Overview of PAL strategy Salah-Eddine Ottmani, MD, MPH TB Strategy and Operations Unit Stop TB Department WHO, Geneva Workshop on TB proposal preparation.

Overview of PAL strategy

Salah-Eddine Ottmani, MD, MPH TB Strategy and Operations Unit

Stop TB DepartmentWHO, Geneva

Workshop on TB proposal preparation for Round 6 of the Global Fund to fight AIDS, TB and Malaria

Geneva, 15 - 18 May 2006

What is the rational behind the Practical Approach to Lung health (PAL)

• Respiratory conditions are very common: 20 – 35% of patients in PHC setting

• TB cases account for a very small proportion among respiratory patients

• TB patients and the other respiratory patients have, in general, similar symptoms

• In most countries, respiratory patients are managed, in PHC setting, on the basis of symptom presentation without clear systematic indications

• A systematic, standardized and sound approach is needed to correctly identify TB cases among a huge number of respiratory patients

• Syndromic management of patients who attend health services for respiratory symptoms

• Focus on

1. PHC setting

2. Priority respiratory diseases > 5 yrs:

+ TB

+ ARI (pneumonia)

+ CRDs: mainly Asthma, COPD

What is PAL strategy?

What are the objectives of PAL strategy?

PAL has 2 objectives:

• 1. Improvement of the quality of care for every

respiratory patient in PHC setting

• 2. Improvement of the efficiency of health care

delivery system for respiratory diseases in

general

What are the components of PAL strategy?

PAL has 2 components:

• 1. Standardization of health care procedures:

management and follow-up through the adaptation

and development of clinical guideline

• 2. Coordination among:– health care levels– the components of the health system particularly at

district level

How to introduce PAL strategy in country?

• Should be adapted to health environment of country– National health policy – Health priorities– Health resources– Country epidemiological profile

• Should follow successive steps to be developed and implemented

Distribution of respiratory diseases’ burden (in DALYs) in the population over 15 years of age by epidemiological profile and socioeconomic status

High HIVprevalencecountries

Low incomecountries

Middle incomecountries

High incomecountries

C. D. 70.8% 59.4% 32.4% 12.8%

N.C.D. 16.0% 30.6% 58.0% 73.5%

Otherdiseases

13.2% 10.0% 9.6% 13.7%

Overall 100.0% 100.0% 100.0% 100.0%

Countries with PAL activities (May 2006) • Countries at the preliminary phase:

– Discussion: Costa-Rica, Mexico, Venezuela– Official request: China, Iran– Countries at the phase of adaptation and development:– Egypt, Lebanon, Lithuania, Oman, Rep. Korea (South)

• Countries at the phase of feasibility test:– Algeria, Estonia, Guinea, Peru, Syria, Uganda

• Countries at the preparatory phase of implementation:– Bolivia, Jordan and Tunisia

• Countries at the phase of implementation:– Chile, El Salvador, Kyrgyzstan, Morocco, South Africa (FSP and

WCP)

• Operational research: Nepal

Key results from country experience

• PAL is likely to decrease the referral of respiratory patients to upper health level; this suggests that PAL is liklely to improve the integration in PHC (Kyrgyzstan, Jordan, Bolivia)

• PAL is likely to improve the quality of the process of diagnosis of TB (South-Africa, Tunisia, Bolivia??)

• PAL is likely to improve TB case detection among respiratory patients in PHC (adj. OR=1.72, in South Africa)

• PAL decreases drug prescription, particularly antibiotics and adjuvant drugs (Bolivia, Jordan, Kyrgyzstan, Morocco, Nepal, Tunisia)

• PAL improves the quality drug prescription for CRD patients (Chile, Jordan, Kyrgyzstan, Morocco, South Africa, Tunisia)

• PAL reduces the average cost of drug prescription per respiratory patient (Bolivia, Jordan, Kyrgyzstan, Morocco, Tunisia)

Impact on the referral of respiratory patients in Kyrgyzstan

Referral Baseline study Impact study Variation p-value

No (%) No (%) in % 893 (100.0) 992 (100.0)-----------------------------------------------------------------------------------------------Overall referral 358 (40.1) 266 (26.8) - 33.2 < 0.0001

Hospital 17 (1.9) 7 (0.7) - 63.2 < 0.03

Specialists 102 (11.4) 52 (5.2) - 54.4 < 0.0001

Ancillary tests 321 (35.9) 241 (24.9) - 30.6 < 0.0001

Laboratory tests 245 (27.4) 185 (18.6) - 32.1 < 0.0001

Chest x-ray 171 (19.1) 114 (11.5) - 39.8 < 0.0001 ----------------------------------------------------------------------------------------------

Impact on the overall referral of respiratory patients in Bolivia, Jordan and Kyrgyzstan

Referral Baseline study Impact study Variation p-value

in %

-----------------------------------------------------------------------------------------------

Bolivia 137/1033 (13.3%) 100/1154 (8.7%) - 34.6 < 0.001

Jordan 386/6287 (6.1%) 121/2719 (4.5%) - 26.2 < 0.01

Kyrgyzstan 358/893 (40.1%) 266/992 (26.8%) - 33.2% < 0.0001

Tunisia 134/2366 (5.7%) 172/1475 (11.7%) + 101.0% < 0.0001

-----------------------------------------------------------------------------------------------

SSE request among patients with respiratory symptoms for more than 2 weeks, Tunisia

Type of study SSE request Total Proportion RP

---------------------------------------------------------------------------

Baseline 8 160 5.0% 1

Impact 23 129 17.8% 3.6

X2= 12.28, p < 0.001

---------------------------------------------------------------------------

Total 31 289 10.7%

---------------------------------------------------------------------------SSE: sputum smear examination; TB: tuberculosis; RP: ratio of proportions.

