An integrated electronic health record system is a common platform for efficient and active inter... more An integrated electronic health record system is a common platform for efficient and active interaction of four major subsystems namely the medical record system, laboratory system, picture archiving and communication system and enterprise resource planning system. Barriers like knowledge and attitude of computer usage, time consumption, information technology workforce, electricity, cost of technology and devices, data safety and security deter institutions from implementation. However, implementation of this system is inevitable with its inherent advantages of efficient storage and timely retrieval, comparison of lab and imaging data over time, cash billing, institutional resource planning and finally ease of processing insurance claims as the Government of Nepal is looking forward to financing public health sector through the national health insurance system. Many hospitals struggle to implement and maintain integrated electronic health records. We aimed to discuss the steps unde...
IntroductionDespite carrying a disproportionately high burden of depression, patients in low-inco... more IntroductionDespite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings.MethodsWe conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers’ behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of pati...
Background: In pleural effusion, differentiating exudative and transudative fluid is an importan... more Background: In pleural effusion, differentiating exudative and transudative fluid is an important clinical evaluation. The objective of the study was to determine the efficacy of pleural fluid serum bilirubin ratio in differentiating exudative and transudative effusions. In resource-limited settings with no facilities to measure lactate dehydrogenase (LDH) levels, using pleural fluid bilirubin ratio may help in better clinical decision. Methods: It was a prospective observational study, conducted in the emergency department of Tribhuvan University Teaching Hospital. All the patients attending for emergency care with pleural effusion from 6th Jan 2015 to 5th Jan 2016 were included. The cases were divided as exudates and transudates on basis of final diagnosis. Serum and pleural fluid specimen were collected and sent for investigations. The data for various laboratory parameters especially those of lights criteria and bilirubin ratio were then analyzed and fluid nature was compared ...
Background In Nepal, the burden of non-communicable, chronic diseases is rapidly rising, and disp... more Background In Nepal, the burden of non-communicable, chronic diseases is rapidly rising, and disproportionately affecting low- and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs. Methods A twelve-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated non-communicable disease care management intervention within Nepal’s new municipal governance structure. The intervention will leverage the government’s planned roll-out of the World H...
Journal of Karnali Academy of Health Sciences, 2018
Background: Complex partial seizure with sudden onset in near term pregnancy can be challenging t... more Background: Complex partial seizure with sudden onset in near term pregnancy can be challenging to the attending clinician and it is essential to proceed with a presumptive diagnosis of eclampsia, especially in resource poor settings. Unlike generalized tonic clonic seizures, which are more common in eclampsia, complex partial seizures may not jeopardize the fetus with the same severity. However the associated postictal aggression manifested in self-inflicted trauma poses an imminent risk onto the fetus. Case presentation: A nineteen year old gravida two para one living zero woman presented with seizure at thirty six weeks and three days of gestation in a district hospital. The blood pressure recordings during her entire pregnancy were normal and proteinuria was not present. Her previous pregnancy had a similar course, with self-inflicted trauma to her abdomen in a postictal state and resulted in loss of fetus. She did not have any seizures in between then and the current admission....
Low-income and middle-income countries are struggling with a growing epidemic of non-communicable... more Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care—first-contact access, care coordination, comprehensiveness and continuity—offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular ‘at-goal’ metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, a...
International Journal of Noncommunicable Diseases, 2018
Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportio... more Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportional mortality in Nepal and is increasingly diagnosed in rural population. We aimed to evaluate the care delivery in diabetes patients in a rural primary care hospital that had implemented the World Health Organization's Package of essential NCDs interventions (PEN) protocol. Subjects and Methods: This was a descriptive study in a rural district hospital. The study was conducted over 5 months and was undertaken as a part of the quality improvement project in the hospital. Data were extracted from the electronic medical record of the hospital after approval from hospital administration. Results: The total diabetic patient visits during the study period were 682 of 30,758 total outpatient visits (2%). There were 240 unique diabetic patients. The age ranged from 25 to 82 years with the median age of 52. Glycated hemoglobin was done in 15 of 59 new cases and in 33 of 181 follow-up cases. Urine protein was assessed in 65 of 240 patients. Comorbidities and complications were documented in 96 of 240 patients (40%), hypertension being the most common. Fifty-six patients (23%) had obtained control as per the target levels with different modalities of treatment, 69 (29%) had partial control, 85 (35%) struggled to reach targets, and 30 (13%) failed to appear in follow-up visits. Conclusion: The study described our adherence to the PEN protocol and identified several areas of improvement in our diabetes care delivery such as continuous medical education activities and monitoring of care delivery with similar study in future after implementation of proposed interventions.
