Meeting Report Technical Consultation to Strengthen Hypertension Care in Thailand November 2017

Transcription

1 Meeting Report Technical Consultation to Strengthen Hypertension Care in Thailand November 2017 INTRODUCTION Cardiovascular diseases (CVD), including Ischemic heart disease and stroke, cause an estimated 145,000 deaths annually or 29% of all deaths in Thailand and rank as #1 and #3 causes of premature death in Thailand. High blood pressure is a key risk factor responsible for approximately half of the disease burden from cardiovascular disease including heart attack and stroke. Reducing blood pressure prevents stroke, heart attack, kidney damage, and other health problems. Hypertension (SBP 140 and or DBP 90 mm Hg) is highly prevalent in Thailand. According to the latest National Health Examination Survey conducted in 2015, one out of four Thais (24% of adult Thais) had hypertension but less than one out of three (29%) had their blood pressure under control. According to the same national survey, almost half of adult Thais with hypertension were not even aware that they had high blood pressure. Under the universal health care policy, the government of Thailand has been scaling up treatment for hypertension. Information available in the Health Data Centre (HDC) shows that the number of registered patients for hypertension treatment has increased from 3,946,902 in 2013 to 5,584,007 in November Currently, 2,048,145 (37%) patients have documented blood pressure control (based on two consecutive readings in the past year). Of 76 provinces, only 2 have achieved the national target of achieving at least 50% blood pressure control among registered patients. Thus, there is scope for further improvement both by creating public awareness to increase assess to diagnosis and treatment, and by strengthening the quality of care to improve blood pressure control. The WHO CDC Global Hearts Initiative and the recently launched Resolve To Save Lives initiative are both examples of increasing global momentum to reduce avoidable burden of cardiovascular disease. As part of these initiatives, Thailand has been chosen as one of the 10 countries to pilot test evidence based strategies for hypertension care. This offers a great opportunity for Thailand to take stock of the existing hypertension care programme, identify gaps and challenges and take the necessary steps to further improve programmatic impact. MEETING OBJECTIVES The Technical Consultation to Strengthen Hypertension Care in Thailand held on November 2018 was a gathering of: policy makers from the central Ministry of Public Health; physicians, nurses, data analysts and programme managers from the district, provincial and regional levels; senior and programme level leadership from the National Health Security Office; and representatives from academic organizations, including the Thai Hypertension Society. The specific objectives of the meeting were to: 1. Review the current status of the hypertension control programme in Thailand including successful practices and challenges. 2. Introduce the Global HEARTS technical package and discuss the relevance and application of various Global HEARTS tools in Thailand. 3. Develop a 2 year action plan for strengthening hypertension control in Thailand. 1

2 The objectives of the meetings were realized through interactive presentations by experts, plenary discussions and in depth discussions in smaller groups. KEY DISCUSSION POINTS The main themes discussed throughout the meetings were in the areas of: Public Awareness Approximately 45% of adults with hypertension are not aware of their condition and remain untreated. Therefore, increasing mass public awareness about harms of hypertension and the need for treatment is an important priority. A comprehensive communication strategy should be developed to increase public awareness. Increasing access to diagnosis and treatment for vulnerable populations including males should be given due focus within this strategy. Diagnosis and screening Each year, approximately 90% of the population over 35 years undergoes annual screening for hypertension, diabetes and other behavioral risk factors. Additionally, BP is measured for all patients at out patient clinics within the MoPH health facilities. The quality of the annual screening is of variable quality, leading to suboptimal follow up of individuals with hypertension and other risk factors. A large number of individuals with clinical hypertension are lost to follow up after screening. Therefore, development of standardized guidelines for screening and diagnosis, referral and follow up are needed. Availability of BP instruments and equipment in public areas should be expanded so that people can measure blood pressure at any time. Appropriate diagnosis after screening system (such as daytime ambulatory blood pressure monitoring and/or home blood pressure monitoring for diagnosis of hypertension) should be established and monitored to reduce the number of undiagnosed individuals (after screening). Involvement of local authorities and the private sector should be promoted in order to increase access to BP measurement tools. Self care including BP measurement and self monitoring should be promoted as part of the communication strategy. Treatment Practices and Quality of Care The current Thai guidelines need to be updated with consideration of a lower treatment threshold. Increased medical costs of hypertension care as well as increased workload at health facilities should be discussed while revising treatment guidelines. Lack of adherence to current treatment guidelines is common. This can be overcome by simplifying guidelines into a one page wall/desk charts for easy reference by treating staff. Once guidelines are updated, continued capacity building for treating staff is required, perhaps via a continuing medical education programme (CME) or other means. Clinical audits are required to determine the extent to which guidelines are being followed. A checklist for the audit needs to be developed based on the guidelines. Rewarding and recognizing high performing health facilities and workers for HTN care can further improve quality of care and treatment outcomes. This could be executed by institutionalizing a hypertension champions programme where health facility staff are acknowledged and rewarded (by non financial incentive) for their 2

