Dr Satish Mishra at the first world congress on non-communicable diseases event in Chandigarh, India last month.

Between April-October 2017 842 diabetes patients that attended Dispensary 9 at the Bhabha Atomic Research Centre had their feet examined once by physicians that had received additional training from Imperial College London, comprising planning and data analysis.

Neuropathy, which can occur in diabetes patients following prolonged exposure to high blood sugar which can damage delicate nerve fibers, was found in 9% of the patients. Peripheral arterial disease, which occurs when a build-up of fatty deposits in the arteries restricts blood supply to leg muscles, was found in 0.5%.

Previously, not all diabetic patients were receiving foot examinations as part of the standard treatment pathway. The diabetic foot project aimed to use QS to achieve measurable indicators of healthcare improvement. The key process measure for the project was the cumulative sum of patients with diabetes receiving foot examination; and the key outcome measure was the percentage of patients screened for neuropathy and peripheral artery disease.

The pilot project met its objective and provides important evidence to show that diabetic foot care can improve by training healthcare providers, standardising processes, regular data review and feedback. Lessons learned on how to integrate diabetic foot care in a high-volume primary care clinic has relevance for India and other populous south Asian countries.

The findings were presented by principal investigator Dr Satish Mishra at the first world congress on non-communicable diseases event in Chandigarh, India last month.

Visit the National Health Mission’s website to read how the QS were developed from the recommendations in the standard treatment guideline on diabetic foot. Details of the planning and implementation of the project are on the poster presented at the first world congress on non-communicable diseases.

Hypertension is a leading risk factor for mortality in India with more than 200 million people in the country estimated to have high blood pressure (BP). There is, however, very little awareness about this silent killer with 75% of the rural and 60% of the urban Indian population unaware of their hypertensive status. BP control in these patients is worse, 90% of the rural and 80% of the urban Indian population have a BP above recommended target values. This needs to be addressed by providing urgent attention towards provision of access to diagnosis, management and monitoring of hypertension at the primary care level. For clinical guidance on this issue, the Ministry of Health and Family Welfare, India recently published the standard treatment guideline on screening, diagnosis, assessment, and management of primary hypertension in adults in India. This guideline balances the best available evidence with what is operationally feasible and affordable in the context of the Indian public health system, by using a pragmatic adaptation methodology, which was recently published in the BMJ.

Steps towards improvement

The State Government of Kerala, with technical assistance from iDSI, is now planning to implement quality standards which are measurable prioritised recommendations from this guideline. It aims to increase identification of new cases of hypertension by providing opportunistic BP measurement to adults when they visit a primary healthcare center (also called family health center). It also aims to improve BP control in hypertensive patients by setting clinic BP targets. Technology will be used to measure adherance to these recommendations and track patient compliance and blood pressure control. The State Government of Kerala will be integrating indicators for hypertension in the Aadhar linked electronic  medical records captured by Kerala Government’s eHealth project. This is in accordance to the cochrane review on ‘Interventions used to improve control of blood pressure in patients with hypertension’, which recommended that primary care clinics need to have an organized system of regular follow-up and review of their hypertensive patients.

Find out more

This work on hypertension quality standards implementation in Kerala was recently presented by iDSI in the First NCD Congress in Chandigarh, India, you can view the presentation here. The final results from this work will be available next year and will contribute to the evidence base on how to improve detection and management of hypertension in low and middle income countries.

I remember very vividly two of the hospitals I visited in Vietnam, during my first field trip as a global health advisor on the iDSI. In a central hospital in Hanoi, I saw an acute stroke centre that was spotlessly clean and gleaming with the latest equipment, with specialised stroke clinicians offering a range evidence-based treatments matching Western standards. In contrast, in a district hospital a mere two hours away from the capital city, I saw an elderly woman with suspected stroke who had been hospitalised for two weeks, seemingly not getting any better and not receiving any meaningful treatment (and there was no way to confirm the diagnosis as no brain imaging could be done). There was no question as to which hospital I would choose, if I could, if a relative or I were unfortunate to have a stroke.

The reality is that for most people, there is no choice – those who have the means to access the better hospitals, perhaps simply because they live closer to the city, likely get better treatment. This is unfair. Universal health coverage (UHC) is only truly universal if everyone has fair access to good quality health services, irrespective of where they live, what facilities they have access to, their education, income, religion or ethnic background.

Variation in quality is not a phenomenon unique to Vietnam, but is a reality in health systems across the world – even in relatively well-resourced and well-performing UHC systems such as the UK National Health Service. Some variation in quality may be acceptable, but one reason why unacceptable variation occurs is that there is a lack of clarity across the system about what is best practice.

