Do Short-Term Medical Trips Make a Difference in Treating NCDs? Mark Ryan, MD Goldie Chang, P3; Camille Hochheimer, PhD student; Marwah Khalid, MD; Dien Tu, P4; Michelle Vy, M3

2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Mark Ryan, Goldie Chang, Camille Hochheimer, Marwah Khalid, Dien Tu, and Michelle Vy have indicated they have no relevant financial relationships to disclose.

Objectives Discuss the impact of non-communicable diseases in developing nation, with a focus on the Dominican Republic, and describe how short-term medical trips may play a role in their treatment. Review trends among hypertension control, hypertension treatment, and CVD risk in a community in Santo Domingo served by a twice-yearly short-term medical trip, and compare these trends with general community trends. Assess whether a regular short-term medical trip has had an impact on awareness, treatment, and control of non-communicable diseases (NCD) in this community, and evaluate what program changes might improve treatment of non-communicable diseases. 3

Non-Communicable Disease and the DR NCDs were responsible for 68% of all deaths in 2012, with cardiovascular disease accounting for 52% and diabetes accounting for 6%. 40% of deaths due to NCDs are premature deaths before the age of 70, and the majority occur in low and middle income countries. Hypertension is the 2 nd leading cause of death in the Dominican Republic, while diabetes is the 6 th leading cause of death. Nearly 35% of Dominicans are hypertensive and approximately 10% have diabetes. A recent study showed continuing gaps in awareness, treatment, and control of NCDs in developed vs. developing nations. 4

Treating NCDs in Paraiso Short-term medical trip (STMT) in Paraiso since Following AAFP Global Health Workshops in 2010 and 2011, increased focus on addressing NCDs and tracking patients’ care. Local public health systems are underfunded and overworked, with medications often unavailable. In 2010 we began to source medications for NCDs in-country; in 2013 we started to more directly assess impact of NCDs in our community. We have now built the clinic flow around an EHR to better allow ongoing treatment. 5

Challenges to NCD Treatment in STMT Patient understanding and awareness of NCDs: our research suggests patients are in agreement with importance of treating NCDs. Patients’ access to medications, both from STMTs and from local medical systems: we have learned that patient insurance does not sufficiently cover medications, and pharmacy access is an issue. Risks/benefits of intermittent versus uninterrupted treatment? Importance of having useful access to ongoing health records. Impact of social determinants of health on NCDs, and the ability of STMT to address these. 6 We were unable to find any literature assessing the impact of STMT focused on NCDs. The literature we found was focused on the impact of procedurally- based STMT.

Data Collection Methods Patients were required to be at least eighteen years of age, have a complete clinical data, and could not be pregnant. Returning patients (i.e. those with a documented visit in both 2014 and 2016) were identified by manual review of all patient records. A random sample of new patients was selected from remaining eligible patients. New patients at each time point were matched on gender and age. 7

Statistical Methods A paired t-test was used to detect a difference in systolic blood pressure (SBP) and diastolic blood pressure (DBP) over the two year period within both the repeat and non-repeat groups individually. A two sample t-test was used to compare the change in SBP and DBP over time between the two groups. A generalized linear mixed model (GLMM) was used to compare the proportion of patients receiving BP treatment and more than one BP treatment within and between both groups. 8

Results 44 total returning patients, 42 pairs of new patients The general trend in returning patients was lower BPs, where DBP was significantly lower in 2016 than in 2014 (-6.9 mmHg, P<0.001). SBP improvement was significantly better in return patients than in new patients (P=0.01). The general trend in new patients appears to be for more frequent BP treatment and more intense BP treatment (as assessed by patients with >1 BP treatment) (P<0.001, P=0.04). There was a larger increase in new patients receiving BP treatment than return patients (P=0.01). 9

Discussion There appears to be an increased tendency for the presence and intensity of HTN treatment in the community, independent of the role of our STMT. Return patients do appear to have some benefit in terms of the outcomes of treatment. This may be due to more-intense treatment, or may be due to availability of medications. Overall, unclear balance of costs vs. benefits given the small improvements in these outcomes. 10

Assessing the Impact of STMT Very difficult to assess, despite the presence of records over the course of time, and labor-intensive process using paper records: need complete, standardized data sets in easily- analyzed formats. Efforts need to continue to assess the benefits vs. costs of STMT which focus on NCDs. Partnerships with local health systems and/or greater support for medications/treatments for NCDs may be better options than STMTs focused on MD assessments, etc. 11 Continued work to evaluate the impacts (both benefits and risks) of STMT is critical, given the costs and challenges that exist in this work, and the ethical obligation to provide proper care to patients and communities.