3 contribution to hypertension control. The criteria and process of recognizing hypertension champions can be pre defined and overseen by a central committee. Appropriate tools are needed (e.g., flip chart for health workers) to communicate to patients about the need for treatment initiation and adherence to treatment. Implementation research on task sharing and task shifting should be documented at facilities. If shown to be successful and effective, this may be considered to be upscaled as a policy intervention. Monitoring and evaluation The electronic medical record system also called the Health Data System (HDC) has a line list of nearly 55 million Thais including 5.8 million patients with hypertension. In addition to detailed information at registration, each patients record is updated at every visit with key variables including blood pressure, results of investigations and medicines prescribed. A total of 13 hypertension related indicators are generated and monitored in the HDC dashboard. There is a need to review the indicators and their definitions. For example, indicators could be categorized into four: (1) screening and diagnosis; (ii) access to treatment; (iii) blood pressure control, and (iv) complications. Currently, there are many problems with the HDC, including, incomplete records, inadequate quality, lack of use of indicators at the facility level, issues with data extraction, and variable definitions to define indicators. Due to the wide range of issues, a separate meeting should be organized to discuss problems with HDC and ways to improve the quality and use of HDC data. The two global indicators on hypertension may be considered for use in Thailand after piloting their extraction from the current HDC database in one province. Conclusion and next steps Thailand has many strengths when it comes to hypertension care. These include: strong public health systems, availability of treatment guidelines, opportunistic BP screening at health facilities and annual screening in communities, standard treatment guidelines, individual electronic records, computerized data analysis, and most importantly financial risk protection through universal health care. To achieve national targets and reduce the burden of cardiovascular disease, it is planned that partner agencies work collaboratively on the following Action Plan over the next two years. Funding for the activities will be mobilized through MoPH, NHSO, WHO CCS, Resolve and US CDC. Beyond achieving national goals, the realization of the action plan should yield lessons and best practices that can be showcased within and beyond Thailand s borders for public good. 3

