Models of care for sickle cell disease in low-income and lower-middle-income countries: a scoping review.

Sickle cell disease has a growing global burden falling primarily on low-income countries (LICs) and lower-middle-income countries (LMICs) where comprehensive care is often insufficient, particularly in rural areas. Integrated care models might be beneficial for improving access to care in areas with human resource and infrastructure constraints. As part of the Centre for Integration Science's ongoing efforts to define, systematise, and implement integrated care delivery models for non-communicable diseases (NCDs), this Review explores models of care for sickle cell disease in LICs and LMICs. We identified 99 models from 136 studies, primarily done in tertiary, urban facilities in LMICs. Except for two models of integrated care for concurrent treatment of other conditions, sickle cell disease care was mostly provided in specialised clinics, which are low in number and accessibility. The scarcity of published evidence of models of care for sickle cell disease and integrated care in rural settings of LICs and LMICs shows a need to implement more integrated models to improve access, particularly in rural areas. PEN-Plus, a model of decentralised, integrated care for severe chronic non-communicable diseases, provides an approach to service integration that could fill gaps in access to comprehensive sickle cell disease care in LICs and LMICs.

Decentralising chronic disease management in sub-Saharan Africa: a protocol for the qualitative process evaluation of community-based integrated management of HIV, diabetes and hypertension in Tanzania and Uganda.

INTRODUCTION: Sub-Saharan Africa continues to experience a syndemic of HIV and non-communicable diseases (NCDs). Vertical (stand-alone) HIV programming has provided high-quality care in the region, with almost 80% of people living with HIV in regular care and 90% virally suppressed. While integrated health education and concurrent management of HIV, hypertension and diabetes are being scaled up in clinics, innovative, more efficient and cost-effective interventions that include decentralisation into the community are required to respond to the increased burden of comorbid HIV/NCD disease. METHODS AND ANALYSIS: This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomised trial (INTE-COMM) in Tanzania and Uganda that will compare community-based integrated care (HIV, diabetes and hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension and diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet and exercise) provided by community nurses and trained lay workers, as well as the devolvement of NCD drug dispensing to the community level. Based on Bronfenbrenner's ecological systems theory, the process evaluation will use qualitative methods to investigate sociostructural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multistakeholder interviews (patients, community health workers and volunteers, healthcare providers, policymakers, clinical researchers and international and non-governmental organisations), focus group discussions (community leaders and members) and non-participant observations (community meetings and drug dispensing) will explore implementation from diverse perspectives at three timepoints in the trial implementation. Iterative sampling and analysis, moving between data collection points and data analysis to test emerging theories, will continue until saturation is reached. This process of analytic reflexivity and triangulation across methods and sources will provide findings to explain the main trial findings and offer clear directions for future efforts to sustain and scale up community-integrated care for HIV, diabetes and hypertension. ETHICS AND DISSEMINATION: The protocol has been approved by the University College of London (UK), the London School of Hygiene and Tropical Medicine Ethics Committee (UK), the Uganda National Council for Science and Technology and the Uganda Virus Research Institute Research and Ethics Committee (Uganda) and the Medical Research Coordinating Committee of the National Institute for Medical Research (Tanzania). The University College of London is the trial sponsor. Dissemination of findings will be done through journal publications and stakeholder meetings (with study participants, healthcare providers, policymakers and other stakeholders), local and international conferences, policy briefs, peer-reviewed journal articles and publications. TRIAL REGISTRATION NUMBER: ISRCTN15319595.

Integrated chronic care models for people with comorbid of HIV and non-communicable diseases in Sub-Saharan Africa: A scoping review.

