benjamin o. anderson, m.d. - harvard...
Post on 15-Feb-2018
215 Views
Preview:
TRANSCRIPT
www.bhgi.infowww.bhgi.infowww.bhgi.info
Benjamin O. Anderson, M.D.Benjamin O. Anderson, M.D.
www.bhgi.infowww.bhgi.info
BHGI resource-stratified guidelines
Low-income: Ghana, West Africa
Middle-income: Latin America
www.bhgi.infowww.bhgi.info
BHGI resource-stratified guidelines
Low-income: Ghana, West Africa
Middle-income: Latin America
www.bhgi.infowww.bhgi.info
The The Breast Health Global Initiative (BHGI)Breast Health Global Initiative (BHGI) strives to strives to develop, implement and study evidencedevelop, implement and study evidence--based, based, economically feasible, and culturally appropriate economically feasible, and culturally appropriate
guidelines for international breast health and guidelines for international breast health and cancer control for low and middle income cancer control for low and middle income
countries to improve breast health outcomes.countries to improve breast health outcomes.
www.bhgi.infowww.bhgi.info
Comprehensive guidelinesComprehensive guidelines by selected expert panelsby selected expert panels
Consensus opinionsConsensus opinions based on evidence reviewbased on evidence review
PublicationPublication of a) consensus and b) individual manuscriptsof a) consensus and b) individual manuscripts
Global Summit 2002: Global Summit 2002: Health Care DisparitiesHealth Care Disparities
Global Summit 2005: Global Summit 2005: Resource StratificationResource Stratification
Global Summit 2007: Global Summit 2007: Guideline ImplementationGuideline Implementation
www.bhgi.infowww.bhgi.info
Basic level Basic level —— Core resourcesCore resources or fundamental services or fundamental services necessary for any breast health care system to function. necessary for any breast health care system to function.
Limited level Limited level —— SecondSecond--tier resourcestier resources or services that or services that produce major improvements in outcome such as survival.produce major improvements in outcome such as survival.
Enhanced level Enhanced level —— ThirdThird--tier resourcestier resources or services that are or services that are optional but important, because they increase the number optional but important, because they increase the number and quality of therapeutic options and patient choice. and quality of therapeutic options and patient choice.
Maximal level Maximal level —— HighestHighest--level resourceslevel resources or services used in or services used in some high resource countries that have lower priority on some high resource countries that have lower priority on the basis of extreme cost and/or impracticality.the basis of extreme cost and/or impracticality.
www.bhgi.infowww.bhgi.info
Cancer: 113 (8 suppl), 2008 Cancer: 113 (8 suppl), 2008
CONSENSUS STATEMENTSCONSENSUS STATEMENTSEarly DetectionEarly DetectionDiagnosisDiagnosisTreatmentTreatmentHealth Care SystemsHealth Care Systems8 Stratified Tables8 Stratified Tables10 Individual Manuscripts10 Individual Manuscripts
EARLY DETECTION DIAGNOSIS
STAGE I STAGE II LOCALLY ADVANCED METASTATIC
HEALTH CARE SYSTEMS
www.bhgi.infowww.bhgi.info
Dissemination & implementation (D&I) research Dissemination & implementation (D&I) research
Education and training programs Education and training programs
Technology application and developmentTechnology application and development
IMPLEMENTATION STRATEGY: IMPLEMENTATION STRATEGY: Create Create BHGIBHGI Learning LaboratoriesLearning Laboratories in different parts of the in different parts of the world to develop and test educational modules world to develop and test educational modules based on BHGI guidelines and to model program based on BHGI guidelines and to model program expansion to other LMCs.expansion to other LMCs.
www.bhgi.info
RESEARCH RESEARCH SEQUENCE SEQUENCE Early DetectionEarly Detection DiagnosisDiagnosis TreatmentTreatment
Guideline Guideline DevelopmentDevelopment
In print Oct 08In print Oct 08
In print Oct 08In print Oct 08
In print Oct 08In print Oct 08
Readiness Readiness AssessmentAssessment
TurkeyTurkeyBHGI Pilot 5/08BHGI Pilot 5/08
GhanaGhanaPath Lab 4/06Path Lab 4/06
ColombiaColombiaPSPGH Pilot 7/08PSPGH Pilot 7/08
Guideline Guideline AdoptionAdoption
ColombiaColombiaBHGI Pilot 7/07BHGI Pilot 7/07
IndonesiaIndonesiaBHGI Pilot 7/07BHGI Pilot 7/07
Ghana (GBCA)Ghana (GBCA)Open 11/09Open 11/09
SystemSystem--wide wide ScaleScale--upup
Latin AmericaLatin AmericaSummit 4/10Summit 4/10
Latin AmericaLatin AmericaSummit 4/10Summit 4/10
Latin AmericaLatin AmericaSummit 4/10Summit 4/10
www.bhgi.infowww.bhgi.info
BHGI resource-stratified guidelines
Low-income: Ghana, West Africa
Middle-income: Latin America
www.bhgi.infowww.bhgi.info
BHGI resource-stratified guidelines
Low-income: Ghana, West Africa
Middle-income: Latin America
www.bhgi.info
““Some countries are so poor that breast Some countries are so poor that breast cancer is not a significant problem for them.cancer is not a significant problem for them.””