4 2-Year Action Plan for Strengthening Hypertension Care in Thailand Goal: To achieve blood pressure control in an additional 1 million adults over two years through improved diagnosis, enhanced quality of care and improved monitoring systems What (Actions) Overall Set up a small core hypertension technical group at the central level for overall direction and review of hypertension control in Thailand Conduct rapid situation assessment (including clinical audit) to document lessons in hypertension care in a representative sample Establish model sites (learning centres) for hypertension care to facilitate exchange of experiences nationally and internationally Improving Diagnosis Develop a communication strategy for mass awareness about harms of uncontrolled blood pressure and the need for prompt diagnosis and treatment Implement a public awareness campaign, including recruiting a celebrity, using patient stories, social media etc. Increase access to BP measurement equipment in public places including malls, banks, convenience stores, government buildings and other work places Revise the protocol for annual community-level screening including the use of Thai CVD non-lab based risk charts Develop protocol for follow-up of individuals detected with high BP (and other risk factors) during screening Conduct research on improving diagnosis and self-screening Enhancing Quality of Care Revise and simplify treatment guidelines Disseminate treatment guidelines and train health workers (doctors, nurses) via CME and other channels Design standard clinical audit- cum-supervision system and pilot test it Institutionalize hypertension champions programme to recognize good performance Create public awareness on the need for adherence to treatment Develop an educational HTN Flip Book to facilitate communication between health worker and patients Conduct research on patient-centric care (removing barriers to treatment and increasing access to care among males and other vulnerable populations) Generate and document evidence about the effectiveness of team based care (including nurse led care) Improving Systems for Monitoring Refine HTN indicators (screening, diagnosis, control, complications) Organize a platform for HDC users to discuss the issues and for improving the data collection system Explore the feasibility and value of using standard global HTN indicators for use in Thailand by analyzing data in one province Who (Responsible Agency) DG DDC Jan 2018 Centre for Policy and Strategy, Dr Chaisiri, WHO BoNCD, Dr Sukanya, Dr Supattra, WHO WHO, CDC, NCD Alliance, Thai Health When (Timeframe) Jan-June 18 Jan-June 2018 Jan-June 2018 DDC, Alliance, Thai Health July 18-Dec 19 NHSO, Rotary Thailand, Jan 18-Dec 19 Public-private CSR, THLO, local authorities BoE, Dr Phanthanee Jan-June 18 BoNCD, NHSO Jan-June 18 Research network Thai hypertension society, Jan-June18 Dr Apichard BoNCD and NHSO, Royal Jan 18-Dec 19 college Research network, Dr Pattara Jan-Dec 18 Core technical group, WHO Jan-June 2018 and CDC WHO, CDC, BoNCD, Jan ThaiHealth WHO July-December 2018 Research network June 18-June 19 Selected community hospitals June 18-June 19 BoE, BoNCD, NHSO, Dr Jan-June 2018 Ram BoE, Dr Ram December 2017 Dr Ram, FETP Jan-June

5 Technical Consultation to Strengthen Hypertension Care in Thailand November 2017 Centara Grand and Bangkok Convention Centre at CentralWorld, Bangkok Programme Thursday 16 November 2017_Meeting room: M4 (23 rd floor) 8:30 9:00 Registration 9:00 9:30 Opening session Opening Remarks by Dr Asadang Ruayajin, Deputy Director General, Department of Disease Control, MOPH Dr Daniel Kertesz, WHO Representative to Thailand Dr John MacArthur, TUC Country Director Why hypertension control is important Dr Renu Garg, WHO 09:30 10:00 Coffee break 10:00 12:00 Session Co Chairs: Dr John MacArthur and Dr Supattra Srivanichakorn Overview of hypertension services in Thailand (10 minutes) a. Screening and diagnosis of hypertension By Assoc.Prof.Dr Somkiat Sangwatanaroj, Dept of Medicine, F of Medicine, Chulalongkorn University b. Treatment guidelines for hypertension By Prof.Dr Apichard Sukonthasan, President, Thai Hypertension Society c. Quality assurance for hypertension care services By Dr Panthep Khananuraksa, Director, NHSO d. Monitoring and evaluation of hypertension programme By Asst.Prof.Col. Ram Rangsin, Dept of Military and Community Medicine, Phramongkutklao College of Medicine Discussion 20 minutes Introduction to Global HEARTS Technical Package: Dr Lorna M. English, Deputy Global NCD Branch, Centers for Disease Control and Prevention, Atlanta Global experiences in hypertension care: Dr Taskeen Khan, WHO Geneva Q&A (20 minutes minutes) 12:00 13:00 Lunch 13:00 15:00 Session Co Chairs: Dr Daniel Kertesz and Dr Sumanee Watcharasin Successful practices and challenges to hypertension control Experiences from the field (15 minutes each) Screening, diagnosis, treatment and follow up in Community/District 5

