SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA Findings from a Cascade Analysis 16422-WB_Macedonia Report-5thPgs.indd 1 2/2/23 9:09 AM © 2022 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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Photo credits Front and back covers: All photos by Tomislav Georgiev, except lower right photo by Evgenia Tuzinska/Shutterstock.com Page 2: Photo by Shalev Cohen on Unsplash Page 8: © Olja Latinovic/World Bank on Flickr.com Page 40: © Aisha Faquir/World Bank on Flickr.com Page 42: © Tomislav Georgiev 16422-WB_Macedonia Report-5thPgs.indd 2 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA Findings from a Cascade Analysis Nicole Fraser, Ana Krsteska, Kiril Soleski, Tonny Brian Mungai Muthee, Zara Shubber & Federica Secci November 2022 16422-WB_Macedonia Report-5thPgs.indd 1 2/2/23 9:09 AM Contents Acknowledgments................................................................................................................................................................... v Abbreviations........................................................................................................................................................................... vi Executive Summary................................................................................................................................................................ vii Introduction................................................................................................................................................................................. 1 Methodology............................................................................................................................................................................. 3 Design of the cascade analysis....................................................................................................................................... 3 Burden estimations............................................................................................................................................................. 3 Medical records review..................................................................................................................................................... 5 Definitions used in the cascade analysis...................................................................................................................... 6 Hospital admission data.................................................................................................................................................... 7 Focus group discussions and interviews with key informants................................................................................ 7 Results......................................................................................................................................................................................... 9 Diabetes................................................................................................................................................................................ 9 Diabetes burden............................................................................................................................................................. 9 Diabetes treatment cascades..................................................................................................................................... 11 Hypertension....................................................................................................................................................................... 16 Hypertension burden.................................................................................................................................................... 16 Hypertension treatment cascades............................................................................................................................ 16 Use of digital tools in the patient sample.................................................................................................................. 20 COVID-19 and seasonal influenza vaccinations...................................................................................................... 20 Hospital admissions and COVID-morbidity................................................................................................................. 21 Qualitative results on diabetes and hypertension care.......................................................................................... 23 Primary prevention....................................................................................................................................................... 23 Screening and diagnosis............................................................................................................................................ 24 Treatment initiation....................................................................................................................................................... 28 Treatment maintenance and monitoring................................................................................................................. 31 Summary of barriers and facilitators........................................................................................................................ 37 Limitations of the Analysis.................................................................................................................................................... 41 Conclusions and Recommendations................................................................................................................................ 43 Endnotes.................................................................................................................................................................................. 49 Annex 1: GP Sites and Patients Reviewed........................................................................................................................ 51 Annex 2: Additional Cascade Charts............................................................................................................................... 52 16422-WB_Macedonia Report-5thPgs.indd 2 2/2/23 9:09 AM FIGURES Figure ES. 1. Population-level diabetes cascade, North Macedonia.......................................................................... ix Figure ES. 2. Population-level hypertension cascade, North Macedonia................................................................. ix Figure 1. Mixed-methods design of the analysis.............................................................................................................. 3 Figure 2. Geographic distribution of participating GP practices................................................................................. 5 Figure 3. Estimated diabetes risk population in North Macedonia (2021)................................................................ 9 Figure 4. Registered diabetes cases in 2019 and 2020.............................................................................................. 10 Figure 5. Diabetes treatment cascade (all patients reviewed)..................................................................................... 11 Figure 6. Diabetes treatment cascade (urban vs. rural GP practices)....................................................................... 12 Figure 7. Diabetes treatment cascade (insulin vs. no-insulin treatment).................................................................. 14 Figure 8. Diabetes treatment cascade (with or without hypertension)..................................................................... 15 Figure 9. Diabetes treatment cascade (by BMI band)................................................................................................... 15 Figure 10. Estimated hypertension risk population in North Macedonia (2019)..................................................... 16 Figure 11. Reported hypertension cases diagnosed at GP services (ICD-10 code I10, 2020)............................. 17 Figure 12. Hypertension treatment cascade (all patients reviewed)......................................................................... 18 Figure 13. Hypertension treatment cascade (urban vs. rural GP practices)............................................................. 19 Figure 14. Hypertension treatment cascade (by grade at diagnosis)........................................................................ 19 Figure 15. Hypertension treatment cascade (by BMI band)......................................................................................... 21 Figure A2.1. Diabetes treatment cascade (by gender)................................................................................................ 52 Figure A2.2. Diabetes treatment cascade (by age group).......................................................................................... 53 Figure A2.3. Hypertension treatment cascade (by gender)....................................................................................... 53 Figure A2.4. Hypertension treatment cascade (by age group)................................................................................. 54 TABLES Table 1. Diabetes and hypertension burden estimation................................................................................................. 4 Table 2. GP practices participating in the medical records review............................................................................. 6 Table 3. Digital tools used for consultation and self-monitoring................................................................................ 21 Table 4. Hospital admission data in reviewed patient records................................................................................. 22 Table 5. “Health for All” number of preventive health examinations: 2013–2020.............................................. 26 Table 6. Identified barriers and facilitators across the diabetes and hypertension care cascades................. 38 Table 7. Priority actions to strengthen the control of metabolic NCDs.................................................................... 47 Table A1. Patient samples by GP practice......................................................................................................................... 51 16422-WB_Macedonia Report-5thPgs.indd 3 2/2/23 9:09 AM BOXES Box 1. Screening: What do the guidelines say?............................................................................................................. 25 Box 2. Diagnosis: What do the guidelines say?............................................................................................................. 27 Box 3. Treatment initiation: What do the guidelines say?........................................................................................... 29 Box 4. Treatment monitoring: What do the guidelines say?....................................................................................... 32 Box 5. Case study: Is there sufficient focus on closing service gaps and reaching desired outcomes?....... 37 16422-WB_Macedonia Report-5thPgs.indd 4 2/2/23 9:09 AM Acknowledgments Acknowledgments Nicole Fraser, Ana Krsteska, Kiril Soleski, Tonny Brian Mungai Muthee, Zara Shubber, and Federica Secci wrote this report. The authors are extremely grateful to the Ministry of Health of North Macedonia for their partnership throughout the study. In particular, the authors wish to thank Gordana Majnova, Advisor to the Minister of Health, for her collaboration on the preparation and implementation of the study and her feedback on the draft report. Special thanks go to Dr. Kiril Soleski for coordinating and supervising the data collection at the General Practitioners’ (GP) practices and to Prof. Dr. Goran Dimitrov of the Macedonian Medical Association for advice on the design of the data collection activity. The study team is very grateful to the 12 participating GP practices who extracted and provided anonymous, unlinked patient data to understand the routine care provided to chronic patients across North Macedonia. We also thank the participants of the focus group discussions for sharing their perspectives on noncommunicable diseases (NCDs) programming and care provision. They include care providers, health administrators, NCD patients, representatives of the Union of Associations of Diabetics of Macedonia, and the Association for Prevention of Cardiovascular Diseases ‘Healthy Future’. Also, thanks to Marko Naumovski for taking notes during these discussions. Dr. Federica Secci, the Task Team Leader, provided technical guidance throughout the process and led the policy dialogue, including disseminating study findings. Leonora Emini and Jasminka Sopova provided invaluable program assistance towards conducting the study and finalizing the report. The authors wish to thank Anna Koziel and Renzo Sotomayor, who provided insightful comments on the draft report. Thanks also go to Richard Crabbe for providing editorial services. The authors greatly appreciated the support provided by Dr. Tania Dmytraczenko (Practice Manager, Health, Nutrition, and Population Global Practice, Europe and Central Asia Region) and by Massimiliano Paolucci (Country Manager for North Macedonia, Europe, and Central Asia Region). Finally, the authors gratefully acknowledge Access Accelerated Trust Fund and the Health, Nutrition, and Population Global Practice, for the generous funding provided towards this study and for the helpful comments that improved the content and presentation of the final report. v 16422-WB_Macedonia Report-5thPgs.indd 5 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA Abbreviations ABC HbA1C-blood pressure-cholesterol IPH Institute of Public Health BMI Body mass index LDL Low-density lipoprotein BP Blood pressure MMA Macedonian Medical Association CAD Coronary artery disease mmHg Millimeters of mercury CVD Cardiovascular disease MOH Ministry of Health DALY Disability-adjusted life year NCD Noncommunicable disease DBP Diastolic blood pressure NGO Nongovernmental organization FDC Fixed-dose combination OOP Out-of-pocket FGD Focus group discussion PDL Positive Drug List FMS Family medicine specialist PHC Primary health care FPG Fasting plasma glucose RPG Random plasma glucose GP General practitioner SBP Systolic blood pressure HbA1C Glycated hemoglobin SEEHN South-East Europe Health Network HDL High-density lipoprotein WHO World Health Organization HIF Health Insurance Fund vi 16422-WB_Macedonia Report-5thPgs.indd 6 2/2/23 9:09 AM Executive Summary Executive Summary KEY POINTS 1. North Macedonia maintains a strong momentum for health system reform to provide higher quality services to its population, including for noncommunicable diseases (NCDs). This analysis of routine medical data confirms that the quality and continuity of care for chronic diseases like diabetes and hypertension need further improvement to prevent unnecessary morbidity, hospitalization, and costs. 2. North Macedonia lacks a national prevalence survey on diabetes and hypertension, which hampers reliable estimation of total diabetes and hypertension burden and makes it difficult to understand how many people remain undiagnosed. The diabetes care cascade shows concerning gaps in key steps towards diabetes control: glycemic control (A1C <7%), ABC control (HbA1C-blood pressure-cholesterol), and complication screen coverage is 41 percent, 38 percent, and 13 percent, respectively, among diabetes patients. The situation is slightly better for the hypertension cascade. Of those in hypertension care, 98 percent had blood pressure (BP) measurements done at the last visit, 87 percent in the last six months, and 64 percent recorded BP control in the last six months. 3. Notably, for both diabetes and hypertension, there were important differentials in care quality and coverage between the urban and rural care settings, diabetes treatment regimens, and comorbidities with diabetes, hypertension, and obesity. The analysis also found that diabetes patients had higher rates of recorded hospital admissions than those with hypertension and that rural patients had much higher admission rates than urban patients – twice as high in the hypertension sample. Focus group discussions with patients and health workers illuminated various bottlenecks in service provision, which could explain these results. For example, the insufficient focus on and scale of primary prevention across the life course and sectors to facilitate lifestyle adjustments and screening resulted in delayed treatment initiation and maintenance, with those in rural settings disproportionately affected. 4. Based on the above, there is a need to strengthen the delivery system and primary health care (PHC) services by utilizing monitoring and outcome data to focus additional support on patients who do not do well in care, especially in rural settings. Proactive targeting should be prioritized with patient education adopting a “push” approach rather than the “pull” approach, in which education relies primarily on patients’ initiative and disadvantages certain patient types. Reforming or refocusing the current PHC model can help the country address differences in health service coverage through diverse measures. These include fit-for-purpose service configuration, sustainable payment models for PHC services, leveraging telemedicine platforms, expanding prescription authority, and improving access to essential medicines and training. INTRODUCTION North Macedonia, an Eastern European nation of 1.836 million inhabitants, has a growing burden of non- communicable diseases (NCDs). An aging population and high levels of NCD risk factors are mainly responsible, with tobacco, raised blood pressure, and unhealthy diets driving mortality and disability. To better address vii 16422-WB_Macedonia Report-5thPgs.indd 7 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA the needs of its rapidly aging population, the growing challenges posed by chronic conditions, and improve overall health system performance, the country is developing a new PHC model. This model should improve the quality of care and the efficiency of primary care by reducing fragmentation, enhancing coordination, prioritizing prevention, and strengthening the role of primary care nurses. AIM OF THE STUDY To strengthen the evidence on quality and continuity of care for diabetes and hypertension – the two conditions driving the burden of chronic NCDs and associated health care costs in North Macedonia – a cascade analysis was carried out using a mixed methods design. The assessment drew on secondary quantitative data from national and international sources, primary quantitative data from 2,400 patients in 12 GP practices, and primary qualitative data from health care providers and patients. Patient data were extracted from the eHealth system (MojTermin) and paper medical records from September to November 2021. MAIN FINDINGS Diabetes • North Macedonia lacks a national prevalence survey on diabetes, which hampers reliable estimation of the total diabetes burden. • The country registered 133,258 adult diabetes cases in 2020. The “diagnosed” stage of the care cascade (Figure ES. 1) used this officially reported number. • Using a published prevalence estimate for high fasting plasma glucose (FPG) in North Macedonia, the study approximated the size of the total burden – diagnosed and undiagnosed – to 251,000 adults with raised FPG; however, the estimate was uncertain (Figure ES. 1, dashed first column). • The rest of the diabetes cascade used the results from medical records of diabetes cases diagnosed and in care. Among 715 diabetes patients with reviewed data, 91 percent of women and 92 percent of men had a glucose test done during their last visit to their general practitioner GP). • Sixty-five percent of all reviewed diabetes patients had evidence of glucose control (Figure 6). Still, only 41 percent of all patients had evidence of longer-term glycemic control indicated by hemoglobin A1C (HbA1C) results, as shown in Figure ES. 1. • Thirty-eight percent of all patients had ABC (HbA1C, BP, cholesterol) control. • Only 13 percent of all patients had evidence of having received the four complication screens in the past 24 months: foot exam, and screens for retinopathy, nephropathy, and coronary artery disease. Hypertension • As with diabetes, the total burden is also not well understood for hypertension due to the lack of a population-based prevalence survey. • GP service statistics recorded 429,000 hypertension diagnoses in 2020; the ‘diagnosed’ stage of the care cascade used this officially reported number (Figure ES. 2). viii 16422-WB_Macedonia Report-5thPgs.indd 8 2/2/23 9:09 AM Executive Summary FIGURE ES. 1. POPULATION-LEVEL DIABETES CASCADE, NORTH MACEDONIA 189% High FPG (IHME estimate) Diagnosed (as per registry) Glucose monitored 