Decentralisation, health and Sustainable Development Goal 3

SETTING

Kerala State, India, implemented decentralising reforms of healthcare institutions 25 years ago through transfer of administrative control and a sizeable share of the financial allocation.

OBJECTIVE

To describe the main impacts of decentralisation in Kerala on local policy formulation, programme implementation and service delivery for sustainable health systems.

DESIGN

This was part of a broader qualitative study on decentralisation and health in Kerala. We conducted 25 in-depth interviews and reviewed 31 government orders or policy documents, five related transcripts and five thematic reports from the main study.

RESULTS

Liaising between health system and local governments has improved over time. A shift from welfare-centric projects to infrastructure, human resources and services was evident. Considerable heterogeneity existed due to varying degrees of involvement, capacity, resources and needs of the community. State-level discourse and recent augmentation efforts for moving towards the UN Sustainable Development Goals (SDGs) strongly uphold the role of local governments in planning, financing and implementation.

CONCLUSION

The 25-year history of decentralised healthcare administration in Kerala indicates both successes and failures. Central support without disempowering the local governments can be a viable option to allow flexible decision-making consistent with broader system goals.

Re-engineering primary healthcare in Kerala

INTRODUCTION

In the backdrop of the Sustainable Development Goals (SDGs), the state of Kerala, India, revamped its existing primary health centres (PHCs) into people-friendly family health centres (FHCs) in order to provide comprehensive primary care as part of a mission-based ('Aardram') initiative. It was envisioned that the mission's implementation and operation would make use of decentralised governance. The present study explored how the decentralised governance influenced reorganisation of primary care.

METHODS

The study adopted an exploratory approach using qualitative methods: key informant interviews (n = 8), in-depth interviews (n = 20) and document reviews. Thematic analysis was done following deductive coding and the themes that emerged were organised under a schema.

RESULTS

The results could be summarised under five overarching themes. Strong political commitment, combined with bureaucratic competence, facilitated implementation and functioning of 'Aardram' primary care. The insights developed through multi-sectoral training helped local governments (LGs) get involve and engage with the health system as a team in order to plan and implement interventions. The decentralised governance structures enabled re-engineering of PHCs by mobilisation of financial resources, provision of human resources, infrastructure modification, and enhanced community participation at various levels. Non-uniformity of commitment, sub-optimal engagement of urban LGs and issues of sustainability and monitoring were the shortcomings observed.

CONCLUSION

Decentralised governance played a positive role in the re-engineering of PHCs, which was utilised as a platform to demonstrate best practices in health governance through a participatory approach. The importance of empowering LGs through capacity building to address challenges in achieving primary care SDGs is highlighted in this study.

A176 ASSOCIATIONS OF ANTIBIOTICS, HORMONAL THERAPIES, ORAL CONTRACEPTIVES, AND LONG-TERM NSAIDS WITH INFLAMMATORY BOWEL DISEASE: RESULTS FROM THE PROSPECTIVE URBAN RURAL EPIDEMIOLOGY (PURE) STUDY

Background

The pathogenesis of inflammatory bowel disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC), is believed to involve activation of the intestinal immune system in response to the gut microbiome among genetically susceptible hosts. IBD has been historically regarded as a disease of developed nations, though in the past two decades there has been a reported shift in the epidemiological pattern of disease. High-income nations with known high prevalence of disease are seeing a stabilization of incident cases, while a rapid rise of incident IBD is being observed in developing nations. This suggests that environmental exposures may play a role in mediating the risk of developing IBD. The potential environmental determinants of IBD across various regions is vast, though medications have been increasingly recognized as one broad category of risk factors.

Purpose

Several medications have been considered to contribute to the etiology of IBD. This study assessed the association between medication use and risk of developing IBD using the Prospective Urban Rural Epidemiology (PURE) cohort.

