Conference Material > Slide Presentation
Ansbro E, Masri S, Prieto-Merino D, Bahous SA, Molfino L, et al.
MSF Scientific Days International 2022. 2022 May 11; DOI:10.57740/mzsh-8t29
Conference Material > Video
Masri S
MSF Scientific Days International 2020: Innovation. 2020 May 14
Journal Article > ResearchFull Text
BMJ Open. 2023 January 25; Volume 13 (Issue 1); e063668.; DOI:10.1136/bmjopen-2022-063668
Ansbro É, Masri S, Prieto-Merino D, Willis R, Aoun Bahous S, et al.
BMJ Open. 2023 January 25; Volume 13 (Issue 1); e063668.; DOI:10.1136/bmjopen-2022-063668
OBJECTIVES
This pre–post implementation study evaluated the introduction of fixed dose combination (FDC) medications for atherosclerotic cardiovascular disease (ASCVD) secondary prevention into routine care in a humanitarian setting.
SETTING
Two Médecins sans Frontières (MSF) primary care clinics serving Syrian refugee and host populations in north Lebanon.
PARTICIPANTS
Consenting patients ≥18 years with existing ASCVD requiring secondary prevention medication were eligible for study enrolment. Those with FDC contraindication(s) or planning to move were excluded. Of 521 enrolled patients, 460 (88.3%) were retained at 6 months, and 418 (80.2%) switched to FDC. Of these, 84% remained on FDC (n=351), 8.1% (n=34) discontinued and 7.9% (n=33) were lost to follow-up by month 12.
INTERVENTIONS
Eligible patients, enrolled February–May 2019, were switched to Trinomia FDC (atorvastatin 20 mg, aspirin 100 mg, ramipril 2.5/5/10 mg) after 6 months’ usual care. During the study, the COVID-19 pandemic, an economic crisis and clinic closures occurred.
OUTCOME MEASURES
Descriptive and regression analyses compared key outcomes at 6 and 12 months: medication adherence, non-high density lipoprotein cholesterol (non-HDL-C) and systolic blood pressure (SBP) control. We performed per-protocol, intention-to-treat and secondary analyses of non-switchers.
RESULTS
Among 385 switchers remaining at 12 months, total adherence improved 23%, from 63% (95% CI 58 to 68) at month 6, to 86% (95% CI 82 to 90) at month 12; mean non-HDL-C levels dropped 0.28 mmol/L (95% CI −0.38 to −0.18; p<0.0001), from 2.39 (95% CI 2.26 to 2.51) to 2.11 mmol/L (95% CI 2.00 to 2.22); mean SBP dropped 2.89 mm Hg (95% CI −4.49 to −1.28; p=0.0005) from 132.7 (95% CI 130.8 to 134.6) to 129.7 mm Hg (95% CI 127.9 to 131.5). Non-switchers had smaller improvements in adherence and clinical outcomes.
CONCLUSION
Implementing an ASCVD secondary prevention FDC improved adherence and CVD risk factors in MSF clinics in Lebanon, with potential for wider implementation by humanitarian actors and host health systems.
This pre–post implementation study evaluated the introduction of fixed dose combination (FDC) medications for atherosclerotic cardiovascular disease (ASCVD) secondary prevention into routine care in a humanitarian setting.
SETTING
Two Médecins sans Frontières (MSF) primary care clinics serving Syrian refugee and host populations in north Lebanon.
PARTICIPANTS
Consenting patients ≥18 years with existing ASCVD requiring secondary prevention medication were eligible for study enrolment. Those with FDC contraindication(s) or planning to move were excluded. Of 521 enrolled patients, 460 (88.3%) were retained at 6 months, and 418 (80.2%) switched to FDC. Of these, 84% remained on FDC (n=351), 8.1% (n=34) discontinued and 7.9% (n=33) were lost to follow-up by month 12.
INTERVENTIONS
Eligible patients, enrolled February–May 2019, were switched to Trinomia FDC (atorvastatin 20 mg, aspirin 100 mg, ramipril 2.5/5/10 mg) after 6 months’ usual care. During the study, the COVID-19 pandemic, an economic crisis and clinic closures occurred.
OUTCOME MEASURES
Descriptive and regression analyses compared key outcomes at 6 and 12 months: medication adherence, non-high density lipoprotein cholesterol (non-HDL-C) and systolic blood pressure (SBP) control. We performed per-protocol, intention-to-treat and secondary analyses of non-switchers.