100% (last visit) 91% Glycemic control A1C<7% (A1C tests of two last visits) ABC control 41% 38% (tests of two last visits) All 4 complication screens 13% (past 24 months) Adults 18+ years Sources: IHME, National Population Census 2021, and medical records review 2021. Notes: The high fasting plasma glucose (FPG) estimate is from the Global Burden of Disease estimation process. Levels are uncertain due to a lack of local empirical data. The complication screens should happen annually, but due to pandemic-related service continuity challenges, a window of 24 months was used. The number diagnosed and recorded in the registry was used as the denominator; the first bar (high FPG) is uncertain. FIGURE ES. 2. POPULATION-LEVEL HYPERTENSION CASCADE, NORTH MACEDONIA 123% 100% 98% Raised SBP (estimate) 87% Diagnosed (GP statistics) 64% BP done (at last visit) BP done (last 6 months) BP control (last 6 months) Adults 18+ years Sources: IHME, National population census 2021, and medical records review 2021. Notes: The raised systolic blood pressure (SBP) estimate is from the Global Burden of Disease estimation process, and levels are uncertain due to a lack of local empirical data. The number diagnosed and reported in the registry was used as the denominator; the first bar (raised SBP) is uncertain. ix 16422-WB_Macedonia Report-5thPgs.indd 9 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA • Using a published prevalence estimate for raised systolic blood pressure (SBP), the study estimated 524,000 adults in North Macedonia to have raised SBP (Figure ES. 2, dashed first column). • Again, the care cascade used the results from medical record data of hypertension cases diagnosed and in care. A BP measurement at the last GP visit was almost universal, with 98 percent of the 1,687 hypertension patients reviewed having a BP result recorded in their file. • Eighty-seven percent of all patients reviewed had a record of BP measurement in the last six months: the COVID-19-related discontinuity of services may have impacted this statistic. • Sixty-four percent of all patients reviewed had evidence of BP control in the last six months. CROSS-CUTTING ISSUES Differentials in care: For both diabetes and hypertension, there were notable differentials in care quality and coverage between the urban and rural care settings (Figures 6 and 13), diabetes treatment regimens (Figure 7), and comorbidities with diabetes, hypertension, and obesity (Figures 8, 9, 15). The analysis also found that diabetes patients had higher rates of recorded hospital admissions than those with hypertension and that rural patients had much higher rates of admission than urban patients – twice as high in the hypertension sample (Table 4). Diabetes patients had a higher risk of admission if comorbid with hypertension, on a treatment regimen with insulin, and with a Type-1 diagnosis. COVID-19 was the top reason for admission in diabetes patients and the second most important cause in hypertension patients. Secondary hypertension was in second and first place, respectively, as the cause of hospital admission. Telemedicine: The use of digital tools mainly supported consultations done by GPs and had increased during the pandemic as a measure to ensure basic service continuity (Table 3). Seventy-two percent of diabetes and 78 percent of hypertension patients had teleconsultations. Self-monitoring was also common, with almost half of diabetes patients reporting home-measurements of BP and glucose to the GP and over a third of hypertension patients reporting BP results (and one in ten reporting glucose results) from at-home testing. BARRIERS AND FACILITATORS OF NCD CARE The focus group discussions (FGDs) with providers and patients confirmed the findings from the care cascades (Table 6). They also identified several bottlenecks in service provision and shared insights on patient-provider interactions. Findings highlighted the insufficient focus on and scale of primary prevention across the life course and sectors to facilitate the uptake of physical activity and healthy diets. Primary prevention barriers include a low level of health literacy in the general population, limited health promotion and screening activities, and insufficient funds for their implementation. Also included are insufficient risk factors management for smoking, obesity, stress, lack of physical activities, air pollution, and transformation of the green areas for recreation and relaxation in urban areas into buildings. On the positive side, health promotion activities do exist, and patients’ associations and other nongovernmental organizations (NGOs) are dedicated to raising disease awareness. However, the level of screening activities was found to be insufficient, and was further diminished by the effects of the COVID-19 pandemic on regular health programs. The nonfunctional screening programs, the current model of care which overburdens the providers, the number and availability of specialists, the lack of care providers in some rural areas, the mandatory referrals to specialists due to the Health Insurance Fund (HIF) restrictions for GPs to order specific lab tests (supply side barriers), and the low-risk perception and disease awareness, coupled with low health literacy in the general population (demand side barriers), have led to late diagnosis, acute emergencies, x 16422-WB_Macedonia Report-5thPgs.indd 10 2/2/23 9:09 AM Executive Summary and expensive tertiary care. On the other hand, the accessibility of PHC providers, screening targets linked with the variable part of the payment for GPs, government screening programs, awareness in the medical community on the importance of screening, involvement of patients’ associations and other NGOs in the screening of communities, and the existence of the MojTermin (eHealth system) could facilitate the screening and diagnosis of NCDs. Regarding treatment initiation and maintenance, the current HIF restrictions for GPs to prescribe certain drugs and the outdated reimbursement list that limits access to novel and efficacious treatment are major barriers and sources of frustration among patients and providers. In addition, there are serious weaknesses in educating patients on lifestyle changes, which must be part of the treatment intervention. Better knowledge among patients on disease and the risks of poor treatment adherence are central to improved outcomes, and continuous patient education on these issues is necessary for all patients. However, care providers are overburdened by service provision demands, especially during the pandemic, while also starting to harness digital tools to support patients better and mitigate the disruptions caused by the pandemic. The introduction of electronic prescriptions has further improved access to reimbursed medicines which are available for all patients. The accessibility of PHC providers, the existence of active patients’ associations, and the support and experience exchanges among patients are also important facilitators in treatment maintenance and monitoring. Notably, patients faced a substantial financial burden in accessing essential medicines, given the outdated list of reimbursable medicines. Out-of-pocket (OOP) spending is also driven by the unavailability of appointments with specialists in the public sector that patients feel they need. While some patients are proactive in their care, others require more support, but community health outreach activities that could provide additional support to improve their care outcomes are still lacking. CONCLUSION Based on the routine patient data analyzed, key aspects of prevention, treatment, and monitoring of diabetes and hypertension must be improved, especially at the PHC level. The cascades pointed to missed opportunities, for instance, among diabetes patients with comorbid hypertension – generally, at higher risk of symptomatic disease and complications – who received less monitoring attention than diabetes patients without hypertension. In addition, monitoring and outcome data need to be better used to focus additional support on patients who do not do well in care. Along the same lines of proactive targeting, patient education must adopt a “push” approach rather than the “pull” approach, in which education relies primarily on patients’ initiative, which disadvantages certain patient types. The pandemic affected diabetes and hypertension care in multiple ways in North Macedonia. Like everywhere else, the patients included in this study became a high-risk group for COVID-19 during 2020 and 2021. In fact, COVID-19 was the top cause of recent hospital admissions in this patient population, which has had suboptimal diabetes and hypertension treatment success with significant gaps in active treatment management and prevention of complications. By autumn 2021, 56 percent of diabetes patients and 61 percent of hypertension patients had been fully vaccinated against COVID-19. The cascade analysis and qualitative research provided insight into the gaps and bottlenecks in chronic care while highlighting areas with scope for improvements and reform. The conclusions from this analysis on gaps in care and suboptimal outcomes are especially pertinent after the COVID-19 pandemic has highlighted the increased risk of NCD cases contracting COVID-19. The pandemic helped increase the use of digital tools supporting the continuum of NCD care. The scale-up of virtual appointments xi 16422-WB_Macedonia Report-5thPgs.indd 11 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA resulted from the COVID-19 service continuity measures in North Macedonia. The HIF introduced electronic prescriptions for patients with chronic conditions during the first COVID-19 wave. Self-monitoring among chronic patients and the subsequent reporting of results into MojTermin (eHealth system) by GPs is an excellent indicator of meaningful engagement in tracking the patients’ NCD care. The analysis identified priority actions needed to strengthen the control of metabolic NCDs (Table 7). Reforming the delivery system with a more prominent role in PHC can provide an opportunity to strengthen the engagement of patients with the system within their communities at each stage of the continuum of chronic care. The reforms will need to effectively reduce waiting times and free up health provider capacity with more efficient administrative processes. The public sector needs to move towards service integration (“one-stop shop”) so that patients have a less fragmented and drawn-out experience. This change will improve the quality of care and foster efficient management of NCDs. Finally, patient education on NCD risks will need redesigning to maximize its value in preventing future NCD morbidity and mortality. xii 16422-WB_Macedonia Report-5thPgs.indd 12 2/2/23 9:09 AM Introduction Introduction North Macedonia, a country of 1.8 million population in Eastern Europe, has a growing burden of non- communicable diseases (NCDs). An aging population and high levels of NCD risk factors are mainly responsible, with tobacco, high blood pressure, and unhealthy diets driving mortality and disability.1 In the population, increasing rates of overweight (58 percent) and obesity (24 percent), together with a rising prevalence of smokers among people 15–64 years old (from 43 percent in 2002 to 46 percent in 2017), indicate concerning trends, especially in vulnerable populations. In 2019, cerebrovascular diseases were the leading cause of disability- adjusted life years (DALYs).2 Life expectancy is 6.2 years lower than the European Union (EU) average for women and 4.6 years lower for men.3 Overall, above-average rates of amenable and preventable sickness and death translate into significant losses of productive life years.4 The primary health care (PHC) level in North Macedonia is underused for chronic and non-communicable diseases. The portion of the PHC service coverage index related to NCDs is 25 percent, which shows enormous potential for improvement.i Assessments on ambulatory care-sensitive conditions showed that 24 percent of such patients visited outpatient specialists at hospitals, and two percent were hospitalized.5 Three conditions – chronic obstructive pulmonary disease (COPD), hypertension, and angina – account for 64 percent of all hospitalizations of ambulatory care-sensitive conditions. These three conditions and multiple other NCDs can potentially be addressed at the PHC level by tackling behavioral and metabolic risk factors through preventive and curative interventions. A multi-stakeholder process is actively rethinking the role of PHC in North Macedonia. Despite delays due to the pandemic, this represents an important step to better serve the population’s needs, especially regarding NCD prevention and management. As a result, a new PHC model is being developed, which should improve the quality management and efficiency of primary care by reducing fragmentation, enhancing coordination, prioritizing prevention, and strengthening the role of primary care nurses. Two conditions that dominate the burden of chronic NCDs in North Macedonia are diabetes and hypertension. They are highly prevalent among adults and impact their well-being and productivity while causing high costs to the health sector. With the aim of strengthening the evidence on care quality and continuity for diabetes and hypertension, a mixed-methods cascade analysis was carried out. Cascade studies ask key questions about whether people with the condition are: • Diagnosed promptly and linked to appropriate care • Initiated on treatment regimens, including counseling and education • Monitored while on treatment at the right intervals • Successfully reach their treatment targets Failure at each stage precludes a successful outcome at the next, and the cascade (or continuum of care) quickly tumbles. This report presents the quantitative and qualitative findings of a cascade analysis conducted at GP practices in 2021. i Given the limitations of internationally comparable data on NCDs, this index includes only one indicator related to hypertension, the percentage of population with normal blood pressure. 1   16422-WB_Macedonia Report-5thPgs.indd 1 2/2/23 9:09 AM 16422-WB_Macedonia Report-5thPgs.indd 2 2/2/23 9:09 AM Methodology Methodology DESIGN OF THE CASCADE ANALYSIS The analysis used a convergent mixed-methods design, triangulating the evidence from various data sources.6 The data collection methods were used sequentially, with the main quantitative component (medical records review) preceding the qualitative component, focus-group discussions (FGDs) and interviews. Figure 1 summarizes the design with the two convergent strands of quantitative and qualitative data collection strands. The study obtained ethics approval from the Ethical Commission for Human Research in the Medical Faculty, Skopje. BURDEN ESTIMATIONS The analysis used data from multiple sources to capture the burden of the two conditions and bring them into the population-level cascades, as detailed below in Table 1. FIGURE 1. MIXED-METHODS DESIGN OF THE ANALYSIS Estimated Diagnosed On Monitored Disease burden treatment according to control the norm Burden estimates ~ Disease registry ~ Medical records QUANTITATIVE STRAND Health statistics triangulation FGDs with patients FGDs /interviews with care providers & administrators QUALITATIVE STRAND Source: Adapted from Improving Health Services and Redesigning Health Systems: Using Care Cascade Analytics to Identify Challenges and Solutions, Volume 1. Population-level Cascade Analytics. World Bank, Washington, DC. https:// openknowledge.worldbank.org/handle/10986/36993. 3   16422-WB_Macedonia Report-5thPgs.indd 3 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA TABLE 1. DIABETES AND HYPERTENSION BURDEN ESTIMATION Metric Calculation Sources Diabetes Risk population High fasting plasma High FPG x Adults 18+ IHME 2022 glucose (FPG >4.9– (separately for 3 age https://vizhub.healthdata. 5.3 mmol/L) in 15–49, groups and female (F)/ org/gbd-compare/; 50–69, 70+, 2019. male (M)). https://www.healthdata.org/ terms-defined. North Macedonia Census 2021. Prevalence Prevalence in adults The International IDF 2021 (Atlas 10th edition aged 20–79, 2020. Diabetes Federation p22) https://diabetesatlas. reports prevalence as org/atlas/tenth-edition/. number of people with diabetes (diagnosed and undiagnosed) divided by total population, using multiple data sources. Registered Registered cases n/a Registry, Ministry of Health cases (E10, E11) aged 20+, 2020. (MOH) 2021. Hypertension Risk population Raised systolic blood Raised SBP x Adults IHME 2022. pressure (SBP of at least 18+ (separately for https://vizhub.healthdata. 110–115 mm Hg) for 3 age groups and F/M). org/gbd-compare/; ages 15–49, 50–69, Forouzanfar et al. 2017, 70+, 2019. doi:10.1001/jama.2016. 19043;. North Macedonia Census 2021. Recorded Essential (primary) — Outpatient statistics, cases hypertension (International MOH 2021. Classification of Diseases 10th Revision (ICD-10) code I10) recorded in GP services, 2020. 4 16422-WB_Macedonia Report-5thPgs.indd 4 2/2/23 9:09 AM Methodology MEDICAL RECORDS REVIEW The treatment cascades used data extracted from MojTermin, the national integrated health information system that creates and stores medical records data and information related to health care including e-referrals, e-prescriptions, and medical diaries. Paper-based patient data were also consulted. Data were extracted by 12 GP practices across the country from September 1 to November 29, 2021. The spatial distribution of the participating GP practices is shown in Figure 2 below. The Macedonian Medical Association (MMA) provided a study coordinator. The GP list from the HIF was used to select suitable GP practices in terms of location (sampling stratified by region) and size – minimum number of patients 1,500 (urban), 1,000 (rural practices). Among the 12 GP practices to be selected, three had to represent the rural PHC system, and there had to be, at least, one practice selected in each of the eight regions (but four in Skopje and two in Polog Region). The study also required the practices to have, at least, one person with basic Excel data entry skills. Over several rounds, GP practices were randomly selected from the master list of suitable practices and contacted for participation, until the right mix of consenting practices was obtained with sufficient diabetes and hypertension cases and representing both urban and rural settings (Table 2). In total, 15 GP practices were contacted to obtain 12 eligible and consenting practices (two practices needed replacement after the first round of random selection both had fewer than 1,000 patients, one practice was replaced as it was urban, but an additional rural practice was required). An Excel-based data collection tool previously used in Samoa7 was adapted to the North Macedonia PHC context, piloted in one GP practice, and finalized for use in this study. The participating GPs received written FIGURE 2. GEOGRAPHIC DISTRIBUTION OF PARTICIPATING GP PRACTICES Source: Mapped GP practices selected from the GP list of the Health Insurance Fund. 5 16422-WB_Macedonia Report-5thPgs.indd 5 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA TABLE 2. GP PRACTICES PARTICIPATING IN THE MEDICAL RECORDS REVIEW Registered Region of GP Registered # Setting hypertension Type of practice practice diabetes cases cases 1 Eastern Urban 143 429 Single GP 2 Northeastern Urban 267 1,113 Group 3 Pelagonia Urban 127 602 Two GPs 4 Polog – a Urban 171 403 Two GPs 5 Polog - b Rural 163 535 Single GP 6 Skopje – a Urban 471 1,116 Group 7 Skopje – b Urban 155 426 Single GP 8 Skopje – c Rural 195 489 Single GP 9 Skopje – d Urban 160 389 Group 10 Southeastern Urban 248 896 Two GPs 11 Southwestern Rural 317 1,299 Group 12 Vardar Urban 143 813 Single GP information about the study and online training in small groups on how to complete the data collection task. Each GP tested the data entry matrix by extracting data from five diabetes and five hypertension patients into separate worksheets and getting it reviewed by the MMA coordinator. The GP practices randomly enrolled patients from MojTermin if they fulfilled the eligibility criteria. The RAND function ensured randomness; every second medical record was picked in practices using paper records. The extracted data did not contain personal identifiers and was anonymous and unlinked. MojTermin data often required double-checking with data in paper records since private health institutions (hospitals, clinics, laboratories, etc.) are not integrated into MojTermin. The study’s target number was 60 diabetes patients and up to 200 hypertension patients. The MMA study coordinator aggregated the data from the 12 practices and checked quality and completeness. Confidentiality of the patients’ data was ensured throughout. No patient name, address, Unique Health Number, date of birth, or medical notes were captured in the data extraction process at any time. The data file was password- protected. Also, the identities of the GP practices that have contributed data remain concealed. DEFINITIONS USED IN THE CASCADE ANALYSIS Diabetes: The “Evidence-based Medicine Guidelines for Endocrinology” from the Ministry of Health was used for cutoffs and norms.8 6 16422-WB_Macedonia Report-5thPgs.indd 6 2/2/23 9:09 AM Methodology To define “control” while on treatment, the following cutoffs were used: • Glucose control = FPG 4.4 –7.2 mmol/L or RPG <11.1 mmol/L. • Long-term glucose (glycemic) control = HbA1C <7%. • ABC control = A1C <7% + BP<140/90 + cholesterol <200 mg/dL. Hypertension: The European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines were used for definitions and cutoffs.3 Hypertension was defined as an office SBP ≥140 and/or diastolic blood pressure (DBP) ≥90 millimeters of mercury (mmHg). The following BP categories were used: • BP control = SBP <140 and/or DBP <90 mmHg. • Grade 1 = 140–159 or 90–99 mmHg. • Grade 2 = 160–179 or 100–109 mmHg. • Grade 3 = 180+ or 110+ mmHg. Obesity: The standard Body Mass Index (BMI) categories were used: <18.5 = underweight; 18.5–24.9 = healthy weight; 25–29.9 = overweight; and 30+ = obese. HOSPITAL ADMISSION DATA The data matrix collected simple data on specific causes of hospital admissions to compare the pattern between patients. All available data in a patient record, regardless of date of admission, were drawn on. The following causes for admission were captured in the data matrix: diabetic retinopathy, diabetes with kidney damage, diabetic cataract, diabetic gangrene, limb amputation, stroke, ischemic/coronary heart disease, myocardial infarction, cerebrovascular disease, hypertension, and COVID-19. FOCUS GROUP DISCUSSIONS AND INTERVIEWS WITH KEY INFORMANTS The FGDs with care providers and patients used discussion guides structured by the cascade stage: screening and diagnosis, treatment start, treatment maintenance and monitoring, and primary prevention. The following groups were convened: • Six specialists from Skopje, Tetovo, Shtip, and Bitola, with representatives of the Scientific Association of Endocrinologists and Diabetologists of Macedonia and the Macedonian Association of Cardiology • Seven GPs and internists from smaller cities, and a university information technology (IT) professor, with representatives of the Association of General Practitioners – Family Medicine Specialists • Eight nurses working with diabetes and hypertension patients, with representatives of the National Association of Nurses, Technicians, and Midwives • Eight patients with either regulated diabetes or diabetes complications, with representatives of the Union of Associations of Diabetics of Macedonia – two FGDs with four participants each • Four patients with either controlled hypertension or complications, with representatives of the Association for Prevention of Cardiovascular Diseases “Healthy Future” Additional information was gathered through interviews with two patronage nurses, two representatives from the Institute of Public Health, and the Ministry of Health-appointed Focal Point for PHC reform. 