Sandeep Bhalla

Adherence to diabetes care processes at general practices in the National Capital Region-Delhi, India

Aim: To assess the level of adherence to diabetes care processes, and associated clinic and patient factors at general practices in Delhi, India. Methods: We interviewed physicians (n = 23) and patients with diabetes (n = 406), and reviewed patient charts at general practices (government = 5; private = 18). We examined diabetes care processes, specifically measurement of weight, blood pressure (BP), glycated hemoglobin (HbA1c), lipids, electrocardiogram, dilated eye, and a foot examination in the last one year. We analyzed clinic and patient factors associated with a number of care processes achieved using multilevel Poisson regression model. Results: The average number of clinic visits per patient was 8.8/year (standard deviation = 5.7), and physicians had access to patients previous records in only 19.7% of patients. Dilated eye exam, foot exam, and electrocardiogram were completed in 7.4%, 15.1%, and 29.1% of patients, respectively. An estimated 51.7%, 88.4%, and 28.1% had ≥1 measurement of HbA1c, BP, and lipids, respectively. Private clinics, physician access to patients previous records, use of nonphysicians, patient education, and the presence of diabetes complication were positively associated with a number of care processes in the multivariable model. Conclusion: Adherence to diabetes care processes was suboptimal. Encouraging implementation of quality improvement strategies like Chronic Care Model elements at general practices may improve diabetes care.

Innovation in capacity building of primary-care physicians in diabetes management in India: a new slant in medical education

India is home to more than 69 million individuals with diabetes, and this fi gure is expected to rise to 123 million by 2040.1 In view of the low doctor-to-population ratio (1:1800),2 uneven distribution of specialists (most of whom are in urban areas), and the fact that most initial diagnoses of dia betes (about 70%) are made by nonspecialists, one key to eff ectively tackling the challenge of diabetes is to strengthen primary health care

Drugs for cardiovascular disease in India: perspectives of pharmaceutical executives and government officials on access and development-a qualitative analysis

BackgroundIndia shoulders the greatest global burden of cardiovascular diseases (CVDs), which are the leading cause of mortality worldwide. Drugs are the bedrock of treatment and prevention of CVD. India’s pharmaceutical industry is the third largest, by volume, globally, but access to CVD drugs in India is poor. There is a lack of qualitative data from government and pharmaceutical sectors regarding CVD drug development and access in India.MethodsBy purposive sampling, we recruited either Indian government officials, or pharmaceutical company executives. We conducted a stakeholder analysis via semi-structured, face-to-face interviews in India. Topic guides allow for the exploration of key issues across multiple interviews, along with affording the interviewer the flexibility to examine matters arising from the discussions themselves. After transcription, interviews underwent inductive thematic analysis.ResultsTen participants were interviewed (Government Officials: n = 5, and Pharmaceutical Executives: n = 5). Two themes emerged: i) ‘Policy-derived Factors’; ii) ‘Patient- derived Factors’ with three findings. First, both government and pharmaceutical participants felt that the focus of Indian pharma is shifting to more complex, high-quality generics and to new drug development, but production of generic drugs rather than new molecular entities will remain a major activity. Second, current trial regulations in India may restrict India’s potential role in the future development of CVD drugs. Third, it is likely that the Indian government will tighten its intellectual property regime in future, with potentially far-reaching implications on CVD drug development and access.ConclusionsOur stakeholder analysis provides some support for present patent regulations, whilst suggesting areas for further research in order to inform future policy decisions regarding CVD drug development and availability. Whilst interviewees suggested government policy plays an important role in shaping the industry, a significant force for change was ascribed to patient-derived factors. This suggests a potential role for Indian initiatives that market the unique advantages of its patient population for drug research in influencing national and multinational pharmaceutical companies to undertake CVD drug development in India, rather than simply IP policy-directed factors.

Improving primary care physicians' capacity: A pan India initiative on management of chronic obstructive pulmonary disease and asthma

1. Stedman TL. Stedman’s Medical Dictionary. 28th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006. p. 872. 2. Dixit R, Singh N, Gupta RC. Management issues in haemoptysis: More questions than answers. Indian J Chest Dis Allied Sci 2013;55:237‐8. 3. Halezeroğlu S, Okur E. Thoracic surgery for haemoptysis in the context of tuberculosis: What is the best management approach? J Thorac Dis 2014;6:182‐5. 4. Bertolaccini L, Viti A, Di Perri G, Terzi A. Surgical treatment of pulmonary tuberculosis: The phoenix of thoracic surgery? J Thorac Dis 2013;5:198‐9. 5. Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis 2017;9:S1069‐86.

