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Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal

Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care—first-contact access, care coordination, compre...

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Autores principales: Kumar, Anirudh, Schwarz, Dan, Acharya, Bibhav, Agrawal, Pawan, Aryal, Anu, Choudhury, Nandini, Citrin, David, Dangal, Binod, Deukmedjian, Grace, Dhimal, Meghnath, Dhungana, Santosh, Gauchan, Bikash, Gupta, Tula, Halliday, Scott, Jha, Dhiraj, Kalaunee, SP, Karmacharya, Biraj, Kishore, Sandeep, Koirala, Bhagawan, Kunwar, Lal, Mahar, Ramesh, Maru, Sheela, Mehanni, Stephen, Nirola, Isha, Pandey, Sachit, Pant, Bhaskar, Pathak, Mandeep, Poudel, Sanjaya, Rajbhandari, Irina, Raut, Anant, Rimal, Pragya, Schwarz, Ryan, Shrestha, Archana, Thapa, Aradhana, Thapa, Poshan, Thapa, Roshan, Wong, Lena, Maru, Duncan
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6509610/
https://www.ncbi.nlm.nih.gov/pubmed/31139453
http://dx.doi.org/10.1136/bmjgh-2018-001343
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author Kumar, Anirudh
Schwarz, Dan
Acharya, Bibhav
Agrawal, Pawan
Aryal, Anu
Choudhury, Nandini
Citrin, David
Dangal, Binod
Deukmedjian, Grace
Dhimal, Meghnath
Dhungana, Santosh
Gauchan, Bikash
Gupta, Tula
Halliday, Scott
Jha, Dhiraj
Kalaunee, SP
Karmacharya, Biraj
Kishore, Sandeep
Koirala, Bhagawan
Kunwar, Lal
Mahar, Ramesh
Maru, Sheela
Mehanni, Stephen
Nirola, Isha
Pandey, Sachit
Pant, Bhaskar
Pathak, Mandeep
Poudel, Sanjaya
Rajbhandari, Irina
Raut, Anant
Rimal, Pragya
Schwarz, Ryan
Shrestha, Archana
Thapa, Aradhana
Thapa, Poshan
Thapa, Roshan
Wong, Lena
Maru, Duncan
author_facet Kumar, Anirudh
Schwarz, Dan
Acharya, Bibhav
Agrawal, Pawan
Aryal, Anu
Choudhury, Nandini
Citrin, David
Dangal, Binod
Deukmedjian, Grace
Dhimal, Meghnath
Dhungana, Santosh
Gauchan, Bikash
Gupta, Tula
Halliday, Scott
Jha, Dhiraj
Kalaunee, SP
Karmacharya, Biraj
Kishore, Sandeep
Koirala, Bhagawan
Kunwar, Lal
Mahar, Ramesh
Maru, Sheela
Mehanni, Stephen
Nirola, Isha
Pandey, Sachit
Pant, Bhaskar
Pathak, Mandeep
Poudel, Sanjaya
Rajbhandari, Irina
Raut, Anant
Rimal, Pragya
Schwarz, Ryan
Shrestha, Archana
Thapa, Aradhana
Thapa, Poshan
Thapa, Roshan
Wong, Lena
Maru, Duncan
author_sort Kumar, Anirudh
collection PubMed
description Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care—first-contact access, care coordination, comprehensiveness and continuity—offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular ‘at-goal’ metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. ‘At-goal’ status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.
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spelling pubmed-65096102019-05-28 Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal Kumar, Anirudh Schwarz, Dan Acharya, Bibhav Agrawal, Pawan Aryal, Anu Choudhury, Nandini Citrin, David Dangal, Binod Deukmedjian, Grace Dhimal, Meghnath Dhungana, Santosh Gauchan, Bikash Gupta, Tula Halliday, Scott Jha, Dhiraj Kalaunee, SP Karmacharya, Biraj Kishore, Sandeep Koirala, Bhagawan Kunwar, Lal Mahar, Ramesh Maru, Sheela Mehanni, Stephen Nirola, Isha Pandey, Sachit Pant, Bhaskar Pathak, Mandeep Poudel, Sanjaya Rajbhandari, Irina Raut, Anant Rimal, Pragya Schwarz, Ryan Shrestha, Archana Thapa, Aradhana Thapa, Poshan Thapa, Roshan Wong, Lena Maru, Duncan BMJ Glob Health Practice Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care—first-contact access, care coordination, comprehensiveness and continuity—offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular ‘at-goal’ metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. ‘At-goal’ status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions. BMJ Publishing Group 2019-04-29 /pmc/articles/PMC6509610/ /pubmed/31139453 http://dx.doi.org/10.1136/bmjgh-2018-001343 Text en © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
spellingShingle Practice
Kumar, Anirudh
Schwarz, Dan
Acharya, Bibhav
Agrawal, Pawan
Aryal, Anu
Choudhury, Nandini
Citrin, David
Dangal, Binod
Deukmedjian, Grace
Dhimal, Meghnath
Dhungana, Santosh
Gauchan, Bikash
Gupta, Tula
Halliday, Scott
Jha, Dhiraj
Kalaunee, SP
Karmacharya, Biraj
Kishore, Sandeep
Koirala, Bhagawan
Kunwar, Lal
Mahar, Ramesh
Maru, Sheela
Mehanni, Stephen
Nirola, Isha
Pandey, Sachit
Pant, Bhaskar
Pathak, Mandeep
Poudel, Sanjaya
Rajbhandari, Irina
Raut, Anant
Rimal, Pragya
Schwarz, Ryan
Shrestha, Archana
Thapa, Aradhana
Thapa, Poshan
Thapa, Roshan
Wong, Lena
Maru, Duncan
Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal
title Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal
title_full Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal
title_fullStr Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal
title_full_unstemmed Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal
title_short Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal
title_sort designing and implementing an integrated non-communicable disease primary care intervention in rural nepal
topic Practice
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6509610/
https://www.ncbi.nlm.nih.gov/pubmed/31139453
http://dx.doi.org/10.1136/bmjgh-2018-001343
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