7 16422-WB_Macedonia Report-5thPgs.indd 7 2/2/23 9:09 AM 16422-WB_Macedonia Report-5thPgs.indd 8 2/2/23 9:09 AM Results Results DIABETES Diabetes burden Diabetes risk population The prevalence of high FPG9 from the Global Burden of Disease database was applied to the 1.463 million adults aged 18 and above;10 Figure 3 shows the number of people with high FPG across the six age and sex groups used in the cascade analysis. • The estimated prevalence of high FPG was 17.2 percent, with little difference between women and men (16.5 percent vs. 17.9 percent). • This is equivalent to 251,000 adults aged 18 years and older at risk of diabetes (Females: 123,000, Males: 128,000). • The estimated number of persons at risk of diabetes was most prominent in the 55–69 year age group. Prevalence of diabetes: The International Diabetes Foundation has published an estimate of 7.4 percent for adults 20–79 with a wide confidence interval (6.8-14.6),11 and a size estimate of 116,000 diabetes cases in this age bracket (CI95%; 107K–229K). FIGURE 3. ESTIMATED DIABETES RISK POPULATION IN NORTH MACEDONIA (2021) Number of adults with high fasting plasma glucose 60,000 54,000 48,000 40,000 28,000 21,000 Males Females Males Females Males Females 18–54 years 55–69 years 70+ years Source: North Macedonia census 2021 and Global Burden of Disease 2019 (high FPG), https://vizhub.healthdata.org/ gbd-compare/. 9   16422-WB_Macedonia Report-5thPgs.indd 9 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA Registered diabetes cases: According to the MOH diabetes registry, there were 133,258 adults aged 20+ years and 434 cases of persons aged below 20. Compared with 2019, this represents a 49  percent increase in registered diabetes cases (Figure 4). The increases are seen in all age groups of women and men. They are due to improvements in data collection, according to the Center for Statistical Processing of Health Data, Institute for Public Health of the Republic of North Macedonia. Similarly, Ahmeti et al.12 reported the increasing trend in registered diabetes patients in recent years. However, the yearly increases were much smaller (4–6 percent annually) than the one reported for 2020 compared with 2019.ii Notably, based on FGDs with health providers, there was a consensus of a gap in making timely diabetes diagnoses, mainly from restrictions for GPs to perform specific tests (low-density lipoprotein (LDL), high-density lipoprotein (HDL), HbA1c) needed for patient diagnosis and monitoring. As a result, healthcare providers reported that patients were diagnosed late, often presenting with symptoms and complications at the hospital level. While the ICDiii code E10 (Type-1 diabetes) had stable registry numbers between our two years of analysis (1,058 patients in 2019, 1,020 in 2020), it was the E11 code (Type-2 diabetes) that showed a considerable increase (88,838 patients in 2019, 132,672 in 2020). It may be that reporting was affected by the COVID-19 pandemic, which has highlighted the need to identify diabetes cases for targeting vaccination and other prevention measures. Taken together, there is a large number of adults at risk of diabetes (~258,000), but high uncertainty as to the prevalence of the disease due the lack of a population-based survey quantifying diagnosed and undiagnosed diabetes. In 2020, 133,258 adult diabetes cases were officially registered in the North Macedonia health system. FIGURE 4. REGISTERED DIABETES CASES IN 2019 AND 2020 60000 50000 26738 20765 40000 30000 17874 14058 20000 21 43 11009 31005 32870 10000 25 45 7089 20740 22870 276 346 6161 782 10197 674 0 2019 2020 2019 2020 2019 2020 2019 2020 <20 years 20–54 years 55–69 years 70+ years Type-1 Type-2 (F) Type-2 (M) Sources: Diabetes registry reports for 2019 and 2020; Institute of Public Health, North Macedonia. ii Ahmeti et al. (2020) reported total registered patient numbers as follows: 103,480 in 2015; 108,130 in 2016 (+4.5%); 114,408 in 2017 (+5.8%)’ 119,999 in 2018 (+4.9%); and 124,450 in 2019 (+3.7%). iii ICD is the International Statistical Classification of Diseases and Related Health Problems. 10 16422-WB_Macedonia Report-5thPgs.indd 10 2/2/23 9:09 AM Results Diabetes treatment cascades Among the 715 patients included in the medical records review, 77.8 percent had received in-depth counseling (nutrition, lifestyle, psychological) at diagnosis and treatment start. However, there was only evidence that 46 percent had received specific advice on diet/exercise. FGDs confirmed these results with providers and patients that highlighted a shared sentiment that health education to facilitate lifestyle adjustment among the general population is very low. The findings on treatment patterns and glucose monitoring are shown in Figure 5 below: • Treatment pattern: Almost all patients (99 percent, first column) had evidence of being currently under active treatment, of which 98 percent was pharmacological (second column) and 1 percent was non- pharmacological (counseling). • Twenty-eight percent were on insulin alone or in combination with oral sugar-lowering drugs (third column). • Glucose monitoring gap: The vast majority had some type of glucose test done during the last GP visit (9 percent gap, fourth column). • Three-quarters had their long-term blood glucose levels measured with the HbA1C test at the last visit (fifth column).iv FIGURE 5. DIABETES TREATMENT CASCADE (ALL PATIENTS REVIEWED) Treatment pattern Glucose monitoring GIucose/ABC Control Complication monitoring gap gap gap –9% –24% –35% –59% –61% 43–71% of patients have no 99 evidence of the annual screen 98 91 being done, largest for ophthalmology and CAD screen 76 65 Percent 57 52 41 39 28 29 30 Any glucose test Any Pharma Insulin Any test done A1C done A1C<7% ABC control Foot exam Retinopathy Nepropathy CAD screen On treatment Glucose check Control (among those Monitoring for complications (last visit) with test) (past 12 months) Source: Medical records review 2021. There is no official document that specifies which tests the GP performs during a visit of a diabetes patient, and HbA1c can only be iv ordered for already diagnosed patients. There are no Evidence-Based Medicine (EBM) Guidelines for PHC, and patient examinations are not standardized. This is being addressed in the ongoing PHC reforms. According to the manual, Diabetes Type 2 - from Prevention to Appropriate Treatment, Practical Guide for Family Medicine and General Practitioners, written by the Scientific Association of Endocrinologists and Diabetologists of Macedonia in 2018, HbA1c is recommended to be done 4 times per year. 11 16422-WB_Macedonia Report-5thPgs.indd 11 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA Using the different metrics and respective threshold values for “disease control,” the findings were: • Glucose/ABC control gap: Sixty-five percent of all patients had evidence of good glucose control (35 percent gap, sixth column). Among the 654 results of any glucose tests (FPG, HbA1C, RPG), 462 were in the controlled range (orange circles in Figure 5, 29 percent drop-off). • Forty-one percent of all patients had evidence of long-term glycemic control (59 percent gap, seventh column); among the 543 HbA1C test results recorded, 293 were <7% (green circles, 46 percent drop-off). • Thirty-nine percent had evidence of ABC control (61 percent gap, eighth column). Results of the annual screening for diabetic complications showed that the gaps were smallest for foot (43 percent gap) and kidney screens (48 percent) and considerably larger for heart and eye screens (70–71 percent) (Figure 5, four columns to the right). Screens for coronary heart disease (CAD) are done with electrocardiogram, cardiac ultrasound and carotid/peripheral Doppler scan at cardiologist or internal medicine specialists. FGDs with providers posited that a potential contributor to the treatment and control gaps outlined above was the restricted possibilities for prescription of medicines by GPs imposed by the HIF. For example, insulin can only be prescribed by specialists such as endocrinologists and diabetologists. The consequent unnecessary referrals for laboratory tests and prescription renewals (which could and should be done by GPs) significantly contribute to this burden. FIGURE 6. DIABETES TREATMENT CASCADE (URBAN VS. RURAL GP PRACTICES) Treatment pattern Glucose monitoring gap Control gap Gap in complication monitoring Gap consistently larger for rural 100 98 99 Large di erential in patients, especially for 93 94 glycemic and ABC control ophthalmology and nephrology 84 84 –51% –83% 68 64 63 Percent 59 52 51 49 45 36 29 31 28 25 20 21 17 7 Any glucose test Any Pharma Insulin Any test done A1C done A1C<7% ABC control Foot exam Retinopathy Nepropathy CAD screen On treatment Glucose check Control (among those Monitoring for complications (last visit) with test) (past 12 months) Urban GP practice (N = 537) Rural GP practice (n = 178) Source: Medical records review 2021. 12 16422-WB_Macedonia Report-5thPgs.indd 12 2/2/23 9:09 AM Results The following key observations were made by comparing the treatment cascades between the nine urban and the three rural GP practices, as illustrated in Figure 6: • Glucose monitoring gap: Patients in rural practices have lower glucose monitoring levels – there was a 10 percent difference through considering all tests and a 32 percent difference for HbA1C. • Control gap: The lower HbA1C testing levels translated to lower levels of known long-term glucose control in rural patients – only 17 percent of all rural patients have evidence of glycemic control compared to 49 percent of all urban patients (32 percent differential). • Lower use of monitoring tests in rural practices leads to few rural patients having evidence of ABC control (25 percent differential). • Gap in complications monitoring: Similarly, annual monitoring for diabetic complications is lower in rural patients for all four screens. Coverage gaps are the largest for ophthalmology and nephrology screens. When evaluating “disease control” for only those patients who had had the respective glucose tests, the following pattern emerged: • Any type of glucose test done: Controlled results are more prevalent in rural patients (81 percent) than urban (68 percent). • HbA1C tests done: Controlled results are more prevalent in urban patients (58 percent) than rural (33 percent), which further underlines that diabetes care is not working well for rural patients. It is plausible that in rural care settings, HbA1C tests are done more selectively for patients with clinical need. The analysis comparing the cascade indicators between Type-1 and Type-2 diabetes cases was inconclusive as there were only 38 Type-1 diabetes patients enrolled in the study through the random selection method. The available data indicated possible challenges among Type-1 diabetes patients in long-term glucose control (9/38 patients with HbA1C<7% test results). Data on complication monitoring suggested particularly low levels of annual eye exams (8/38) and kidney screens (12/38). Figure 7 compares cascade findings between treatment regimens, which showed that patients on insulin had slightly higher levels of glucose monitoring at their last visit, but lower levels of control across all three metrics, including ABC control. They also had lower coverage of annual foot exams, but higher coverage of retinopathy checks, according to their medical record data. The diabetes treatment cascades compared groups of gender and age and these showed very similar patterns between male and female patients and between different age groups – charts are in Annex 2. ABC control was the same for men and women. However, at 46 percent, ABC control was higher in younger patients than those aged 55 and above (36 percent). Next, the team compared diabetes patients who also have a diagnosis of hypertension (“comorbid”) (n = 538) to diabetes cases without such a diagnosis (n = 177). Comorbid hypertension was present in 75 percent of the diabetes patients. Hypertension and diabetes are co-occurring conditions that share underlying risk factors and complications. Macrovascular complications arise in patients with longstanding comorbidity and manifest as coronary artery disease, myocardial infarction, stroke, congestive heart failure, and peripheral vascular disease.13 Microvascular complications (retinopathy, nephropathy, and neuropathy) are conventionally linked to diabetic hyperglycemia. However, comorbid hypertension constitutes a significant risk factor, especially for nephropathy. The shared lifestyle factors in the etiology of hypertension and diabetes provide ample opportunity for non-pharmacologic intervention. The initial approach to co-management of diabetes and hypertension generally emphasizes weight control, physical activity, and dietary modification. 13 16422-WB_Macedonia Report-5thPgs.indd 13 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA FIGURE 7. DIABETES TREATMENT CASCADE (INSULIN VS. NO INSULIN TREATMENT) Glucose monitoring gap Glucose/ABC control gap Complication monitoring gap 94 Insulin patients have overall More insulin patients lack evidence of the 91 lower disease control annual foot exam More non-insulin patients lack evidence of 79 the ophthalmology screen 75 69 61 54 Percent 53 52 48 43 42 35 37 34 30 29 25 Any test A1C done Any glucose A1C<7% ABC Foot Retinopathy Nepropathy CAD screen done test control exam Glucose check (last visit) Control (among those with test) Monitoring for complications (past 12 months) Insulin treatment (N = 201) No insulin (N = 514) Source: Medical records review, 2021. Figure 8 shows the results of the comparison between diabetes patients with and without comorbid hypertension: • Glucose monitoring gap: Comorbid patients had less glucose/HbA1C monitoring during GP visits. • Control gap: The lower monitoring in comorbid patients translated into insufficient evidence of disease control (A1C control 11 percent differential, ABC control 15 percent). • Gap in complication monitoring: Comorbid patients also had lower coverage of annual complication screens, especially retinopathy (23 percent differential) and nephropathy (25 percent). The analysis also explored the treatment cascade across BMI categories, and Figure 9 below presents the results. The study excluded 51 patients (7 percent) with no recent BMI data and one with a BMI below the healthy range. • Treatment pattern: Insulin treatment was most prevalent in the lowest BMI band (33 percent) and due to a patient mix of more advanced Type-2 diabetes requiring insulin (27  percent) and Type-1 diabetes (6 percent). • Control gap: Glycemic and ABC control was slightly poorer at lower BMI values. This may be because of confounding factors, including Type-1 cases and the lower disease control in insulin patients (Figure 7). • Gap in complication monitoring: Annual monitoring was more prevalent in obese patients – foot exams, eyes, and coronary artery disease (CAD) screens, except for kidney screens. 14 16422-WB_Macedonia Report-5thPgs.indd 14 2/2/23 9:09 AM FIGURE 8. DIABETES TREATMENT CASCADE (WITH OR WITHOUT HYPERTENSION) Treatment pattern Glucose monitoring gap Control gap Gap in complication monitoring 99 99 Lower glucose, Co-morbid patients hove less 98 97 98 glycernic and ABC evidence of ophthalmology and 89 control in co-morbid nephrology screens 85 73 72 71 65 62 Percent 55 49 50 46 46 38 35 30 32 30 23 23 Any glucose test Any Pharma Insulin Any test done A1C done A1C<7% ABC control Foot exam Retinopathy Nepropathy CAD screen On treatment Glucose check Control (among those Monitoring for complications (last visit) with test) (past 12 months) DM (N = 177) DM+HTN (N = 538) Source: Medical records review, 2021. FIGURE 9. DIABETES TREATMENT CASCADE (BY BMI BAND) Treatment pattern Glucose monitoring gap Control gap Gap in complication monitoring 100 Patients with higher BMI get 99 99 97 9998 97 Higher ABC control in more screening attention (feet, 92 obese patients 89 eyes, heart) 83 75 76 Percent coverage 69 71 64 65 61 59 51 54 53 48 49 46 40 42 39 37 37 33 29 27 25 23 23 22 Any glucose test Any Pharma Insulin Any test done A1C done A1C<7% ABC control Foot exam Retinopathy Nepropathy CAD screen On treatment Glucose check Control (among those Monitoring for complications (last visit) with test) (past 12 months) "Healthy" BMI (N = 158) Overweight (N = 320) Obese (N = 185) Source: Medical records review, 2021. 15 16422-WB_Macedonia Report-5thPgs.indd 15 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA HYPERTENSION Hypertension burden Hypertension risk population The estimate uses the rates of raised SBP3 and applies them to the 1.463 million adults aged 18 years and older in the country’s population. Figure 10 below presents the following findings: • The estimated prevalence of raised SBP was 35.8 percent in 2019 (F: 32.6 percent, M: 39.1 percent). • This is equivalent to 524,000 adults aged 18 years and older at risk of hypertension (F: 243,000, M: 281,000). • The estimated at-risk population is most prominent in adults aged 18–54, especiallyin men; with a total of 173,000 reported hypertension diagnoses in males, this young age group may contain many undiagnosed men. Recorded hypertension cases: A total of 428,759 cases of essential (primary) hypertension were recorded in GP services in 2020 (ICD code I10).14 As shown in Figure 11, this comprised 255,658 female cases and 173,101 male cases; the highest numbers were in the 65–74 age category. An additional 2,680 female and 1,688 male cases were diagnosed with other hypertensive diseases (ICD codes I11-15, which are not included). Hypertension treatment cascades Data from 1,687 patients in hypertension care are in the analysis (no diagnosis of diabetes). Initially, the medical records of 2,393 (1,370 female and 1,023 male) hypertension patients were reviewed, but 706 of these patients also had a diagnosis of diabetes. Therefore, the hypertension cascade analysis excluded these comorbid patients. FIGURE 10. ESTIMATED HYPERTENSION RISK POPULATION IN NORTH MACEDONIA (2019) Numbers of adults with raised systolic BP 128,000 96,000 88,000 81,000 73,000 57,000 Males Females Males Females Males Females 18–54 years 55–69 years 70+ years Sources: North Macedonia population census 2021; Global Burden of Disease 2019 (high SBP). 