Method

This was a prospective cohort study of 133,137 individuals between the ages of 20-80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed prospectively at least every 3 years. The main outcome was development of IBD, including CD and UC. Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) was evaluated. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Result(s)

During the median follow-up of 11.0 years [interquartile range (IQR) 9.2-12.2], we recorded 571 incident cases of IBD (143 CD and 428 UC). Higher risk of incident IBD was associated with baseline antibiotic use [aOR: 2.81 (95% CI: 1.67-4.73), p=0.0001] and hormonal medication use [aOR: 4.43 (95% CI: 1.78-11.01), p=0.001]. Among females, previous or current oral contraceptive use was also associated with IBD development [aOR: 2.17 (95% CI: 1.70-2.77), p=5.02E-10]. NSAID users were also observed to have increased risk of IBD [aOR: 1.80 (95% CI: 1.23-2.64), p=0.002], which was driven by long-term users [aOR: 5.58 (95% CI: 2.26-13.80), p<0.001]. All significant results were consistent in direction for CD and UC with low heterogeneity.

Conclusion(s)

Antibiotics, hormonal medications, oral contraceptives, and long-term NSAID use were associated with increased odds of incident IBD after adjustment for covariates.

Please acknowledge all funding agencies by checking the applicable boxes below

Other

Please indicate your source of funding below:

Salim Yusuf is supported by the Heart & Stroke Foundation/Marion W. Burke Chair in Cardiovascular Disease. The PURE Study is an investigator-initiated study funded by the Population Health Research Institute, the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Ontario, support from CIHR’s Strategy for Patient Oriented Research (SPOR) through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies, with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithkline, and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries; these include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases; Colombia: Colciencias, grant number 6566-04-18062; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia, grant numbers 100 -IRDC/BIOTEK 16/6/21 (13/2007) and 07-05-IFN-BPH 010, Ministry of Higher Education of Malaysia grant number 600 -RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the UN Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research & Development; Poland: Polish Ministry of Science and Higher Education grant number 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number RG -1436-013); South Africa: the North-West University, SANPAD (SA and Netherlands Programme for Alternative Development), National Research Foundation, Medical Research Council of SA, The SA Sugar Association (SASA), Faculty of Community and Health Sciences (UWC); Sweden: grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemasons Foundation, AFA Insurance, Swedish Council for Working Life and Social Research, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, grant from the Swedish State under the Läkar Utbildnings Avtalet agreement, and grant from the Västra Götaland Region; Turkey: Metabolic Syndrome Society, AstraZeneca, Turkey, Sanofi Aventis, Turkey; United Arab Emirates (UAE): Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai UAE.

Disclosure of Interest

C. Pray: None Declared, N. Narula Grant / Research support from: Neeraj Narula holds a McMaster University Department of Medicine Internal Career Award. Neeraj Narula has received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, and Ferring, E. C. Wong: None Declared, J. K. Marshall Grant / Research support from: John K. Marshall has received honoraria from Janssen, AbbVie, Allergan, Bristol-Meyer-Squibb, Ferring, Janssen, Lilly, Lupin, Merck, Pfizer, Pharmascience, Roche, Shire, Takeda and Teva., S. Rangarajan: None Declared, S. Islam: None Declared, A. Bahonar: None Declared, K. F. Alhabib: None Declared, A. Kontsevaya: None Declared, F. Ariffin: None Declared, H. U. Co: None Declared, W. Al Sharief: None Declared, A. Szuba: None Declared, A. Wielgosz: None Declared, M. L. Diaz: None Declared, R. Yusuf: None Declared, L. Kruger: None Declared, B. Soman: None Declared, Y. Li: None Declared, C. Wang: None Declared, L. Yin: None Declared, M. Erkin: None Declared, F. Lanas: None Declared, K. Davletov: None Declared, A. Rosengren: None Declared, P. Lopez-Jaramillo: None Declared, R. Khatib: None Declared, A. Oguz: None Declared, R. Iqbal: None Declared, K. Yeates: None Declared, Á. Avezum: None Declared, W. Reinisch Consultant of: Speaker for Abbott Laboratories, Abbvie, Aesca, Aptalis, Astellas, Centocor, Celltrion, Danone Austria, Elan, Falk Pharma GmbH, Ferring, Immundiagnostik, Mitsubishi Tanabe Pharma Corporation, MSD, Otsuka, PDL, Pharmacosmos, PLS Education, Schering-Plough, Shire, Takeda, Therakos, Vifor, Yakult, Consultant for Abbott Laboratories, Abbvie, Aesca, Algernon, Amgen, AM Pharma, AMT, AOP Orphan, Arena Pharmaceuticals, Astellas, Astra Zeneca, Avaxia, Roland Berger GmBH, Bioclinica, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Covance, Danone Austria, DSM, Elan, Eli Lilly, Ernest & Young, Falk Pharma GmbH, Ferring, Galapagos, Genentech, Gilead, Grünenthal, ICON, Index Pharma, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, LivaNova, Mallinckrodt, Medahead, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nash Pharmaceuticals, Nestle, Nippon Kayaku, Novartis, Ocera, Omass, Otsuka, Parexel, PDL, Periconsulting, Pharmacosmos, Philip Morris Institute, Pfizer, Procter & Gamble, Prometheus, Protagonist, Provention, Robarts Clinical Trial, Sandoz, Schering-Plough, Second Genome, Seres Therapeutics, Setpointmedical, Sigmoid, Sublimity, Takeda, Therakos, Theravance, Tigenix, UCB, Vifor, Zealand, Zyngenia, and 4SC, Advisory board member for Abbott Laboratories, Abbvie, Aesca, Amgen, AM Pharma, Astellas, Astra Zeneca, Avaxia, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Danone Austria, DSM, Elan, Ferring, Galapagos, Genentech, Grünenthal, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nestle, Novartis, Ocera, Otsuka, PDL, Pharmacosmos, Pfizer, Procter & Gamble, Prometheus, Sandoz, Schering-Plough, Second Genome, Setpointmedical, Takeda, Therakos, Tigenix, UCB, Zealand, Zyngenia, and 4SC, P. Moayyedi: None Declared, S. Yusuf: None Declared

