Improving primary care for diabetes and hypertension: findings from implementation research in rural South India

The Effectiveness of Collaborative Advanced Practice Nursing in Primary Hypertension Management: A Randomized Controlled Trial

BACKGROUND

Hypertension is a global health concern that is best managed at the primary care level. In low- and middle-income countries (LMICs) facing resource constraints, collaboration between well-prepared entry-level advanced practice nurses (APNs) and physicians (medical doctors [MDs]) can enhance the care of patients with primary hypertension.

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of collaborative entry-level APNs in primary hypertension management, including patient knowledge, physiological and behavioral outcomes, consultation length, and patient satisfaction.

METHODS

Sixty-three eligible patients were randomly assigned to either an entry-level APN intervention group or a control group with MDs. Three master's-prepared nurses, trained in hypertension management, acted as entry-level APNs, following the Joint National Committee guidelines in collaboration with a physician. The control group underwent standard clinic consultations. After 1 month, a mixed analysis of variance was used to assess intervention effectiveness, examining both between-groups and within-groups outcomes.

RESULTS

Both groups shared similar sociodemographic and baseline characteristics. Significant improvements in blood pressure, body mass index, knowledge, self-management, and medication adherence were found at the 1-month follow-up, with no significant differences in outcomes or patient satisfaction between the entry-level APN and MD groups. However, clinical consultation time was significantly longer for entry-level APNs than for MDs.

CONCLUSIONS

Collaborative entry-level APNs managing primary hypertension are comparable with MD care; however, larger, longer trials are essential for a thorough assessment. Strengthening the development of entry-level advanced practice nursing roles in low- and middle-income countries is crucial for addressing service gaps in primary hypertension and other chronic diseases.

The Effect of Telehealth on Patterns of Health Care Utilization and Medication Prescription in Patients with Diabetes or Hypertension During COVID-19: A Nationwide Study

Background: In response to the coronavirus disease-19 pandemic, audio-based telehealth services for consultation and medication prescription were temporarily introduced in Korea. This study investigated the impact of telehealth services on patterns of health care utilization and medication prescription in patients with hypertension or diabetes. Methods: The 2019 to 2021 Health Insurance Review and Assessment Service claims data were used. The difference-in-difference approach was used to investigate the effect of telehealth services between the case and control group before and after the intervention period. The pre-intervention period was from February 24, 2019, to February 23, 2020, and the post-intervention period from February 24, 2020, to February 23, 2021. The control group included individuals who used in-person outpatient services and the case group those who utilized both telehealth and in-person services. Results: A total of 250,640 patients with hypertension and 154,212 patients with diabetes were included. The use of telehealth services was associated with an increase in outpatient visits in those with hypertension (0.07, p = 0.0027) and diabetes (0.32, p < 0.0001). A decrease in hospitalizations (-0.2%, p = 0.0007) and emergency department visits (-0.11%, p = 0.0016) was found in individuals with hypertension. Policy implementation also resulted in an increase in medication possession ratio (MPR) and the proportion of appropriate prescription in patients with hypertension (MPR: 3.0%, p < 0.0001, prescription: 3.1%, p < 0.0001) and diabetes (MPR: 3.4%, p < 0.0001, prescription: 1.7%, p < 0.0001). Conclusions: The findings confirm a relationship between implementing telehealth services and improved patterns of health care utilization and medication prescription, suggesting the potential benefit of telehealth in managing chronic diseases.

'Oxidative stress'-A new target in the management of diabetes mellitus

Diabetes mellitus (DM) is a chronic condition that poses a mammoth challenge for the healthcare system in developing as well as developed nations. Diabetes mellitus is associated with damage to the vasculature which leads to microvascular and macrovascular complications. Oxidative stress is a consequence of glucotoxicity and lipotoxicity, which are associated with diabetes. Glucotoxicity and lipotoxicity play a part in the pathogenesis of β-cell dysfunction. The hyperglycemic state in DM leads to oxidative stress which further hampers insulin secretion. In diabetes, the biological antioxidants also get depleted along with a reduction in glutathione (GSH), an increase in the oxidized glutathione (GSSG)/GSH ratio, and a depletion of non-enzymatic antioxidants. This results in the formation of a viscous circle of hyperglycemia leading to increased oxidative stress that further hampers insulin secretion which in turn results in hyperglycemia. Antioxidants are efficacious in reducing diabetic complications. The antioxidants produced biologically fall short, hence external supplements are required. In this review, the authors have discussed the relationship between oxidative stress in DM and the advantages of antioxidant supplements in controlling blood glucose levels and also in deaccelerating the complications related to DM.

Developing an integrated model of care for vulnerable populations living with non-communicable diseases in Lebanon: an online theory of change workshop

INTRODUCTION

The Syrian crisis, followed by a financial crisis, port explosion, and COVID-19, have put enormous strain on Lebanon's health system. Syrian refugees and the vulnerable host population have a high burden of Non-communicable Diseases (NCD) morbidity and unmet mental health, psychosocial and rehabilitation needs. The International Committee of the Red Cross (ICRC) recently introduced integrated NCD services within its package of primary care in Lebanon, which includes NCD primary health care, rehabilitation, and mental health and psychosocial support services. We aimed to identify relevant outcomes for people living with NCDs from refugee and host communities in northern Lebanon, as well as to define the processes needed to achieve them through an integrated model of care. Given the complexity of the health system in which the interventions are delivered, and the limited practical guidance on integration, we considered systems thinking to be the most appropriate methodological approach.