BACKGROUND: Integrated health care is an approach characterized by a high degree of collaboration and communication among health professionals. Integration of HIV/NCD is recommended to enhance the quality of healthcare services being provided. Duplication of limited resources is minimized, and a holistic care approach is promoted by shifting from acute and reactive care to care that embraces patient-centredness that includes promotive health and disease surveillance. The high burden of HIV disease in sub-Saharan Africa (SSA) combined with the increasing prevalence of chronic non-communicable diseases (NCDs) necessitates a review of how health systems has been doing to deliver quality integrated care for people living with HIV (PLWH) and comorbid chronic NCDs. METHODS: A scoping review was conducted to identify and describe all publications on integrated chronic care management models at the primary care level in the SSA context, particularly those that addressed the care of PLHIV with co-morbid chronic NCDs. The inclusion and exclusion criteria were applied, and duplicates were removed. RESULTS: A total of twenty-one articles were included in the final review. Integrated healthcare systems were reported in only eight SSA countries-(South Africa, Uganda, Kenya, the United Republic of Tanzania, Zambia, Malawi, Zimbabwe and Swaziland). Integrated care systems adopted one of three health models. These included added-on NCD services to previously dedicated HIV care facilities, expansion of primary care facilities to include HIV care and establishment of integrated care services. Short-term benefits included staff capacitation, improved retention of patients and improved screening and detection of NCDs. However, the expansion of existing services resulted in an increased workload with no additional staff. A significant positive change noted by communities was that there was less or no stigmatisation of people living with HIV when attending dedicated HIV clinics. CONCLUSION: Evidence of integrated healthcare services for PLWH and co-morbid of NCDs in SSA is scanty. Data on some short-term benefits of integrated care was available, but evidence was absent on the long-term outcomes. Randomized clinical trials with clearly defined comparator groups and standardized measures of HIV and NCD outcomes are needed to demonstrate non-inferiority of integrated against non-integrated care.

Differences in integrated assessment and management of non-communicable diseases (NCDs) for people with HIV across the WHO European region.

OBJECTIVES: We aimed to assess the extent of integration of non-communicable disease (NCD) assessment and management in HIV clinics across Europe. METHODS: A structured electronic questionnaire with 41 multiple-choice and rating-scale questions assessing NCD assessment and management was sent to 88 HIV clinics across the WHO European Region during March-May 2023. One response per clinic was collected. RESULTS: In all, 51 clinics from 34 countries with >100 000 people with HIV under regular follow-up responded. Thirty-seven clinics (72.6%) reported shared NCD care responsibility with the general practitioner. Systematic assessment for NCDs and integration of NCD management were common overall [median agreement 80%, interquartile range (IQR): 55-95%; and 70%, IQR: 50-88%, respectively] but were lowest in central eastern and eastern Europe. Chronic kidney disease (median agreement 96%, IQR: 85-100%) and metabolic disorders (90%, IQR: 75-100%) were regularly assessed, while mental health (72%, IQR: 63-85%) and pulmonary diseases (52%, IQR: 40-75%) were less systematically assessed. Some essential diagnostic tests such as glycated haemoglobin (HbA1c) for diabetes (n = 38/51, 74.5%), proteinuria for kidney disease (n = 30/51, 58.8%) and spirometry for lung disease (n = 11/51, 21.6%) were only employed by a proportion of clinics. The most frequent barriers for integrating NCD care were the lack of healthcare workers (n = 17/51, 33.3%) and lack of time during outpatient visits (n = 12/51, 23.5%). CONCLUSION: Most HIV clinics in Europe systematically assess and manage NCDs. People with HIV appear to be screened more frequently than the general population at the same age. There are, however, larger gaps among eastern European clinics in general and for clinics in all regions related to mental health, pulmonary diseases and the employment of some essential diagnostic tests.

