Can non-physician health-care workers assess and manage cardiovascular risk in primary care?

Abstract

Objective To ascertain the reliability of applying the WHO Cardiovascular Risk Management Package by non-physician health-care workers (NPHWs) in typical primary health-care settings. Methods Based on an a priori 80% agreement level between the NPHWs and the "expert" physicians (gold standard), 649 paired (matched) applications of the protocol were obtained for analysis using Kappa statistic and multivariate logit regression. Findings Results indicate over 80% agreement between raters, from moderate to perfect levels of agreement in almost all of the sections in the package. The odds of obtaining a difference between raters and a benchmark are not statistically significant. Conclusion Applying the WHO Cardiovascular Risk Management Package, NPHWs can be retrained to reliably and effectively assess and manage cardiovascular risks in primary health-care settings where there are no attending physicians. The package could be a useful tool for scaling up the management of cardiovascular diseases in primary health care. IntroductionChronic noncommunicable diseases, especially cardiovascular diseases, are a major and increasing cause of death and disability worldwide, and may have retarding effects on the economies of affected individuals, households and countries. 1,2 The epidemiological and economic effects of cardiovascular diseases (specifically stroke and heart diseases) and diabetes, are especially pervasive in low-and middle-income countries 1-3 where health systems are less likely to adequately respond to the challenges of the increasing burden. Socioeconomic barriers and inequalities in access to treatment, suboptimal staffing of health-care facilities and limited capacity for ancillary investigations that complement cardiovascular risk profiling are some of the common problems limiting these countries' control of chronic diseases, especially at the primary healthcare level. 4 This situation is worsened by the brain-drain syndrome 5-9 resulting in shortages of skilled workers.Can non-physician health-care workers assess and manage cardiovascular risk in primary care? 29 However, such risk profiling protocols lack universal applicability 11,13,14,[29][30][31][32][33][34][35][36][37][38][39][40][41][42] and may be of limited applicability in developing countries, whose populations were not sampled for the Framingham 31,32 and other studies. Uncritical adoption of such protocols may result in negative clinical and economic consequences. 43 To address the absence of a CVD risk profiling tool for developing countries, WHO in 2000 developed a package for the assessment and management of cardiovascular risk in low-resource settings. 44 The package, developed through consultations with experts from all WHO regions, was designed as an adaptable, cost-effective tool for systematic case management at all health-care levels, and consequently for scaling up countries' health systems. The expert panel based the design of the package on the graded evidence available.The package includes three scenarios that reflect commonl...

The Rural Andhra Pradesh Cardiovascular Prevention Study (RAPCAPS)

“…However, most NPHWs are trained only in maternal and child health and the delivery of care for communicable diseases. There is good evidence that NPHWs in India have made significant improvements in maternal and child health by providing basic services to many at an affordable price (18,19). Our study suggests that a policy that added to the skills of NPHWs in the diagnosis and treatment of CVD might also deliver significant benefits for noncommunicable diseases, which are now the leading causes of death in most parts of the country.…”

“…In a situation in which there is a large and growing burden of CVD that is untreated, there seems little doubt that a management system along the lines of that proposed here would produce substantial net population health benefits (19). Approximately one third of all vascular events occur in individuals with existing disease, meaning that treatment targeted at a very small proportion of the population could deliver large absolute health gains at low cost (24).…”

Global Inequalities in Access to Cardiovascular Health Care

“…Table 3 sets out estimates of the cost effectiveness of interventions for CVD prevention in developing regions of the world (42). Primary health care services should be organized such that core interventions can be delivered by nonphysician health care workers, ideally working under the supervision of a physician, to enable the most efficient use of scarce resources including health care personnel (43). Importantly, this would reduce the costs and other barriers to accessing primary health care associated with traditional physician-based models.…”

Fatal and Nonfatal Cardiovascular Disease and the Use of Therapies for Secondary Prevention in a Rural Region of India

“…There is some evidence to support the notion that nonphysician health workers can be trained to make safe and appropriate treatment decisions for the management of patients with CVD. 49 India has a wellestablished primary healthcare system based on nonphysician healthcare providers that currently focuses on maternal and child health and infectious diseases. Developing this system to provide basic care for chronic conditions such as CVD may be one approach that could be delivered at relatively low cost and in a relatively short timeframe.…”