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A new study by <keyword id="5069783" type="General" weightage="20" keywordseo="Centre-for-Chronic-Disease-Control" source="Orion">Centre for Chronic Disease Control</keyword>, India (CCDC) on cardiovascular risk reduction in South Asia has demonstrated significant long-term benefits of a multi-faceted quality improvement (QI) strategy, comprising of task sharing, and clinical decision support software (CDSS) with electronic health records, in managing type-2 diabetes in India and Pakistan. The study, published in the prestigious journal PLOS Medicine, highlights the sustained impact of QI interventions on <keyword id="21411276" type="General" weightage="100" keywordseo="diabetes-care" source="keywords">diabetes care</keyword> and associated complications over a median follow-up period of 6.5 years. The burden of diabetes Diabetes control remains a global challenge, leading to severe complications such as <keyword id="22908" type="General" weightage="20" keywordseo="heart-disease" source="Orion">heart disease</keyword>, <keyword id="25191" type="General" weightage="20" keywordseo="stroke" source="Orion">stroke</keyword>, <keyword id="16753" type="General" weightage="20" keywordseo="blindness" source="Orion">blindness</keyword> or visual impairment, and kidney and nerve damage. LMICs are often faced with challenges such as inadequate infrastructure and trained healthcare staff with digital literacy. In that respect, the study's findings are crucial for integrating care models sustainably and identifying relevant organizational barriers. Previous studies from high-income countries showed improvements in diabetes care, but their long-term impact on vascular complications and mortality was unclear. This study aimed to address the critical gap in data regarding the long-term effectiveness of QI strategies and their impacts on vascular complications in LMICs. Professor Nikhil Tandon, Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, and senior author of the study explained the relevance of these findings in the context of national efforts to combat non-communicable diseases (NCDs). He said, "The <keyword id="22511956" type="General" weightage="20" keywordseo="National-Programme-for-NCDs" source="keywords">National Programme for NCDs</keyword> [NP-NCDs] operationalized by the Government of India has already a functional portal which provides an electronic health record functionality. Integrating the CDSS in this portal will provide significant incremental benefit to the impact of the National Programme, and bolster governmental efforts to battle the scourge of NCDs including diabetes and hypertension." Speaking about the findings, Prof. (Dr) Dorairaj Prabhakaran, Executive Director, CCDC, and one of the study authors, said, "Through the trial, we've demonstrated that a sustained quality improvement strategy can significantly enhance diabetes care and reduce complications in South Asia. For every 13 patients treated with this strategy, one major adverse cardiovascular event like heart attacks or strokes- or a microvascular event -like eye disease or decline in kidney function- was prevented, showcasing its profound impact on patient outcomes." Professor MK Ali, William H. Foege Distinguished Professor of Global Health, Emory University and one of the key authors of this article, said, "This study is an exemplar of trans-national collaboration for benefits of both, the global south and global north." Study Design and Findings The randomized clinical trial included 1,146 patients with poorly controlled type 2 diabetes across ten outpatient diabetes clinics from January 2011 through September 2019. Participants were randomized to receive either the QI strategy, which involved trained non-physician care coordinators and a clinical decision support software (CDSS) integrated into the electronic health record form, for physicians, or the usual care. Some of the key findings from the study include: <ul><li>At 6.5 years, patients in the QI strategy group were nearly twice as likely to achieve and maintain target levels for HbA1c (&lt;7%), systolic blood pressure (&lt;130mmHg), and LDL-cholesterol (&lt;100mg/dl), compared to the usual care group. </li><li> The incidence of first microvascular complications, such as diabetic eye disease, decline in kidney function, and nerve pain was notably 32% lower in the QI group. </li><li>There was a significant 28% reduction in the combined occurrence of microvascular and macrovascular events in the QI group.</li></ul> Importantly, these benefits were sustained only in clinics that continued the QI strategy for 6.5 years. With diabetes accounting for one in seven deaths in South Asia, the study provides unique insights into the sustainability of QI strategies in achieving diabetes care goals in low- and middle-income (LMICs) and the effects of these improvements on reducing vascular complications and diabetes-related deaths.

CCDC study reveals multi-pronged diabetes care improves patient outcomes in India, Pakistan

India prides itself in being a galloping economy with great ideas and cultural diversity. 
 
However, it also stands out for its colossal neglect of some basic factors---such as health. 
 
For instance, Bill Gates recently made an embarrassing comparison of India with Ethiopia. The African country, he said, was reportedly terrible 10 years ago. However, it has become very good today, and continues to improve due to efficient surveillance systems. Worryingly, the world’s problem areas include parts of India, Pakistan, Nigeria and the DRC, he said. 
 
