Abstract
Abstract
Brimkulov, Nurlan, Louis Louton, Salima Sydykova, Denis Vinnikov, and Farida Imanalieva. Morbidity in the mountainous Province of Kyrgyzstan: Results from a population-based cross-sectional study. High Alt Med Biol 18:338–342, 2017.—The aim of this study was to identify the main causes of using primary care facilities in the mountainous Naryn Province of Kyrgyzstan to set resources allocation priorities. We collected data on all admissions to family doctors in three Family Medical Centers (FMCs) in Naryn Province: (1) the city of Naryn (2200 meters above sea level [MASL]); (2) the town of At-Bashy (3200 MASL); and the town of Kochkor (1800 MASL) by using an original questionnaire during one full week (5 days) in spring 2016. Within 1 week, we recorded 1136 cases in Naryn and 782 cases in Bishkek after exclusion of missing data. The top three reasons for admissions were respiratory (23% of all in Naryn and 36% in Bishkek), nonspecific general (19% and 17%), and neurological (13% and 9%). Naryn residents were 3.84 times (confidence interval [95% CI] 2.07–7.11) more likely to apply with musculoskeletal and 3.05 times (95% CI 1.02–9.12) more likely to apply with cardiovascular conditions. This first population-based study in Naryn stresses the need to prioritize cardiovascular and rheumatological care in these mountainous conditions.
Introduction
M
In Kyrgyzstan, which is one of the poorest countries in the world, mountainous areas, including Naryn Province with low population density, suffer from severe cold continental winters, poor road quality and access, and population malnutrition, which may be worsened with difficult and limited evacuation capacity to central facilities for proper specialized care. Most outpatient services have to be delivered through local facility medical practice, but organizational and financial implications may lessen the quality of care, especially for vulnerable populations. Such implications include, but are not limited to, significant distances to the Family Medical Centers (FMCs), long and cold winters, overall insufficient training and qualification of the personnel caused by low salaries, and limited opportunities for professional development. Therefore, Naryn Province, indicative of other high-altitude and poorly accessed territories in Central Asia, exhibits high respiratory and cardiovascular morbidity and mortality indicators (Igisinov et al., 2002; Grabman, 2004), despite a high-altitude environment being successfully used for the treatment of selected respiratory conditions (Vinnikov et al., 2016).
Precise knowledge on the overall disease profiles of high-altitude locations of the affected countries is essential for resource allocation and proper referral system establishment. In Kyrgyzstan, such comparative analyses have been traditionally based on the official governmental reports built on ICD classification, which entails a number of significant biases. Inability to claim ICD diagnosis at the first admission is one of such gaps, leading to notably biased statistics. We, therefore, planned and conducted this study to gain epidemiological data on the most frequent causes of visits to the primary care facilities to help setting priorities in resources allocation for the high-altitude Naryn Province of Kyrgyzstan.
Materials and Methods
Study design
This study was planned as a cross-sectional analysis of all outpatient admissions to three main FMCs of Naryn Province during 1 week in March 2016, on five working days in total. One of the biggest FMCs in lowland Kyrgyzstan, located in Bishkek, was used as a control venue, using a similar data collection methodology 2 weeks before the Naryn survey with a similar data analysis. This study was authorized by the Committee on Bioethics and Research of Kyrgyz State Medical Academy. After such authorization, a group of residents in internal medicine of the Department of Internal Medicine, Occupational Health and Hematology of the Kyrgyz State Medical Academy were trained to conduct the study while sitting next to a doctor in charge in the selected venues. Those data collectors were not allowed to get involved in the physical examination or any subsequent steps of either diagnostic or treatment components. Using an original questionnaire, they registered all information related to every admission during the work shift of a family doctor, including telephone calls. In total, during five working days in both Naryn and Bishkek, data collectors gathered information on all visits to 45 doctors.
Study venue
In Naryn Province, data were collected on all admissions to family doctors in three FMCs: (1) Naryn City FMC (altitude 2200 meters above sea level [MASL]); (2) Kochkor Town FMC (altitude 1800 MASL); and (3) At-Bashy town FMC (altitude 3200 MASL). These FMCs are the only public admission centers for all patients with any medical condition of all ages in these locations. Any patient should get admitted, by personally applying the registration office in these centers. After registration, a patient is then referred to a family doctor corresponding to his/her exact address. After a short examination, the family medicine doctor should establish the preliminary reason for admission and the preliminary diagnosis, possible referral to ancillary examinations or to a specialist for consultation. Reasons for admission may vary from physical examination to issue or extend a prescription for a medication, hospitalization, fitness screening, and others. Such admissions to the FMC are fully indicative of the entire spectrum of outpatient conditions presented in the selected geographic terrain. All three FMCs occupy a separate building, located in the very center of the town.
Kyrgyzstan is currently in transition toward developing more comprehensive family practice; however, the services provided by family medicine doctors may differ from country to country. All current family doctors are, in fact, retrained professionals who initially specialized and practiced in other fields, including internal medicine, pediatricians, and obstetricians. Therefore, even within one province, FMCs may differ in the qualification of providers, depending on their background. In general, family doctors in Kyrgyzstan do not take charge of surgical and gynecological patients, referring them to narrow specialists.
