D Prabhakaran DM, FRCP, FNAScVice President and Professor Epidemiology , Public Health Foundation of India

Executive Director, Centre for Chronic Disease Control, New Delhi

Chair, Department of Epidemiology, London School of Hygiene and Tropical Medicine, London, UK

Adjunct Professor, Emory University, Atlanta, GA, USA

Innovative Service Delivery Experiences from India

Innovations ?

Disruptive innovation : An innovation that creates a new

market by applying a different set of values, which ultimately

(and unexpectedly) overtakes an existing market.

Not necessarily new or path breaking

What are the innovations at the level of Health

Systems in Chronic Disease management and

control

• Health system strengthening through task shifting and task

sharing; team based care

• Use of affordable technologies

• Enhancing Human Resource Capacity

• Structured behavior change communication using frontline health

care workers

• Traditional approaches

• Integration of chronic care

• Setting based interventions

• Individual level

• Improving compliance/ FDC

• Health system strengthening through task

sharing using frontline health workers/nurses

and using inexpensive technology

– An example of disruptive innovation

Study/Program Location Features

mPower ( HT+

DM)

Himachal

Pradesh

frontline health workers/nurses and

mobile phone/tablet at CHCs

UDAY ( HT+ DM) Haryana/AP Comprehensive intervention package at

Community and Health system

SIMCARD (HT) Haryana/Tibet frontline health workers/nurses at

PHCs and Community

mWellcare (

Integration of

Chronic Care)

Haryana/TN frontline health workers at PHCs +m

Health

Why task

shifting/task

sharing

• High patient load

• Emphasis on curative

care over prevention

• Positive experience

of task shifting from

HIV and other

diseases

mHealth technologies

• Consumers : improved

convenience, more active

engagement in self-care, and

greater personalization.

• Clinicians: demands on time and

refocus on the art of medicine.

• Potential to change every aspect

of the health care environment;

delivering better outcomes and

substantially lowering costs

Need: Real-world clinical trial evidence to provide a roadmap for

implementation

Steinbuhl, Muse, Topol, JAMA, Oct 2013

From asking a research question to

scaling up: an example

Can we demonstrate the efficacy of frontline health

workers enabled with IT or smart phones in reducing

outcomes for patients with hypertension and diabetes ?

Receiver Operator Curve for comparing the

DSS and independent experts on drug management.

mhealth in HT: Development of EHR

and DSSFeb- September 2011

•Development

•Beta testing

•Validation

Methods

•Qualitative research

•End User testing

•Real vs virtual

comparison

•Comparison against

experts

Anchala R, Di Angelantonio E, Prabhakaran D, Franco OH (2013)

Development and Validation of a Clinical and Computerised Decision

Support System for Management of Hypertension (DSS-HTN) at a

Primary Health Care (PHC) Setting. PLoS ONE 8(11): e79638.

Mean blood pressure in randomised groups by month and

differences vs. baseline

Unpublished data – not for quoting

CBS: Chart based support; DSS: Decision Support System

*Covariates included: age, gender, height, waist, body mass index, alcohol intake, pickle and papad (salty food)

intake, portions of vegetable/fruit consumed per day and baseline differences in blood pressure

mhealth in HT: cRCT among physicians ( 16 PHCs ; AP)

Can these results be extended to

Community Health Workers?

CHWs and Hypertension Management in

India : Economic Modeling

– 3 day training program 3 day training program 3 day training program 3 day training program

– $700,000 hospital cost savings / million population annually$700,000 hospital cost savings / million population annually$700,000 hospital cost savings / million population annually$700,000 hospital cost savings / million population annually

– 700 CVD deaths / million averted700 CVD deaths / million averted700 CVD deaths / million averted700 CVD deaths / million averted

– 750 hospitalizations for stroke / MI averted 750 hospitalizations for stroke / MI averted 750 hospitalizations for stroke / MI averted 750 hospitalizations for stroke / MI averted

– If annual salary of CHW drops below $3500 ( 200000 Rs) If annual salary of CHW drops below $3500 ( 200000 Rs) If annual salary of CHW drops below $3500 ( 200000 Rs) If annual salary of CHW drops below $3500 ( 200000 Rs) then the program is cost saving.then the program is cost saving.then the program is cost saving.then the program is cost saving.

Gaziano, Prabhakaran et al. for ICHEALTH

Objective

• To design a feasible and

sustainable evidence-

based, decision support-

enabled, health care

delivery model for the

management of

hypertension and diabetes

at the primary health care

facilities of Himachal

Pradesh

Funded by Medtronic foundationUnpublished data: Please do not quote

Smartphone DSS

Screen-shot

Unpublished data: Please do not quote

#WCC2014

Screening of eligible patients at 5 CHCs (12

Months: March 2013- Feb 2014)

Unpublished data: Please do not quote

82,698 clinic attendees

17,590 eligible (>30 years)

5,968 HT or DM

New HT or DM (50.4%)

#WCC2014

Changes in BP and FBS at 3 and 6 months Follow up

Unpublished data: Do

not Quote

Innovations in Health Promotion :

Can we use frontline health workers?

• Diet and lifestyle InterventionS for

Hypertension Risk reduction

through Anganwadi Workers and

Accredited Social Health Activists

Acknowledgement: ICMR

‘Tell Me and I Will Forget; Show Me and I May

Remember; Involve Me and I Will Understand.’