16 16422-WB_Macedonia Report-5thPgs.indd 16 2/2/23 9:09 AM Results FIGURE 11. REPORTED HYPERTENSION CASES DIAGNOSED AT GP SERVICES (ICD-10 CODE I10, 2020) 79,928 71,764 54,916 52,647 48,217 37,745 34,519 23,969 11,338 9,306 2,236 2,174 <35 yrs 35–44 yrs 45–54 yrs 55–64 yrs 65–74 yrs 75+ yrs Female cases Male cases Source: PHC report 2020, Tables 4 and 7. Taken together, there is a large number of adults at risk of hypertension (~524 thousand), and ~429 thousand diagnoses were reported in the GP service statistics in 2020. Although the risk population estimates are uncertain, the GP statistics suggest that a higher proportion of at-risk women are in hypertension care compared to at-risk men. The findings on treatment patterns and BP results, including the types of drugs, as shown in Figure 12 below, were as follows: • Treatment pattern: Ninety-eight percent of the patients were on at least one of the four main types of hypertension drugs (Figure 12, light blue columns): 42 percent received just one type, 35 percent two or more, and 21 percent were on fixed-dose combinations (FDCs). • Nine percent of patients had five or more hypertension or associated drugs (polypharmacy, purple column). • Monitoring gap: Most patients had BP measured and recorded at their last GP visit (green column), but visits were sometimes infrequent, which meant that 13 percent of the patients had no evidence of a BP check in the last six months (orange column). • Control gap: Among the 87 percent with a BP result in the last six months, 64 percent of patients had a recorded BP result below the cutoff of 140/90 (red column). Across all patients in care, and using recent BP data, this implies that 36 percent did not have BP control while in hypertension care. While there may be other reasons why 36 percent of those diagnosed with hypertension did not achieve control, findings from FGDs highlight a significant gap in accessing essential hypertension medicines. Patients reported that reimbursement of contemporary pharmacological treatment options for hypertension, often available through private specialists, was limited. This resulted in a significant financial burden on families to pay out-of-pocket for these medicines, particularly affecting treatment initiation and adherence. 17 16422-WB_Macedonia Report-5thPgs.indd 17 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA FIGURE 12. HYPERTENSION TREATMENT CASCADE (ALL PATIENTS REVIEWED) Treatment pattern Monitoring gap Control gap 100 98 –13% –36% • Only 2% lack a BP result at last visit • Manitaiing gap (last 6 months): 13% 87 • Control gap (among those with a recent BP –26% result): 26% • Monitoring & control gap: 36% 64 Percent 42 35 21 9 In care 1 type of 2+ types of Fixed dose Polypharmacy BP result BP result BP <140/90 HTN drug HTN drugs combination N = 1687 Treatments Last visit Last 6 mths BP control (last 6 mths) Types of HTN drugs: a) Thiazide-diuretics, b) Calcium antagonists, c) ACE inhibitors, d) Angiotensin receptor blockers Polypharmacy: 5 or more drug types, also includes supportive drugs like aspirin, statins and other lipid-lowering drugs, beta-blockers, FDCs Source: Medical records review, 2021. Comparing the treatment cascades between the nine urban and the three rural GP practices, analysts made the following key observations, illustrated by Figure 13 below: • Treatment pattern: Urban patients, on average, received more types of drugs (21 percent differential for 2+ drug types); the use of FDCs was similarly prevalent in both settings. • Polypharmacy was twice as high in urban patients compared with rural patients. • Monitoring gap: Rural patients had slightly lower coverage of BP measurement at a GP visit and longer intervals between visits, leading to a 17 percent differential in the six-monthly BP checks. • Control gap: However, BP control among those with a BP taken was much better in rural patients at 87 percent compared to 70 percent in urban patients. This may partly be due to the different patient populations at rural versus urban GP practices. • The better BP results in rural patients compensated for their lower BP checking frequency and led to the same care outcome of nearly two-thirds of rural and urban patients having recent evidence of BP control. The analysis also evaluated the treatment cascade in light of the degree of severity of the patients’ hypertension when first diagnosed. This cascade did not include the 505 patients missing a record of BP results at diagnosis (30 percent) and 24 patients with high-normal BP at diagnosis who are eligible for hypertension treatment if cardiovascular disease (CVD) risk is high. Figure 14 below presents the following findings: • Treatment pattern: The treatment pattern reflected the clinical guidelines of treatment step-up for more severe hypertension, and 1 in 4 patients diagnosed with grade 3 hypertension were on monotherapy. 18 16422-WB_Macedonia Report-5thPgs.indd 18 2/2/23 9:09 AM Results FIGURE 13. HYPERTENSION TREATMENT CASCADE (URBAN VS. RURAL GP PRACTICES) Treatment pattern Monitoring gap Control gap 100 100 Urban patients tend to receive 99 95 more types of drugs, and 92 polypharmacy (5+ drugs) is twice as high 75 64 65 Percent 52 39 40 19 22 19 10 5 All 1 type of 2+ types of Fixed dose Polypharmacy BP result BP result BP <140/90 HTN drug HTN drugs combination In care Treatments Last visit Last 6 mths BP control (last 6 mths) Urban GP practice (N = 1229) Rural GP practice (N = 458) Source: Medical records review, 2021. FIGURE 14. HYPERTENSION TREATMENT CASCADE (BY GRADE AT DIAGNOSIS) Treatment pattern Monitoring gap Control gap Lower BP 100 100 100 Pattern reflects clinical 100 99 98 94 control at guidelines of treatment step-up 90 87 higher stage for more severe hypertension 74 69 Percent 60 51 47 41 37 27 28 24 19 20 16 4 8 All 1 type of 2+ types of Fixed dose Polypharmacy BP result BP result BP <140/90 HTN drug HTN drugs combination In care Treatments Last visit Last 6 mths BP control (last 6 mths) Grade 1 (N = 404) Grade 2 (N = 596) Grade 3 (N = 158) Source: Medical records review, 2021. 19 16422-WB_Macedonia Report-5thPgs.indd 19 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA • Patients diagnosed with grade 3 had four times higher levels of polypharmacy than those with grade 1. • Monitoring gap: The intensity of BP monitoring was higher in grade 3 cases (94 percent with BP results in the last six months) compared to less severe cases, suggesting monitoring effort is somewhat focused on more severe cases. • Control gap: This increased monitoring effort did not convert to a better overall outcome, as only 60 percent of the grade 3-diagnosed patients had recent evidence of BP control. • The underachievement also held if only patients with a 6-month BP result were considered (not shown in the Figure) – grade 1: 84 percent of recent BP results below cutoff; grade 2: 77 percent controlled; grade 3: only 64 percent below cutoff. Akin to diabetes care, the cascades for hypertension were very similar between female and male patients and patients in the three age groups – the relevant charts are available in Annex 2. Monitoring and BP control were, in fact, identical between female and male patients at 64  percent (627/973 females, 456/714 males). There were differences across age groups in treatment patterns, with older patients receiving multiple drug types more frequently. They also had slightly higher BP monitoring frequency, but the overall cascade outcome was similar, with about two-thirds having evidence of recent BP control. If only the patients with a 6-month BP results were considered (not in the Figure), patients aged below 55 had the best levels of BP control (80 percent of BPs below cutoff), while the two older age groups had lower treatment success – 72 percent and 70 percent of BPs below the cutoff in 55–69 and 70+ age groups, respectively. The analysis explored the treatment cascade across BMI categories; the findings are presented in Figure 15. The cascade excluded 197 patients lacking recent BMI data (12 percent) and one underweight patient. The central differential was at the final cascade outcome, with increasing BMI associated with lower levels of BP control. This may be partly due to different drug regimens or dispositions, but it could also be linked to heavier patients genuinely finding it harder to attain BP targets. USE OF DIGITAL TOOLS IN THE PATIENT SAMPLE At the time of the patient file review in September to November 2021, the majority of patients had had teleconsultations with their GPs (Table  3). The scale-up of virtual appointments resulted from the COVID-19 service continuity measures in North Macedonia. Nearly half of diabetes patients reported home measurements of BP and glucose in the system. Over a third of hypertension patients reported BP measurements, and one in ten reported glucose results taken at home into the system. COVID-19 AND SEASONAL INFLUENZA VACCINATIONS By the autumn of 2021, 56.1 percent of diabetes patients and 61.4 percent of hypertension patients were fully vaccinated against COVID-19. In comparison, by October 31, approximately 42.2 percent of the total population of North Macedonia had been fully vaccinated.15 Among the diabetes patients, 22.5 percent had a record of annual influenza vaccination, and 6.7  percent of the hypertension patients had a record of having been immunized. The influenza guidelines recommend vaccination for NCD patients.16 The integration of data on influenza vaccination is not strong in the system, but it has improved during the pandemic. 20 16422-WB_Macedonia Report-5thPgs.indd 20 2/2/23 9:09 AM Results FIGURE 15. HYPERTENSION TREATMENT CASCADE (BY BMI BAND) Treatment pattern Monitoring gap Control gap 100 100100 100100 100 Lower BP No clear treatment pattern control at emerging, treatment decisions 92 90 90 higher BMI likely driven by other co-factors 69 66 61 Percent 48 47 39 40 29 27 25 19 19 6 10 9 All 1 type of 2+ types of Fixed dose Polypharmacy BP result BP result BP <140/90 HTN drug HTN drugs combination In care Treatments Last visit Last 6 mths BP control (last 6 mths) "Healthy" BMI (N = 563) Overweight (N = 729) Obese (N = 197) Source: Medical records review, 2021. TABLE 3. DIGITAL TOOLS USED FOR CONSULTATION AND SELF-MONITORING Diabetes patients Hypertension patients Digital tool (715) (1,687) Had teleconsultations with GP 71.6% 77.8% Reporting BP home-measurement to their GP practice 47.8% 35.9% Reporting glucose home-measurements to their 48.5% 9.8% GP practice Source: Medical records review, 2021. HOSPITAL ADMISSIONS AND COVID-MORBIDITY Analysts assessed the pattern of hospital admissions, as captured in the data extraction matrix (see Methodology). For the 2,402 patients reviewed, the following pattern, as presented in below Table 4, was observed: • Diabetes patients had higher rates of recorded admissions compared to hypertension patients. • For both conditions, rural patients had much higher admissions rates than urban patients – twice as high in the hypertension sample. Patients living in rural areas may be more likely to be admitted than sent home for ambulatory monitoring. • Admission rates were higher in older vs. younger diabetes cases and in younger vs. older hypertension cases. • COVID-19 was the top reason for admission in either type of diabetes patients and the second most important cause for hypertension patients. 21 16422-WB_Macedonia Report-5thPgs.indd 21 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA TABLE 4. HOSPITAL ADMISSION DATA IN REVIEWED PATIENT RECORDS Diabetes patients Hypertension patients (715) (1,687) n Percent n Percent Any record of hospital admission 276 38.6% 435 25.8% Location of patient’s GP practice Urban 178 33.1% 249 20.3% Rural 98 55.1% 186 40.6% Patient’s gender Female 146 37.2% 256 26.3% Male 130 40.4% 179 25.1% Age group 18–54 59 32.6% 152 28.8% 55–69 146 41.5% 175 26.6% 70+ 71 39.0% 108 21.5% BMI band (more recent) Healthy weight 84 53.2% 142 25.2% Overweight 127 39.7% 201 27.6% Obese 57 30.8% 58 29.4% Leading causes among recorded hospital admissions Covid-19 74 26.8% 89 20.5% of which with ICU core 16 8 Hypertension 71 25.7% 142 32.6% Ischemic/coronary heart disease 28 10.1% 26 6.0% Myocardial infarction 12 4.3% 19 4.4% Stroke 9 3.3% 17 3.9% Cerebrovascular disease 9 3.3% 9 2.1% Diabetes with kidney damage 9 3.3% Diabetic retinopathy 14 5.1% 22 16422-WB_Macedonia Report-5thPgs.indd 22 2/2/23 9:09 AM Results TABLE 4. HOSPITAL ADMISSION DATA IN REVIEWED PATIENT RECORDS cont/… Diabetes patients Hypertension patients (715) (1,687) n Percent n Percent Diabetic cataract 14 5.1% Diabetic gangrene 6 2.2% Limb amputation 4 1.4% Diabetes type Type-1 24 63.2% Type-2 252 37.2% Co-morbidity Diabetes 42 23.7% Diabetes + hypertension 234 43.5% Diabetes treatment Insulin 96 47.8% No insulin 180 35.0% • Hypertension was in second and first place, respectively, as a cause for the hospital admission. • Diabetes patients had a higher risk of admission if comorbid with hypertension, on a treatment regimen with insulin, and with a Type-1 diagnosis. Regarding COVID-19 test results, 15.7 percent of diabetes patients and 12.6 percent of hypertension patients had a positive test result ever recorded in their medical file. Patient records also showed that 22 diabetes patients (3.1 percent) and 13 hypertension patients (0.8 percent) had a diagnosis of long COVID-19. QUALITATIVE RESULTS ON DIABETES AND HYPERTENSION CARE Primary prevention A shared sentiment among the FGD participants and key informants was that not enough is being done to prevent NCDs and that health education among the general population is deficient. The Institute of Public Health (IPH) and the ten public health centers organize health promotion activities and publish brochures and leaflets to raise disease awareness, but these were limited in quantity. There are also several TV health talk shows in which doctors discuss various health topics. Notably, the health promotion activities and the preventive programs were reported to have insufficient finances and need strengthening through a more systematic approach to implementation. All FGD participants noted that health education was vital and emphasized the need for early health education, starting from kindergarten and continuing throughout the formal education process. In addition, participants 23 16422-WB_Macedonia Report-5thPgs.indd 23 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA agreed that children need to learn about proper nutrition and acquire healthy habits in their families. The following quotes capture some of the ideas: “Education on a healthy lifestyle, promotion of healthy habits, and prevention of diseases is the only way” (GP). “Children should be educated, so the quality of life of the whole family will change. If children hear about healthy habits, so will the adults. Let’s not transmit our damaging habits to the children” (Female diabetes patient). Other suggestions made on how to improve primary prevention are media campaigns similar to COVID-19, health education at the health centers (polyclinics), the opening of special centers for health education and support to lifestyle changes, free-of-charge access to nutritionists, health education at the workplace, mandatory health education classes at school, health education in the hotel, restaurant and catering sector, providing healthy food at kindergartens and schools, and introduction of compulsory screenings for targeted population groups. The quotes below illustrate how some participants stated their views: “Education must have the first place. Maybe, the media should step forward and make advertisements like the ones with messages about corona [COVID-19]. The advertisements will emphasize how we should eat, healthy food, the importance of physical activity. A lot of people watch TV, especially the elderly. Through the media, more people will be reached, and they will understand the seriousness of the problem” (Female diabetes patient). “It would be nice to have nutritionists available free of charge in the health system for people who wish to visit them. . . . Among other things, there should also be psychosocial support and support in dealing with stress; people should work on themselves. Stress is a key factor for causing diabetes” (Female diabetes patient). It was also noted that smoking, obesity, stress, and lack of physical activity contribute to development of chronic diseases. The reasons brought forward in the discussions highlighted changes that had occurred in many urban communities. The following statement aptly summarized those reasons and redress actions needed. “There are no more outdoor spaces where to do sports, the green areas are disappearing, people cannot walk on pavements anymore, there are parked cars, the air is very polluted. There is no infrastructure, no walking paths; you cannot walk in the neighborhoods anymore. Municipalities need to show initiative to provide halls for sports and parks, to stimulate people to change their lifestyle . . . to make them go outside to take a walk or run instead of watching Turkish soap operasv in their spare time” (Patronage nurse, interview). Patients Associations demanded to be part of the health counsels in the municipalities; they also stated the need for financial support from the government for health promotion and prevention activities, which should be incorporated into the legal framework. Screening and diagnosis Screening Data collected during the FGDs and interviews showed that diabetes and hypertension screening is organized through the GPs/family medicine specialists (FMS), the IPH “Health for All” preventive program, occupational v The Turkish soap operas are very popular in North Macedonia with the large part of the population regularly watching several soap operas on a daily basis, eagerly waiting for the next episode. 24 16422-WB_Macedonia Report-5thPgs.indd 24 2/2/23 9:09 AM Results BOX 1. SCREENING: WHAT DO THE GUIDELINES SAY? Hypertension:17 Screening should be undertaken at regular intervals, with the frequency dependent on the BP level. Healthy people with BP <120/80 mmHg should be remeasured at least every five years, those with BP 120–129/80–84 mmHg at least every three years, and those with BP 130–139/85–89 mmHg annually. All adults should have their BP recorded in their medical records and be aware of their BP. Diabetes:18 Screening is recommended for persons with BMI ≥25 kg/m2 and additional risk factors such as CVD history, physical inactivity, hypertension, dyslipoproteinemia, persons with previously diagnosed glucose impairment and conditions related to insulin resistance, first-generation relatives with diabetes, and women with gestational diabetes, macrosomia or polycystic ovary syndrome. Screening is recommended from the age of 45 for persons who do not have any of these risk factors. If the results are normal, the test should be repeated at least at three-year intervals or more frequently, depending on the initial results and risk factors. For individuals with prediabetes,vi the test should be repeated every year. medicine examinations for the working population, Patients Associations, and other NGOs in collaboration with the Red Cross and local health institutions. Screening did not take place in 2020 and 2021 due to COVID-19. However, the screening programs did not function well even before the pandemic, and all stakeholders stated that changes were necessary. “We did not invite patients for screening in the last two years. It is a missed period for many diseases, not just for diabetes and hypertension. Now, when we perform routine lab analysis, we detect many [ailments] . . . Screening does not function well because we do not have time; we are overburdened . . . However, if some order is established for the work of a GP with scheduling appointments, if the workday is structured differently, for sure it would be better for all of us, for the patients and for us” (Family medicine specialist). “I will quote one doctor working at the Clinic for Infectious Diseases when she was talking about COVID-19 deaths among the younger population. She pointed out that people find out that they have hypertension or diabetes when they get COVID-19. This is a big deal for us. It is easy when patients with symptoms come, and we detect the disease. The problem is with the ones who never come, but have risk of diabetes, undiagnosed diabetes, or undetected hypertension. We need to detect people who have hypertension and diabetes but have never visited their GP.” (Family medicine specialist). According to their contract with the HIF, GPs have an annual target for implementing measures and activities to prevent diabetes, renal, and cardiovascular diseases for 45 percent of insured persons aged 35 to 56. Payment of the variable part of the capitation fee was linked to implementing this target before the COVID-19 pandemic. Reviewing the annual targets and the variable amount of the capitation fee for GPs should be part of the PHC reform. Key issues: The significant issues raised by participants regarding screening performed by GPs/FMSs were: (1) patients ignore GPs’ calls for screening, (2) there are hard-to-reach patients, such as the elderly, people in vi Prediabetes is a condition defined by the presence of impaired glucose tolerance (IGT) - fasting glycemia < 7.0 mmol/l; plasma glucose ≥ 7.8 to < 11.1 mmol/l after 120 minutes from oral glucose tolerance test (OGTT); or impaired fasting glycemia (IFG) - fasting glycemia 5.6 to 6.9 mmol/l; plasma glucose < 7.8 mmol/l after 120 minutes from OGTT; or HbA1c from 5.7 to 6.4 percent. 