6 Hospital Dr Kawin Klubkun, Director of Kong Ra Hospital Ms Sumittar Pranfan, Chiang Klang Hospital Data analyses, reporting and quality improvement: Provincial hospital Mr Thinakorn Tipsuitr, Phra Nakhon Si Ayutthaya Provincial Health Office Technical supervision and quality improvement: Regional Health Office Mrs Suprawee Paphadakul, Office of Disease Prevention and Control 2 Discussion 15:00 15:15 Coffee break 15:15 17:00 Group work (meeting room M1 23 rd floor) a. How to improve diagnosis of hypertension, including public awareness, community level screening and opportunistic screening b. How to improve treatment practices and quality of care including clinical audit and recognition of good performance for improving hypertension control c. How to improve refine indicators and improve data quality, analyses and use for hypertension control Friday 17 November 2017_Meeting room: Lotus Suite11 (22 nd floor) 09:00 10:30 Group work presentation and discussion 10:30 10:45 Coffee break 10:45 11:45 The cost effectiveness of introducing out of office blood pressure monitoring for screening and diagnosis purpose By Dr Auttakiat Karnjanapiboonwong, Department of Disease Control, MOPH 11:45 12:30 2 year Plan of Action for strengthening hypertension control in Thailand Discussion Conclusion 12:30 13:30 Lunch and close 6

7 Technical Consultation to Strengthen Hypertension Care in Thailand November 2017 Centara Grand and Bangkok Convention Centre at CentralWorld, Bangkok List of Participants Ministry of Public Health Department of Disease Control Dr Asadang Ruayajin Deputy Director General Tel: Dr Angkana Charoenwattanachokchai Senior Expert angkana_dr@yahoo.com Tel: Dr Sumanee Watcharasin Section Chief, Public Health System Development Division, Bureau of Non Communicable Disease E mail: wsu_1978@hotmail.com Dr Sasamon Srisutthisak Public Health System Development Div. ssrisutthisak@hotmail.com Tel: Dr Phanthanee Thitichai Bureau of Epidemiology phanthanee@gmail.com Tel: Community and District Hospital Dr Kawin Klubkun Kong Ra Hospital Khlong Sai Khao, Kong Ra District Phatthalung k.klubkun@gmail.com Tel: Fax: Mrs Suda Khamnurak Kong Ra Hospital Khlong Sai Khao, Kong Ra District Phatthalung sk.du2411@gmail.com Tel: x 110 Fax: Dr Supattra Srivanichakorn Director, Center for Policy and Strategy Development for NCDs supattra@health.moph.go.th; spsrivanich@gmail.com Dr Boosbun Chua intra Director of Office of International Cooperation Tel: oic.ddc@gmail.com Dr Auttakiat Karnjanapiboonwong Center of Policy and Strategy Development for NCDs auttakiat@yahoo.com Tel: Ms Metta Kampiboon Public Health Technical Officer mettakum@gmail.com Tel: Dr Aratta Rangpueng Bureau of Epidemiology a.rangpueng@gmail.com Tel: Dr Sukanya Hangsaphruek Ongkharak Hospital Nakorn Nayok Province shangsaphruek@gmail.com Tel: Ms Patthicha Pinyosawadsakul Noen Maprang Hospital Noen Maprang, Noen Maprang District, Phitsanulok patthichapp@gmail.com Tel: Fax: Mrs Sumittar Pranfan Chiang Klang Hospital 563 Moo 11, Aduldetcharas Road, 7