The <keyword id="102649" type="ORGANIZATION" weightage="20" keywordseo="Gates-Foundation">Gates Foundation</keyword> 
 To streamline processes, the Bill and <keyword id="142497" type="ORGANIZATION" weightage="20" keywordseo="Melinda-Gates-Foundation">Melinda Gates Foundation</keyword> recently launched the Child Health and Mortality Prevention Surveillance Network, or CHAMPS. It is putting some special focus on improving the structure and getting systems into place, said Bill Gates, to <a href="http://www.theatlantic.com/health/archive/2015/05/bill-gates-child-health-mortality-prevention-surveillance-network/392549/">The Atlantic</a>. 
 
For instance, it is not clear why neonatals die, yet their project is trying to probe the drivers of mortality for all children. The Gates announced that they are investing $75 million in a number of surveillance sites expected to collect information "about how, where and why children are getting sick and dying.” The plan will be spread first through six nations in Africa and South Asia, depending on field workers to take the autopsies of children who have died, especially in “beefed-up laboratories.” 
 
Disease surveillance system 
 The Integrated Disease Surveillance Programme (IDSP) was launched in India with the support of the World Bank in November, 2004, so that the country could detect and respond to disease outbreaks quickly. In March 2010 to March 2012, World Bank funds were made available for <keyword id="2858752" type="UNKNOWN" weightage="20" keywordseo="Central-Surveillance-Unit">Central Surveillance Unit</keyword> as well as nine identified states (Uttarakhand, Rajasthan, Punjab, Maharashtra, Gujarat, Tamil Nadu, Karnataka, Andhra Pradesh and West Bengal). The other 26 states were funded only by local budgets. 
 
The Surveillance Programme will continue well into the 12th Plan (2012-17) under the National Health Ministry, with an outlay of Rs 640 crore from the domestic budget. 
 
The World Bank’s focus was to strengthen the system for epidemic-prone diseases, improve central monitoring and coordination, improve state and district surveillance focusing on nine states, gear up and prevent influenza epidemics. 
 
Findings of the project 
 
The project seemed to have detected a few parameters for progress in surveillance as well as in identification and response, related to IDSP and also assessed the infrastructure and systems in place. A number of future goals have been evolved to improve the public health information and intervention. 
 
Only recently, it was found that ratings for the Integrated Disease Surveillance Project (IDSP) for India were just moderately satisfactory. The survey factored the risks to development outcome, bank and borrower performance. 
 
Unfortunately, Non-Communicable Diseases (NCDs), which should be a core, important public health function in India became part of the surveillance survey very late. The NCD risk factor was thus delayed and was improved only in some provinces, not countrywide. Ultimately, the country plans to integrate the NCD factor into the national programme. 
 
Inequalities 
 
The solutions to fight epidemics and diseases are distributed unevenly among different groups and communities, impacting socially and economically sensitive groups. Unfortunately, the inequitable system of distribution in India is glaringly evident in the implementation of the system. 
 
Take TDAP (Tetanus, diphtheria and pertussis), for instance. At first, the programme was not implemented with efficiency. It was restructured only in 2010 in the nine “best performing states”, selected on the basis of their performance as well as administrative and reporting efficiency. It was an ironical conclusion, as the states that needed support lagged behind the most, yet got the least central assistance. 
 
The twin outbreaks of dengue and chikungunya were a major public health concern and pain point a few years ago. The Aedes mosquito-borne chikungunya, with more than a million suspected cases in India, could be controlled by general hygiene and sanitation, but the disease was not shaken off due to the problems in the sanitation, hygiene and environment. 
 
Amazingly, the health minister at the time, Anbamoni Ramadoss, actually commented that the health ministry can't do much in the job! “(We need) involvement of general public, the associations and the civil society," he said. 
 
Efficient implementation 
 
The centre cannot wash off its responsibilities, but the execution is too erratic. For instance, Andhra Pradesh has noted that a special sanitation drive was launched, including massive disease surveillance, to improve the vaccination system in its state. In Gujarat, traditional medicines have been harnessed to fight the disease. 
 
The surveillance system reveals that a number of measures are being identified and put in place--for instance, deployment of trained personnel, appropriate technology as well as efficient administrative services. Establishing extensive laboratory networks are needed for careful investigation. 
 
So far, the ratings of the system have been just moderately satisfactory. Hence, the nation should gear up and streamline the administration, which is crying out for attention.

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CCDC study reveals multi-pronged diabetes care improves patient outcomes in India, Pakistan

ANI

Good surveillance could be the lifeline of India’s healthcare system

Preetam Kaushik

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