Quality standards

In a bid to address this variation, NICE in the UK introduced Quality Standards (QS). QS are concise sets of statements that describe what is best practice in a given disease area (drawn from existing evidence based guidelines). For instance, what kinds of and how many antenatal checks a pregnant woman should ideally receive; sets out the practical steps required to achieve improvement, *and* most importantly quantifies the improvement. In essence, QS brings everyone together to identify the top 5 or 10 things that need improving nationally, and focus efforts towards raising standards in those areas.

Since 2012, iDSI has been working with India, China, Vietnam and recently Thailand, to develop and implement QS as ways of tackling inequalities in healthcare quality, and to raise overall standards in key areas such as antenatal and maternal health, non-communicable diseases (stroke, hypertension, and diabetes), and antimicrobial resistance. We have drawn on our UK and international experience to create resources section of the site and on our new iDSI Knowledge Gateway.

Thailand, long seen as a success story of UHC, also recognises unacceptable variation in quality among public healthcare providers. In particular, there is now a push to raise and standardise quality in health promotion and disease prevention, beginning with QS in antenatal care. I was privileged to be invited as an international expert to observe and advise on this process. The discussions I heard among policymakers, clinicians and grassroots health volunteers were so rich that I can already anticipate insights and lessons that will go into the next version of the QS guide.

The enthusiasm and expertise of the stroke clinicians I met in the central hospital in Vietnam was unquestionable; the challenge is to sustain those excellent standards of practice and to ensure that all healthcare services across a country can reach those standards. iDSI’s vision is that everyone has fair access to quality healthcare, and we hope that our efforts in introducing and localising the QS model is a small step in the right direction.

In Vietnam, iDSI has been collaborating as part of a Working Group convened by Medical Services Administration, Ministry of Health and the Oxford University Clinical Research Unit (OUCRU) to develop quality standards for better antibiotic prescribing practices, as a key element of better patient care in specific high-priority clinical conditions. In 2016, we developed draft quality standards on improving antibiotic prescribing in acute exacerbations of chronic obstructive pulmonary disease (COPD) and community-acquired pneumonia. COPD and lower respiratory tract infections together account for 8% of deaths in Vietnam, greater than for heart disease, and there is evidence of significant inappropriate antibiotic prescribing.

Dr Cao Hung Thai, Vice Director of Medical Services Administration, opens the workshop

The draft quality standards were presented to a national Quality Standards & Indicators Committee at a workshop in Hanoi, June 2016. The Committee comprised senior officials from the Ministry of Health, as well as over 40 frontline clinicians from various disciplines among central and provincial hospitals across Vietnam. The workshop generated robust discussion among Committee members, particularly around the the feasibility of international best practice in diagnostic tests in the Vietnamese public hospital setting, and the choice of first-line treatment where a substantial proportion of patients may have used antibiotics recently, and there is little scientific evidence about local microbial strains and antibiotic resistance patterns.

Doctors, pharmacists and microbiologists from across Vietnam debate the quality standards

These discussions will serve as valuable inputs for the Working Group who will finalise the quality standards and submit them for the Committee’s approval in Q4 2016.

Quality Standards Committee

Quality improvement initiatives for reducing maternal mortality in the form of Quality Standards represent a cross cutting programme of work that will enable joint working on key activities while addressing a major health priority in south Africa. However, while Quality Standards have been used internationally to goo effect, it is imperative that any initiative is tailored to local need and context.

Addressing the above, on the 6th of April this year PRICELESS and iDSI organised a workshop with the topic “Maternal Care Quality Standards in the South African Context” in Pretoria, South Africa, led by Karen Hofman.

The meeting objectives were:

• to identify existing guidance and quality improvement initiatives in maternal health and seek coordination and potential synergies
• Learn about the experience of adapting NICE developed Quality Standards in Maternal health to the context of Kerala, India
• Explore the applicability of the Quality Standard approach to the South Africa Context.

During the workshop, topics were introduced by speakers from all over the world. The workshop started with an introduction by Karen Hofman. After, Carol Marshall talked about the current status and existing quality improvement initiative in South Africa and Bob Pattinson discussed the 2015 Maternal Guidelines. Dr Francoise Cluzeau (NICE International) gave an introduction to Quality Standards (QS) and Dr Vakkanal Pailey (Kerala Federation of Obstetrics and Gynaecology) spoke about Lessons Learned: Developing Maternal Quality Standards Adapting to Kerala, India. The group discussed whether Quality Standards could be adapted to the South African Context, identifying the scope of QS, the key stakeholders in this context and the proposed timeline.