QUESTION:QUESTION: At what point are resources so At what point are resources so limited, and competing demands so great, limited, and competing demands so great, that breast care programs make no sense to that breast care programs make no sense to create?create?
GHANA BREASTGHANA BREASTCANCER ALLIANCECANCER ALLIANCE
OCTOBER 2008OCTOBER 2008
SITUATION ANALYSIS:SITUATION ANALYSIS:GHANA, WEST AFRICAGHANA, WEST AFRICA
OCTOBER 2004OCTOBER 2004
www.bhgi.info
Public education and advocacyPublic education and advocacy–– DevelopDevelop public education materials (BHGI guidelines)public education materials (BHGI guidelines)
–– CollaborateCollaborate with (NGOs) and advocacy groups to with (NGOs) and advocacy groups to distribute materials and assess impact on breast caredistribute materials and assess impact on breast care
Professional education and trainingProfessional education and training–– DevelopDevelop education curricula (BHGI guidelines)education curricula (BHGI guidelines)
–– CollaborateCollaborate withwith international health organizations international health organizations and medical groups to provide situation appropriate and medical groups to provide situation appropriate education and training and assess impacteducation and training and assess impact
Komen for the Cure TeamOct 16, 2008, Kumasi
Breast Cancer Awareness MarchOct 16, 2008, Kumasi
Breast Cancer Awareness MarchOct 16, 2008, Kumasi
www.bhgi.info
Ghana College of Physicians and SurgeonsGhana College of Physicians and Surgeons–– Paul Nyame, MDPaul Nyame, MD
KorleKorle--Bu Teaching HospitalBu Teaching Hospital–– JoeJoe--Nat CleggNat Clegg--Lamptey, MDLamptey, MD
Komfo Anokye Teaching Hospital (KATH)Komfo Anokye Teaching Hospital (KATH)–– Anthony NsiahAnthony Nsiah--Asare, MD / Baffour Awuah, MD Asare, MD / Baffour Awuah, MD
Peace and Love HospitalPeace and Love Hospital–– Beatrice Wiafe, MD (Kumasi)Beatrice Wiafe, MD (Kumasi)
Reach for RecoveryReach for Recovery–– Gladys BoatengGladys Boateng
HopeXchange Medical CenterHopeXchange Medical Center–– Riccardo Massetti, MD / Mario CappelloRiccardo Massetti, MD / Mario Cappello
Ghana Breast Cancer Alliance (GBCA) meetingJanuary 30, 2009, Kumasi
www.bhgi.info
HopeXchange: Institute for Professional TrainingHopeXchange: Institute for Professional Training
Training in early detection, diagnosis and treatment Training in early detection, diagnosis and treatment adjusted for lowadjusted for low--income country resourcesincome country resources–– Curriculum based on BHGI GuidelinesCurriculum based on BHGI Guidelines
–– International faculty to teach and learnInternational faculty to teach and learn
D&I methodology applied inD&I methodology applied in--countrycountry
Educational outcomes assessed and reportedEducational outcomes assessed and reported
Groot et al, Breast Journal 12:S81, 2006
Simulation model to estimate costs and health effects of treating stage I, II, III, and IV breast cancer
Data used from 3 regions: North America, Africa and Asia
Effect of extensive early detection (screening) program was assessed
METRICS: Disability adjusted life- years (DALYs) and 2000 dollars
Groot et al, Breast Journal 12:S81, 2006
www.bhgi.infowww.bhgi.info
BHGI resource-stratified guidelines
Low-income: Ghana, West Africa
Middle-income: Latin America
www.bhgi.infowww.bhgi.info
BHGI resource-stratified guidelines
Low-income: Ghana, West Africa
Middle-income: Latin America
www.bhgi.infowww.bhgi.info
Target: MiddleTarget: Middle--Income CountriesIncome Countries
BHGI Breast Early Detection Module (BSM):BHGI Breast Early Detection Module (BSM):–– Patient and professional educationPatient and professional education–– Screening and early detection (CBE + mammography)Screening and early detection (CBE + mammography)–– Diagnosis (imaging / tissue sampling / pathology)Diagnosis (imaging / tissue sampling / pathology)–– Triage to linked diagnosis and treatment programsTriage to linked diagnosis and treatment programs
Model program development for middleModel program development for middle--income income regions of Latin America, Eastern Europe and regions of Latin America, Eastern Europe and Asia Pacific.Asia Pacific.