There is a global health workforce shortage, which is considered critical in Nepal, a low-income ... more There is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital. We perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, a...
Background The Collaborative Care Model (CoCM) for mental healthcare, where a consulting psychiat... more Background The Collaborative Care Model (CoCM) for mental healthcare, where a consulting psychiatrist supports primary care and behavioral health workers, has the potential to address the large unmet burden of mental illness worldwide. A core component of this model is that the psychiatrist reviews treatment plans for a panel of patients and provides specific clinical recommendations to improve the quality of care. Very few studies have reported data on such recommendations. This study reviews and classifies the recommendations made by consulting psychiatrists in a rural primary care clinic in Nepal. Methods A chart review was conducted for all patients whose cases were reviewed by the treatment team from January to June 2017, after CoCM had been operational for 6 months. Free text of the recommendations were extracted and two coders analyzed the data using an inductive approach to group and categorize recommendations until the coders achieved consensus. Cumulative frequency of the ...
Journal of Karnali Academy of Health Sciences, 2018
Background: Complex partial seizure with sudden onset in near term pregnancy can be challenging t... more Background: Complex partial seizure with sudden onset in near term pregnancy can be challenging to the attending clinician and it is essential to proceed with a presumptive diagnosis of eclampsia, especially in resource poor settings. Unlike generalized tonic clonic seizures, which are more common in eclampsia, complex partial seizures may not jeopardize the fetus with the same severity. However the associated postictal aggression manifested in self-inflicted trauma poses an imminent risk onto the fetus.
Background: There is a global health workforce shortage, which is considered critical in Nepal, a... more Background: There is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital. Case presentation: We perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, appendectomy, tubal ligation, and vasectomy. This time period was associated with increased emergency department visits, inpatient admissions, and institutional birth rate in the hospital's catchment area. Non-clinical contributions included the development of a continuing medical education curriculum and implementation of a series of quality improvement initiatives.
International Journal of Noncommunicable Diseases, 2018
Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportio... more Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportional mortality in Nepal and is increasingly diagnosed in rural population. We aimed to evaluate the care delivery in diabetes patients in a rural primary care hospital that had implemented the World Health Organization’s Package of essential NCDs interventions (PEN) protocol. Subjects and Methods: This was a descriptive study in a rural district hospital. The study was conducted over 5 months and was undertaken as a part of the quality improvement project in the hospital. Data were extracted from the electronic medical record of the hospital after approval from hospital administration. Results: The total diabetic patient visits during the study period were 682 of 30,758 total outpatient visits (2%). There were 240 unique diabetic patients. The age ranged from 25 to 82 years with the median age of 52. Glycated hemoglobin was done in 15 of 59 new cases and in 33 of 181 follow‑up cases. Urine protein was assessed in 65 of 240 patients. Comorbidities and complications were documented in 96 of 240 patients (40%), hypertension being the most common. Fifty‑six patients (23%) had obtained control as per the target levels with different modalities of treatment, 69 (29%) had partial control, 85 (35%) struggled to reach targets, and 30 (13%) failed to appear in follow‑up visits. Conclusion: The study described our adherence to the PEN protocol and identified several areas of improvement in our diabetes care delivery such as continuous medical education activities and monitoring of care delivery with similar study in future after implementation of proposed interventions. Keywords: Diabetes, essential medicines, package of essential noncommunicable diseases protocol, primary care, rural
Introduction: In pleural effusion, differentiating exudative and transudative fluid is an importa... more Introduction: In pleural effusion, differentiating exudative and transudative fluid is an important clinical evaluation. The objective of the study was to determine the efficacy of pleural fluid serum bilirubin ratio in differentiating exudative and transudative effusions. In resource-limited settings with no facilities to measure lactate dehydrogenase levels, using pleural fluid bilirubin ratio may help in better clinical decision.