Added value of the measles-rubella supplementary immunization activity in reaching unvaccinated and under-vaccinated children, a cross-sectional study in five Indian districts, 2018-20

INTRODUCTION

Supplementary immunization activities (SIAs) aim to interrupt measles transmission by reaching susceptible children, including children who have not received the recommended two routine doses of MCV before the SIA. However, both strategies may miss the same children if vaccine doses are highly correlated. How well SIAs reach children missed by routine immunization is a key metric in assessing the added value of SIAs.

METHODS

Children aged 9 months to younger than 5 years were enrolled in cross-sectional household serosurveys conducted in five districts in India following the 2017-2019 measles-rubella (MR) SIA. History of measles containing vaccine (MCV) through routine services or SIA was obtained from documents and verbal recall. Receipt of a first or second MCV dose during the SIA was categorized as "added value" of the SIA in reaching un- and under-vaccinated children.

RESULTS

A total of 1,675 children were enrolled in these post-SIA surveys. The percentage of children receiving a 1st or 2nd dose through the SIA ranged from 12.8% in Thiruvananthapuram District to 48.6% in Dibrugarh District. Although the number of zero-dose children prior to the SIA was small in most sites, the proportion reached by the SIA ranged from 45.8% in Thiruvananthapuram District to 94.9% in Dibrugarh District. Fewer than 7% of children remained measles zero-dose after the MR SIA (range: 1.1-6.4%) compared to up to 28% before the SIA (range: 7.3-28.1%).

DISCUSSION

We demonstrated the MR SIA provided considerable added value in terms of measles vaccination coverage, although there was variability across districts due to differences in routine and SIA coverage, and which children were reached by the SIA. Metrics evaluating the added value of an SIA can help to inform the design of vaccination strategies to better reach zero-dose or undervaccinated children.

Determinants of neointimal strut coverage in bio-degradable polymer coated ultrathin strut stent

Introduction

Incomplete strut coverage (ISC) is the most important morphometric determinant of stent thrombosis. Determinants of ISC have been studied in thick and thin strut stents.

Purpose

To identify morphometric factors causing ISC in the biodegradable polymer-coated ultra-thin strut drug eluting stent (BP-UTS-DES) that are designed to encourage better strut coverage.

