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 Single disease. NCDs are a collection of disease. the health New and highly visible health Not perceived as a novel threat. challenge in a threat. A variety of treatments. clear and ART shown to be highly Seen as disease of the elderly, or the compelling way effective. wealthy. Humanitarian crisis. Secure the 1996 UN established UNAIDS. Low awareness, especially where ID is still support of Activists effectively high. strong destigmatized AIDS. Some multisectoral partnerships individuals and established (NCD Alliance in 2009, WHO organizations GCM/NCD 2014). Advocacy 90’s/00’s era of economic 2008 global economic downturn. operates in a growth. Perceived as a disease of preventable variety of key Long-term commitments from behaviors. environments the Global Fund, PEPFAR. No “NCDs PEPFAR.” Included in the MDGs. 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
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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
Community-based case finding Blood Pressure Blood Glucose (>140/90 mm Hg) (<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 2500 346 community Gov’t req’d # of patients to have been 1500 207 found (60%) Actual number found and records 1353 457 established Government required # patients to be under 975 134 management (65%) Number being managed 824 292
Results Blood Pressure Blood Glucose (<7.0 (>140/90 mm Hg) mmol/L) Male Female Total Male Female Total Number analyzed (with 252 363 615 77 93 170 complete information) Pre-management % under 44.4% 39.1% 41.3% 46.2% 54.3% 50.6% control Post-management % under 74.9% 72.3% 73.3% 70.1% 63.4% 68.2% control (gov’t req’d is 40%) Mean # visits ± S.D. 6.1 ± 6.2 6.2 ± 1.84.8 ± 1.7 4.6 ± 4.7 ± 1.9 1.8 1.8 ± 1.8 Clinic utilization rate (≥2 29.7% 43.5% times)
Pre- and Post-management Blood Pressure Pre- Post- Differ T-test manage- manage- -ence p ment ment value Systolic 138.4 130.0 8.4 0.00 BP (mm ± 16.7 ± 12.9 Hg) Diastolic 85.9 79.3 6.6 0.00 BP (mm ± 34.7 ± 7.8 Hg)
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- Post- Differ- T-test p managem manage ence value ent ment 7.32 6.72 ± 2.06 ± 1.48 Mean mmol/L mmol/L 0.60 ± SD (131.9 (121.1 0.00 mg/dL) mg/dL) Est. 5.88% 5.57% 0.31% A1C*
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
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