An integrated electronic health record system is a common platform for efficient and active inter... more An integrated electronic health record system is a common platform for efficient and active interaction of four major subsystems namely the medical record system, laboratory system, picture archiving and communication system and enterprise resource planning system. Barriers like knowledge and attitude of computer usage, time consumption, information technology workforce, electricity, cost of technology and devices, data safety and security deter institutions from implementation. However, implementation of this system is inevitable with its inherent advantages of efficient storage and timely retrieval, comparison of lab and imaging data over time, cash billing, institutional resource planning and finally ease of processing insurance claims as the Government of Nepal is looking forward to financing public health sector through the national health insurance system. Many hospitals struggle to implement and maintain integrated electronic health records. We aimed to discuss the steps unde...
IntroductionDespite carrying a disproportionately high burden of depression, patients in low-inco... more IntroductionDespite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving mental health outcomes. However, evidence from real-world implementation of CoCM is necessary to inform its expansion in low-resource settings.MethodsWe conducted a 2-year mixed-methods study to assess the implementation and clinical impact of CoCM using the WHO Mental Health Gap Action Programme protocols in a primary care clinic in rural Nepal. We used the Capability Opportunity Motivation-Behaviour (COM-B) implementation research framework to adapt and study the intervention. To assess implementation factors, we qualitatively studied the impact on providers’ behaviour to screen, diagnose and treat mental illness. To assess clinical impact, we followed a cohort of 201 patients with moderate to severe depression and determined the proportion of pati...
Background: In pleural effusion, differentiating exudative and transudative fluid is an importan... more Background: In pleural effusion, differentiating exudative and transudative fluid is an important clinical evaluation. The objective of the study was to determine the efficacy of pleural fluid serum bilirubin ratio in differentiating exudative and transudative effusions. In resource-limited settings with no facilities to measure lactate dehydrogenase (LDH) levels, using pleural fluid bilirubin ratio may help in better clinical decision. Methods: It was a prospective observational study, conducted in the emergency department of Tribhuvan University Teaching Hospital. All the patients attending for emergency care with pleural effusion from 6th Jan 2015 to 5th Jan 2016 were included. The cases were divided as exudates and transudates on basis of final diagnosis. Serum and pleural fluid specimen were collected and sent for investigations. The data for various laboratory parameters especially those of lights criteria and bilirubin ratio were then analyzed and fluid nature was compared ...
Background In Nepal, the burden of non-communicable, chronic diseases is rapidly rising, and disp... more Background In Nepal, the burden of non-communicable, chronic diseases is rapidly rising, and disproportionately affecting low- and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs. Methods A twelve-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated non-communicable disease care management intervention within Nepal’s new municipal governance structure. The intervention will leverage the government’s planned roll-out of the World H...
Journal of Karnali Academy of Health Sciences, 2018
Background: Complex partial seizure with sudden onset in near term pregnancy can be challenging t... more Background: Complex partial seizure with sudden onset in near term pregnancy can be challenging to the attending clinician and it is essential to proceed with a presumptive diagnosis of eclampsia, especially in resource poor settings. Unlike generalized tonic clonic seizures, which are more common in eclampsia, complex partial seizures may not jeopardize the fetus with the same severity. However the associated postictal aggression manifested in self-inflicted trauma poses an imminent risk onto the fetus. Case presentation: A nineteen year old gravida two para one living zero woman presented with seizure at thirty six weeks and three days of gestation in a district hospital. The blood pressure recordings during her entire pregnancy were normal and proteinuria was not present. Her previous pregnancy had a similar course, with self-inflicted trauma to her abdomen in a postictal state and resulted in loss of fetus. She did not have any seizures in between then and the current admission....