www.bhgi.infowww.bhgi.info
BHGI EARLY DETECTION RESOURCE ALLOCATION Latin America 2009Latin America 2009
????
ColombiaColombiaNational Early Detection ProgramNational Early Detection Program
www.bhgi.infowww.bhgi.info
The Ministry of Social ProtectionThe Ministry of Social Protection
Resolution 1439 issued Resolution 1439 issued November 1, 2002November 1, 2002
Clinical Practice Guidelines by Clinical Practice Guidelines by INSTITUTO NACIONAL DE INSTITUTO NACIONAL DE CANCEROLOGCANCEROLOGÍÍA published A published August 2006August 2006
Presented October 2006Presented October 2006
Colombian National Early Detection ProgramBHGI / NCI Research Team Meeting (2009)
www.bhgi.infowww.bhgi.info
2 year pilot randomized trial for women 50 2 year pilot randomized trial for women 50 --69: 69: –– Intervention: Training + screening mammographyIntervention: Training + screening mammography
–– Control: Control: Current standard of careCurrent standard of care
–– Outcome: Outcome: Tumor size / stage at diagnosisTumor size / stage at diagnosis
Cluster randomized by primary health care centerCluster randomized by primary health care center
7,000 women to be recruited for each arm7,000 women to be recruited for each arm–– 224 physicians trained in 16 health centers224 physicians trained in 16 health centers
–– 24 techs trained from 8 radiology centers24 techs trained from 8 radiology centers
–– > 2,500 women recruited to each arm> 2,500 women recruited to each arm
Proyecto piloto para la implementación de estrategias de detección temprana de cáncer
de mama en Colombia
Instituto Nacional de CancerologíaBogotá - Colombia
Study Design
Health Care Centers RandomizationStratified by Insurance Plan
Intervention GroupEnroll 7,000 women
Control GroupEnroll 7,000 women
Training for primary care MDs, nurses, radiologists, technologists
and breast specialistsNo intervention in health care center
Screening based oncurrent clinical practices
Implement screening programIn health care center
Screening based oncurrent clinical practices
Screening mammogram with diagnosticFollow-up in women > age 50
Follow-up in one yearFollow-up in one year
Statistical Analysis
Clinical stageCancer incidenceEvaluation of participationCost assessmentAdverse effects
Informed consent
Technical skills training Clinical Breast Exam
Screening invitation, documentation,patient follow-up, quality control, etc
Outcome Variables
20 HMOs
Mamografías en el estudio
PruebasMamografias Solicitadas 3627 100.0% 690 23.1%Mamografias Realizadas 2681 73.9% 386 55.9%
Intervenciòn Control
Awareness
Survivorship
Early Detection
Diagnosis
Treatment
Advocacy
Public ParticipationPublic Participation Health Care DeliveryHealth Care Delivery
Awareness
Survivorship
Early Detection
Diagnosis
Treatment
Advocacy
Public ParticipationPublic Participation Health Care DeliveryHealth Care Delivery
LB COLOMBIALB COLOMBIA
LB MEXICOLB MEXICO
LB BRAZILLB BRAZIL
www.bhgi.infowww.bhgi.info
Breast cancer is an international problem Breast cancer is an international problem affecting countries at all economic levelsaffecting countries at all economic levels
BHGI guidelines provide a framework for BHGI guidelines provide a framework for systematic, comprehensive improvementsystematic, comprehensive improvement
Dissemination and implementation Dissemination and implementation through BHGI Learning Laboratories can through BHGI Learning Laboratories can steer guideline application in LMCssteer guideline application in LMCs
BHGI guideline implementation can serve BHGI guideline implementation can serve underserved populations in all countriesunderserved populations in all countries
www.bhgi.info
top related