RESULTS
Among 385 switchers remaining at 12 months, total adherence improved 23%, from 63% (95% CI 58 to 68) at month 6, to 86% (95% CI 82 to 90) at month 12; mean non-HDL-C levels dropped 0.28 mmol/L (95% CI −0.38 to −0.18; p<0.0001), from 2.39 (95% CI 2.26 to 2.51) to 2.11 mmol/L (95% CI 2.00 to 2.22); mean SBP dropped 2.89 mm Hg (95% CI −4.49 to −1.28; p=0.0005) from 132.7 (95% CI 130.8 to 134.6) to 129.7 mm Hg (95% CI 127.9 to 131.5). Non-switchers had smaller improvements in adherence and clinical outcomes.
CONCLUSION
Implementing an ASCVD secondary prevention FDC improved adherence and CVD risk factors in MSF clinics in Lebanon, with potential for wider implementation by humanitarian actors and host health systems.
Conference Material > Abstract
Ansbro E, Masri S, Prieto-Merino D, Bahous SA, Molfino L, et al.
MSF Scientific Days International 2022. 2022 May 11; DOI:10.57740/8697-vn33
INTRODUCTION
Cardiovascular disease (CVD) is the leading cause of death and disability globally, including in humanitarian contexts. Fixed-dose combination (FDC) drugs are cost-effective for primary and secondary prevention of CVD. From 2012 until the end of 2020, MSF provided care for CVD patients from Syrian refugee and host populations in primary care clinics in Tripoli, north Lebanon. In this implementation study, we assessed whether FDC use is linked with adherence to CVD medications and treatment simplification in a humanitarian setting.
METHODS
Our prospective, before-and-after cohort study followed CVD patients in MSF clinics in Lebanon during two consecutive six month periods. Eligible patients, enrolled February-May 2019, were switched to Trinomia® FDC (atorvastatin 20mg, aspirin 100 mg, ramipril 2.5/5/10/mg) after six months’ usual care. During the study, the Covid-19 pandemic, an economic crisis, and clinic closures occurred. Descriptive and regression analyses compared key outcomes: medication adherence, non-high density lipoprotein cholesterol (non-HDL-C) levels, and systolic blood pressure (SBP) control, at six and twelve months. We performed intention-to-treat analyses and secondary analyses of non-switchers.
ETHICS
This study was approved by the MSF Ethics Review Board, the LSHTM Research Ethics Committee, and the Lebanese American University’s Institutional Review Board.
RESULTS
Of 521 enrolled patients, 460 (88.3%) were retained at six months and 418 (80.3%) switched to FDC. By month 12, 84% of switched patients remained on FDC (n=351), 8.1% (n=34) discontinued, and 7.9% (n=33) were lost to follow-up. Among the 385 who initially switched and remained in the study at 12 months, total adherence improved by 23% from 63% (95% confidence intervals (CI) 0.58-0.68) at month six to 86% (95% CI 0.82-0.90) at month 12. Mean non-HDL-C levels dropped 0.28 millimoles/litre (mmol/L; 95% CI -0.38 to -0.1; p=0.000) from 2.39 (95% CI 2.26 - 2.51) to 2.11 mmol/L (95% CI 2.00 - 2.22); mean SBP dropped 3.07 mmHg (95% CI -4.76 to -1.38; p= 0004) from 132.7 (95% CI 130.8 - 134.6) to 129.7 mmHg (95% CI 127.9 - 131.5). Among non-switchers, total adherence was lower and improvements in clinical outcomes were less pronounced.
CONCLUSION
Implementing a CVD secondary prevention FDC was associated with better adherence and intermediate clinical outcomes inan MSF primary care clinic in Lebanon. Further operational experience is needed to ascertain how best to integrate and sustain CVD FDC’s in humanitarian operations. MSF could advocate for their broader use with other humanitarian actors and within public health systems of crisis-affected countries.
CONFLICTS OF INTEREST
None declared.
Cardiovascular disease (CVD) is the leading cause of death and disability globally, including in humanitarian contexts. Fixed-dose combination (FDC) drugs are cost-effective for primary and secondary prevention of CVD. From 2012 until the end of 2020, MSF provided care for CVD patients from Syrian refugee and host populations in primary care clinics in Tripoli, north Lebanon. In this implementation study, we assessed whether FDC use is linked with adherence to CVD medications and treatment simplification in a humanitarian setting.
