Chronic disease, healthcare use, financial protection and disability in Sri Lanka:
In connection with Colombo University, we will undertake a nationally representative survey (n=14,200) of adults aged >20 years, covering all 25 districts in Sri Lanka. Fieldwork will be conducted in 2016 by the epidemiology unit of Colombo University, building on its experience in undertaking the Sri Lanka Diabetes, Cardiovascular Survey 2005 (Katulanda et al., 2008). The survey will collect data on current medications, past history of CVD, smoking, alcohol, diet and exercise; physical measurements including weight, height and blood pressure; and biochemical measurements including fasting blood sugar, oral glucose tolerance test, and a lipid profile. Survey instruments will be used to assess depression and chronic pain. Modules will also assess socioeconomic status (SES), healthcare utilization (HCU), work productivity, knowledge of a diagnosis of NCD, health literacy and barriers to seeking assessment and treatment for NCD. A tracking system will be established, allowing brief yearly follow-up of each individual to identify reasons for any hospitalizations and deaths in the preceding year. At the end of 2019-beginning of 2020, the sample will be resurveyed to collect data on health outcomes and healthcare use, and work and socioeconomic status. Clinical and laboratory tests will be made to assess CVD risk only at this point.
Two intervention studies will be undertaken. The first will evaluate the impact of expanding CVD treatment coverage by extending primary prevention to the middle risk population who are below the risk threshold currently used by the Ministry of Health (MOH) to define treatment eligibility. All survey respondents who qualify for treatment under the current MOH guidelines (CVD risk >30% as assessed using MOH-WHO risk charts) will be referred to an MOH clinic for treatment. Those with a CVD risk of 15%–30% as assessed using the Framingham risk tool or equivalent (estimated at 23% of sample over 40 years old – 2,100 people) will be randomized into intervention and control groups. The intervention group will be referred for treatment at MOH clinics, with an official MOH letter asking the doctor consulted to commence treatment. The control group will receive no referral. The impact of treating at a lower threshold on health outcomes, healthcare use, OOP expenditure, socioeconomic status, and work patterns will be assessed in the yearly follow-ups and the Year 2019-2020 resurvey.
A second intervention will aim to increase attendance at treatment clinics after individuals are identified as high risk of CVD at screening clinics. A sample of ten pairs of screening clinics, each of which feeds into one treatment clinic will be randomly selected, and from this, one screening clinic will be randomized to the control group and the other to the intervention group. Both groups of screening clinics will be provided with a computer to record patient details, including contact details and a mobile phone number. A feedback system will be established between the screening and treatment clinics to allow tracking of attendance at the treatment clinic. People in the intervention clinics that are referred for treatment will receive a comprehensive package (including a booked appointment, SMS reminders of their appointment and rebooking of an appointment on no-show) designed to increase subsequent attendance at the treatment clinic. The impact on attendance at treatment clinics within 3 months of initial referral will be compared between the intervention and control group.