25 16422-WB_Macedonia Report-5thPgs.indd 25 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA rural areas, and seasonal workers abroad, (3) GPs are overburdened with numerous patient visits (many of them unnecessary), limiting the time to focus on screening, (4) the long waiting time at GP’s office discourages patients who want to use preventive services, and (5) GPs obtain screening results generated elsewhere only if patients share the report with them. “When we were performing the screening requested by the HIF before corona, there were patients who were invited by phone; we send invitations by mail, but they do not come. On the other hand, there are patients who come for check-ups six times a year. Now I think that the state should find a way to make people come for screenings once, and for the elderly twice per year, like it is done in Slovenia for cervical cancer screening” (GP). “We are truly overburdened with patients’ entries. It is not clear when they come or why they come. An order should be established. [. . . . ] we should know approximately how many patients we would have during the day so that we could provide sufficient attention, properly examine the patients, refer them, and perform screening. With this [current] way of working, with this administrative work loaded on the top of our heads, all of that is not possible to be done . . . A PHC service package should be established, indicating how many times patients with each diagnosis can come for examination and control” (GP). Preventive measures: The “Health for All” preventive program of the MOH, implemented by the IPH and the centers for public health in collaboration with the health centers, is to provide free preventive examinations to all citizens, especially in rural areas. Each health center has a target to execute six actions for preventive examinations in rural areas. These examinations are organized indoors or in outdoor venues with a doctor and a nurse performing the examinations, including measurement of blood glucose, cholesterol, BP, waist circumference, and determining BMI. During the examinations, advice is given on healthy diet and protection from high temperatures. In addition, print materials on proper lifestyle and nutrition are distributed. In the last three annual “Health for All” reports (2018, 2019, 2020), it is noted that the goal of this program was not fully achieved (see Table 5 below) and that it is necessary to intensify activities to increase program awareness through the media.19 TABLE 5. “HEALTH FOR ALL” NUMBER OF PREVENTIVE HEALTH EXAMINATIONS: 2013–2020 Year Total number of examinations 2013 8,392 2014 9,991 2015 6,143 2016 2,500 2017 1,833 2018 3,179 2019 2,664 2020 891 Source: IPH, Health for All Report 2020. Note: 2020 was the year the COVID-19 pandemic began. 26 16422-WB_Macedonia Report-5thPgs.indd 26 2/2/23 9:09 AM Results The annual Program for Prevention of Cardiovascular Diseases of the MOH does not include any preventive activities; instead, it funds adult and pediatric cardiovascular and neurosurgical interventions. Patients Associations and other NGOs organize free-of-charge measuring of glucose and BP in public outdoor venues once or twice per year. Interest from the public is high, especially among the elderly population. Representatives of Patients Associations stated during the FGDs that this type of screening should be regulated in the legal framework and financially supported by the government. All care providers who participated in the FGDs (GPs/FMSs, endocrinologists, cardiologists, internists, and nurses) suggested the introduction of mandatory screenings for targeted population groups. Diagnosis According to FGD participants, hypertension and diabetes are usually diagnosed late, with manifested symptoms or developed complications. Diagnosis of asymptomatic diseases rarely occurs. “We diagnose patients when they come to secondary health care for other medical reason. Regular controls that the GPs should perform are not done. We know that hypertension could persist long before symptoms occur, patients get used to it and do not see a doctor. . . . They come when complications appear” (Cardiologist). The restrictions for GPs to perform certain tests (LDL, HDL, HbA1c) needed for diagnosing and monitoring the patients and prescribing drugs, such as statins, and B-blockers, were reported to complicate each step in the care cascade. These complications create frustration among patients and care providers at all levels of health care. To complete the diagnostic procedure, patients are usually referred to an internal medicine specialist for hypertension, and to an endocrinologist or diabetologist for diabetes. “We recommend measuring blood pressure at home or, if necessary, we install a Holter monitor. In terms of therapy and patient monitoring, we are restricted to perform analyses such as [cholesterol] HDL and LDL, which are very important in further patient management and risk factor assessment, we are limited in prescribing therapy as well. Patients that could easily be treated have to be referred to secondary health care” (GP). During the pandemic, the internal medicine specialists were engaged at COVID-19 centers, and scheduling a visit has been challenging. There is scarcity of internal medicine specialists in some cities, whereas in BOX 2. DIAGNOSIS: WHAT DO THE GUIDELINES SAY? Hypertension20 (≥140/90 mmHg) is confirmed with office BP measurements on repeat visits or out-of-office BP measurements (ambulatory, home). Diagnosis is confirmed at first measurement if BP is substantially increased – for example, grade 3 – and there is clear evidence of hypertensive retinopathy with exudates and hemorrhages, left ventricular hypertrophy, vascular or renal damage. Then, a clinical evaluation and assessment of hypertension-mediated organ damage is carried out in newly-diagnosed patients. Diabetes.21 Diagnosis of diabetes is established if any of the following criteria are met: fasting plasma glucose levels ≥ 7.0 mmol/l (≥ 126 mg/dl) after overnight fasting of at least 8 hours; 2 hours plasma glucose ≥ 11.1 mmol/l (≥ 200 mg/dL) during the oral glucose tolerance test (OGTT); HbA1c > 6.4 percent (48 mmol/mol); or random plasma glucose ≥ 11.1 mmol/l (≥ 200 mg/dL) in patients with classical symptoms of hyperglycemia (polyuria, polydipsia, weight loss). 27 16422-WB_Macedonia Report-5thPgs.indd 27 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA some smaller towns in the eastern part of the country there is none because of retirement or outward labor mobility. Additionally, some rural areas have neither a medical doctor nor a nurse, although there is an existing health facility. Most patients’ diagnoses occurred in a hospital setting while hospitalized with serious symptoms. Most of them had low levels of awareness about the disease or its complications. Some were satisfied with the health professionals and the care received, while others were not, depending on the facility where the diagnostic procedure took place. At one private clinical hospital and one public university clinic, the experiences were the most positive. In these clinics, proper health education on the disease, lifestyle, nutrition, and treatment were provided. In general, patients do not receive in-depth information and education about the disorders, possible complications, lifestyle changes, and treatment unless they proactively search and ask for it. “I got the diagnosis 17 years ago. I was lying in bed, drinking abnormal amounts of fluids, I couldn’t move, couldn’t function. I was taken to the hospital and was diagnosed with Type 1 diabetes. I was referred directly to Skopje for treatment” (Female diabetes patient). “I have had hypertension for more than 23 years. I was diagnosed at the Cardiology Clinic when I was there for cardiac catheterization and stenting” (Male hypertension patient). Treatment initiation Treatment regimen: The FGDs/interview responses indicated that initial treatment is almost always pharmacological. Patients are diagnosed too late to start with non-pharmacological treatment exclusively. Non-pharmacological treatment is recommended, but not much support is provided in terms of education about nutrition, physical activity, smoking cessation, and lifestyle changes in general. Due to the restricted possibilities for prescribing medicines by GPs, imposed by the HIF, patients usually take the medication prescribed by specialists. For example, insulin can only be prescribed by endocrinologists and diabetologists. The specialist explains the treatment plans and options during the patient’s visit. It was noted that time is limited to provide adequate and focused guidance as specialists are scarce and overburdened with providing care for many patients. The unnecessary referrals for laboratory tests and prescription renewals – which could and should be done by GPs – significantly contribute to this burden. When the treatment initiation occurs in a hospital setting, nurses also guide treatment, especially insulin use. “We provide minimal education, as time permits. . . . We cannot have 50–60 patients per day and have time for education. We are just a few internists, and we cover the whole internal medicine field. The nurse that works at the diabetes center works for other doctors as well” (Internist) “In the smaller [health facilities], there is no opportunity for education at all. The few doctors cannot manage to say, “Good afternoon” to all of us, let alone educate us. They just help us if we get stuck but do not have time for education, which is normal. But, in my opinion, there should be counseling centers in every town for every newly diagnosed [person] to have complete treatment with education for a certain period of time until they learn” (Female diabetes patient). GPs also have limited time to explain the treatment to patients and answer their questions. “No, there is no education. The problem is not that the doctor does not want to work on education. Imagine, we have only one diabetologist in [name of town] and many patients on insulin. For each patient, a lab referral is written for HbA1c; the patient comes back with the result, then insulin is prescribed for many patients. The center is open only one day in a week. There is no 28 16422-WB_Macedonia Report-5thPgs.indd 28 2/2/23 9:09 AM Results BOX 3. TREATMENT INITIATION: WHAT DO THE GUIDELINES SAY? Hypertension:3 For all patients below 80 years with hypertension grade 1, 2, or 3, medication is initiated alongside lifestyle interventions such as sodium restriction, alcohol moderation, healthy eating, regular exercise, weight control, and smoking cessation. High normal BP Grade 1 Grade 2 Grade 3 BP 130–139/85–89 mmHg Hypertension Hypertension Hypertension BP 140–159/90–99 mmHg BP 160–179/100–109 mmHg BP ≥180/110 mmHg Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle advice Immediate drug treatment Consider drug treatment in Immediate drug in high or very high risk Immediate drug very high risk patients with treatment in all patients patients with CVD, treatment in all patients CVD, espacially CAD renal disease or HMOD Drug treatment in Aim for BP control Aim for BP control low moderate risk patients within 3 months within 3 months without CVD, renal disease or MOD after 3–6 months of lifestyle intervention if BP not controlled Source: ESC/ESH Guideline 2018, p3050. Diabetes:22,23 Treatment is initiated with advice on lifestyle changes, setting target values for HbA1c, and starting with pharmacological treatment based on HbA1c. Patient education and support for self-management should be individualized, i.e., adjusted to the patient’s priorities, respecting their needs and values system, which will help in the clinical decision-making. Evaluation of the educational needs of the patients should be done (1) when diagnosed, (2) annually, (3) when a complication occurs, and (4) when the level of care changes. In addition, there are recommendations on nutrition, weight loss management, physical activity, smoking cessation, and screening for psychological problems. A patient-centered approach is recommended for choosing the pharmacological treatment, considering drug efficacy, risk of hypoglycemia, presence of atherosclerotic CVD, effect on weight, potential side-effects, administration mode (oral vs. sub-cutaneous), cost, and patient preference. For the pharmacological treatment of Type 2 diabetes, metformin is the preferred initial drug if not contraindicated. For patients with atherosclerotic CVD or indicators of high risk, renal disease, or heart failure, sodium-glucose co-transporter-2 (SGLT2) inhibitors or glucagon-like peptide-1 receptor agonists (GLP-1 RA) with proven cardiovascular benefit are recommended. Some patients with Type 2 diabetes require insulin, which can be combined with oral hypoglycemic drugs. Re-evaluation of the medication regimen and adjustment as needed is recommended at intervals of 3–6 months. The pharmacological treatment of all Type 1 diabetes patients is with insulin (prandial and basal insulin, continuous subcutaneous insulin infusion or insulin pump). 29 16422-WB_Macedonia Report-5thPgs.indd 29 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA time to serve all the patients. In such circumstances, education is out of the question” (Family medicine specialist). “[When] I was diagnosed with hypertension over 20 years ago, I did not get any education or advice. Two years later, I was urgently operated upon when I was diagnosed with an enlarged aorta. Again, I did not get recommendations and education [for lifestyle changes, diet, etc.] in the public health care facility, but at [name of a private clinic], I received education and detailed instruction on how to take my therapy” (Male hypertension patient). According to patients, GPs refer patients and write prescriptions recommended by specialists. However, GPs are available for patients to contact them at any time. Especially since the beginning of the pandemic, GPs have been accessible via telephone and electronic devices. Diabetes questions are answered by local endocrinologists or diabetologists who work at the centers for diabetes. These endocrinologists and diabetologists are employed at the hospital or health center level (in smaller towns) and provide care for all internal medicine diseases in a hospital and outpatient setting, and in COVID-19 centers since 2020. An important point raised was that due to insufficient staff, the centers for diabetes are not open every day in most towns. As the following statements show, there are different reasons for the lack of preventive and therapeutic education: “The educational part does not exist because there is no staff. We have issues with the availability of doctors because many of the colleagues retire. When the new ones come, they leave for specialization for 5–6 years” (Cardiologist). “I introduce the treatment to the patient, be it oral or insulin. Education at our hospital is individual. As head of the center for diabetes, I have requested management to provide us with minimal conditions for education, but there is no understanding for establishing such a center for education” (Endocrinologist). “Yes, I was educated about the disease by the professor [visiting from the University Clinic of Endocrinology] and the doctor from the general hospital in [name of town]. More education is needed for patients because people do not know, they do not understand that it is a serious disease. From the beginning, I was also unaware about the severity of the disease . . . I thought it was nothing; I was on a diet for one month, everything went well, but then suddenly the glycemia jumped. Greater diligence is needed. The biggest problem is that patients are uninformed” (Male diabetes patient). Medicines covered by the HIF are catalogued in the Positive Drug List (PDL) issued by the MOH. It comprises both medications dispensed through community pharmacies (referred to as “List A”) and those used in hospitals (referred to as “List B). For each medicine in “List A”, it is determined whether it can be prescribed by GP/FMS, PHC pediatrician, PHC gynecologist, PHC dentist, upon recommendation by specialist, sub-specialist, hospital concilium, or clinical concilium. New medicines were last added to the PDL over seven years ago, in February 2015, and the list has not been substantively reviewed or updated since 2008. While the PDL lacks many contemporary treatments, it contains a few very old medicines that are seldom used or no longer used in the EU and are not recommended by the World Health Organization’s 2021 Model List of Essential Medicines. Usually, medications that the HIF covers could be acquired at any pharmacy with paper and electronic prescriptions. However, with prescriptions valid for three months, only the monthly quantity can be taken from the pharmacy. Insulin and test stripes for measuring glycemia are provided at the insulin pharmacies once per month. Both doctors and patients stated that for diabetes, reimbursed modern treatment options are available, but some medicines are not reimbursed. Also, contemporary pharmacological treatment options for hypertension that are reimbursed are limited. As previously mentioned, the list of medications covered by the HIF is not up to date, 30 16422-WB_Macedonia Report-5thPgs.indd 30 2/2/23 9:09 AM Results and some cost-effective modern drugs are available only for OOP payment. Notably, the HIF does not recognize medicines prescribed by private specialists. Patients who regularly undergo check-ups at private hospitals are additionally referred to a specialist at the public health institution to be able to take the reimbursed drugs from the pharmacy. Patients stated that the most important medicines (insulin excluded) are expensive and are not reimbursed. It is a substantial financial burden on families to pay for these medicines, and people who cannot afford them are treated with outdated reimbursed ones. As shared below, patients and doctors are not satisfied with the current situation. “There are so many drugs that are not available on the positive list. Some of them could be bought in Macedonia but have enormous prices that patients cannot afford. And if we would like to follow the protocols – the Guidelines for management of patients with diabetes – it means that in different situations we must give a drug with cardioprotective properties, drugs that will decrease the body weight of the patients, drugs that will not cause hypoglycemia; but these drugs are not on the positive list, they are paid for out-of-pocket” (GP). “Our positive lists have not been changed for a long time. Patients must buy all combined drugs, [or] they are left on monotherapy. Drugs that are on the positive list most often are not the most suitable for the patient. They take 5–6 drugs during the day. That is why it is time to revise the positive lists, to include drugs that contribute to the well-being of our patients, to have a healthy nation, and properly treated comorbidities” (Cardiologist). “For our condition, some drugs are on the positive list, others cost almost 100 Euro. That is the problem. All new generations of drugs for hypertension, anticoagulants, and others should be put on the positive list and be available for the wider patient population. [The expensive ones] are drugs that can only be used by people with deeper pockets” (Male hypertension patient). Most patients start their prescribed treatment. However, some do not initiate treatment as they either hope to postpone initiating a life-long treatment or are unwilling to change their lifestyle. For the drugs that are not reimbursed, the reason is financial. In general, there is unawareness of the possible complications. Both groups of patients with hypertension and diabetes stated that people usually do not take the disease seriously until damage is done. “Until they see a problem caused by hypertension, people do not perceive it as a problem. When the damage is done, they understand the seriousness of the situation and the hypertension” (Male hypertension patient). “A large part of the population [with diabetes] is not aware [of the seriousness of the condition]. There are people on tablet treatment saying: “We are not diabetics. Only those on insulin are diabetics. They do not even measure blood sugar. I am shocked by such lack of education” (Female diabetes patient). Treatment maintenance and monitoring The previously mentioned issues with the HIF restrictions for GPs regarding prescriptions and laboratory referrals, the reimbursement list lacking regular updates, insufficient and overburdened medical staff, and the absence of centers for education and counseling complicate treatment maintenance and monitoring. A positive development recognized by patients is improved availability of the reimbursed medicines in the pharmacies throughout the whole month, which was not the case in the past when there were monthly quotas in each pharmacy and medicines were available only on the first days of the month. Patients had to see a specialist every three months, then six months, and now, since the pandemic began, 12 months for renewal of prescriptions. 