Low-income and middle-income countries are struggling with a growing epidemic of non-communicable... more Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care—first-contact access, care coordination, comprehensiveness and continuity—offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular ‘at-goal’ metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, a...
International Journal of Noncommunicable Diseases, 2018
Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportio... more Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportional mortality in Nepal and is increasingly diagnosed in rural population. We aimed to evaluate the care delivery in diabetes patients in a rural primary care hospital that had implemented the World Health Organization's Package of essential NCDs interventions (PEN) protocol. Subjects and Methods: This was a descriptive study in a rural district hospital. The study was conducted over 5 months and was undertaken as a part of the quality improvement project in the hospital. Data were extracted from the electronic medical record of the hospital after approval from hospital administration. Results: The total diabetic patient visits during the study period were 682 of 30,758 total outpatient visits (2%). There were 240 unique diabetic patients. The age ranged from 25 to 82 years with the median age of 52. Glycated hemoglobin was done in 15 of 59 new cases and in 33 of 181 follow-up cases. Urine protein was assessed in 65 of 240 patients. Comorbidities and complications were documented in 96 of 240 patients (40%), hypertension being the most common. Fifty-six patients (23%) had obtained control as per the target levels with different modalities of treatment, 69 (29%) had partial control, 85 (35%) struggled to reach targets, and 30 (13%) failed to appear in follow-up visits. Conclusion: The study described our adherence to the PEN protocol and identified several areas of improvement in our diabetes care delivery such as continuous medical education activities and monitoring of care delivery with similar study in future after implementation of proposed interventions.
There is a global health workforce shortage, which is considered critical in Nepal, a low-income ... more There is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital. We perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, a...
Background The Collaborative Care Model (CoCM) for mental healthcare, where a consulting psychiat... more Background The Collaborative Care Model (CoCM) for mental healthcare, where a consulting psychiatrist supports primary care and behavioral health workers, has the potential to address the large unmet burden of mental illness worldwide. A core component of this model is that the psychiatrist reviews treatment plans for a panel of patients and provides specific clinical recommendations to improve the quality of care. Very few studies have reported data on such recommendations. This study reviews and classifies the recommendations made by consulting psychiatrists in a rural primary care clinic in Nepal. Methods A chart review was conducted for all patients whose cases were reviewed by the treatment team from January to June 2017, after CoCM had been operational for 6 months. Free text of the recommendations were extracted and two coders analyzed the data using an inductive approach to group and categorize recommendations until the coders achieved consensus. Cumulative frequency of the ...
Journal of Karnali Academy of Health Sciences, 2018
Background: Complex partial seizure with sudden onset in near term pregnancy can be challenging t... more Background: Complex partial seizure with sudden onset in near term pregnancy can be challenging to the attending clinician and it is essential to proceed with a presumptive diagnosis of eclampsia, especially in resource poor settings. Unlike generalized tonic clonic seizures, which are more common in eclampsia, complex partial seizures may not jeopardize the fetus with the same severity. However the associated postictal aggression manifested in self-inflicted trauma poses an imminent risk onto the fetus.
Background: There is a global health workforce shortage, which is considered critical in Nepal, a... more Background: There is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital. Case presentation: We perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, appendectomy, tubal ligation, and vasectomy. This time period was associated with increased emergency department visits, inpatient admissions, and institutional birth rate in the hospital's catchment area. Non-clinical contributions included the development of a continuing medical education curriculum and implementation of a series of quality improvement initiatives.