Integrated care teams in primary care improve clinical outcomes and care processes in patients with non-communicable diseases

INTRODUCTION@#Primary care physicians face the increasing burden of managing multimorbidities in an ageing population. Implementing an integrated care team (ICT) with defined roles and accountability to share consultation tasks is an emerging care model to address this issue. This study compared outcomes with ICT versus usual care for patients with multimorbidities in primary care.@*METHODS@#Data was retrospectively extracted from the electronic medical records (EMRs) of consecutive adult Asian patients empanelled to ICT and those in UC at a typical primary care clinic (polyclinic) in eastern Singapore in 2018. The study population had hypertension, and/or hyperlipidaemia and/or type 2 diabetes mellitus (T2DM). Clinical outcomes included the proportion of patients (ICT vs. UC) who attained their treatment goals after 12 months. Process outcomes included the proportion of patients who completed annual diabetic eye and foot screenings, where applicable.@*RESULTS@#Data from 3,302 EMRs (ICT = 1,723, UC = 1,579) from January 2016 to September 2017 was analysed. The ICT cohort was more likely to achieve treatment goals for systolic blood pressure (SBP) (adjusted odds ratio [AOR] = 1.52, 95% confidence interval [CI] = 1.38-1.68), low-density lipoprotein cholesterol (AOR = 1.72, 95% CI = 1.49-1.99), and glycated haemoglobin (AOR = 1.28, 95% CI = 1.09-1.51). The ICT group had higher uptake of diabetic retinal screening (89.1% vs. 83.0%, P < 0.001) and foot screening (85.2% vs. 77.9%, P < 0.001).@*CONCLUSION@#The ICT model yielded better clinical and process outcomes than UC, with more patients attaining treatment goals.

Perfil clínico e epidemiológico dos pacientes em uso de terapia biológica em uma policlínica universitária do Rio de Janeiro: um estudo descritivo / Clinical and epidemiological profile of patients using biological therapy in a university polyclinic in Rio de Janeiro: a descriptive study / Perfil clínico y epidemiológico de los pacientes que utilizan terapia biológica en un policlínico universitário de Rio de Janeiro: un estudio descriptivo

OBJETIVO: descrever o perfil socioeconômico, demográfico e as condições clínicas dos pacientes em uso de terapia biológica em uma unidade de saúde de atenção secundária do município do Rio de Janeiro. MÉTODO: estudo descritivo, transversal com abordagem quantitativa. RESULTADOS: A maioria dos pacientes eram do sexo feminino, com idade ≥50 anos, pardos, casados ou convivendo com parceiro, sem filhos e com ensino médio completo. Declararam-se 28,75% inválidos e possuírem como principal fonte de renda, o beneficio de seguridade social a pensão do Instituto Nacional do Seguro Social com valor entre 1-2 salários mínimos e contribuírem permanentemente com a renda da família com a qual residem. Quanto às características clínicas, 54% relataram realizar acompanhamento no ambulatório de gastroenterologia, 55% fazerem uso de Infleximabe e estarem em tratamento a mais de 24 meses. CONCLUSÃO: A partir do conhecimento das características dessa clientela podemos proporcionar um apoio organizacional de prestação de cuidados que influenciará diretamente a qualidade e a satisfação dos pacientes e profissionais.

OBJECTIVE: to describe the socioeconomic, demographic and clinical conditions of patients on biological therapy in a secondary health care unit in the city of Rio de Janeiro. METHOD: a descriptive, cross-sectional study with a quantitative approach. RESULTS: Most patients were female, aged ≥50 years, brown-skinned, married or living with a partner, without children and having concluded high school. 28.75% were declared disabled and had as their main source of income the social security pension from the National Institute of Social Security, amounting between 1 and 2 minimum wages, all of them contributing permanently to the total income of the families they were living with. As for clinical characteristics, 54% reported being followed up at the gastroenterology clinic, 55% of them taking Infleximab and having been on treatment for more than 24 months. CONCLUSION: Based on the knowledge of the characteristics of this clientele, we can provide an organizational support to the provision of care that may have direct influence on the quality of life and well-being of patients and professionals.

