. Best practices for global partnerships in

reducing NCDs

• 1. Contribution of Non-

communicable Diseases to the Global Burden of Disease

Chronic Disease Definition

Chronic diseases are diseases which are

• Slow in progression
• Long in duration
• Do not resolve spontaneously (Never completely cured)
• Limit the function, productivity and quality of life of

someone with the disease

• Usually non-infectious

Non-Communicable Disease

• Noncommunicable diseases (NCDs) tend to be of

long duration and are the result of a combination of genetic, physiological, environmental and behaviors factors rather than pathogens.

• NCD4  Cancers, Diabetes, Cardiovascular diseases,

Respiratory diseases

Total deaths around the world: 58 million.

Total deaths around the world: 58 million. 41 million deaths from noncommunicable diseases (red).

Total deaths around the world: 58 million. 41 million deaths from noncommunicable diseases. 32 million deaths of the noncommunicable disease deaths in low- and middle-income countries (blue).

Total deaths around the world: 58 million. 41 million deaths from noncommunicable diseases. 32 million deaths of the noncommunicable disease deaths in low- and middle- income countries (blue). 16 million noncommunicable disease deaths in LMIC countries could have been prevented (grey).

Global Causes of Death 2016

NCD Countdown 2030 Collaboration. Lancet, 2018;392:1072-88.

Measuring and reporting NCDs

• The burdensomeness of NCDs is not best measured by mortality.
• Mortality reports on the nature of the disease, and the quality of

healthcare available to prevent death from happening.

• NCDs are less diseases that kill you than they are diseases which

compromise overall health, functionality and quality of life.

• Therefore prevalence and disability weighting are better measures

(DALY Years Lived with Disability).

• Prevalence rate describes how much care is needed. This addresses

chronic disease management.

• Incidence rate reflects the number of new cases, and thus the

effectiveness of prevention efforts.

Reasons for Increased Rates of Chronic Disease

• People are living longer.
• Dietary changes.
• Socioeconomic and demographic changes.

Harris, Epi of Chronic Disease 2012, p. 3

World Health Organization 25X25 Target

• WHO High-level Commission on NCDs
• WHO goal is to reduce by 2025 mortality from

NCD4 (cancer, cardiovascular disease, chronic respiratory diseases and diabetes) in people age 30-70 by 25% relative to 2010 rates.

• Country-level measures. E.g. China
• Men: 20%  15%
• Women: 15%  11.25%
• WHO. Time to deliver. https://www.thelancet.com/journals/lancet/article/PIIS0140-

6736(18)31258-3/fulltext

Sustainable Development Goals

• SDG target 3.4, to “by 2030 reduce by one third

premature mortality from NCDs through prevention and treatment.”

• Country-level measures: E.g. China
• By 2025, reduce deaths from cardiovascular diseases by 15

percent,

• increase the five-year survival rate for cancer victims by 10

percent, and

• reduce the under-70 mortality from chronic respiratory

diseases by 15 percent on the basis of that of 2015.

https://sustainabledevelopment.un.org/sdg3

U.S. FY17 Global Health Funding

https://www.kff.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of- the-fiscal-year-2017-budget-request/

Gaining Political Will for NCDs

HIV/AIDS NCDs Communicate the health challenge in a clear and compelling way Single disease. New and highly visible health threat. ART shown to be highly effective. Humanitarian crisis. NCDs are a collection of disease. Not perceived as a novel threat. A variety of treatments. Seen as disease of the elderly, or the wealthy. Secure the support of strong individuals and

• rganizations

1996 UN established UNAIDS. Activists effectively destigmatized AIDS. Low awareness, especially where ID is still high. Some multisectoral partnerships established (NCD Alliance in 2009, WHO GCM/NCD 2014). Advocacy

• perates in a

variety of key environments 90’s/00’s era of economic growth. Long-term commitments from the Global Fund, PEPFAR. Included in the MDGs. 2008 global economic downturn. Perceived as a disease of preventable behaviors. No “NCDs PEPFAR.” NCDs omitted from MDGs but included in SDGs in 2015.

Palma et al. Global Heart,2016;11(4): 403-408, Table 1.

• 2. Prevention and Management of

NCDs and the Role of Trained Community Health Workers: China Case Study

Chronic Disease Experience

Kornelia Grötken and Hokenbecker-Belke, Trajectory Model.

Compression of Morbidity

Current situation 75 years Extension of morbidity 80 years Compression of morbidity 80 years

Life expectancy

Prevalence of chronic disease

Fries et al, Compression of Morbidity. Journal of Aging Research, 2011, Article ID 2617021-10.

