The EP’s Role in Facing the Non-Communicable Disease Pandemic

Published on July 16, 2015
Cardiovascular and pulmonary disease, diabetes, and mental illness are all managed regularly in the ED, but their burden is falling disproportionately on developing countries. Could EPs intervene and change the course of their country’s health trajectory?

Non-communicable diseases (NCDs) form the inescapable pandemic of the twenty-first century that now threaten the developing world’s advances in health and economic stability.(1-5) Through what has been coined the “double burden” of disease, involving the superimposition of NCDs on existing infectious diseases, healthcare systems now face greater strain with more complicated patients, particularly given patient presentations in late stages of disease, longer durations of follow-up, and more expensive testing and treatment for care.(4,6) The World Health Organization (WHO) convened a high-level assembly meeting in September 2011 to raise concerns and to set actionable targets on this major problem.(7-8)

Prevalence and Repercussions of NCDs

NCDs annually constitute more than 60% of deaths worldwide, reported at 36 million deaths in 2008.(1,5) Furthermore, current disease trends suggest significant growth over the next decade, with the WHO projecting 55 million deaths from NCDs annually by 2030 if there is no acute action made.(1) Furthermore, NCDs have surpassed communicable diseases as the lead cause of death in all continents except Africa, where NCDs are nevertheless projected to surpass deaths from communicable diseases, maternal and perinatal conditions, and nutritional deficiencies by 2030.(1,7) Eighty-percent of deaths from NCDs occur in low- and middle- income countries (LMICs) with the majority of these occurring prematurely as compared to high-income countries.(1,4,9)

Not only do the majority of NCDs require more involved care but these diseases also complicate infectious disease presentations. This is seen in the case of cardiovascular complications with HIV patients, diabetes in TB patients, and rheumatic heart disease with under-diagnosed or mismanaged rheumatic fever cases in childhood.(1,6,7) Additionally, some NCDs have primary infectious causes such as Kaposi’s sarcoma with HIV and herpes virus, liver cancer due to hepatitis viruses, chronic kidney disease due to schistosomiasis, and cholangiosarcoma due to liver flukes.(1) So what can the Emergency Physician (EP) do about it?

How and Where Emergency Physicians Can Battle NCDs

The World Health Assembly released the global NCD action plan for 2013-2020 building on the 2008-2013 work plan with a multi-tiered strategy to address the rise in NCDs, including a goal for a “25% relative reduction in premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases (especially chronic obstructive pulmonary disease and asthma) by 2025”.(1) These four disease groups highlight the lead causes of death from NCDs, but are also diseases managed routinely in the Emergency Department (ED).(4)

While there is only sparse literature on the distribution of NCDs amongst ED populations in LMICs, the concerning death rates from diseases that are likely to present to the ER cannot be debated. This is shown by the 2013 Global Burden of Disease study, which reported a 41% increase in global deaths from cardiovascular disease, given aging and burgeoning populations. Multiple sources also report injury as one of the leading causes of mortality and morbidity in these regions.(4,5,9,10,11) Ogunmola and Olamoyegun published a retrospective review on patient admissions presenting through the ED to a federal hospital in Nigeria, between 2010-2012, which revealed cardiovascular disease as the lead cause of death at 33.5%.(12) Another retrospective review on patients accessing care through the ED in Karachi, Pakistan found that among >78,000 patient visits and 601 deaths, the lead causes of death were sepsis at 23%, followed closely by myocardial infarction at 20%, and cerebrovascular accident as the third leading cause at 11%.(13)

Some of the most important tools in the case of global NCD control are prevention, patient empowerment, and health promotion.(5,14,15) The NCDs causing the highest burden of deaths are primarily tied to actionable risk factors, which are diet, exercise, and alcohol and tobacco use, and WHO recommendations suggest that targeting these risk factors are cost-effective best practices in addressing the burden of disease.(1,16,17)

The ED has the potential to act with regard to this, and there are different means of doing so. Ensuring adequate drug therapy for diabetes and hypertension control, especially in those with a history of cardiovascular disease (eg, ensuring acetylsalicylic for myocardial infarction patients), are highly cost-effective interventions.(1,4) Educating patients on their diseases, as well as important attributable risk factors to address them are also cost-effective and critical actions.(1,4,7) Concerningly low rates of patient awareness on disease presence such as in the case of the “silent killer” and most important risk factor of cardiovascular disease, hypertension, is still seen in LMICs, along with dismal control rates in those already on treatment.(18) Alcohol, tobacco, and other drug use have been associated with violence and unintentional injuries, so providing education, resources, and treatment where possible for cessation of these substances is key.(1) Additionally, education on diet regarding mitigating salt intake and saturated fats, and increasing consumption of fruits and vegetables, are further best practice actions.(1,4,7) Task-shifting to enable greater realization of some of the educational needs addressing NCD care may be considered.(9,19)

Appropriate management of asthma, and influenza vaccination for COPD patients are equally important. Other risk factors that can be highlighted to patients are minimizing occupational exposures/hazards and indoor pollution owing to cooking gases, which worsen chronic respiratory disease and increase the risk of lung cancer.(1) Recognizing the association between other NCDs and mental illness is also important for EPs, as well as the critical underrecognition of NCDs in patients with mental illness. Finally, using available infrastructure to refer early—and stressing this to patients—is paramount, especially in light of the danger of delayed care for hypertension and its effect on chronic kidney disease progression.(1,6)