31 16422-WB_Macedonia Report-5thPgs.indd 31 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA BOX 4. TREATMENT MONITORING: WHAT DO THE GUIDELINES SAY? Hypertension: Once treatment is initiated, the effect on BP should be checked regularly, at least once within the first two months, and then at appropriate intervals depending on the severity of hypertension, the urgency to achieve BP control, and the patient’s comorbidities. Once the BP target is reached, a visit interval of 3–6 months is recommended in the guidelines. Non-physician health workers can perform maintenance check-ups. Home BP monitoring and electronic communication with the physician are acceptable alternatives for stable patients. Repeated BP measurements are required to monitor changes and up-titrate the treatment regimen if warranted in case of elevated BP at monitoring visits. Treatment adherence should be assessed to find individualized solutions. Diabetes:24 The effect of diabetes treatment must be monitored carefully, with monitoring intervals depending on the treatment regimen. The goal of diabetes management is to maintain a long period of good and optimal glycoregulation and maintain the desired values of lipids and BP. The guidelines provide recommendations for dealing with obesity (diet, physical activity, behavioral therapy, pharmacotherapy, surgery), management of CVD and risk factors, lipid management, monitoring microvascular complications (nephropathy, retinopathy, neuropathy), and care of feet. Timely screening for complications and secondary prevention aims to delay complications and maintain a healthy and productive life. A new protocol for diabetes management is in the process of development within the PHC reforms. Source: ESC/ESH Guideline 2018. Specialists also performed and prescribed laboratory analyses that could not be done by the GPs, which further complicated the process. “GPs are overloaded with administrative work, but I agree that the referrals are unnecessary, and these patients occupy places for patients who are in urgent need of specialist care. They (GPs) can prescribe statins without problems, and B-blockers as well” (Internist). “At my GP’s practice there were huge waiting lines. It rarely happens not to wait an hour or two. Prior to corona, we had to see specialists every three months, then six months, and now once per year. We take the same therapy for many years, but we [always] have to see a specialist to prescribe us that therapy. . . . Doctors spend too much time on administrative work” (Male hypertension patient). Patients with diabetes visit endocrinologists or diabetologists at the diabetes centers for routine treatment. Diabetes Centers are located at health centers, hospitals (secondary level of care), and a university clinic in Skopje (tertiary level of care). Services at these centers are provided by diabetologists, endocrinologists, or internal medicine specialists and nurses. Patients with regulated hypertension visit internal medicine specialists. Still, patients with developed complications who undergo treatment via invasive procedures visit the public or private tertiary clinic where the procedures were performed. The HIF pays for cardiac procedures performed at two private clinics, and patients can choose where they want the procedure done. However, out-of-pocket, regular check-ups at these clinics have relatively high prices, which is considered counterproductive. One of the private clinics offers a 30 percent discount for these check-ups for patients who had cardiovascular surgery there. The patients indicated that it is crucial that the HIF also pays for these services at the private clinics and that private health providers incorporate them into the overall health system. When a specialist at these private clinics prescribes medicines on the HIF’s Reimbursement (Positive) List, the patient 32 16422-WB_Macedonia Report-5thPgs.indd 32 2/2/23 9:09 AM Results must go back to the GP to ask for an appointment in MojTermin with the same type of specialist in the public health institution. This specialist copies the medicines prescribed by the colleague at the private facility; the patient then goes back to the GP to get prescriptions to obtain the reimbursed medication at the pharmacy. This modality protracts the process and unnecessarily creates cost and time inefficiencies for the GPs and patients. “We go to private clinics for controls, but a specialist from a public cardiology (clinic) must confirm the prescription” (Male hypertension patient). “You do not wish to be in their shoes [patient who cannot afford to pay for medicines or services at private providers]. They have to wait for 5 to 6 hours for an examination, and they come from [name of remote town], for example” (Male hypertension patient). Diabetes patients remarked that they now have to pay user fees for specialist examinations in public health institutions. Even though the amount is not high, it could be a barrier for some patients. In the past, they had one free-of-charge medical examination annually. Another remark was regarding the long waiting time in the morning to give blood samples at the laboratory where they have no priority, sometimes waiting for an hour and a half, which disturbs their eating and insulin administration schedule. There are also long waiting lines at the centers for diabetes when patients go to pick up the insulin prescription. At insulin pharmacies, there are no waiting lines. Still, the working hours of some insulin pharmacies (7–14h) are an issue, especially for the working population and people who travel long distances to the insulin pharmacy. Patients with hypertension also reported long waiting times, overcrowded waiting rooms, lack of privacy, and suboptimal conditions at public health institutions. Quality of care at these public facilities is a big concern for them. Due to the aforementioned scarcity and overburdening of specialists in public health institutions, it is challenging to schedule an appointment with them. “We have two internists; one will [soon] retire, so there will be just one. The lower the number of internists at the health center, the bigger the problem for all GPs and patients. Regarding monitoring of patients, we call them, monitor them, and refer to secondary level when needed. Now it is difficult during the pandemic, as there are no available slots for appointments with specialists, so the situation is out of control” (GP). “The problem is the small number of doctors versus the number of patients. For all patients to be properly monitored and prevented from all complications, they must be referred in a timely manner for further examinations. But due to the small number of examiners in centers outside Skopje, we have a problem with appointments. Patients either wait for a long time or they give up and they skip such investigations. Then after a year, they show up with a complication. The lack of specialists is a big problem” (Cardiologist). Patients with medical needs who can afford to pay out-of-pocket will visit private providers where services are a one-stop shop. Unfortunately, that is not the case at public health institutions. For example, for a patient to complete one cardiovascular examination it could take up to a month or two months and several visits to the institutions for each different diagnostic procedure. This is a huge issue, especially for patients who have to travel to the health facility. In addition, according to patients, the existing staff shortage for doctors and nurses is exacerbated by the outdated and non-functional equipment in the centers for diabetes. “The problem is that when we get an appointment in MojTermin to see a cardiologist, he asks for Doppler, computerized tomography (CT), magnetic resonance imaging (MRI), and other examinations. To complete all of them, it takes another one to two months waiting. At [name of a private clinic] you get everything done at the same venue and immediately. The private health capacities are not used, but the public healthcare [system] does not have the capacity to meet the needs of the population” (Male hypertension patient). 33 16422-WB_Macedonia Report-5thPgs.indd 33 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA Patients also remarked that GPs do not monitor patients with hypertension and diabetes and proactively inform them when it is time to see a specialist (cardiologist, ophthalmologist, nephrologist) for a regular preventive examination. Consequently, patients must self-monitor and judge when they need to visit specialists and ask GPs for referrals. “Ninety percent of the GPs just give referrals. The ones that monitor patients and even perform certain investigations, such as Doppler, are rare. My GP often tells me, ‘you know better than me,’ and she even sends patients to me for consultations. GPs are not to blame, because experience is really needed to be able to do all that they have to deal with” (Female diabetes patient). “My GP has not even once asked me whether I have visited an endocrinologist, and what I was told. And I have had diabetes for 40 years. I monitor myself. But there are patients who just take their insulin and that’s it. They haven’t even visited an eye doctor. They are not aware of the consequences” (Female diabetes patient). However, not all patients will know when to ask for a referral or even that they need to have preventive examinations. According to the Union of Associations of Diabetics of Macedonia, the reason for a high number of complications is the fact that patients are not referred to specialists for preventive examinations, which is a violation of the existing protocol for diabetes management. However, the FGD participants with diabetes believe they must be their own doctors, and some take pride in it. “I am my own doctor; I determine by myself whether this new insulin they gave me and the tablets that I’m taking are [effective]” (Female diabetes patient). “In the whole country, there is not a single endocrinologist who does not advise us, support us, or convince us that we must use the prescribed treatment. But we must be our own ‘doctors’; we must know how much to eat and how much activity to have during the day” (Female diabetes patient). GPs are very collaborative when writing referrals upon a patient’s request. For most patients, the definition of a good GP is one who writes referrals and prescribes drugs when they request them. In addition, both patients and care providers pointed out that the health workers are overburdened with administrative work. “. . . the GP does not have a problem to refer you. But we are not followed [monitored] by them as we should be” (Male diabetes patient). “I cannot say that I am unsatisfied, but it bothers me that I have to request everything. I have to try to get something, I need to be the initiator, I need to ask. I miss receiving care from the doctor, being supported and guided by the doctor. Otherwise, I have received everything I have asked for. But I need to feel that someone cares about me, whether the endocrinologists or the other doctors. Regarding GPs, I don’t even want to discuss about them, because I get nothing from them; no advice, just referrals to a higher level . . . No, my GP has no initiative. I visit him with a list and ask for all referrals I need” (Female diabetes patient). The education of patients relies on their initiative as well. In the past, education for diabetes was better organized, led by endocrinologists at the University Clinic of Endocrinology. Nowadays, as reported by participants, there is almost no time available for endocrinologists and diabetologists to educate or provide information to patients. As such, diabetes patients simply receive a leaflet about nutrition. For hypertension, patients are satisfied with the education at the private clinics, but that is not the case with the public sector. They stated that the quality of 34 16422-WB_Macedonia Report-5thPgs.indd 34 2/2/23 9:09 AM Results care is incomparable between the two. It is important to note that for diabetes, the Patients’ Associationvii is very active in the community. “. . . And through the [Patients] association, I am trying to introduce regular education for the population with diabetes, especially for the newly diagnosed, so that in time they learn how to do, what they should do, and not to be like me, to spend many years learning. I often also have patients who call me asking me questions, so I see how uninformed they are” (Female diabetes patient). “There used to be more [staff], there were also diabetic nurses. Every newly diagnosed patient with diabetes was immediately handled properly, diet, how to use the insulin pen, what to eat, what not to eat. When the corona came, all those things were discontinued. Every new (patient) had to manage on his own. They consult with me on the phone what to eat, what not to eat, and what to look out for” (Female diabetes patient). Through the Association, patients communicate, ask for information, exchange experiences, and even share insulin among themselves in case of deficiencies. However, when the Association organizes group lectures in the community, attendance is very low, and local government support is needed to organize these events. In smaller towns and rural areas, the stigma around diabetes still exists. In larger cities, that has changed positively. “In the rural areas and smaller towns, stigma around diabetes unfortunately still exists. Last year we had a case when everyone found out that a bride had diabetes at her wedding when she went into a diabetic coma” (Male diabetes patient). “Yes, there is stigma and indifference. Our population places health last unless something [bad] happens to them” (Cardiologist). According to patients who participated in the FGDs, prejudice and stigma exist at schools and in the workplace. In addition, patients remarked that during the pandemic, most of the persons that had their work terminated had had diabetes or another chronic condition. “We have information that everywhere the number of employees with a chronic condition is decreased to a minimum; it involves any chronic condition, from hypertension to cancer. As their contracts expired, they were not renewed, because they are deemed not productive. Being in the high-risk group, they stayed at home longer to protect themselves from corona [COVID-19]” (Male diabetes patient). Notably, a group of patients is very disciplined concerning treatment adherence. Unfortunately, some patients are unaware that pharmacological therapy for hypertension and diabetes needs to be taken regularly – some stop taking the drugs and then resume when the condition worsens, or a complication occurs. There are also examples of diabetes patients who switched from prescription drugs to alternative medicine, such as herbal teas, followed ill advice in the media and ended up with bad outcomes. In general, it is important to note that patients adhere better to the pharmacological than to the non-pharmacological treatment for both diseases. “There are patients who strictly adhere to prescribed treatment and get upset by the slightest change in values. We also have patients who do not understand the risk factors and changes in laboratory results, and there is a whole group of patients between these two groups. We need to explain the There are 23 patients’ associations in 21 municipalities that are united in the Union of Associations of Diabetics of Macedonia. vii 35 16422-WB_Macedonia Report-5thPgs.indd 35 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA risks to patients, to spend more time with them. But it requires more staff, and we are in a race against time. A patient cannot change the lifestyle with one visit; it is necessary to follow up and educate continuously . . . Patients seem to accept treatment with medicines more than having to make lifestyle changes” (Internist). The medical staff (GPs, specialists, nurses) emphasize the importance of adherence to treatment during their interaction with patients, if and when time permits, but there is limited to no support for lifestyle changes. For example, in 2014, free-of-charge smoking cessation counseling centers opened in all ten centers for public health. However, during the FGDs, these counseling centers were mentioned only by one care provider who was not sure in which centers for public health they are currently available. This indicates that both the medical community and the general public are not informed about the existence of such centers. Furthermore, according to the IPH annual reports, the number of users of this service in each center for public health is low. “There are patients who strictly adhere to everything you tell them; there are also those patients who want to go to a bar, to eat and drink and not take the prescribed therapy. Few adhere to all the [medical] recommendations” (Family medicine specialist). “At first, they are scared and adhere to treatment, but as time goes by, they give in. Food is a pleasure. They will lose weight but then gain it back” (Internist). The MOH had a project several years ago through which patronage nurses visited patients with chronic conditions to control blood pressure and glycemia for people above 65  years of age. The patronage services received lists with contact details of elderly chronic patients from the MOH. However, this project only lasted for a year. Even though the patronage services are polyvalent, after the termination of the project, the patronage nurses now provide services only for chronic patients that live in the household that they visit for mother and childcare. Communication between the patronage services and the GPs is lacking. Because of its importance, this communication is expected to be established when the patronage services start using MojTermin. COVID-19 had disrupted the patronage services, mainly since the latter months of 2021, when all patronage nurses were engaged at COVID-19 vaccination sites. Another issue in providing care for chronic patients by patronage services is the lack of equipment. “GPs do not provide information to the patronage services. Communication with them is lacking. It is the same with gynecologists. They do not give us names and contact details of patients. We find the patients on our own. After New Year’s [2022] we will start using MojTermin for mother and childcare in the beginning and we will have easier access to information.” (Patronage nurse, interview). During one of the FGDs with healthcare providers, the Cross4all project was presented. It is a cross-border initiative toward establishing inclusive health and social services, focusing on improving the management and cross-border use of disadvantaged and high-risk citizens’ health and medical data. The project in North Macedonia has been piloted in the Municipality of Ohrid and the Cardiology Center St. Stephan in Ohrid.25 Patients are given devices for measuring glycemia, oxygen saturation, and blood pressure, and data is collected through a mobile application connected to a central application. Trackers are placed on patients’ arms so that doctors can remotely monitor their health information. All these digital tools are available to the citizens of North Macedonia and Greece. Rolling out this initiative across the country should be considered and, perhaps, prioritized. In 2018, a multi-stakeholder process to rethink the role of PHC in North Macedonia was activated, setting the direction for strengthening PHC to serve the population’s needs better, especially regarding NCD prevention 36 16422-WB_Macedonia Report-5thPgs.indd 36 2/2/23 9:09 AM Results BOX 5. CASE STUDY: IS THERE SUFFICIENT FOCUS ON CLOSING SERVICE GAPS AND REACHING DESIRED OUTCOMES? Using MojTermin routine data, the following case illustrates the gaps in care for a multi-morbid diabetic patient. This 67-year-old female patient is registered in an urban GP practice. She was diagnosed with diabetes in 2016 and commenced oral diabetes treatment the same day. By late 2021, diabetes will continue to be managed with oral diabetes drugs. She is also diagnosed with hypertension and is prescribed multiple drugs – a thiazide- diuretic, a calcium channel blocker, an angiotensin receptor blocker, aspirin, a lipid-lowering drug, and a beta- blocker. Her HbA1C levels were uncontrolled at her penultimate check-up in 2020 and her last visit in 2021, a 12-month interval. Her BP was not controlled at these two check-ups. Her BMI has been stable at about 28. There is no evidence in her file that she has received COVID-19 vaccination. Regarding the prevention of diabetes complications, she has no record of a foot exam, but her kidney and retina screens are up to date. The last recorded CAD screen was three years ago. She was last admitted to the hospital in 2018. The full list of past causes of admissions of this patient lists diabetic retinopathy, diabetic cataract, heart disease, cerebrovascular disease, and angina pectoris. and management. The Steering Group appointed by the Minister of Health to monitor the announced PHC reforms was obliged to deliver protocols for managing the following NCDs at the PHC level: hypertension, diabetes, asthma, COPD, and hypothyroidism. Based on these protocols, the Positive List of Drugs was expected to be updated to include evidence-based medicine treatment options and to remove the existing restrictions for the prescription of drugs by PHC doctors. Whether due to the COVID-19 pandemic or other factors, only a few of the agreed activities are implemented. The new model of care that the MOH promoted in February 2020 has not yet been piloted, and no informant could answer the question of when the new model will be piloted. As mentioned earlier, at the PHC level, the protocols for managing NCDs have not been finalized yet. Only the protocol for hypertension is in its final stage, but it still needs to undergo an approval process. In December 2021, the MOH identified what it termed “quick gains” for the PHC reforms; they included the implementation of the protocol for the management of hypertension at the PHC level. Summary of barriers and facilitators The FGDs with care providers and patients provided rich perspectives on individual and shared experiences. In addition, the analysis of the FGD content allowed the identification of distinct barriers and facilitators at all key stages of the cascade (Table 6). 