SSE request among patients with respiratory symptoms for less and more than 2 weeks, Bolivia

Type of study SSE request Total Proportion RP p-value ---------------------------------------------------------------------------------------

Baseline

≥ 15 days 48 113 42.5% 6.1 < 0.0001

15 days < 43 920 4.7% 1

Impact

≥ 15 days 54 98 55.1% 42.4 < 0.0001

15 days < 14 1055 1.3% 1---------------------------------------------------------------------------------------

- Total 159 2186 7.3%

Controlled trial, Free State Province, South Africa

TB Non TB RP adj.OR

------------------------------------------------------------------

PAL 57 873 1.67 1.72

(p = 0.01) (p = 0.04)

No PAL 34 892 1 1

------------------------------------------------------------------

Total 91 1765

Morocco Kygyzstan Tunisia Jordan Bolivia---------------------------------------------------------------------------------------------------------

-% patients withdrug prescription - 3.1%* + 2.6%** - 2.5%* 0.0% + 0.1%§

Ratio of drugs perpatients who receiveddrug prescription - 15%* - 11.1%* - 18.8%* - 12.2%* - 16.2%*

% patients with ATBamong all respi. patients - 25%* - 22.0%* - 21.1%* - 15.9%* -

11.1%**

Average drug prescription cost per patient - 18%* - 32.4%* -19.3%* - 8.7%*** - 32.2%*---------------------------------------------------------------------------------------------------------

-*: p<0.001, **: p < 0.01, ***: p < 0.05, §: p > 0.05.

PAL impact on drug prescription in five countries

Variations in prescription frequencies of the adjuvant drugs after training in PAL among patients who received any drug prescription

Bolivia Jordan Kyrgyzstan Tunisia ---------------------------------------------------------------------------------------------------------

-

Expectorant - 88.9% - 37.3% - 17.2% - 47.3%

Vitamin - 57.1% - 100.0% - 41.7% - 14.7%

NSAID + 163.3% - 41.7% - 28.8%

Aspirin - 50.0% + 375.0% - 49.4% - 33.1%

Antitussive - 47.0% - 19.8% - 2.0%

Nasal decongestant + 4.5% + 75.0% + 26.8% + 0.4%

Paracetamol - 43.8% - 4.3% + 62.7% + 17.8%Antihistaminic - 79.3% - 45.4% - 51.3%

Average cost perpatient - 25.1% - 16.3% - 30.9% - 20.2%

PAL impact on bronchodilator prescription, Kyrgyzstan

• Among patients who received a drug prescription:– Reduction by 35.1% (baseline: 94/850; impact: 70/969)

• Among patients who received bronchodilator prescription:– 26.6% increase of beta-2-agonist prescription

(baseline: 53/94; impact: 50/70)– 26.5% increase of the average cost per patient

(baseline: 155.0 Coms; impact: 196.0 Coms)

Bronchodilator Baseline Impact Variation p-value drug study study in % No = 2341 No = 1422----------------------------------------------------------------------------------------Any bronchodilator 4.7% 5.8% + 23.4 0.141* Inhaled β agonist 2.2% 4.7% + 113.0 < 0.0001* Other β agonist form 0.5% 0.1% - 80.0 0.07 * Theophylline 2.6% 2.3% - 11.5 0.547*Other Bronchodilator 0.3% 0.0% - 100.0 0.530*----------------------------------------------------------------------------------------

Among patients who were prescribed bronchodilator

Inhaled β agonist 46.8% 80.7% + 72.4% < 0.0001

Average cost per patient 4.3 DT 2.7 DT - 36.4% < 0.03

Bronchodilator prescription, Tunisia

• Among patients who received a drug prescription:– Reduction by 54.3% (baseline: 39/850; impact: 20/969)

• Among patients who received corticosteroid prescription:– Inhaled steroid prescription 4.3 times more in the impact

study (baseline: 4/39; impact: 11/20)– 12.3% decrease of oral steroid prescription in the impact

study (baseline: 20/39; impact 9/20) – Average cost per patient 2.4 times more in the impact

study (baseline: 90.2 Coms; impact: 310.6 Coms)

PAL impact on corticosteroid prescription, Kyrgyzstan

Corticosteroid Baseline Impact Variation p-value drug study study in % No = 2341 No = 1422----------------------------------------------------------------------------------------Any cortico-steroid 8.1% 5.2% - 35.8 < 0.001

* Bronchial inhalation 1.5% 1.3% - 20.0 0.617

*Nasal inhalation 0.2% 0.3% + 50.0 0.737* Tablets 0.7% 0.4% - 43.0 0.246*Injection 6.1% 3.6% - 41.0 < 0.002----------------------------------------------------------------------------------------

Among patients who were prescribed corticosteroid

Inhaled Corticosteroid 18.9% 25.7% + 36.0 0.227

Average cost per patient 2.7 DT 2.9 DT + 8.4% 0.505

Corticosteroid prescription, Tunisia

Expected outcomes of PAL in countries• Contribution to improving national health policy since it defines

health policy and intervention for the 1st leading cause of care demand in PHC setting (provision of an integrated package to 20 - 35% of patients)

• Further step in DOTS quality improvement • Contribution to improving TB case detection, and quality of TB

diagnosis• Maintaining the high profile of TB among respiratory conditions in

daily practice• Strengthening the integration of TB control in PHC services• Improvement of the referral system for respiratory conditions and TB • Strengthening PHC services ( PHC attendance for respiratory

conditions)• Reduction of drug prescription, particularly antibiotics and adjuvant

drugs• Contribution to improving the competency of PHC workers• Contribution to improving health planning and formulation of

resources needed within health system