METHODS
Our prospective, before-and-after cohort study followed CVD patients in MSF clinics in Lebanon during two consecutive six month periods. Eligible patients, enrolled February-May 2019, were switched to Trinomia® FDC (atorvastatin 20mg, aspirin 100 mg, ramipril 2.5/5/10/mg) after six months’ usual care. During the study, the Covid-19 pandemic, an economic crisis, and clinic closures occurred. Descriptive and regression analyses compared key outcomes: medication adherence, non-high density lipoprotein cholesterol (non-HDL-C) levels, and systolic blood pressure (SBP) control, at six and twelve months. We performed intention-to-treat analyses and secondary analyses of non-switchers.
ETHICS
This study was approved by the MSF Ethics Review Board, the LSHTM Research Ethics Committee, and the Lebanese American University’s Institutional Review Board.
RESULTS
Of 521 enrolled patients, 460 (88.3%) were retained at six months and 418 (80.3%) switched to FDC. By month 12, 84% of switched patients remained on FDC (n=351), 8.1% (n=34) discontinued, and 7.9% (n=33) were lost to follow-up. Among the 385 who initially switched and remained in the study at 12 months, total adherence improved by 23% from 63% (95% confidence intervals (CI) 0.58-0.68) at month six to 86% (95% CI 0.82-0.90) at month 12. Mean non-HDL-C levels dropped 0.28 millimoles/litre (mmol/L; 95% CI -0.38 to -0.1; p=0.000) from 2.39 (95% CI 2.26 - 2.51) to 2.11 mmol/L (95% CI 2.00 - 2.22); mean SBP dropped 3.07 mmHg (95% CI -4.76 to -1.38; p= 0004) from 132.7 (95% CI 130.8 - 134.6) to 129.7 mmHg (95% CI 127.9 - 131.5). Among non-switchers, total adherence was lower and improvements in clinical outcomes were less pronounced.
CONCLUSION
Implementing a CVD secondary prevention FDC was associated with better adherence and intermediate clinical outcomes inan MSF primary care clinic in Lebanon. Further operational experience is needed to ascertain how best to integrate and sustain CVD FDC’s in humanitarian operations. MSF could advocate for their broader use with other humanitarian actors and within public health systems of crisis-affected countries.
CONFLICTS OF INTEREST
None declared.
Conference Material > Slide Presentation
Masri S, Gutierrez M, Pieck AV, Botha I, Boulle P
MSF Scientific Days International 2020: Innovation. 2020 May 14; DOI:10.7490/f1000research.1117915.1
Conference Material > Abstract
Masri S, Gutierrez M, Pieck AV, Botha I, Boulle P
MSF Scientific Days International 2020: Innovation. 2020 May 14
INTRODUCTION
The management of diabetes in children in refugee settings brings challenges, including glucose monitoring, upon which adaptation of insulin treatment depends. Continuous glucose monitoring (CGM) provides information on glucose trend variations and relieves patients from frequent finger pricking by automatically measuring and storing glucose levels. CGM has been adopted in resource-rich settings, but experience on its use in refugee settings is lacking. In 2019, MSF implemented CGM for Syrian refugee children living with type 1 diabetes who receive medical care at MSF clinics in Bekaa valley and Tripoli, Lebanon. In a retrospective descriptive study, we aimed to assess the feasibility of CGM use in this setting and whether its use would improve with time.
METHODS
Children <17 years old, treated for type 1 diabetes in six MSF clinics where NCD care is provided, were eligible for CGM using Freestyle Libre (Abbott). Patients were given a sensor to insert and wear for 2 weeks each month, which they were required to scan every 8 hours for data capture. They resumed finger prick testing for the rest of the month to minimise cost. We analysed sensor data from the first 12 weeks of CGM patient use, using Excel and Stata 15.1. We compared the proportions of data captured, including readings within target range (70-180 mg/dL), and the frequency and duration of low glucose events (LGE; <70 mg/dL) in the first 2 weeks versus the last 2 weeks of implementation.
ETHICS
This pilot implementation study of a tool in wide use in resource-rich settings used data routinely collected for clinical care and was exempted from review by the MSF Ethics Review Board by Monica Rull, Medical Director, Operational Centre Geneva, MSF.
