Preeti Kudesia

Capitalizing on the Demographic Transition: Tackling Noncommunicable Diseases in South Asia

This book looks primarily at Cardio Vascular Disease (CVD) and tobacco use because they account for a disproportionate amount of the Non Communicable Disease (NCD) burden the focus is strategic rather than comprehensive. It considers both country and regional level approaches for tackling NCDs, as many of the issues and challenges of mounting an effective response are common to most South Asian countries. The prevention and control of NCDs constitute a development issue that low-income countries in South Asia are already facing. Both country and regional-level strategies are important because many of the issues and challenges of mounting an effective response to NCDs are common to most South Asian countries, even though their disease burden profiles vary. Hence, the rationale for this book is that strategic decisions for prevention and treatment of NCDs can effectively address the future burden of disease, promote healthy aging, and increase the potential benefit from the demographic transition, thus contributing to economic development. This books goal is to encourage countries to develop, adopt, and implement effective and timely country and regional responses that reduce the population-level risk factors and NCD disease burden.

Quality Improvement for Cardiovascular Disease Care in Low- and Middle-Income Countries: A Systematic Review.

Background The majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care. Objectives As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs. Methods We conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD. Results From 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months. Conclusions The results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs.

Cardiovascular, respiratory, and related disorders: key messages from Disease Control Priorities, 3rd edition

Cardiovascular, respiratory, and related disorders (CVRDs) are the leading causes of adult death worldwide, and substantial inequalities in care of patients with CVRDs exist between countries of high income and countries of low and middle income. Based on current trends, the UN Sustainable Development Goal to reduce premature mortality due to CVRDs by a third by 2030 will be challenging for many countries of low and middle income. We did systematic literature reviews of effectiveness and cost-effectiveness to identify priority interventions. We summarise the key findings and present a costed essential package of interventions to reduce risk of and manage CVRDs. On a population level, we recommend tobacco taxation, bans on trans fats, and compulsory reduction of salt in manufactured food products. We suggest primary health services be strengthened through the establishment of locally endorsed guidelines and ensured availability of essential medications. The policy interventions and health service delivery package we suggest could serve as the cornerstone for the management of CVRDs, and afford substantial financial risk protection for vulnerable households. We estimate that full implementation of the essential package would cost an additional US

Quality Improvement in Cardiovascular Disease Care

21 per person in the average low-income country and

Regional Aging and Disease Burden

24 in the average lower-middle-income country. The essential package we describe could be a starting place for low-income and middle-income countries developing universal health coverage packages. Interventions could be rolled out as disease burden demands and budgets allow. Our outlined interventions provide a pathway for countries attempting to convert the UN Sustainable Development Goal commitments into tangible action.

Rationale for Action

This chapter reviews the diagnosis and treatment of cardiovascular disease in lowand middle-income countries (LMICs) with a view to improving the quality of care. In keeping with the Institute of Medicine’s definition of quality as the “degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Lohr 1990, 4), the focus is on studies of specific interventions and measurable health outcomes. Because the resources available to support health care delivery in LMICs are scarce, this chapter seeks to improve clinical quality by getting the most out of known effective interventions within the limits of available resources rather than recommending unproven interventions that require early-phase studies or substantial investment to scale up. Clinical quality can be improved anywhere and at any time and doing so need not be expensive. Quality standards and measures contain principles that can be compared and shared across countries and local settings. However, quality care delivery in lowresource settings does not necessarily mean dissemination and implementation of a universal set of standards— especially those formulated for cardiovascular diseases in high-income countries (HICs). Standards and interventions should be dictated by context and community capacity. Adaptation to the local setting is necessary for achieving optimal clinical outcomes and patient satisfaction. A conceptual framework guided this chapter. The authors specified four domains, cutting across two distinct phases of cardiovascular disease (acute versus chronic) and two levels of intervention (health system versus patientprovider) (table 18.1). Health system–level interventions include those directly targeting one or more of the six “building blocks of a health system” as defined by the World Health Organization (2007). Patient-provider-level interventions are focused on influencing patient or provider behavior. Acute phases of cardiovascular disorders, such as acute myocardial infarction, stroke, and limb ischemia, occur unpredictably. Good outcomes demand timely clinical responses, which require adequate and accessible facilities, functional transportation networks, providers prepared to treat cases that present at all hours, and patient awareness of when and how to seek medical attention. In contrast, chronic phases of cardiovascular disorders, such as diabetes mellitus, hypertension, and congestive heart failure, require screening for preclinical risk factors, systematic monitoring for complications, and substantial