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Fundamental shifts needed to ensure continuity of cardiac care for all

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Sep 28, 2022

By the Philips Foundation team

Health kiosk of Estación Vital installed in a mall in Nicaragua

Cardiovascular disease (CVD) is the leading cause of death globally, but it does not affect the world’s population equally. Over three-quarters of the estimated 17.9 million deaths from CVD in 2019 [1] occurred in low- and middle-income countries. Although there are advances in the diagnosis and treatment of CVD, the health systems in these countries have not been able to keep up with the growing burden of this disease. In collaboration with partners such as NCD Alliance and Heart Healers International, Philips Foundation explored ways of expanding access to CVD care in a dedicated webinar, in line with its mission of providing access to quality healthcare for underserved communities. This webinar brought together like-minded experts to discuss key topics such as the prevention of CVD, how to scale up successful pilot projects, and the fundamental shifts required to improve access to cardiovascular care.

In June 2022, Philips Foundation hosted a webinar with cardiologists and other experts to explore ways to improve the prevention, diagnosis, and treatment of cardiovascular disease for underserved communities. You can view the recording of the webinar here. Key learnings and recommendations from this webinar are shared below. For more information on our webinar series, click here.

Strengthening CVD care models in underserved communities


Dr. Andrea Beaton, Representative of Heart Healers International, stressed the importance of prevention when it comes to rheumatic heart disease (RHD). Over 40 million people currently live with RHD [2], commonly caused by a streptococcal throat infection left untreated. It particularly affects populations suffering from social deprivation and limited access to primary healthcare, among which only 1% are aware that RHD has caused damage to their cardiovascular function [2]. Because of this low level of awareness, and the fact that RHD is a cumulative disease, compounded by limited access to care, patients often do not present themselves until they suffer from severe symptoms resulting from heart damage. This dramatically increases fatality rates, but it is possible to detect RHD much sooner. 


This is where the Philips Foundation comes in – supporting Heart Healers International with RHD screening in Uganda by focusing on frontline health worker training and simple ultrasound protocols through the use of point-of-care ultrasound technology. In these low-income settings, 2 out of 100 children were diagnosed with early valve damage [3]. It was unclear how to offer treatment – so Philips Foundation partnered with Heart Healers International to run a clinical trial focusing on the early initiation of antibiotics to treat strep throat, as it is the original infection leading to heart damage.

 

The results were conclusive, and very encouraging. Preventative antibiotic treatment provided strong protection against heart damage after two years: less than 1% of children who had received the treatment suffered from progressive heart disease, compared to 8% who did not receive preventative antibiotics. Over 100,000 children received echocardiographic screening through the program in 2018, out of which 1,000 have been enrolled in a penicillin treatment program, and five have received life-saving heart surgeries.

We believe scaling up active detection of RHD could overcome the incredibly low diagnostic inertia […] which we now know when coupled with early initiation of antibiotics is a powerful tool for preventing advanced heart disease and early death for millions of youths around the world

Andrea Beaton

Associate Professor of Paediatrics at Cincinnati Children’s Hospital & Representative of Heart Healers International

UN woman at work with semi-manufactured goods

Beyond preventative treatment and early diagnosis, it is crucial to look further at preparedness to determine a health system’s ability to prevent serious CVD. To achieve this, Philips Foundation partnered with Heart Attack Concerned Kenya (HACK) to improve the level of preparedness for heart attack diagnosis and treatment in three counties in Kenya.

 

This partnership looked at the ability of public health facilities to deliver prompt diagnosis and treatment of heart attacks, and developed a suite of interventions to address the gaps identified. A survey in one of the counties showed a high prevalence of cardiovascular risk factors, as well as a lack of access to adequate care in instances of heart attacks. To tackle this, they focused on providing educational material designed for the local community, in the local language, explaining what a heart attack is and when it is important to seek help.