The agenda and the slides can be downloaded below

Maternal QS meeting Agenda

Quality of Care Initiatives by Dr Carol Marshall
Maternal Care Quality Standards in the South African context by Karen Hofman
Implimenting Quality: An Introduction to Quality Standards by Dr Francoise Cluzeau
Quality standards in ob care : the right approach by Dr Vakkanal Pailey

1.  Health Technology Assessment

Under the terms of the partnership MoU between NICE and the MoHFW Department of Health Research (DHR), and linking to the bilateral India-UK MoU, a Joint Steering Committee (JSC) linking with the Medical Technology Advisory Board (MTAB) has been established. The Committee is comprised of senior members from DHR , the India Council of Medical Research (ICMR), the National Health Systems Resource Centre (NHSRC), iDSI and NICE. The JSC provides strategic guidance and advice on how India can implement a system for health technology assessment (HTA) and priority setting and strengthen evidence-informed healthcare policy and practice. A work programme has now been defined for 2016, including training (Health Economics) and HTA demonstration projects on HTAs. This will be a significant step for India towards Universal Health Coverage, improving the way that the heath budget is spent by prioritising cost effective practices. Prime Minister Narendra Modi and Prime Minister David Cameron acknowledged this valuable partnership in a Joint Statement following a recent UK visit by the Indian Prime Minister: “The two Prime Ministers welcomed the cooperation in the health sector between the two countries and the on-going Memorandum of Understanding covering areas including Medical Education and Training, Universal Health Coverage, containment of Anti-Microbial Resistance (AMR), improving patient safety through quality, safe and efficacious drugs and the collaboration between NICE International, UK and the Department of Health Research in India on medical technology assessment

2.  Standard Treatment Guidelines (STGs)

As a part of its efforts towards Universal Health Coverage the National Health Mission (NHM) has established an STG Task Force, one of four coordinated by NHSRC. Its aim is to oversee the development of authoritative, national STGs for healthcare services, including those covered by existing large scale insurance schemes (RSBY), and to help expand access to care that is affordable, equitable and effective. NICE International is helping NHSRC and the ten Clinical Subgroups, both from the public and private sectors that have been convened to develop STGs in 12 prioritized topics, based on robust evidence and using a transparent and inclusive process. STGs on hypertension and the diabetic foot have been sent to the MoHFW for public consultation before approval by the Directorate General of Health Services (DGHS). As part of this engagement, NICE International is a member of the Working Group (including AIIMs, WHO, NHSRC) that is developing the process and methods manual underpinning the STGs and associated Quality Standards for India. The manual aims to guide the STG developers in producing STGs that are inclusive, of high quality and relevant to India

3.  STG Implementation and Primary Care

NICE International is working closely with the Primary Care Task Force to implement the STGs at state-level. It is a member of the Primary Care Implementation Group responsible for designing the action plan and prioritising topics for implementation, focusing on better management of non-communicable diseases (NCDs) in primary care. NICE International brings in its experience of working in partnership with the Government of Kerala (National Health Mission) and the Kerala Federation of Obstetricians & Gynecologists (KFOG) to help reduce maternal mortality through Quality Standards for maternal care, and specifically on post-partum haemorrhage and hypertensive disorders in pregnancy. The Government developed quality measures to improve the care mothers receive during delivery, in both public and private hospitals, and these have been implemented in several hospitals in Kerala leading to improvement of care and outcomes.

In addition to these three work packages, NICE International has engaged with policy makers in Bihar and Odisha and hosted delegations from Karnataka, ICMR, NHSRC, MTAB and the main health insurers at NICE. RSBY also contributed to an international workshop held under iDSI on the development of Health Benefit Packages.

NICE International work in India is funded by DFID and the Bill and Melinda Gates Foundation.

The workshop focused on developing Quality Standards and indicators for AMR. It was jointly organised by the Department of Medical Services Administration (MSA) of the Ministry of Health and the National Hospital for Tropical Diseases and attendees included members of the AMR subcommittee programme as well as representatives from relevant MoH institutes and universities.

A  plan for developing standards to improve AMR management in hospitals in Vietnam has now been drawn up and will be operationalized with relevant partners over the next 12 months.