Methods

Patients undergoing implantation of a 65μm BP-UTS-DES had opportunistic OCT during staged PCI to assess strut coverage at 90 days. Images were analysed offline by experienced operators blinded to patient and procedural data. Neointimal thickness (NIT, μm) was measured as the minimum endoluminal distant between the strut and lumen border. All malapposed struts were considered uncovered. ISC was defined as &lt;100% covered struts in a frame. Stepwise logistic regression using multiple morphometric variables was used to identify independent determinants of ISC including markers of circumferential distribution of neointimal growth (CVS,NUS,RUS), symmetry of stent expansion (SEI, AVS, MAS) in each cross section and the geographical location of the frame along the axis of the stent.

Results

We analysed 11652 frames of 65 stents (1976 mm) in 46 arteries of 40 patients. All stents were post dilated. 95.6% arteries had &gt;20mm stents, 39.1% were overlapped and 15.2% were chronic total occlusions. Malapposition was seen in 2.6% of all struts and 39.2% of uncovered struts. The proportion of covered struts decreased as indices of circumferential uniformity of distribution of neointimal hyperplasia increased (CVS: r=0.37, p&lt;0.001; RUS: r=0.36, p&lt;0.001; NUS: r=0.52, p&lt;0.001). As uniformity of stent expansion improved (SEI increased) strut coverage and circumferential uniformity of neointimal hyperplasia increased (CVS, NUS and RUS decreased) suggesting that distribution of neointimal growth becomes homogeneous as uniformity of stent expansion improves (Fig. 1). Determinants ISC is shown in Table 1.

Conclusion

SEI but not AVS or MAS determines ISC. Compared to the distal third of the stent frames in the middle third had lower and the proximal third had high risk of ISC.

Funding Acknowledgement

Type of funding sources: None.

Post-load glucose spike: a better predictor of post-MI prognosis than post-load glucose in patients without known diabetes

Funding Acknowledgements

Type of funding sources: None.

Background

In non-diabetic population, number of deaths increase as the post-challenge glucose spike (PGS) i.e. difference between the fasting and 2h-PG increases in the DECODE study.

Purpose

To assess whether PGS is a better predictor of post-ACS prognosis in patients without known diabetes.

Methods

Retrospective cohort analysis of post-MI survivors (n=1056) without known diabetes undergoing pre-discharge oral glucose tolerance test. A standardised dataset was collected for the Myocardial Infarction National Audit Project. MACE (death or non-fatal re-infarction) over 5 (median 3.4) years was collected from notes review. Predictors of MACE were determined from Cox proportional hazard regression (stepwise) models adjusted for several variables (tested for collinearity) including GRACE score (GRS), fasting (FG) and 2-hour post-load glucose (2hG) and PGS as % of the 2hG (%PGS) (VIF=3.12). Incremental predictive value of PGS over 2hG was tested using probabilities of MACE calculated from logistic regression models using the same covariates and FG, 2hG and PGS individually and in combination applying c-statistics, continuous net reclassification improvement (cNRI) and integrated discrimination improvement (IDI).

Results

Of the patients 469 (44.4%) had normal glucose tolerance, 378(35.8%) preDM and 209 (19.8%) had new DM. In the whole cohort, MACE was predicted by %PGS (HR 1.02 (1.01-1.03), p&lt;0.0001), GRS (HR 1.01, (1.01-1.02), p&lt;0.0001), discharge with betablockers (HR 1.50 (1.14-1.98), p=0.0037), previous history of MI (HR 1.44 (1.02-2.03), p=0.039) but neither FG nor 2hG were included in the final model. MACE was predicted by %PGS (HR 1.04 (1.02-1.06), p&lt;0.0001) in the non-diabetic group but not in the new DM patients (HR 1.02 (0.99-1.05), p=0.296). Addition of PGS to models containing FG and 2hG improved reclassification by 22.6% for events and 5.0% for non-events (NRI&gt;0 0.275, p&lt;0.001) and discrimination (IDI 0.0076, p=0.033). However the c-statistics did not change significantly (ΔAUC 0.0094, p=0.099).

Conclusion

PGS is a better predictor of post-MI prognosis than FG or 2hG in patients without known diabetes.

Does pre-diabetes predict the extent of coronary artery disease?

Funding Acknowledgements

Type of funding sources: None.

Background

Extensive coronary artery disease (CAD) is common in diabetes mellitus. This relation between the extent of CAD and prediabetes (pDM)is less well established.