Keys to NCD Prevention and Mangement

1.

Prevention – reduce tobacco use, alcohol use, BP control, weight management

2.

Screening – case finding through early detection

3.

Management -- high quality primary health care, high coverage, at a sustainable economic cost

NCD Countdown 2030 Collaboration. Lancet, 2018;392:1084-85.

• “Training of community health workers

should be undertaken even in places where physicians are abundant since community- based, closely supervised care represents the highest standard of care for chronic diseases.”

J Kim, P Farmer: AIDS in 2006-Moving Toward One World, One Hope. NEJM, 2006:645-647.

Chronic Disease Management program in China

• Partner with a local CHS Center.
• 1. Detection through home-based screening
• 2. Treatment plan
• 3. Frequent contact with patients

t

The CDM Program

1.

Screening of all individuals in the capitation area (pop’n=22,507).

• 2. Enrollment of all eligible patients.
• HTN 1353
• DM 457

3.

Monthly management

Blood Pressure (>140/90 mm Hg) Blood Glucose (<7.0 mmol/L) Total Total # adults >18 yrs in the community 13,298 13,298 National prevalence rate estimates 0.188 0.026 Estimated # of patients >18 yrs in community 2500 346 Gov’t req’d # of patients to have been found (60%) 1500 207 Actual number found and records established 1353 457 Government required # patients to be under management (65%) 975 134 Number being managed 824 292

Community-based case finding

Blood Pressure (>140/90 mm Hg) Blood Glucose (<7.0 mmol/L) Male Female Total Male Female Total Number analyzed (with complete information) 252 363 615 77 93 170 Pre-management % under control 44.4% 39.1% 41.3% 46.2% 54.3% 50.6% Post-management % under control (gov’t req’d is 40%) 74.9% 72.3% 73.3% 70.1% 63.4% 68.2% Mean # visits ± S.D. 6.1± 1.9 6.2 ±1.8 6.2± 1.84.8 ± 1.7 4.6 ± 1.8 4.7 ± 1.8 Clinic utilization rate (≥2 times) 29.7% 43.5%

Results

Pre- and Post-management Blood Pressure

Pre- manage- ment Post- manage- ment Differ

• ence

T-test p value Systolic BP (mm Hg) 138.4

±16.7

130.0 ±12.9 8.4 0.00 Diastolic BP (mm Hg) 85.9

±34.7

79.3 ±7.8 6.6 0.00

Progression in mean systolic blood pressure with visit number

Importance of Controlling Mild HTN

• Patients had mild hypertension, and 41.3% of

patients had controlled blood pressure before we began managing them.

• Meta-analysis has shown that prehypertensives (130–

139/85–89 mm Hg) have increased stroke risk (RR 1.79, 95% CI 1.49–2.16), especially in nonelderly.

Lee et al. Neurology. E-publish Sept 28, 2011.

Fasting Plasma Glucose Control (n=170)

Pre- managem ent Post- manage ment Differ- ence T-test p value Mean ±SD 7.32 ±2.06 mmol/L (131.9 mg/dL) 6.72 ±1.48 mmol/L (121.1 mg/dL) 0.60 0.00 Est. A1C* 5.88% 5.57% 0.31%

Project Assessment

1.

Primary care doc

2.

Community-based clinic setting (proximity)

3.

Continuous care (move beyond responding to acute needs)

4.

Case manager and other care team members (improve patient self-management)

• Non-voluntary enrollment in a program of chronic disease management can be

effective for managing moderately elevated, but previously undetected, blood pressure and blood glucose.

• Individuals with serious hypertension or diabetes will likely seek care in tertiary

hospitals.

• Modest BP or blood glucose control to a large number of low-risk persons gives

greater reduction in population-wide burden of disease than with intensive care to a small number of patients with severe hypertension or diabetes.

Rose, G. The Strategy of Preventive Medicine. New York, Oxford Press. 1992:24.

• 3. Best Practices for Global

Partnerships in Reducing NCDs

NCD Prevention and Management Best Practices

• Community-based prevention activities
• Community-based screening and case detection
• Health professionals, including CHWs, providing

affordable, continuous care for NCD patients

• Accessible, consistent medical records

NCD Systems Best Practices

• Political will to address NCDs
• Payers amenable to funding prevention and

management of NCDs

• Sustainable, high quality healthcare systems, not just

institutions

• NCDs and primary care in medical education system
• Professionals working at the top of their credentials

Conclusion