37 16422-WB_Macedonia Report-5thPgs.indd 37 2/2/23 9:09 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA TABLE 6. IDENTIFIED BARRIERS AND FACILITATORS ACROSS THE DIABETES AND HYPERTENSION CARE CASCADES Stage Barriers Facilitators Primary • Low level of health literacy in the general • Health promotion activities prevention population. and preventive programs • Limited health promotion and screening exist but need strengthening. activities. • Patients Associations and • Insufficient funds for health promotion other NGOs work on raising activities and preventive programs. disease awareness. • Smoking, obesity, stress, lack of physical activity, and air pollution contribute to the development of chronic diseases. • In urban communities, the green areas for recreation and relaxation are replaced with buildings. Screening & • Non-functional screening program. • Accessibility of PHC diagnosis • Lack of coordination among care providers at providers. different levels in the system. • Screening in the targets set • The current model of care is overburdening by HIF for GPs (variable part providers. of payment). • Low-risk perception and disease awareness • Government screening coupled with low health literacy in the general programs. population. • Awareness in the medical • Diagnosis of asymptomatic diseases rarely community on the importance occurs. of screening. • HIF restrictions for GPs to order specific • Patients Associations and laboratory tests and mandatory referral to other NGOs are involved specialists. in the screening of the communities. • Number and availability of specialists. • eHealth system – MojTermin. • No care providers in some rural areas. Treatment • HIF restrictions for GPs to prescribe certain • Availability of the reimbursed initiation drugs. drugs. • Reimbursement list not updated for many years; limited access to novel and efficacious treatment. • Lack of staff that would provide in depth information and education about the diseases, possible complications, lifestyle changes, and treatment. 38 16422-WB_Macedonia Report-5thPgs.indd 38 2/2/23 9:09 AM Results TABLE 6. IDENTIFIED BARRIERS AND FACILITATORS ACROSS THE DIABETES AND HYPERTENSION CARE CASCADES cont/… Stage Barriers Facilitators Treatment • GPs refer and copy prescriptions from • Availability of the reimbursed maintenance specialists. drugs. and • Mandatory prescription of certain drugs by • Introduction of electronic monitoring specialists every 3, 6, 12 months. prescription. • Number and availability of specialists. • Accessibility of PHC • Lack of care providers in some rural areas. providers. • Drugs prescribed by private specialists are not • Existence of active Patients recognized by the HIF (duplication of services). Associations. • People usually do not take the disease • Support and experience seriously until complications appear. exchanges among patients. • Due to limited availability of specialists in • Well-organized patient public health institutions, patients choose to education at the University use services of private providers suffering a Endocrinology Clinic in huge financial burden. Skopje, though it has deteriorated in the last years. • GPs do not actively monitor chronic patients nor proactively refer for a specialist’s • Excellent education at the screening examination. Usually, patients private clinics for patients request a referral by themselves. who can afford to pay OOP. • Long waiting times in the labs, GPs, and • The medical staff (GPs, specialists’ offices. specialists, nurses) emphasize the importance • Health providers are overburdened with of adherence to treatment administrative work. during their interaction with • “One-stop shops’ for examinations exist only patients, if/when time permits. at private clinics; in the public sector, it takes • Successful MOH project that several visits over 1–2 months to complete all engaged patronage nurses procedures. to visit chronic patients • Outdated and non-functional equipment at the proactively. diabetes centers, according to patients. • The education of patients relies mainly on their initiative. • In smaller towns and rural areas, the stigma around diabetes still exists. • Low attendance of patients to lectures organized by Patients Associations in communities. • Limited or no support for lifestyle changes. • Lack of communication between patronage services and other care providers. 39 16422-WB_Macedonia Report-5thPgs.indd 39 2/2/23 9:09 AM 16422-WB_Macedonia Report-5thPgs.indd 40 2/2/23 9:09 AM Limitations of the Analysis Limitations of the Analysis This study had several limitations: First, it only collated data from 12 GP practices across the country, which is a small sample considering there were 1,482 GPs in North Macedonia in 2020. However, a stratified random selection procedure was used to ensure that all regions of the country were represented and that rural GP practices were included. Second, the GP practices extracted the data themselves under the supervision of a national coordinator from the MMA instead of using external data collectors. All efforts were made to explain that the study did not evaluate the work of individual GPs to minimize reporting bias. Also, the GP sites were classified as “urban” or “rural,” and data were neither analyzed nor reported as site-specific. This was explained to the GPs, who were reminded throughout the data collection of the study’s objective to inform PHC improvements nationally. Third, GPs selected the patients for inclusion in the study. A random selection method was used to enroll patients from the database to reduce the risk of selection bias. Fourth, most patient data were extracted manually, and there could have been transcription errors despite the care taken by the data extractors. To control this, the coordinator and the data analyst ran data range and plausibility checks, and data points were removed if the query could not be resolved. Fifth, some GP practices use a manual sphygmomanometer, and it is their usual practice to record rounded BP values in the patient file to the nearest 5 or even 10 mmHg. This will have led to misclassifications of BP results when using the cutoffs for hypertension (≥140/≥90 mmHg) and grades 1, 2, and 3. However, the analysts posit that this will not significantly alter the results. Furthermore, the cutoff for hypertension used in the study was not stringent, given the GPs use the office treatment target range of SBP <130–140 mmHg and DBP 80 mmHg if tolerated by the individual. Sixth, the FGD participants opted into the study and, thus, may not have represented the full spectrum of care providers and patient types. Finally, the study team invited a mix of care providers and patients with different care experiences to ensure diversity in the FGDs. It could be concluded that the participants provided a helpful range of perspectives considering the recurrent opinions and evidence of data saturation across the different FGDs. 41   16422-WB_Macedonia Report-5thPgs.indd 41 2/2/23 9:10 AM 16422-WB_Macedonia Report-5thPgs.indd 42 2/2/23 9:10 AM Conclusions and Recommendations Conclusions and Recommendations The pandemic has affected diabetes and hypertension care in North Macedonia. Like everywhere else, the patients included in this study became a high-risk group for COVID-19 during 2020 and 2021. COVID-19 was the top cause of recent hospital admissions in this patient population, with suboptimal diabetes and hypertension treatment success and significant gaps in active treatment management and prevention of complications. By autumn 2021, 56 percent of the diabetes patients and 61 percent of the hypertension patients became fully vaccinated against COVID-19. The cascade analysis, combined with qualitative research, provided insight into the gaps and bottlenecks in chronic care while highlighting areas of scope for improvements and reform. SCREENING The analysis could not assess the coverage of diabetes and hypertension screening and quantify the screening gaps. Still, the available evidence suggests that there is considerable scope for improvement. The number of undiagnosed diabetes and hypertension cases may be vast among men. Screening guidelines are not systematically implemented, and cases are detected late, often as acute cases. This leads to unequal access and variable quality of care across the country, likely generating higher care costs for people with NCDs. Risk-based CVD management at PHC linked to the variable part of the per capita payment for the GPs is focused on processes rather than the effective delivery of services – for example, the number of invitations to preventive screenings rather than services effectively delivered. This proforma risk-based CVD management was suspended during the COVID-19 pandemic state of emergency and resumed in the same form afterward. Redefining screening targets for GPs by the HIF and incentivizing the GPs with payments are steps in the right direction. Given the easy accessibility of PHC providers in large parts of North Macedonia, more demand for screening needs to be created. The annual Program for Prevention of Cardiovascular Diseases of the MOH, which is used to provide funding for adult and pediatric cardiovascular and neurosurgical interventions, must be revised and the same applies to the MOH “Health for All” preventive program implemented by the IPH and the centers for public health. Awareness campaigns about the risks of undetected diseases and highly effective treatments must be implemented. In rural areas, where access to PHC providers is suboptimal, outreach activities can help with disease awareness and screening activities. NGOs, including Patients Associations, are essential partners in this. In smaller towns and rural areas, the stigma around diabetes still exists and poses a barrier to screening. This needs to be considered when designing communication content. The eHealth system MojTermin should be a tool supporting the targeting of regular screening, the linkage to care of suspect cases, and the tracking of progress in screening coverage. Reforming the PHC model can support a learning agenda of what works in improving the demand and frequency of screening for diabetes and hypertension. 43   16422-WB_Macedonia Report-5thPgs.indd 43 2/2/23 9:10 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA DIAGNOSIS For hypertension and diabetes, the at-risk population estimate and resulting diagnostic gap are uncertain, indicating the importance for North Macedonia to assess the prevalence of these major NCDs at the population level. According to FGD participants, diagnosis of asymptomatic diseases rarely occurs. Hypertension and diabetes are usually diagnosed late, with manifested symptoms or developed complications in a hospital setting. FGD participants and key informants confirmed the bottlenecks at the diagnosis stage due to the HIF restrictions for GPs to order certain laboratory tests, the mandatory referral to specialists, and the limited number and availability of specialists. This negatively impacts the efficiency of getting a diagnosis confirmed for both the patient and the treating GP and is especially concerning in some rural areas where patient pathways necessitate travel to see the specialists. The medical community understands the importance of early case finding, but the capacity to deliver high volumes of screening services requires a new approach. Task shifting and decentralization, coupled with training and redefining risk-based CVD management, are essential elements in reforming the PHC model to strengthen the early diagnosis. TREATMENT This analysis suggests that once individuals are diagnosed as diabetic or hypertensive, the vast majority are initiated on treatment regimens. However, there are HIF restrictions for GPs to prescribe certain drugs, which may lead to some undertreatment and delays in starting comprehensive treatment. In our hypertensive patient sample, 27 percent of those identified with grade 3 and 41 percent of those found with grade 2 hypertension were on monotherapy at the time of the file review. Monotherapy was associated with 74 percent of grade 1 patients controlling their BP, 76 percent of grade 2, and 61 percent of grade 3 [N only 43] controlling their BP. Rural GP practices had higher levels of monotherapy (52 percent) compared to urban practices (39 percent). Inadequate up-titration of treatment from monotherapy is a global problem.26 In North Macedonia, the reimbursable medicines list has not been updated for several years,viii limiting access to novel treatments which may be more effective. Similarly, the inability of GPs to prescribe essential drugs have generated delays in treatment start and compromises efficiency. The low medical literacy of patients with chronic NCDs leads to delays in starting treatment, inadequate lifestyle adjustment, and not taking the disease seriously until the occurrence of complications. Knowledge and awareness of the diseases, possible complications, lifestyle changes, and treatment provided at the secondary and tertiary level of care are insufficient due to overburdening and lack of human resources, and lack of centers for education. Health professionals must embrace the health education role at the primary care level, ensuring that more counseling and patient education capacity is built within the communities and at the lower levels of care. The country’s hypertension guidelines emphasize that most hypertension patients should be started with two drugs, not one, as monotherapy is usually inadequate, especially with the BP treatment targets for many patients now lower than in previous guidelines. Monotherapy remains appropriate for patients with a lower baseline BP close to their recommended target and some frail or old patients, according to the country’s hypertension guidelines. Evidence suggests that this treatment approach will improve the speed, efficiency, and consistency of initial BP lowering and BP control, and is well tolerated by patients. Non-pharmacological viii Some new medicines were added to the list in February 2015, but the list has not been substantively reviewed since 2008. The list lacks many contemporary treatments and still contains several drugs that are rarely or not at all used in the European Union and are not recommended by the World Health Organization’s 2021 Model List of Essential Medicines. 44 16422-WB_Macedonia Report-5thPgs.indd 44 2/2/23 9:10 AM Conclusions and Recommendations interventions must complement the drug treatment, and novel approaches to social prescribing of healthy foods or physical exercise should be explored. MONITORING The cascade analysis provided valuable insights into monitoring these chronic NCD patients. Some gaps in monitoring data may be due to the switch to teleconsultations, which became a tool for three-quarters of patients during the pandemic. However, the self-monitoring of patients had also become more prevalent, with nearly half of the diabetes patients reporting their glucometer results and about 40 percent of all patients reporting home BP measurements into the system. Most diabetes cases had a glucose result recorded at their last GP contact – 91  percent had a glucose test (fasting or random plasma glucose, HbA1C), and 76 percent had HbA1C measured. Considering the monitoring done at any of the last two GP contacts to track the ABC metric, the gap in HbA1C coverage was the largest (12.7 percent lacked a result), followed by the gap in cholesterol data (9.4 percent had no result). In contrast, only 2.4 percent of the diabetes patients lacked a BP result across the last two visits. Regarding preventing diabetes complications, patients lacked a BP result across the previous two visits. Regarding preventing diabetes complications, the annual monitoring had significant coverage gaps. Overall, 71 percent of patients did not receive a retinopathy screen in the past 12 months; 93 percent of patients at rural practices and 77 percent of comorbid diabetes/hypertension patients had no evidence of receiving this exam at the ophthalmologist. Foot and kidney screens were also insufficient, with striking coverage gaps in monitoring nephropathy in rural and comorbid patients. Only 13 percent of diabetes patients had had all four screens in the past 24 months. In addition, chronic patients are not proactively referred for specialists’ screening examinations, and often, patients themselves request a referral. Monitoring of BP of hypertensive patients was almost universal at GP visits, but 13 percent of patients did not have a BP result in their file for the previous six months despite the COVID-19 service continuity measures and home-testing. According to FGD participants, treatment maintenance and monitoring face the same issues already discussed, such as the HIF restrictions for GPs regarding prescriptions and laboratory referrals, the reimbursement list lacking regular updates, insufficient and overburdened medical staff, and the absence of centers for education and counseling. DISEASE CONTROL To attain the treatment targets, diabetes and hypertension patients must adhere to the treatment regimen and get medication refills regularly. Among the diabetes patients in the study, 40 percent had glycemic and ABC control, but this figure was lower in rural and comorbid patients and those on insulin. Among the hypertension patients, 64 percent had evidence of a controlled BP in the last six months, with poorer attainment in obese patients and those with grade 3 hypertension at diagnosis. In the North Macedonia health system, electronic prescription has been successfully introduced. However, several issues can create bottlenecks in treatment maintenance. Certain drugs can only be prescribed by the limited number of specialists, and this can negatively affect treatment continuation and adherence. Some prescription intervals are as short as three months, which creates additional medication access challenges for rural patients. Medicines prescribed by private specialists are not recognized by the HIF, which leads to duplication of some services and OOP payments, then a financial burden on individuals and families. A single-pill treatment strategy can improve adherence; research has shown a direct correlation between the (high) number of BP-lowering pills and poor adherence to medications.27 The hypertension guidelines 45 16422-WB_Macedonia Report-5thPgs.indd 45 2/2/23 9:10 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA recommend FDC as the preferred strategy for the initial two-drug combination treatment of hypertension and for three-drug combination therapy, when required, as it has the potential