Questionnaire
To collect all information on admissions, we created an original questionnaire with 17 items, filled in for every admission, including telephone calls. This questionnaire was filled by data collectors in Russian and comprised sections on doctor's and patient's ID, date, day, time of admission, admission duration (minutes), patient's demographics (data of birth, sex, place of residence) and socioeconomic status, type of admission (personal examination, telephone call, examination at home), time on the way to FMC, type of transportation to FMC, followed by the reason for admission (consultation due to disease, hospitalization, issue of a health certificate, referral to a narrow specialist, issue of a prescription).
The following medical section of the questionnaire started with the list of three leading symptoms as reported by the patient. In this questionnaire, the doctor then compiled his own list of symptoms with regard to the patient's current condition. A doctor was also asked to claim the leading and concomitant diagnoses (if any). This part ended with the option to choose between the admission outcomes (diagnosis, hospitalization, ancillary investigation referral, referral to a narrow specialist, treatment, need for a follow-up visit, or issue of a prescription).
If any ICD diagnosis was present as a result of such consultation, data collectors recorded all such diagnoses. However, not every visit ended with such diagnosis; that is why we coded each visit with WONCA's ICPC-2e-v.3.0 Russian (ref) admission classification. In other words, each patient would receive from one to three ICPC codes prioritized by their relevance by the doctor, and from one to three ICD codes if present.
We also collected data from a control FMC in Bishkek (780 MASL), representing lowland facility and patients of Kyrgyzstan, by using similar methodology and during the same period (March).
Statistical analysis
Both dichotomous and continuous variables were tested for normality, and for non-normally distributed data, we report medians with interquartile range (IQR), whereas alternatively we present data as means ± standard deviation. Similarly, data were analyzed for differences by using nonparametric (Mann–Whitney U-test) or parametric (t-test) tests depending on the distribution. The primary outcomes in this analysis were ICPC codes for admission, representing disease profile. In crude and adjusted logistic regression analysis, we tested whether living at altitude increased the probability of selected diseases, where dichotomous place of residence was a predictor, and diagnoses as dependent variables, reported in crude and adjusted models. Such variables as age, sex, and time of admission (morning vs. afternoon) were treated as potential confounders on the pathway from exposure (living at altitude) with the outcome, and we, therefore, adjusted our regression models for these three variables. In the diagnoses analyses, patients with missing data were excluded, and only patients with at least one ICPC code were included in the regression analyses. We analyzed data by using NCSS 10 (Utah).
Results
In total, 22 doctors of Naryn Province had 1218 admissions during 5 days of the study week. During the same week, 23 doctors in Bishkek examined 814 patients, but worked only 4 days, because one of the days that week was a state holiday. Thursday was the busiest day of the week (31.5% of all admissions), followed by the least busy day being Friday (9.7% of admissions). Eighty-seven questionnaires in Naryn and 48 questionnaires in Bishkek had missing demographic data and were excluded from the analysis, yielding 1136 cases in Naryn and 782 cases in Bishkek included in the current analysis. We identified distinct differences when comparing patients' profiles in Naryn and in Bishkek Table 1). Thus, admissions in Naryn were less concentrated to the morning time. There were some differences in the reasons for admission at high-altitude Naryn compared with Bishkek, although in both cases the majority of outpatient admissions were for medical conditions and follow-up for a chronic disease (Table 2).
p < 0.05 in Mann–Whitney U-test for continuous variables or χ2 test for binomial data.
CI, confidence interval; FMC, Family Medical Centers; IQR, interquartile range.
p < 0.05 in Mann–Whitney U-test for continuous variables or χ2 test for binomial data.
We further excluded patients admitted to FMC for any reason other than medical condition or primary consultation. In total, there were 472 admissions in Naryn and 327 admissions in Bishkek for a medical condition. The median (IQR) age of patients in Naryn and Bishkek was 32 (46), and 22 (38), (p < 0.001). In both locations, age distribution was dramatically left-skewed, even more pronounced in Bishkek. Thus, 25% of age distribution was 8 years in Naryn and 4 years in Bishkek. Therefore, compared with Bishkek, patients admitted to FMC at high altitude were more likely to be middle aged. Unlike patients in Bishkek, people with medical condition at high altitude were almost equally likely to visit FMC in the morning or in the afternoon.
In both locations, respiratory conditions were the leading primary diagnoses, but less prevalent at altitude (Table 3). Specifically, Naryn residents complained less from cough compared with those in lowland Bishkek. Noteworthy, living at higher altitude reduced the likelihood of sneezing, and given the smaller prevalence of allergy, high-altitude residents may be less sensitized to allergens. A cleaner environment or a high-altitude environment with fewer automobiles and less pollution may explain dramatically fewer cough diagnoses, sneezing, and allergy taken together. In this univariate analysis, high-altitude residents are more likely to present to FMC with any musculoskeletal problems, including lumbar pain as the primary diagnosis, with the overall prevalence up to 15%. Cardiovascular conditions were also more prevalent in highlanders. Finally, gynecological and urological conditions were less prevalent in high-altitude residents compared with Bishkek residents.
p < 0.05 in χ2 test.