RESULTS
62 children were progressively included in CGM from April, 2019; by December, 2019, 27 children had completed 12 weeks of CGM. Median age was 11.5 years; 30 (48%) were female. Mean (SD) Hba1c was 9.4% (±1.9) in the 52 (84%) children in whom it was measured 46 (±34) days before CGM initiation. The mean proportion of captured sensor data increased from 78.5% (±21.8) in weeks 1-2 to 87.7% (±13.2) in weeks 11-12. Mean LGEs per patient decreased from 11.1 (95%CI 9.1-13.1; n=62) in week 1-2 to 8.3 (5.4-11.2; n=27) in week 11-12. The mean average duration of LGEs decreased from 124.6 (109.7-139.5; n=62) to 103.5 minutes (79.1-127.9; n=27). The mean proportion of glucose readings within target range decreased from 31.3% (27.9-34.8; n=62) to 27.9% (22-33.8; n=27). One patient reported pain and stopped CGM.
CONCLUSION
CGM use improved over time; however, the decrease in the proportion of within-range sensor data should be explored. The study is limited by the absence of targets for the variables, meaning that comparisons were only temporal, and the small number of patients who had completed 12 weeks of sensor use. Next steps should include an analysis of the impact of prolonged CGM use on patient outcomes. Patient and provider satisfaction and perceptions on challenges and benefits of using this tool in refugee settings should also be explored.
CONFLICTS OF INTEREST
None declared.
The management of diabetes in children in refugee settings brings challenges, including glucose monitoring, upon which adaptation of insulin treatment depends. Continuous glucose monitoring (CGM) provides information on glucose trend variations and relieves patients from frequent finger pricking by automatically measuring and storing glucose levels. CGM has been adopted in resource-rich settings, but experience on its use in refugee settings is lacking. In 2019, MSF implemented CGM for Syrian refugee children living with type 1 diabetes who receive medical care at MSF clinics in Bekaa valley and Tripoli, Lebanon. In a retrospective descriptive study, we aimed to assess the feasibility of CGM use in this setting and whether its use would improve with time.
METHODS
Children <17 years old, treated for type 1 diabetes in six MSF clinics where NCD care is provided, were eligible for CGM using Freestyle Libre (Abbott). Patients were given a sensor to insert and wear for 2 weeks each month, which they were required to scan every 8 hours for data capture. They resumed finger prick testing for the rest of the month to minimise cost. We analysed sensor data from the first 12 weeks of CGM patient use, using Excel and Stata 15.1. We compared the proportions of data captured, including readings within target range (70-180 mg/dL), and the frequency and duration of low glucose events (LGE; <70 mg/dL) in the first 2 weeks versus the last 2 weeks of implementation.
ETHICS
This pilot implementation study of a tool in wide use in resource-rich settings used data routinely collected for clinical care and was exempted from review by the MSF Ethics Review Board by Monica Rull, Medical Director, Operational Centre Geneva, MSF.
RESULTS
62 children were progressively included in CGM from April, 2019; by December, 2019, 27 children had completed 12 weeks of CGM. Median age was 11.5 years; 30 (48%) were female. Mean (SD) Hba1c was 9.4% (±1.9) in the 52 (84%) children in whom it was measured 46 (±34) days before CGM initiation. The mean proportion of captured sensor data increased from 78.5% (±21.8) in weeks 1-2 to 87.7% (±13.2) in weeks 11-12. Mean LGEs per patient decreased from 11.1 (95%CI 9.1-13.1; n=62) in week 1-2 to 8.3 (5.4-11.2; n=27) in week 11-12. The mean average duration of LGEs decreased from 124.6 (109.7-139.5; n=62) to 103.5 minutes (79.1-127.9; n=27). The mean proportion of glucose readings within target range decreased from 31.3% (27.9-34.8; n=62) to 27.9% (22-33.8; n=27). One patient reported pain and stopped CGM.
CONCLUSION
CGM use improved over time; however, the decrease in the proportion of within-range sensor data should be explored. The study is limited by the absence of targets for the variables, meaning that comparisons were only temporal, and the small number of patients who had completed 12 weeks of sensor use. Next steps should include an analysis of the impact of prolonged CGM use on patient outcomes. Patient and provider satisfaction and perceptions on challenges and benefits of using this tool in refugee settings should also be explored.
CONFLICTS OF INTEREST
None declared.
Conference Material > Poster
Doumit M, Masri S, Beltran I, Incerti A, Ciglenecki I, et al.