We believe in a multifaceted approach, involving early recognition of heart attacks through public awareness, improved knowledge and skills within the healthcare sector, as well as prompt treatment and timely referral; will reduce morbidity and mortality associated with heart attacks

Dr. Hassan A. Ahmed

Medical Director at Heart Attack Concern Kenya (HACK)

Beyond raising awareness of heart attack symptoms, they also trained healthcare workers to better deliver diagnoses and first aid. They also supplied electrocardiograms (ECG) to hospitals, as surveys had shown there were too few machines available locally. They trained healthcare workers on how to use them and interpret ECG results, increasing their knowledge from 30% to 98%. Identifying the health system’s weaknesses was crucial to address these gaps most efficiently, and they are currently offering refresher ECG courses to maintain the increase in medical education. They are hoping to scale the project to the rest of the country.

 

User-application of EMGuidance for healthcare professionals to find locally relevant information

The challenge of scaling up successful projects


Translating a highly complex clinical trial into public health policy is a challenge. Following the pilot program to prevent RHD in Uganda, it was critical first to understand how to integrate ultrasound screenings into primary care delivery in low-resource settings. According to Dr. Beaton, it is worth looking to innovative solutions such as AI to guide non-expert users, reduce training time, and even provide automatic interpretation of clinical results. Early partnership with key actors is also instrumental in scaling up clinical pilots, which is why they engaged with the Ministry of Health and district health offices from the start.


Dr. Gerald Yonga, Cardiologist and Chair of NCD Alliance Kenya Foundation as well as the Africa NCD Alliances Network, shared examples of three projects successfully scaled from the pilot stage in Sub-Saharan Africa. The first project focused on integrating CVD risk assessment into the care of people living with HIV.

 

It began as a pilot in Kenya and several other sub-Saharan countries, with NCD care for people living with HIV program eventually being rolled out in most of sub-Saharan Africa. To scale this project, it was necessary to tackle horizontal integration to include CVD screening in existing care pathways for HIV patients. Diagonal integration was also important – especially in common areas of operations in HIV and CVD care, such as the supply chain for medication, establishment of essential lab tests and availability of human resources to ensure continuum care for patients. Thirdly, it is important to address sustainable funding mechanisms for the necessary treatment of both CVD and HIV, which frequently co-exists.

You have to establish a best practice model […]. And this best practice model must be simple, and replicable

Dr. Gerald Yonga

Cardiologist and Chair of NCD Alliance Kenya Foundation

To provide another example, he presented a pilot providing community screening, referral, and treatment funding for children and young adults with CVD, especially those suffering from rheumatic and congenital heart disease. What started as screening camps, fundraising dinners and a charity run in Nairobi to fund surgical and catheter interventions at a local hospital evolved into nationwide fundraising runs, including corporate initiatives to support the treatment of over 200 children and young adults in Kenya annually.

 

Finally, he shared the story of the Healthy Heart Africa program, which started by providing screenings for the community and referrals for treatment at health centres at the county level in Kenya. It has been scaled to a national level, enabling the development of Kenya’s first national guidelines on CVD. Most health centers now receive training and introduce CVD risk assessment as routine practice at the primary care level.

 

To successfully scale a pilot project, it is also worth involving decision makers, care providers and the local community early on, so they can experience the pilot step by step. Finally, Dr. Yonga highlighted the importance of regular feedback at each scaling milestone to correct course if necessary, as the environmental, social, cultural, and political environment evolves during the life of the project.

 

Customer sees received patient data through health kiosks of Estación Vital

Mr. Ashvanni Srivastava, Chief Operating Officer of iMedrix, stressed the importance of partnerships to scale pilot projects successfully and achieve health equity. He addressed it essential to collaborate with like-minded partners, such as the Philips Foundation. It is essential to build a network with policymakers, med-tech and philanthropy, to facilitate the scalability and accessibility of key pilots.

