Integrating a diabetes and hypertension case management package within primary health care: a mixed methods feasibility study in Bangladesh

• Published in: BMC health services research 2018-10, Vol.18 (1), p.811-811, Article 811
• Main Authors: Huque, R, Nasreen, S, Ahmed, F, Hicks, J P, Walley, J, Newell, J N, Elsey, H
• Format: Article
• Language: English
• Subjects: Bangladesh; Cardiovascular disease; Care and treatment; Case management; Case Management - organization & administration; Chronic illnesses; Chronic obstructive pulmonary disease; Clinical Competence - standards; Clinics; Delayed Diagnosis; Delivery of Health Care, Integrated - organization & administration; Diabetes; Diabetes mellitus; Diabetes Mellitus - therapy; Disease; Disease prevention; Drug Packaging; Drugs; Family planning; Feasibility Studies; Female; Health Personnel - education; Health Personnel - standards; Health services; Humans; Hypertension; Hypertension - therapy; Low income groups; Male; Management; Medical referrals; Mixed methods research; Non-communicable disease; Nurses; Patients; Physicians; Poverty; Prescription drugs; Primary care; Primary health care; Primary Health Care - organization & administration; Primary Health Care - standards; Public health; Skills; Systematic review
• ISSN: 1472-6963; 1472-6963
• DOI: 10.1186/s12913-018-3601-0

Almost three quarters of non-communicable disease (NCD) deaths, and 82% of premature NCD deaths, occur in low- and middle-income countries. Bangladesh has an estimated 7 million hypertensives and 10 million diabetics, and primary care is struggling to respond. Our aim was to develop and support implementation of a diabetes and hypertension case management package, and assess its appropriateness, feasibility and acceptability in two NCD clinics within two primary-care centres in Bangladesh. We used a convergent mixed methods design. We first assessed the level of appropriate hypertension and cardiovascular disease patient management, based on a composite outcome indicator using data from patients' treatment cards. Appropriate management was primarily informed by International Diabetes Federation (IDF) and World Health Organisation (WHO) guidelines. We then performed qualitative in-depth interviews with doctors and patients to explain these quantitative findings and to understand the challenges to achieving appropriate patient management in the NCD clinics. Eighty-one newly diagnosed patients were recruited. Over 3 months, 53.1% (95% CI 42.3% to 63.6%) of patients were appropriately managed. We found incomplete diagnosis (especially missing hypertension diagnosis alongside diabetes) and non-provision of follow-up appointments were the main causes of the relatively low level of appropriate management. We conducted interviews with 11 patients and 8 health professionals and found a shortage of human resources, reporting materials, available drugs and diagnostic equipment. This undermined patients' willingness to attend clinics and doctors' willingness to offer follow-ups. Hands-on skill-building training was valuable in increasing doctors' competence for appropriate management, but was seen as a novel training method and faced constraints to implementation. A clinical guide, skill-based training and recording package can be implemented in routine primary care and can lead to appropriate management of around half of diabetic and hypertensive patients in a low-income country. However, considerable health systems challenges must be addressed before more patients can be managed appropriately.