Confucius, 551 - 479 BC

DISHA: ICMR Multicentric Study for BP

Management in Underserved Rural PopulationsCluster Randomised Controlled Trial

HP (2), Pondicherry, MP, Maharashtra, Rajasthan, AP, Orissa and Assam

Prabhakaran et al. DISHA Manual. 2012

Intervention Cluster: INTENSE intervention through IEC tools at the individual, household and community level. for control of hypertension and diabetes. The GOAL will be promotion of balanced diet, reduction of salt consumption, tobacco and alcohol consumption, and increasing physical activity. 18 months intervention by multiple methods including household visitsControl Cluster: USUAL intervention through IEC tools.

Secondary Prevention ( prevention of

second heart attack/stroke or death)

• Low hanging fruit for improving outcomes

• Ability to prevent almost 20% deaths and

hospitalization in the first year after heart attack

• Large scope for improvement (Only 10% get adequate

secondary prevention in LIC)

• Several approaches

– Role of Polypill ( CAD/Stroke/CHF); diabetes; hypertension)

– Quality improvement programs ( hospital/community)

– Traditional approaches

– Creation of Virtual clinics

– Universal Health coverage

Insights from Land of Registries:

Sweden

Study of registries concluded that•By investing $70 million yearly in disease registries, data analysis resources and information infrastructure

•Sweden could reduce its annual growth in healthcare spending from an estimated 4.7% to 4.1%

•Estimated cumulative return in reduced direct healthcare costs over 10 years: $7 billion

Policy outcome: Government prioritised expansion of

registries with increased financial commitment: $10 to $45 million/year by 2013

Larsson S et al., Health Affairs 2012;31:220-27.

Registries Improve Care by Catalyzing Healthcare

Providers: Hospitals’ Adherence to Swedish

National AMI Guidelines

Larsson S et al., Health Affairs 2012;31:220-27.

Eur Heart J 2013; 34:121-9.

Kerala ACS Registry

23

Wide variability in outcomes across hospitals

ACS Quality Improvement in Kerala

(ACS QUIK)

• We are leveraging the collaborative strength of the Kerala ACS

Registry network to develop a quality improvement program

for ACS patients in Kerala

– First of its kind in India

To develop, implement, and evaluate the impact of a quality

improvement toolkit on 30-day major adverse cardiovascular

event rates following ACS through a cluster-randomized,

stepped wedge clinical trial.

Specific Aim #1

Expectation

• ACS QUIK aims to improve in-hospital quality of care in Kerala

– Pre-hospital care

– Post-hospital care

– Other disease states (heart failure, stroke, e.g.)

– Other Indian states

• New information on how ACS affects health related quality of life and individual-/household-level costs

• ACS QUIK has the potential to contribute to the larger shift of evaluating the effect of cardiovascular quality improvement interventions using a stronger study design.

26

Traditional Approaches:Similarities between CR and Yoga Care

Using traditional approaches

• YogaCare Trial

• A clinical trial of yoga-based cardiac rehabilitation

programme on cardiovascular health in India

• Mechanistic study in UK

• 4000 patients from 16 hospitals in India

• Outcomes: Composite of death, MI & Stroke

? Yoga Care for Stroke/difficult to treat diabetes

? Yoga in palliative care of cancer patients

? Yoga in prevention of injuries particularly elderly

Increasing and improving Human

Resource capacity

Re education of Primary care

physicians

• On job Certificate courses

• Distance learning

• Innovative learning tools through case studies

and IT tools

• Creating networks for peer education

• 500000 primary care physicians in India: how

do we reach them?

Certificate Course in Evidence Based Diabetes

Management (CCEBDM)

•Objective: To develop core skills and competencies in primary care

physicians for the practice of evidence based diabetes

management and establish networks between primary care

physicians and existing specialized diabetes care centers in India.

• Key Features: 12 modular course, once a month contact session

on designated Sunday, executive on-job training, 1:10-12 class

ratio, latest and updated course curriculum taught by selected

regional Faculty.

SYNOPSIS OF CCEBDM CYCLE – I, II, III

Cycle I launched on 8th Aug, 2010

• 18 States, 57 Cities,

• 100 Centers

• 15 National Expert,

• 128 Regional Faculty, 61 Observers

• 1208 Participants

Cycle II launched on 11th Dec, 2011

• 19 States, 65 Cities,

• 119 Centers

• 15 National Expert,

• 149 Regional Faculty, 84 Observers

• 1568 Participants

Cycle III launched on 24th Feb, 2013

• 19 States, 73 Cities,

• 134 Centers

• 15 National Expert,

• 164 Regional Faculty

• 2306 Participants

Others

Advanced Certificate Course in Prevention and

Management of Diabetes & Cardiovascular Risk

Certificate Course in Hypertenison and Thyroid disorders

Certificate Course in GDM (~ 2500)

GIS Urban: Private Physicians

Private General

Physicians- 31

GIS Urban: RMPs

RMPs: 100

High SES

area

Multi Sectoral

Dialogue

Why and where do we need multi sectoral

action in improving healthcare

• Improve Surveillance system

– Use of tablets/phone for real time data gathering

– Using GIS for community hotspots of chronic diseases

• Improve diagnostics ( POCs for a range of diseases

with blue tooth and other technologies)

• Improve drugs: Polypill

• Improve drug availability and distribution ( e drug

facilities)

• Improve access: Virtual Polyclinic

• Integrating care within chronic Diseases and between

CD and other Diseases

“If you want something you have never had,

You must be willing to do something you have

never done”

Thomas Jefferson

A small group of thoughtful people could change the world.

Indeed, it's the only thing that ever has.

Margaret Mead

(Cultural anthropologist)