 

Ashvanni further emphasized that iMedrix is focused on reducing overall healthcare costs based on early detection and timely intervention in cardiovascular disease; based on the company's own experience with private healthcare providers and public health authorities in more than 14 countries. Scaling impact goes beyond simply innovating and developing a good product; there has to be systemic change to allow for focus on prevention and early detection of CVD. He also underlined the benefit of webinars such as this one to help share learnings and latest developments, to keep track of the great work done by others and foster inspiration and collaboration.

At iMedrix, we are innovating at the local level, where we are connecting community centers for the first time with our mobile point-of-care ECG solution combined with Philips' mobile ultrasound; to accelerate communication between the community and healthcare in case of emergency

Mr. Ashvanni Srivastava

Chief Operating Officer of iMedrix

The necessity of fundamental shifts to improve access to cardiovascular care


According to Dr. Hassan Adan Ahmed, a consultant physician and cardiologist who worked for the project with Heart Attack Concern Kenya (HACK) project, there are two main challenges to improving access to care for CVD in low-income countries. In local communities, there is low literacy and poor health-seeking behaviour. It is very difficult for the population to recognize cardiovascular symptoms and identify dangerous chest pain, and this inability to recognize symptoms is at the core of the problem. Healthcare workers represent a further challenge. The level of medical knowledge on CVD is too low, so it is crucial to improve the education healthcare workers receive from the undergraduate level onwards. Capacity building in both the general population and healthcare workers is key.


Once initiatives to build capacity are established, it is important to keep track of the level of satisfaction of staff taking part in the project. This is especially true if their tasks change, or if the new procedures influence how many patients they can tend to in a day. According to Dr. Yonga (NCD Alliance), it is also crucial to keep the policy environment in mind to ensure that healthcare workers are compensated for new responsibilities, or that procurement policy allows for the upkeep of new equipment.

 

Health worker in India makes use of mobile health technology during counseling

As Dr. Beaton of Heart Healers International explained, there is always an opportunity to learn through collaboration, be it from high to low-income countries or vice-versa. She gave the example of telemedicine, widely used in high-income countries such as the United States, to improve access to diagnosis in more remote parts of the country. This experience and the learnings have been transferable to Uganda, to give populations in remote areas access to the car of the Uganda Heart Institute in the capital, where experts are located. Similarly, Heart Healers International have been able to share the learnings from training non-experts to use handheld ultrasound equipment in Uganda to improve access to care in underserved populations in the United States.

I think the key is always to keep our eyes open, to keep our ears open, to learn lessons from those settings so that we can translate them to improve care globally

Dr. Andrea Beaton

Associate Professor of Paediatrics at Cincinnati Children’s Hospital & Representative of Heart Healers International

Committed to the continuity of cardiac care globally


Philips Foundation continues to explore what is needed to achieve greater scalable impact and remains committed to promoting access to heart care in underserved communities around the world. For example, a heart wellness center was set up in Singapore for the elderly to increase AED access and CPR training. In the Netherlands, Philips Foundation teamed up with the Dutch Heart Foundation to develop an app to help people recognize heart failure earlier. 

 

Together with the International Federation of Red Cross and Red Cross Societies (IFRC) and Philips Design, Philips Foundation co-created inclusive CPRD training kits using context-specific visual language, making it easier for users to recognize symptoms of cardiac arrest and practice critical steps for effective CPR and defibrillation. The cards have already been translated into 9 languages: Arabic, Chinese, English, French, German, Portuguese, Russian, Spanish and Swahili. In addition, a modified version of the tool according to COVID-19 safety protocols was created to support CPRD online training so that people can continue saving lives in times of the pandemic.

 

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[1] WHO (2019). Cardiovascular diseases (CVDs)

[2] World Heart Federation (2022). Rheumatic heart disease (RHD)

[3] Clinical Investigation Valvular Heart Disease (2014). The utility of handheld echocardiography for early diagnosis of rheumatic heart disease

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