METHODS

A Theory of Change (ToC) workshop and follow-up meetings were held online by the ICRC, the London School of Hygiene and Tropical Medicine and the American University of Beirut in 2021. ToC is a participatory and iterative planning process involving key stakeholders, and seeks to understand a process of change by mapping out intermediate and long-term outcomes along hypothesised causal pathways. Participants included academics, and ICRC regional, coordination, and headquarters staff.

RESULTS

We identified two distinct pathways to integrated NCD primary care: a multidisciplinary service pathway and a patient and family support pathway. These were interdependent and linked via an essential social worker role and a robust information system. We also defined a list of key assumptions and interventions to achieve integration, and developed a list of monitoring indicators.

DISCUSSION

ToC is a useful tool to deconstruct the complexity of integrating NCD services. We highlight that integrated care rests on multidisciplinary and patient-centred approaches, which depend on a well-trained and resourced team, strong leadership, and adequate information systems. This paper provides the first theory-driven road map of implementation pathways, to help support the integration of NCD care for crises-affected populations in Lebanon and globally.

Integrating eye care in low-income and middle-income settings: a scoping review

OBJECTIVES

Integrated people-centred eye care has been recommended as a strategic framework for reducing global vision impairment and blindness. The extent to which eye care has integrated with other services has not been widely reported. We aimed to investigate approaches to integrating eye care service delivery with other systems in low resource settings, and identify factors associated with integration.

DESIGN

Rapid scoping review based on Cochrane Rapid Review and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

MEDLINE, Embase, Web of Science, Scopus and Cochrane Library databases were searched in September 2021.

ELIGIBILITY CRITERIA

Papers with interventions involving eye care or preventative eye care integrated into other health systems, peer-reviewed in English, conducted in low-income or middle-income countries, and published between January 2011 and September 2021 were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened, quality appraised and coded included papers. A deductive-inductive iterative analysis approach was used with a focus on integrating service delivery.

RESULTS

The search identified 3889 potential papers, of which 24 were included. Twenty papers incorporated more than one intervention type (promotion, prevention and/or treatment), but none included rehabilitation. Most articles involved human resources development yet rarely appeared to be people-centred. The level of integration was associated with building relationships and enhancing service coordination. Integrating human resources was challenged by the need for ongoing support and worker retention. In primary care settings, workers were often already at full capacity, had competing priorities, varying capabilities and limited motivation. Additional barriers included inadequate referral and information systems, poor supply chain management and procurement practices and finite financing.

CONCLUSION

Integrating eye care into low resource health systems is a challenging task, compounded by resource limitations, competing priorities and ongoing support needs. This review highlighted a need for people-centred approaches to future interventions, and further investigation into integrating vision rehabilitation services.

Prevalence, Awareness, Treatment and Control of Diabetes in India From the Countrywide National NCD Monitoring Survey

Background

To determine the prevalence, awareness, treatment and control of diabetes mellitus (DM) and associated factors amongst adults (18–69 years) in India from the National Noncommunicable Disease Monitoring Survey (NNMS).

Methods

NNMS was a comprehensive, cross-sectional survey conducted in 2017–18 on a national sample of 12,000 households in 600 primary sampling units. In every household, one eligible adult aged 18–69 years were selected. Information on NCD risk factors and their health-seeking behaviors were collected. Anthropometric measurements, blood pressure and fasting capillary blood glucose were measured. DM was defined as fasting blood glucose (FBG) ≥126 mg/dl including those on medication. Awareness, treatment, and control of DM were defined as adults previously diagnosed with DM by a doctor, on prescribed medication for DM, and FBG &lt;126 mg/dl, respectively. The weighted data are presented as mean and proportions with 95% CI. We applied the Student t-test for continuous variables, Pearson's chi-square test for categorical variables and multivariate regression to determine the odds ratio. For statistical significance, a p-value &lt; 0.05 was considered.

Results

Prevalence of DM and impaired fasting blood glucose (IFG) in India was 9.3% and 24.5% respectively. Among those with DM, 45.8% were aware, 36.1% were on treatment and 15.7% had it under control. More than three-fourths of adults approached the allopathic practitioners for consultation (84.0%) and treatment (78.8%) for diabetes. Older adults were associated with an increased risk for DM [OR 8.89 (95% CI 6.66–11.87) and were 16 times more aware of DM. Better awareness, treatment and control levels were seen among adults with raised blood pressure and raised cholesterol.

Conclusions

The prevalence of DM and IFG is high among adults, while the levels of awareness, treatment and control are still low in India, and this varied notably between the age groups. Multifaceted approaches that include improved awareness, adherence to treatment, better preventive and counseling services are crucial to halt diabetes in India. Also, expanding traditional systems of medicine (Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy [AYUSH]) into diabetes prevention and control practices open solutions to manage this crisis.

Lessons for the Design of Comprehensive Primary Healthcare in India: A Qualitative Study

Health systems with strong comprehensive primary health care (CPHC) are known to result in better health outcomes for people. In India, there is a recent push to strengthen CPHC through Ayushman Bharat. This study aimed to document lessons from successful CPHC initiatives in rural and urban India using a qualitative case study approach. A total of 72 CPHC initiatives were identified through desk review and 12 of these were studied as cases. The following two main models of CPHC delivery were seen in India: (a) a hospital or health centre with outreach and (b) social franchising model, prevalent in rural and urban contexts, respectively. Themes identified were related to organisation of services, workforce, financing and challenges in practice. Services being comprehensive, dialoguing with the community, addressing social determinants were themes under organisation of services. There is need for more generalists and training health professionals towards CPHC. Financing of CPHC especially in the rural context remains a major challenge and cannot be sustained with user fees. Leadership, values, team-based care and organisational culture play a vital role in the delivery of good quality CPHC. These findings contribute to the literature on what works and why, which could be used to design CPHC in India.