to improve BP control rates further. Much is known about practical interventions to strengthen medication adherence: linking drug intake with habits,28 giving adherence feedback to patients, self-monitoring29 using pill boxes and other special packaging, and motivational interviewing. There is also evidence that peer support, treatment buddy systems, and adherence clubs may work for some patients.30 In addition, increasing the integration among healthcare providers with the involvement of pharmacists and nurses increases medication and treatment adherence.31 Using multiple components has a more significant effect on adherence, as the effective size of each intervention is generally modest. Many adherence interventions have a core digital component to either strengthen health system functions (for example, supply chain management), facilitate provider-patient interaction, with teleconsultations, remote monitoring, e-prescriptions, or referral coordination, or support patients via self-monitoring, peer-learning, treatment reminders, and notifications. A purposeful collection of digital solutions for better NCD service delivery and treatment outcomes is forthcoming. TARGETING Although physicians understand that not all patients need the same support, more emphasis can be placed on differentiated service delivery approaches that target support to the neediest patients. This analysis shows, for instance, that comorbid patients who are generally at higher risk of symptomatic disease and complications receive less monitoring attention than diabetes patients without hypertension. Along the same lines of targeting, patient education must adopt a “push” approach rather than the “pull” approach, in which education relies mainly on the patient’s own initiative, which disadvantages certain patient types. Education can and should also link to patient empowerment to enable people to take more responsibility for their cardiovascular health. The growing habit of self-monitoring among chronic patients and transmission of results into the system is an excellent indicator that patients are engaged in their care and capable of tracking the progress of their treatment. How education of patients and the public on NCDs and healthy living is done may need a re-consideration. Patients Associations are vital partners in NCD communication with the public, and they may benefit from innovation to reach people in the digital age with the right type of content. Reforms to the current PHC model will need to improve primary care at each stage of the chronic care continuum. It will need to effectively reduce waiting times at GPs, with the potential introduction of an appointment system. A better working PHC level will positively impact waiting times at specialist offices, which already have a functioning appointment system that is congested due to dysfunctionality at the PHC level. Reconfiguration of the PHC model should free up health provider capacity with more efficient administrative processes and monitoring visits based on clinical needs, including intervals of 6–12 months for uncomplicated stable patients. Introduction of Point-of-Care Testing at the PHC level that could provide a result within minutes while the NCD patient is visiting the GP practice could increase treatment adherence and improve a patient’s experience. The public sector needs to move towards service integration (one-stop-shop) so that patients have a less fragmented and drawn-out experience when accessing treatment or follow-up visits. This will improve the perception of quality and facilitate prompt and efficient management of the condition. A successful MOH project has engaged patronage nurses to visit chronic patients proactively. However, communication, especially between patronage nurses and other care providers, needs to be improved for the linkage of care and referral mechanisms to work smoothly. Investment in infrastructure is needed for specialists working in diabetes centers to have well- functioning modern equipment available. 46 16422-WB_Macedonia Report-5thPgs.indd 46 2/2/23 9:10 AM Conclusions and Recommendations The cascade analysis also highlighted several areas of potential improvement in MojTermin. This includes the integration of MojTermin with the HIF information system, improved decision support capabilities, and the development of standards for the production of PHC performance indicators. The last area has taken on special significance because of the agreement between the Doctors Chamber and the HIF to increase the proportion of PHC physician compensation based on doctor performance and expand the list of indicators. In addition, the fragmentation of the service delivery system poses challenges for a national eHealth system. For example, various healthcare providers do not coordinate appropriately with public providers in health centers that are not yet connected to the MojTermin system, hindering communication and collaboration with private providers. The data extraction work carried out by the GP practices for this study showed that to get a full view of the care patients receive, data often needed to be harvested from paper records because private hospitals, clinics, and laboratories are not part of MojTermin. Integrating patient data from the public and private health institutions into the national E-health system should be one of the priority tasks for improving the continuity of care for NCDs in North Macedonia. At the same time, quality indicators and mechanisms for specific quality improvements in diabetes, hypertension, and primary care are needed. In North Macedonia, collecting, collating, and analyzing accurate health statistical data and, consequently, producing accurate reports remains a challenge. Therefore, there is a need for building and maintaining an appropriate information technology (IT) infrastructure that connects all institutions involved in generating and processing data. This ensures efficient two-way communication from the system’s higher levels (national, district) back to lower (community, facility) levels. In addition, it is necessary to provide data access protocols, enable the faster and more accurate generation and distribution of reports, and use the available data and reports to inform policy decision-making. TABLE 7. PRIORITY ACTIONS TO STRENGTHEN THE CONTROL OF METABOLIC NCDs Area Priority actions Improvements to the NCD care continuum Primary • Organize awareness campaigns on the risks of undetected conditions, especially prevention hypertension, prediabetes and diabetes, so that care can be initiated early and and health promptly. promotion • Promote healthy lifestyles through multiple channels, diverse sectors, and strategic partnerships, including communication through GPs. Screening • Consistently implement screening guidelines for these high-burden NCDs, for example, using CVD risk scoring and stratification tools to identify and effectively manage those at increased risk. • Incentivize GPs to assess, record, and act upon cardiovascular and other risk factors. • Introduce measures to address screening gaps, especially to reach men, using diverse screening strategies in work- and meeting places. Diagnosis • Expand GP competencies to prescribe diagnostic tests. • Strengthen the capacity of professionals at the PHC level to determine risk factors and effectively communicate with patients about the disease and its management. • Provide various diagnostic tools and equipment for early detection and monitoring of chronic NCDs at the PHC level, including high-quality automated/ digital BP monitors for reliable results and high throughput. 47 16422-WB_Macedonia Report-5thPgs.indd 47 2/2/23 9:10 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA TABLE 7. PRIORITY ACTIONS TO STRENGTHEN THE CONTROL OF METABOLIC NCDs cont/… Area Priority actions Treatment • Where appropriate, treat hypertension with multiple drugs, including FDCs, as an evidence-based, rational approach to hypertension control and revise the positive list of medications. • Address the undertreatment of hypertension, particularly in rural patients and those with severe hypertension. • Embed non-pharmacological interventions and education in personalized care plans. Monitoring • Devise approaches to ensure rural patients can access HbA1C tests as per clinical guidelines. • Ensure the screening for diabetic complications to prevent unnecessary suffering and costs, with special attention to comorbid cases and rural patients, for example, retinopathy exams. • Promote stronger patient empowerment and provision of targeted, patient- specific education, using a “push” approach, where information is proactively shared with patients rather than relying on patients’ initiative to seek it out. Disease control • Maximize FDC for better hypertension control, as clinically appropriate. • Focus on treatment adherence and assess the root causes of nonadherence in each patient failing disease control. • Strengthen feedback to and motivation of patients to adhere to treatment, including through peers. System-level changes Strengthen • Promote the introduction of group practices and scale-up the multidisciplinary care integration team structure, which includes a medical administrator and health promotion and person- nurses. centered • Continue promoting self-monitoring and information sharing between patients approach and GPs, possibly through MojTermin. • Strengthen outreach services through patronage nurses and increase their coordination with GPs. • Implement task shifting and team-based care with expanded authorizations to prescribe, titrate, and refill medications, including task shifting to medical nurses, especially in caring for stable NCD patients. • Minimize unnecessary clinic visits by lengthening visit intervals to 6–12 months for stable patients. • Refine systems to minimize barriers to treatment adherence, for example, co-payments, multi-month prescriptions for stable patients, convenient access to regular monitoring, and link to mental health support. Communication • Better equip doctors and nurses, especially in PHC settings, to effectively communicate with patients about risk factors, healthy lifestyles, and treatment adherence. • Minimize unnecessary clinic visits by strengthening mechanisms for patients to engage with peers, especially for healthy lifestyles and psychological support. Monitoring and • Integrate patient data among all health institutions. Evaluation, and • Implement representative population-level surveys to quantify NCD risk factors Learning with a minimum measurement of BP, glucose, and anthropometry. • Set up appropriate quality and performance indicators reflecting guideline- compatible care monitoring and outcomes. • Pilot and evaluate innovative practices that have scope to respond to key health system challenges posed by population aging, brain drain, shortage of health professionals, and increased medical and social care needs by patients. 48 16422-WB_Macedonia Report-5thPgs.indd 48 2/2/23 9:10 AM Endnotes Endnotes 1 WHO. 2019. Primary health care organization, performance and quality in North Macedonia. https://www.euro. who.int/data/assets/pdf_file/0009/403020/MKD-PHC-report-160519.pdf. 2 IHME Database. 2021. http://www.healthdata.org/macedonia. 3 The World Bank Data. 2021. https://data.worldbank.org/indicator/SP.DYN.LE00.FE.IN?locations=EU. 4 World Bank. 2019. North Macedonia Strengthening Primary Health Care to Sustain Improvements in Population Health. Internal document with calculations using IHME GBD 2017 and Statistical Yearbook 2017 data. 5 WHO. 2019. Primary health care organization . . . and quality in North Macedonia. 6 Fraser-Hurt, Nicole, Zara Shubber, and Katherine Ward. 2022. Improving Health Services and Redesigning Health Systems: Using Care Cascade Analytics to Identify Challenges and Solutions, Volume 1. Population- level Cascade Analytics. Washington, DC: World Bank. https://openknowledge.worldbank.org/ handle/10986/36993. 7 Fraser-Hurt, N., Leausa Take Naseri, Robert Thomsen, Athena Matalavea et al. 2021. “Improving services for chronic non-communicable diseases in Samoa: an implementation research study using the care cascade framework.” Australian and New Zealand Journal of Public Health 46(1):36–45. doi: 10.1111/1753-6405.13113. https://onlinelibrary.wiley.com/doi/epdf/10.1111/1753-6405.13113. 8 Ministry of Health, North Macedonia. “Evidence-based Guidelines for Endocrinology. http://zdravstvo.gov.mk/ wp-content/uploads/2015/08/Dijabetes-definicija-diferen-dijagnoza.pdf. 9 IHME. 2019. Global Burden of Disease 2019. https://vizhub.healthdata.org/gbd-compare/. 10 North Macedonia Census 2021. 11 International Diabetes Federation (IDF). 2021. IDF Diabetes Atlas 10th edition. Brussels, Belgium: IDF. https:// diabetesatlas.org/atlas/tenth-edition/. 12 Ahmeti I., Iskra Bitovska, Snezhana Markovic, Elena Sukarova-Angelovska, et al. “Growing Prevalence and Incidence of Diabetes in Republic of Macedonia in the Past 5 Years Based on Data from the National System for Electronic Health Records.” Open Access Macedonian Journal of Medical Sciences 2020. https://oamjms.eu/ index.php/mjms/article/view/5071. 13 Long, Amanda N., and Samuel Dagogo-Jack. 2011. “Comorbidities of Diabetes and Hypertension: Mechanisms and Approach to Target Organ Protection.” Journal of Clinical Hypertension (Greenwich) 13(4): 244–251. doi: 10.1111/j.1751-7176.2011.00434.x. 14 Institute of Public Health of the Republic of North Macedonia. 2021. “Outpatient Policlinic Morbidity in the Republic of North Macedonia, 2020.” http://iph.mk/wp-content/uploads/2021/08/apm-2021.pdf. 15 “Our World In Data.” https://ourworldindata.org/coronavirus/country/macedonia. 16 Influenza guidelines: http://zdravstvo.gov.mk/wp-content/uploads/2015/08/Influenca.pdf. 17 The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension, 2018. European Heart Journal 39: 3021–3104. doi:10.1093/eurheartj/ehy339. 49   16422-WB_Macedonia Report-5thPgs.indd 49 2/2/23 9:10 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA 18 Ministry of Health (MOH). 2018. “Guidelines for Practicing Evidence Based Medicine in Prevention, Diagnosis and Treatment of Diabetes.” https://dejure.mk/zakon/upatstvo-za-praktikuvanje-na-medicina-zasnovana- na-dokazi-vo-sproveduvanje-prevencija-dijagnoza-i-tretman-na-dijabetes. 19 1. Institute of Public Health of Republic of North Macedonia. 2020. “Information for the Results Obtained From the Implementation of the Health for All Program in Republic of North Macedonia in 2020.” http://iph.mk/ wp-content/uploads/2021/02/Izvestaj-zdravje-za-site-2020-finish-SO-CIP-BROJCE.pdf. 2. Institute of Public Health of Republic of Macedonia. 2019. “Information for the Results Obtained From the Implementation of the Health for All Program in Republic of North Macedonia in 2019.” http://iph.mk/wp-content/uploads/2020/01/ Izvestaj-zdravje-za-site-2019.pdf. 3. Institute of Public Health of Republic of Macedonia. 2018. “Information for the Results Obtained From the Implementation of the Health for All Program in Republic of Macedonia in 2018.” http://iph.mk/wp-content/uploads/2019/08/Izvestaj-zdravje-za-site-2018.pdf. 20 “2018 ESC/ESH Guidelines for the management of arterial hypertension. 2018. European Heart Journal39(33): 3021–3104. doi:10.1093/eurheartj/ehy339. 21 Ministry of Health (MOH). 2018. “Guidelines for Practicing Evidence Based Medicine in Prevention, Diagnosis and Treatment of Diabetes.” 22 MOH. 2018. “Guidelines for Practicing Evidence Based Medicine. . . .” 23 Scientific Association of Endocrinologists and Diabetologists of the Republic of Macedonia. 2020. “Guidelines for Diabetes from 2018 (Revision 2020).” 24 MOH. 2018. “Guidelines for Practicing Evidence Based Medicine. . . .” 25 Cross4All (n.d.). “Cross-border initiative for integrated health and social services promoting safe ageing, early prevention and independent living for all.” https://cross4all.eu/en/about. 26 “2018 ESC/ESH Guidelines for the management of arterial hypertension.” 27 “2018 ESC/ESH Guidelines. . . .” 28 Conn, V. S., Todd M. Ruppar, Jo-Ana D. Chase, Maithe Enriquez, Pamela S. Cooper. 2015. “Interventions to improve medication adherence in hypertensive patients: systematic review and meta-analysis.” Current Hypertension Reports 17(12): 94. doi: 10.1007/s11906-015-0606-5. 29 Parati, G., and Stefano Omboni. 2010. “Role of home blood pressure telemonitoring in hypertension management: an update.” Blood Pressure Monitoring 15(6): 285–295. doi: 10.1097/MBP.0b013e328340c5e4. 30 Shiyanbola, O., Martha A. Maurer, Mattigan L. Mott, Luke Schwerer, Nassim Sarkarati, Lisa Kay Sharp, and Earlise C. Ward. 2021. “A Feasibility Pilot Trial of a Peer-support Educational Behavioral Intervention to Improve Diabetes Medication Adherence in African Americans.” doi: 10.21203/rs.3.rs-1072559/v1. 31 Alshehri, A. A., Zahraa Jalal, Ejaz Cheema, M. Sayeed Haque, Duncan Jenkins, and Asma Yahyouche. 2020. “Impact of the pharmacist-led intervention on the control of medical cardiovascular risk factors for the primary prevention of cardiovascular disease in general practice: a systematic review and meta-analysis of randomised controlled trials.” British Journal of Pharmacology 86(1): 29–38. 50 16422-WB_Macedonia Report-5thPgs.indd 50 2/2/23 9:10 AM ANNEX 1 Annex 1: GP Sites and Patients Reviewed TABLE A1. PATIENT SAMPLES BY GP PRACTICE Diabetes patient Hypertension Region Setting sample patient sample* Female Male Female Male Eastern Urban 23 36 86 85 Northeastern Urban 33 27 80 61 Pelagonia Urban 35 24 100 44 Polog Urban 25 35 7 6 Rural 34 25 107 71 Skopje Urban 39 21 93 65 Urban 30 30 92 55 Rural 38 21 82 57 Urban 35 25 74 55 Southeastern Urban 31 28 72 94 Southwestern Rural 39 21 99 42 Vardar Urban 31 29 81 79 Total 393 322 973 714 A total of 1,370 female and 1,023 male hypertension patients were initially enrolled from the database, but many of these patients *  also had a diagnosis of diabetes and were excluded from the hypertension cascade analysis to (a) prevent the same patients could be analyzed in the two cascades, and (b) solely assess the care patients diagnosed with hypertension receive. 51   16422-WB_Macedonia Report-5thPgs.indd 51 2/2/23 9:10 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA Annex 2: Additional Cascade Charts FIGURE A2.1. DIABETES TREATMENT CASCADE (BY GENDER) Treatment pattern Glucose monitoring gap Control gap Gap in complication monitoring 99 100 98 98 91 92 78 74 64 65 Percent 60 55 52 53 41 41 38 39 34 30 25 28 30 26 Any glucose test Any Pharma Insulin Any test done A1C done A1C<7% ABC control Foot exam Retinopathy Nepropathy CAD screen On treatment Glucose check Control (among those Monitoring for complications (last visit) with test) (past 12 months) Female (N = 393) Male (N = 322) Source: Medical records review, 2021. 52 16422-WB_Macedonia Report-5thPgs.indd 52 2/2/23 9:10 AM ANNEX 2 FIGURE A2.2. DIABETES TREATMENT CASCADE (BY AGE GROUP) Treatment pattern Glucose monitoring gap Control gap Gap in complication monitoring 1009999 979798 9394 86 7779 69 68 62 60 Percent 56 58 54 55 57 50 44 46 41 37 3637 31 30 2828 31 303031 26 Any glucose test Any Pharma Insulin Any test done A1C done A1C<7% ABC control Foot exam Retinopathy Nepropathy CAD screen On treatment Glucose check Control (among those Monitoring for complications (last visit) with test) (past 12 months) 18–54 yrs (N = 181) 55–69 yrs (N = 352) 70+ yrs (N = 182) Source: Medical records review, 2021. FIGURE A2.3. HYPERTENSION TREATMENT CASCADE (BY GENDER) Treatment pattern Monitoring gap Control gap 100 100 97.8 97.6 87.2 87.0 64.4 63.9 Percent 43 42 35 34 20 22 8 10 All 1 type of 2+ types of Fixed dose Polypharmacy BP result BP result BP <140/90 HTN drug HTN drugs combination In care Treatments Last visit Last 6 mths BP control (last 6 mths) Female (N = 973) Male (N = 714) Source: Medical records review, 2021. 53 16422-WB_Macedonia Report-5thPgs.indd 53 2/2/23 9:10 AM SUPPORTING IMPROVEMENTS IN CONTINUITY OF CARE FOR HYPERTENSION AND DIABETES IN NORTH MACEDONIA FIGURE A2.4. HYPERTENSION TREATMENT CASCADE (BY AGE GROUP) Treatment pattern Monitoring gap Control gap 100 100 100 98 98 96 89 89 83 66 64 63 Percent 46 46 42 40 38 26 22 19 14 3 10 13 All 1 type of 2+ types of Fixed dose Polypharmacy BP result BP result BP <140/90 HTN drug HTN drugs combination In care Treatments Last visit Last 6 mths BP control (last 6 mths) 18–54 yrs (N = 528) 55–69 yrs (N = 657) 70+ yrs (N = 502) Source: Medical records review, 2021. 54 16422-WB_Macedonia Report-5thPgs.indd 54 2/2/23 9:10 AM 16422-WB_Macedonia Report-5thPgs.indd 55 2/2/23 9:10 AM 16422-WB_Macedonia Report-5thPgs.indd 56 2/2/23 9:10 AM 16422-WB_Macedonia Report-5thPgs.indd 3 2/2/23 9:10 AM World Bank World Bank Health, Nutrition World Bank Office in North Macedonia 1818 H Street, NW and Population Global Practice St. Leninova 34 Washington DC 20433 https://www.worldbank.org/en/topic/health 1000 Skopje USA Republic of North Macedonia https://www.worldbank.org/en/region/eap 16422-WB_Macedonia Report-5thPgs.indd 4 2/2/23 9:10 AM