Dr Cluzeau with AMR workshop participants

NICE International Director Kalipso Chalkidou offered an overview of NICE and its core principles and practices. During this she emphasised how important it is to not only measure the cost-effectiveness of a particular drug or intervention, but then comparing it to the existing standard practice. Economic evaluations of these sorts are what the delegation is keen to bring to the Vietnamese health system.

The following presentation was probably of the most interest, both to the delegation and to me, as it outlined the nature of and the methods underlying Health Technology Assessment (HTA). NICE International’s Tommy Wilkinson went into detail on a plethora of topics encompassing: HTA and its workings, from assessment to technology appraisal, and then subsequently to recommendations; regulatory approval, oversight and accountability; the two drug pricing mechanisms in the UK; the Patient Access Scheme (PAS) and reference pricing; pharmacist’s pay; medical device pricing and procurement; deliberate misalignment of the main stakeholders’ incentives; and the Incremental cost-effectiveness ratio (ICER) and QALYs. Predictably, after covering so many areas, the delegation had numerous questions, especially seeing as economic evaluation has great significance to the Vietnamese setting as with many health systems in emerging economies. For someone who is about to study Economics at university these discussions really captured my attention; most significantly how QALYs and the ICER allow for multiple health interventions to be simultaneously compared and graphically illustrated in terms of both health gain and economic impact. This can help decision makers make a better, more informed healthcare decision for the population.

However, HTA methods obviously cannot be taught solely through a short study tour, which raises the question: how much can the delegates take from this? This, in my opinion, is a greater understanding of the fundamental benefits of HTA and possessing an evidence-based policy making ethos. Therefore, Francoise Cluzeau and Ryan Li referenced NICE International’s work in Vietnam itself developing Quality Standards for the Hospital Management of Acute Stroke, demonstrating the application of HTA in that setting. They drew in many features of the project, including identification of problems, creation of innovative, evidence-based solutions, the systematic implementation of the quality standards and their impact on health outcomes. This was well received by the delegation, yet what became evident was how their understanding developed most when explanations were applicable to a familiar setting. Despite being a highly distilled version of the projects, simply referring to a practical real-life example made HTA more relatable to the delegates. This was the most valuable lesson I drew: that clear explanation is vital, but making what you are saying applicable to the audience is even more so. In this case NICE International’s previous work in Vietnam enabled an easier explanation to the Vietnamese delegation

The last presentation came from Steven Edwards representing the British Medical Journal Technology Assessment Group (BMJ-TAG), which is one of the organisations who conduct HTAs for NICE. A much deeper understanding of what is practically involved with doing frequent and large HTAs for NICE was provided, and – coming from an external source – was couched in different terms, creating a good balance. This covered the different types of HTA, the time constraints and the significant work put into analysing manufacturers submissions. The delegates’ questions seemed to focus on identifying where accountability lay, and how legal issues relating to malpractice are handled. Admittedly a sensitive topic, it was clearly important to members of the delegation.

Events were preceded by a one-to-one discussion between Professor Phạm Lê Tuấn and Kalipso Chalkidou. Apparently productive, it felt like it set the tone and thrust of the rest of the day, as well as providing an agreement for NICE International to continue its collaboration with Vietnam under the international Decision Support Initiative (iDSI), specifically developing Quality Standards on Antimicrobial Resistance. For NICE International and the Vietnamese delegation this was considered a productive event, but it was also personally valuable to me, as I am now considering a career in health economics!

Controlling antimicrobial resistance requires a determined action and effort, and the objective of this partnership is to create an evidence-informed methodology and a governed working process to develop and implement policies and guidelines. NICE International’s role is to advise on the development and implementation of quality standards and indicators for AMR, based on previous collaboration with Vietnamese policymakers and clinicians on developing quality standards for acute stroke.

The first workshop [report in Vietnamese] in September 2015, hosted by the Ministry of Health, was attended by delegates from different ministries, national and international agencies, and external AMR experts. Its purpose was to share operational experience, coordination and cooperation to prevent drug resistance in Vietnam, caused in part by overuse of antibiotics. Dr. Nguyen Thi Xuyen, Deputy Minister of Health, highlighted the need to implement the National Action Plan on prevention of drug resistance to combat this issue. A second workshop in Hanoi is planned for 10-11 December 2015, and will cover the development and implementation of quality standards and indicators for AMR.

This work will be one component of iDSI’s ongoing practical support for Vietnam, alongside further health technology assessment capacity building and strategic roadmap development to inform the health benefits plan.

In December 2015, Francoise travelled to Hanoi for a workshop to develop QS in AMR, which you can read more about here