International Journal of Noncommunicable Diseases, 2018
Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportio... more Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportional mortality in Nepal and is increasingly diagnosed in rural population. We aimed to evaluate the care delivery in diabetes patients in a rural primary care hospital that had implemented the World Health Organization’s Package of essential NCDs interventions (PEN) protocol. Subjects and Methods: This was a descriptive study in a rural district hospital. The study was conducted over 5 months and was undertaken as a part of the quality improvement project in the hospital. Data were extracted from the electronic medical record of the hospital after approval from hospital administration. Results: The total diabetic patient visits during the study period were 682 of 30,758 total outpatient visits (2%). There were 240 unique diabetic patients. The age ranged from 25 to 82 years with the median age of 52. Glycated hemoglobin was done in 15 of 59 new cases and in 33 of 181 follow‑up cases. Urine protein was assessed in 65 of 240 patients. Comorbidities and complications were documented in 96 of 240 patients (40%), hypertension being the most common. Fifty‑six patients (23%) had obtained control as per the target levels with different modalities of treatment, 69 (29%) had partial control, 85 (35%) struggled to reach targets, and 30 (13%) failed to appear in follow‑up visits. Conclusion: The study described our adherence to the PEN protocol and identified several areas of improvement in our diabetes care delivery such as continuous medical education activities and monitoring of care delivery with similar study in future after implementation of proposed interventions. Keywords: Diabetes, essential medicines, package of essential noncommunicable diseases protocol, primary care, rural
Introduction: In pleural effusion, differentiating exudative and transudative fluid is an importa... more Introduction: In pleural effusion, differentiating exudative and transudative fluid is an important clinical evaluation. The objective of the study was to determine the efficacy of pleural fluid serum bilirubin ratio in differentiating exudative and transudative effusions. In resource-limited settings with no facilities to measure lactate dehydrogenase levels, using pleural fluid bilirubin ratio may help in better clinical decision.
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Papers by Pawan KB Agrawal
increasingly diagnosed in rural population. We aimed to evaluate the care delivery in diabetes patients in a rural primary care hospital
that had implemented the World Health Organization’s Package of essential NCDs interventions (PEN) protocol.
Subjects and Methods: This was a descriptive study in a rural district hospital. The study was conducted over 5 months and was
undertaken as a part of the quality improvement project in the hospital. Data were extracted from the electronic medical record of the
hospital after approval from hospital administration.
Results: The total diabetic patient visits during the study period were 682 of 30,758 total outpatient visits (2%). There were 240 unique
diabetic patients. The age ranged from 25 to 82 years with the median age of 52. Glycated hemoglobin was done in 15 of 59 new cases
and in 33 of 181 follow‑up cases. Urine protein was assessed in 65 of 240 patients. Comorbidities and complications were documented
in 96 of 240 patients (40%), hypertension being the most common. Fifty‑six patients (23%) had obtained control as per the target
levels with different modalities of treatment, 69 (29%) had partial control, 85 (35%) struggled to reach targets, and 30 (13%) failed to
appear in follow‑up visits.
Conclusion: The study described our adherence to the PEN protocol and identified several areas of improvement in our diabetes care
delivery such as continuous medical education activities and monitoring of care delivery with similar study in future after implementation
of proposed interventions.
Keywords: Diabetes, essential medicines, package of essential noncommunicable diseases protocol, primary care, rural
increasingly diagnosed in rural population. We aimed to evaluate the care delivery in diabetes patients in a rural primary care hospital
that had implemented the World Health Organization’s Package of essential NCDs interventions (PEN) protocol.
Subjects and Methods: This was a descriptive study in a rural district hospital. The study was conducted over 5 months and was
undertaken as a part of the quality improvement project in the hospital. Data were extracted from the electronic medical record of the
hospital after approval from hospital administration.
Results: The total diabetic patient visits during the study period were 682 of 30,758 total outpatient visits (2%). There were 240 unique
diabetic patients. The age ranged from 25 to 82 years with the median age of 52. Glycated hemoglobin was done in 15 of 59 new cases
and in 33 of 181 follow‑up cases. Urine protein was assessed in 65 of 240 patients. Comorbidities and complications were documented
in 96 of 240 patients (40%), hypertension being the most common. Fifty‑six patients (23%) had obtained control as per the target
levels with different modalities of treatment, 69 (29%) had partial control, 85 (35%) struggled to reach targets, and 30 (13%) failed to
appear in follow‑up visits.
Conclusion: The study described our adherence to the PEN protocol and identified several areas of improvement in our diabetes care
delivery such as continuous medical education activities and monitoring of care delivery with similar study in future after implementation
of proposed interventions.
Keywords: Diabetes, essential medicines, package of essential noncommunicable diseases protocol, primary care, rural