Improving access to medicines via the Health Impact Fund in India: a stakeholder analysis

ABSTRACT Background: In India, 50–65% of the population face difficulties in accessing medicines. The Health Impact Fund (HIF) is a novel proposal whereby pharmaceutical companies would be paid based on the measured global health impact of their drugs. We conducted a key stakeholder analysis to explore access to medicines in India, acceptability of the HIF and potential barriers and facilitators at policy level. Objectives: To conduct a stakeholder analysis of the HIF in India: to determine key stakeholder views regarding access to medicines in India; to evaluate acceptability of the HIF; and to assess potential barriers and facilitators to the HIF as a policy. Methods: In New Delhi, we conducted semi-structured interviews. There was purposive recruitment of participants with snowball sampling. Transcribed data were analysed using stakeholder analysis frameworks and directed content analysis. Results: Participation rate was 29% (14/49). 14 semi-structured interviews were conducted among stakeholders in New Delhi. All participants highlighted access to medicines as a problem in India. There were mixed views about the HIF in terms of relevance and scaleability. Stakeholders felt it should focus on diseases with limited or no market and potentially incorporate direct investment in research. Conclusions: First, access to medicines is perceived to be a major problem in India by all stakeholders, but affordability is just one factor. Second, stakeholders despite considerable support for the idea of the HIF, there are major concerns about scaleability, generalisability and impact on access to medicines. Third, the HIF and other novel drug-related health policies can afford to be more radical, e.g. working outside the existing intellectual property rights regime, targeting generic as well as branded drugs, or extending to research and development. Further innovations in access to medicines must involve country-specific key stakeholders in order to increase the likelihood of their success.

Gestational diabetes mellitus training: A well-grounded approach for safeguarding two generations

Diabetes is one of the major medical disorders complicating pregnancy, and it is associated with several risks to unborn child, which can be prevented by early detection and appropriate treatment of maternal hyperglycemia.[1] International Diabetes Federation (IDF) estimated that 20.9 million women suffered from some form of hyperglycemia during pregnancy.[1] In India, it has been estimated that nearly 4 million women had GDM in 2015.[2] Providing screening and care to mothers at risk is therefore likely to have multigenerational impact.

MPS 17-03 A unique model for capacity building of primary care physicians in management of chronic conditions in India

Objective: To describe the model adopted for the capacity building of PCPs in management of chronic conditions in India. Design and Method: An innovative collaborative model between Public Health Foundation of India (PHFI), Delhi and academic partners supported by an educational grant from a stakeholder was designed. The initiatives were implemented with an objective to enhance knowledge, skills and core competencies of Primary Care Physicians (PCP) in the management of chronic conditions. An evidence based curriculum was developed by the academic partners and was later reviewed by national experts in their respective fields. Regional faculties that are specialists in the field delivered the course content to the PCPs. The course comprises of didactic lectures, case studies and instructional videos. We established a strong monitoring and evaluation mechanism comprising of on-site random visits by a team of observers who were drawn from a national pool of public health experts. Results: Seven initiatives have been implemented so far on various chronic conditions including diabetes mellitus, thyroid disorders, hypertension, COPD & asthma. More than 11,500 participants from 531 of the 676 districts (78%) in India have been enrolled in these initiatives till date. The mean age of participants enrolled is 39 years with a clinical experience of 13 years. Over 30% of the participants were affiliated to public sector and 38 % were post- graduates (MD/MS/DNB). The model has been accepted by various state governments for training their medical officers. Some of these programs have received recognition from the International Diabetes Federation & South Asian Federation of Endocrine Societies. One of the initiatives was the finalist in the excellence in medical education category of BMJ awards India, 2014. Conclusions: The success of this model in the Indian setting implies its use in other developing countries with similar backgrounds to effectively manage the increasing burden of chronic conditions.

PS 15-23 CERTIFICATE COURSE IN MANAGEMENT OF HYPERTENSION: AN INNOVATIVE CAPACITY BUILDING MODEL FOR PRIMARY CARE PHYSICIANS (PCPs) IN INDIA.

Objective: Develop and deploy a novel multiple stakeholder model for capacity building to enhance knowledge, skills and core competencies of PCPs in the management of hypertension. Design and Method: A partnership between the Public Health Foundation of India, International Society of Hypertension, British Hypertension Society and Centre for Chronic Disease Control was developed to design a countrywide course for PCPs. This partnership brought together public health experts in India to manage the logistics and delivery of the programme on a country wide basis and develop the curriculum with advice and oversight from international hypertension societies. Results: Twenty five regional centers in 14 states of India have been identified for the implementation of the program with a cardiologist/medicine specialist as the faculty for each centre. The faculty will be trained by a panel of national experts on the course curriculum that has been formulated by the partners. The course will be delivered as monthly modules over 10 months with integrated monitoring and evaluation. The program is expected to train 1000 PCPs over a period of two years. Conclusions: A partnership model for capacity building has been designed to train PCPs in the effective management of hypertension with enormous potential for reducing the burden and mortality associated with raised blood pressure.