8 Nan Tel/Fax: Mob: Provincial Health Office Mr Thinakorn Tipsuirt Phra Nakhon Si Ayutthaya Provincial Public Health Center 3/9 Uthong Rd, Ho Rattanachai, Phra Nakhon Si Ayutthaya District, Phra Nakhon Si Ayutthaya Tel: Fax: Mrs Sujun Kuntee Chiang Mai Provincial Health Office 110/4 Moo 8, Don Kaew Subdistrict, Mae Rim District, Chiang Mai Tel: Office of Disease Prevention and Control Mrs Suprawee Paphadakul Office of Disease Prevention and Control 2, Phitsanulok 306 Phitsanulok Wat Boat Road, Moo 5, Hua Ror Subdistrict, Muang, Phitsanulok Tel: Fax: Ms Mayura Seesarn Office of Disease Prevention and Control 7, Khon Kaen 181/37 Soi Ratchapracha, Srichan Road, Muang, Khon Kaen Tel: Fax: National Health Security Office (NHSO) Dr Panthep Khananuraksa Director, NCD Programme Tel: Mrs Suwaporn Marsook Project Manager Tel: Ms Apisamai Sawatdisarn Project Manager Tel: Academics and others Prof. Dr. Apichard Sukonthasan President Thai Hypertension Society Bangkok Hospital Chiang Mai (Phayao Provincial Health Office) Ms Prapakorn Chuengsamarn Chiang Kam Hospital 602 Phahonyothin Rd, Ban Tom Subdistrict, Mueang Phayao District, Phayao Tel: Fax: Mrs Saowalak Waraphirom Office of Disease Prevention and Control 12, Songkhla 168 Songkhla Nathawee Road, Khao Roopchang Subdistrict, Muang, Songkhla Tel: Fax: Mrs Sirikorn Khunsri Head, Section Chief Tel: Ms Nongnuch Borkham Project Manager Assoc. Prof. Dr Somkiat Sangwatanaroj Department of Medicine Faculty of Medicine Chulalongkorn University 8

9 Tel: Asst. Prof. Col. Ram Rangsin Capt. Dr. Anupong Sirirungruang Department of Military and Community Phramongkutklao College of Medicine Medicine Phramongkutklao College of Medicine Dr Surasak Kantachuvesiri Asst. Prof. Bungon Thepthien Department of Medicine ASEAN Institute for Health Development Faculty of Medicine, Ramathibodi Hospital Mahidol University Dr Chaisiri Angkurawaranon Asst. Prof. Dr Pattara Saenchaisuriya Faculty of Medicine Faculty of Public Health Chiang Mai University Khon Kaen University Asst. Prof. Chutarat Sathirapanya Thanaphan Suksaw Department of Family and Preventive Medicine International Health Policy Program Faculty of Medicine, Prince Songkhla Unviersity Tel: Hadyai, Songkhla Mr Voradej Panjarongkha Yuriko Limmade President of Rotary Club, Sukumvit International Health Policy Program Bangkok Tel: US CDC US CDC/Thailand MOPH US CDC Collaboration Center (TUC) Dr. John MacArthur Dr Lorna M. English Country Director Deputy Global NCD Branch E mail: zae5@cdc.gov Division of Global Health Protection Center for Global Health lenglish@cdc.gov Dr Chakrarat Pittayawonganon Co Director Thailand MOPH US CDC Collaboration Center sjp5@cdc.gov Lalida Ketgudee NCD Specialist Division of Global Health Protection xga9@cdc.gov Nilubon Sirisophon TUC hpr9@cdc.gov Kristy T. Joseph Public Health Advisor Global NCD Branch, Division of Global Health Protection Center for Global Health vios@cdc.gov Pintila Wangviwat Program Management Specialist Division of Global Health Protection ksi3@cdc.gov 9

10 World Health Organization Dr Daniel Kertesz WHO Representative Dr Renu Garg Medical Officer NCD Ms Ganokrat Teachanuntra Executive Assistant (Programme) Mr Jahn Jaramillo WHO Intern Dr Taskeen Khan WHO Headquarter Ms Sushera Bunluesin National Professional Officer NCD Ms Patricka Chulamonkha Translator/Interpretor 10