MSF Scientific Day International 2023. 2023 June 7; DOI:10.57740/wad8-6g32
Journal Article > ResearchFull Text
BMC Health Serv Res. 2022 June 4; Volume 22 (Issue 1); 744.; DOI:10.1186/s12913-022-08040-z
Murphy A, Willis R, Ansbro É, Masri S, Kabbara N, et al.
BMC Health Serv Res. 2022 June 4; Volume 22 (Issue 1); 744.; DOI:10.1186/s12913-022-08040-z
BACKGROUND
We report findings of a qualitative evaluation of fixed-dose combination therapy for patients with established atherosclerotic cardiovascular disease (ASCVD) attending Médecins Sans Frontières (MSF) clinics in Lebanon. Cardiovascular disease is a leading cause of death and disability worldwide, and humanitarian actors are increasingly faced with the challenge of providing care for chronic diseases such as ASCVD in settings where health systems are disrupted. Secondary prevention strategies, involving 3-5 medications, are known to be effective for patients at risk of heart attack or stroke, but supply and adherence are challenging in humanitarian settings. Fixed dose combination therapy, combining two or more medications in one tablet, may be a strategy to address this.
METHODS
The evaluation was nested within a prospective mixed-methods study in which eligible ASCVD patients were followed for 1 year during (i) 6 months of usual care then (ii) 6 months of fixed dose combination (FDC) therapy. After 1 year, we conducted in-depth interviews with a purposive sample of patients, MSF staff and external stakeholders. Interviews focused on acceptability and sustainability of the fixed dose therapy intervention. Interview data were analysed thematically, informed by thea Theoretical Framework of Acceptability. Additional attention was paid to non-typical cases in order to test and strengthen analysis.
RESULTS
Patients and health care providers were positive about the FDC intervention. For patients, acceptability was related to ease of treatment and trust in MSF staff, while, for staff, it was related to perceived improvements in adherence, having a good understanding of the medication and its use, and fitting well with their priorities for patient's wellbeing. External stakeholders were less familiar with FDC therapy. While external clinicals expressed concerns about treatment inflexibility, non-clinician stakeholder interviews suggested that cost-effectiveness would have a major influence on FDC therapy acceptability. Sustainability was tied to the future role of MSF care provision and coherence with the local health system.
CONCLUSIONS
For patients and clinic staff, FDC was an acceptable treatment approach for secondary prevention of ASCVD disease in two MSF clinics in Lebanon. Sustainability is more complex and calls for better alignment of care with public systems.
We report findings of a qualitative evaluation of fixed-dose combination therapy for patients with established atherosclerotic cardiovascular disease (ASCVD) attending Médecins Sans Frontières (MSF) clinics in Lebanon. Cardiovascular disease is a leading cause of death and disability worldwide, and humanitarian actors are increasingly faced with the challenge of providing care for chronic diseases such as ASCVD in settings where health systems are disrupted. Secondary prevention strategies, involving 3-5 medications, are known to be effective for patients at risk of heart attack or stroke, but supply and adherence are challenging in humanitarian settings. Fixed dose combination therapy, combining two or more medications in one tablet, may be a strategy to address this.
METHODS
The evaluation was nested within a prospective mixed-methods study in which eligible ASCVD patients were followed for 1 year during (i) 6 months of usual care then (ii) 6 months of fixed dose combination (FDC) therapy. After 1 year, we conducted in-depth interviews with a purposive sample of patients, MSF staff and external stakeholders. Interviews focused on acceptability and sustainability of the fixed dose therapy intervention. Interview data were analysed thematically, informed by thea Theoretical Framework of Acceptability. Additional attention was paid to non-typical cases in order to test and strengthen analysis.
RESULTS
Patients and health care providers were positive about the FDC intervention. For patients, acceptability was related to ease of treatment and trust in MSF staff, while, for staff, it was related to perceived improvements in adherence, having a good understanding of the medication and its use, and fitting well with their priorities for patient's wellbeing. External stakeholders were less familiar with FDC therapy. While external clinicals expressed concerns about treatment inflexibility, non-clinician stakeholder interviews suggested that cost-effectiveness would have a major influence on FDC therapy acceptability. Sustainability was tied to the future role of MSF care provision and coherence with the local health system.
CONCLUSIONS
For patients and clinic staff, FDC was an acceptable treatment approach for secondary prevention of ASCVD disease in two MSF clinics in Lebanon. Sustainability is more complex and calls for better alignment of care with public systems.