Purpose

To explore whether non-diabetic hyperglycaemia, assessed by HbA1c, is associated with extent of angiographic CAD, independent of traditional cardiovascular risk factors.

Methods

Retrospective cohort analysis of consecutive patients, without known DM undergoing coronary angiography for stable angina, who were screened for hyperglycaemia over 18 months. HbA1c was measured; pre-diabetes was defined as HbA1c 5.7-6.4%.Extent of CAD was assessed using the SYNTAX score. Presence of CAD was defined as visually estimated ≥50% luminal obstruction in arteries ≥1.5 mm diameter. Age, BMI, risk factors for CAD, HbA1c, total and LDL-cholesterol were recorded. The pre-diabetes and normal groups were compared using Mann-Whitney test for continuous variables and chi-squared test for categorical variables. Multiple logistic and linear regressions were used to assess the effect variables on SYNTAX score. Spearman rank correlation was used to assess the relation between HbA1c and SYNTAX score.

Results

1071 patients had angiograms done. 207 had DM, 19 had new diagnosis of DM and 181 missed the screening leaving 664 who had HbA1c measured. 51 poor quality angiograms were excluded from SYNTAX calculation. Data was analysed for 613 (306 normal, 307 pDM) patients. The patients with prediabetes were older, had higher prevalence of risk factors, BMI, fasting glucose and SYNTAX score. HbA1c (OR 2.07, 95% CI 1.32 to 3.25, p=0.002) and the presence of pDM (OR 1.89, 95% CI 1.32 to 2.69, p&lt;0.001) independently predicted the presence of CAD. HbA1c (Coefficient 2.42, SE 1.09, p=0.027) and the presence of pDM (Coefficient 2.25, SE 0.92, p=0.015) independently predicted the SYNTAX score. The correlation between HbA1c and SYNTAX score was weak but significant (Spearman's coefficient 0.206, 95% CI 0.129 to 0.281, p&lt;0.0001).

Conclusion

HbA1c predicts the extent of CAD as measured by SYNTAX score in patients without known diabetes. Presence of pre-diabetes is an independent predictor of extent of CAD.

Smartphone geospatial apps for dengue control, prevention, prediction, and education: MOSapp, DISapp, and the mosquito perception index (MPI)

India has the largest number of dengue cases in the world, contributing approximately 34% of the global burden. The framework for a geospatially enabled early warning and adaptive response system (EWARS) was first proposed in 2008. It was meant to be a decision support system for enhancing traditional surveillance methods for preventing mosquito-borne diseases in India by utilizing remote sensing data and fuzzy logic-based mathematical predictive modeling. This conceptual paper presents a significant evolution of EWARS such that it synthesizes inputs from not only traditional surveillance and reporting systems for dengue but also from the public via participatory disease surveillance. Two smartphone-based applications have been developed to support EWARS. The first-MOSapp-allows field health workers to upload surveillance data and collect key data on environmental parameters by both direct observation and via portable microclimate stations. The second-DISapp-collects relevant information directly from the community to support participatory disease surveillance. It also gives the user a real-time estimate of the risk of exposure to dengue in proximity to their home and has an educational component that provides information on relevant preventive measures. Both applications utilize a new mosquito abundance measure-the mosquito perception index (MPI)-as reported by the user. These data streams will feed into the EWARS model to generate dynamic risk maps that can guide resource optimization and strengthen disease surveillance, prevention, and response. It is anticipated that such an approach can assist in addressing gaps in the current system of dengue surveillance and control in India.

The effect of variations in method of elicitation on maximum sustained phoneme duration

This investigation evaluated the effect of method of elicitation on the maximum sustained durations of /s/, /z/, and /a/ in eighty female subjects. The effect of order of elicitation on the maximum sustained durations of /s/ and /z/, and the effects of method and order of elicitation on the s/z ratio, were analyzed as well. Comparisons of three methods of measuring maximum phoneme duration (MPD) were performed. This study found method of elicitation of MPD to have an effect on the maximum sustained durations of /s/, /z/, and /a/ but not on the s/z ratio. The three methods of measuring MPD were found to correlate highly with one another. Results of this study point to the need for standardized procedures for elicitation of MPD.