OBJETIVO: describir el perfil socioeconómico, demográfico y las condiciones clínicas de los pacientes que utilizan terapia biológica en una unidad de salud de atención secundária en la municipalidad de Rio de Janeiro. MÉTODO: estudio descriptivo, transversal con abordage cuantitativo. RESULTADOS: La mayoría de los pacientes era del sexo femenino, con edad ≥50 AÑOS, morenos, casados o viviendo con pareja, sin hijos y con escuela secundaria completa. 28,75% declaran que son discapacitados y que su principal fuente de ingreso es la pensión que reciben del Instituto Nacional de Seguridad Social con valor entre 1 y 2 salarios mínimos, contribuyendo de manera permanente al ingreso de la família con la cual viven. En cuanto a las características clínicas, 54% reportaron usar Infleximabe y estar en tratamiento hace más de 24 meses. CONCLUSIÓN: A partir del conococimiento de las caracteristicas de esa clientela se puede aportar un apoyo organizativo a la prestación de cuidados, que impactará directamente la calidad de vida y la satisfacción de pacientes y profesionales.

Consensos e dissensos na indicação e continuidade da terapia nutricional enteral nos cuidados paliativos de pacientes com doenças crônicas não transmissíveis / Agreements and disagreements on indication and continuity of enteral nutritional therapy in palliative care patients with non-communicable diseases

As doenças crônicas não transmissíveis (DCNT) representam as principais causas de internações hospitalares, geram impactos socioeconômicos e comprometimento da qualidade de vida em virtude de suas sequelas e incapacidades, justificando a importância e necessidade crescente de associação dos cuidados paliativos ao tratamento curativo. Esta revisão narrativa visa apresentar os consensos e dissensos sobre a indicação e a continuidade da terapia nutricional enteral (TNE) nos cuidados paliativos de pacientes com DCNT. Embasou-se em publicações oficiais sobre o tema e 15 artigos divulgados nas bases de dados: LILACS, SciELO, PubMed, MEDLINE, Cochrane Library e Science Direct, entre os anos de 2005 e 2016. Os objetivos do suporte nutricional nos cuidados paliativos desses pacientes variam com a evolução da doença. O suplemento nutricional oral é indicado para complementar a ingestão alimentar oral insuficiente, reduzindo custos hospitalares e favorecendo melhoras clínicas e funcionais. Na ingestão alimentar menor do que 60% e sem previsão de evolução, é indicada a TNE dentro dos três primeiros dias, mas sua continuidade em doenças avançadas permanece controversa. Na fase terminal, prioriza-se o conforto, o alívio dos sintomas e não mais a adequação nutricional. Nessa fase, a nutrição e hidratação artificiais podem não ser benéficas. Dessa forma, a nutrição nos cuidados paliativos é individualizada, depende do estágio da doença e visa promover a qualidade de vida. As tomadas de decisão devem envolver a vontade do paciente e de seus familiares, considerando os princípios de autonomia, beneficência, não maleficência e justiça.

Non-communicable diseases (NCD) are the leading cause of hospital admissions, result in socioeconomic impacts and prejudice on quality of life due to after-effects and disabilities, justifying the importance and the increasing need to associate palliative care with curative treatment. This narrative review aims to introduce agreements and disagreements on indication and continuity concerning enteral nutritional therapy (ENT) in palliative care patients with NCD. This paper was based on official publications related to the topic and 15 articles found on LILACS, SciELO, PubMed, MEDLINE, Cochrane Library and Science Direct databases, between the years 2005 and 2016. In these patients, the objective of nutritional support in palliative care varies according to the evolution of the disease. Oral nutritional supplement is indicated to supplement insufficient oral food intake, reducing hospital costs and favoring clinical and functional improvements. When food intake is less than 60% and without evolution prospects, ENT is indicated within the first 3 days, but withholding and withdrawing it in advanced diseases remains controversial. In terminal phase, comfort and relief of symptoms are the priority instead of nutritional adequacy. On this stage, artificial nutrition and hydration may not be beneficial. Therefore, nutrition in palliative care is individualized, depends on the stage of the disease and aims to promote life quality. Decisions must be taken considering patient and relatives' will, principles of autonomy, beneficence, no maleficence and justice.