The ED also has a unique role in acting as the safety net in many cases, with the ability to influence the trajectory of patient care and refer patients that may otherwise never get looped into the healthcare system. Additionally, ED and hospital leadership may implement guidelines and protocols addressing treatment and prevention for clinical providers to follow, as well as prioritizing access to basic diagnostics and respective in-country essential medicines to help treat these diseases.(7,20) As EPs, we have a golden ticket to influence the inner workings of an already strained system, especially with the potential to catch patients during early stages of disease before they progress.(4)

Conclusions

All in all, the problem requires a communal awareness and urgency of action amongst all global health players at different levels and from a wide range of sectors.(7) By recognizing the problem as a significant concern in the ED, we can then consider NCDs with greater awareness as we address our patients, guide trainees, and refer patients to outside care. EPs can also be active in joining the effort to raise awareness locally, both in their own communities and at the healthcare level. Along with further research to document specific population-based data on NCDs, there is a need for greater prioritization of NCDs by governments and policy makers.(4) We each have a role to play in curbing an alarming rise of highly preventable diseases and their sequelae in the most vulnerable populations, and the time for action is now.(1)

References

  1. WHO global action plan: for the prevention and control of noncommunicable diseases, 2013-2020. http://apps.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf. Accessed 4/2/2015.

  2. Bloom DE, Cafiero ET, Jané-Llopis E, et al. The global economic burden of non-communicable diseases. Geneva (CH): World Economic Forum; 2011.

  3. Diez-Canseco F, Boeren Y, Quispe R, Chiang Ml, Miranda JJ. Engagement of Adolescents in a Health Communications Program to Prevent Noncommunicable Diseases: Multiplicadores Jóvenes, Lima, Peru, 2011. Prev Chronic Dis. 2015; 12:1 40416

  4. Murray CJL, Vos T, Lozano R, et al. Disability-Adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012; 380: 2197-223.

  5. WHO Global status report on non-communicable diseases 2010: executive summary. 2011. http://www.who.int/nmh/publications/ncdreportsummary_en.pdf?ua=1. Accessed 4/7/2015.

  6. Bukhman G, Kidder A. The PIH Guide to Chronic Care Integration for Endemic Non-Communicable Diseases. http://parthealth.3cdn.net/e9df3e9c18f698e02e_mlbrr0ygv.pdf. Accessed 4/7/2015.

  7. United nations general assembly: sixty-sixth session, agenda item 117: Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. http://www.who.int/nmh/events/unncdsummit2011/politicaldeclarationen.pdf?ua=1. Accessed 4/7/2015.

  8. WHO Global Coordination Mechanism. http://www.who.int/global-coordination-mechanism/background/en/. Accessed 4/10/15.

  9. Binagwaho A, Muhimpundu MA, Bukhman G, NCD Synergies Group. 80 under 40 by 2020: an equity agenda for NCDs and injuries. Lancet. 2014; 383(9911): 3–4.

  10. Yusuf S, McKee M. Documenting the Global Burden of Cardiovascular Disease A Major Achievement but Still a Work in Progress. Circulation. 2014; 129: 1459-1462.

  11. Wachira B, Wallis LA, Geduld H. An analysis of the clinical practice of emergency medicine in public emergency departments in Kenya. Emerg Med J. 2012; 29: 473-476.

  12. Ogunmola OJ, Olamoyegun MA. Patterns and outcomes of medical admissions in the accident and emergency department of a tertiary health center in a rural community of Ekiti, Nigeria. J Emerg Trauma Shock. 2014; 7(4): 261-7.

  13. Khan NU, Razzak JA, Alam SM, Ahmad H. Emergency department deaths despite active management: experience from a tertiary care centre in a low-income country. Emerg Med Australas. 2007; 19(3): 213-7.

  14. Scaling up action on noncommunicable diseases: how much will it cost? World Health Organization, 2011. http://whqlibdoc.who.int/publications/2011/9789241502313_eng.pdf?ua=1. Accessed 4/7/2015.

  15. Rollnick S, Miller WR, Butler C. Motivational interviewing in health care: helping patients change behavior. 2008. New York: The Guilford Press.

  16. April 2014 SNAP caseloads down over the year: SNAP/Food Stamp participation 2014. Washington (DC): Food Research and Action Center; 2014. http://frac.org/reports-and-resources/snapfood-stamp-monthly-parit

  17. Wachira BW, Owuor AO, Otieno HA. Acute management of ST-elevation myocardial infarction in a tertiary hospital in Kenya: Are we complying with practice guidelines? African Journal of Emergency Medicine. 2014; 4(3): 104–108.

  18. van de Vijver S, Akinyi H, Oti S, et al. Status report on hypertension in Africa - Consultative review for the 6th Session of the African Union Conference of Ministers of Health on NCD’s. Pan Afr Med J. 2013; 16: 38.

  19. Binagwaho A, Kyamanywa P, Farmer PE, et al. Rwanda’s human resources for health program: a new partnership. N Engl J Med. 2013; 369: 2054–59.

  20. WHO model lists of essential medicines. http://www.who.int/medicines/publications/essentialmedicines/en/. Accessed 4/7/2015.

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