In such univariate analysis of only those who were admitted for a medical condition, groups differed from each other in sex distribution, age, and time of visit during the day (morning/afternoon). We, therefore, treated these variables as potential confounders in a logistic regression analysis, which tested the association of place of residence (high altitude vs. low altitude) with the admission due to distinct conditions or diagnoses. Crude and adjusted analyses in Table 4 show that Naryn residents got fewer admissions to FMC with respiratory, gynecological and urological conditions. Instead, they were 3.84 times more likely to apply with musculoskeletal and 3.05 times more likely to apply with cardiovascular conditions. Most alarming were much more prevalent chest pain admissions in highlanders, compared to Bishkek residents.
Adjusted models are adjusted for age, sex, and time of a day (morning vs. afternoon).
OR, odds ratio.
Discussion
To our knowledge, this is the first study on a population-based approach to ascertain the morbidity profile of the high-altitude population in Kyrgyzstan. Data from 1218 patients in Naryn show that among admissions for a consultation, respiratory conditions, including simple cough, were the most prevalent, as in lowlands. Musculoskeletal and cardiovascular diseases and symptoms were more prevalent at high altitude, which should direct resources allocation and associated training of professionals to meet the needs of the high-altitude population. One of the most alarming findings was a 13-fold greater prevalence of chest pain in the primary care in Naryn compared with low altitude (5% vs. 0%); however, these findings should be treated with caution because of high probability of outcome misclassification. Should those cases be pain of a cardiac origin, this necessitates proactive and immediate control over cardiovascular risk factors and improved management of these patients at earlier, preclinical stages of these diseases.
The study of primary care admissions in low-resource and high-altitude settings to set priorities for funding and training is also undertaken in other countries around the globe (López-Cevallos and Chi, 2010; Balarajan et al., 2011; Petrera et al., 2013; Meynard et al., 2015; Rosendal et al., 2015; Torres et al., 2015; Tran et al., 2016). In many countries, the leading reasons for admission were respiratory and nonspecific reasons, and musculoskeletal pain was one of the top complaints of patients. Most high-altitude countries are in great need for resources to tackle maternal healthcare and the health of newborns (Furuta and Salway, 2006). This study, however, demonstrates the need to improve cardiovascular care right on site, controlling for risk factors, such as smoking and unhealthy eating, because tertiary-level facilities, where patients from Naryn may be evacuated for high-tech care, are situated remotely in the capital, and such transportation may be fatal. This considerable disparity in access to care for high-altitude populations should be addressed by the governmental bodies in charge. For cardiovascular care, remoteness from central facilities in Bishkek puts Naryn residents at risk of complications, and, therefore, intensive care for cardiovascular care should be set in Naryn, minimizing the need for evacuation. The city has its cardiovascular department at the Provincial hospital, but this study may demonstrate likely weak primary prevention. Clinical protocols and guidelines for integrated care at the primary healthcare level should emphasize the leading symptoms specifically for high-altitude locations, such as better management of cardiovascular and musculoskeletal problems.
The limitations of this study arise from its cross-sectional design. We could only assess the prevalence of admissions at one point in time, with some potential for disease misclassification. High prevalence of lumbar pain may serve as one of the examples of typical diagnostic problems, potentially leading to misclassification of primary care. Many doctors mistreat lumbar pain as acute kidney disease, but being under pressure of immediate diagnosis, this condition is probably quite often misclassified. Moreover, with regard to higher prevalence of musculoskeletal admissions in Naryn, the demand for physical labor in these two locations under comparison may be considerably different. Naryn residents are far more involved in low-mechanized labor in agriculture and breeding cattle compared with those living in Bishkek. Therefore, admissions for this reason in Naryn are unlikely associated with living under hypoxic conditions, but rather with greater physical exertion in daily life and at work. Another important potentially misclassified diagnosis in this study is chest pain. Chest pain with a significantly greater prevalence at high altitude is unlikely to have a cardiac origin, and it may be a symptom of other conditions. Therefore, a need for better doctors' training in remote high-altitude regions is obvious and calls for better support of skills training in differential diagnosis of chest pain. If the reported chest pain has a true cardiovascular explanation, then greater preparedness for the secondary-level facilities is vitally important for Naryn to save time and treat patients on site, thus avoiding high risk related to transportation to Bishkek. Moreover, diagnosis misclassification, not only associated with cardiovascular conditions, arises from the current system of immediate diagnosis, where a doctor in up to one out of three cases may have doubts in the primary diagnosis. ICPC classification may assist doctors in proper management and prioritization of symptoms, eventually leading to better clarity and reducing confusion.
This study has potential implications for practice. Respiratory conditions as a leading cause of admissions at altitude call for proactive prevention of modifiable risk factors such as smoking. However, wide use of fossil fuel for cooking and heating has been shown to contribute to respiratory infections in children and chronic diseases in adults in low-income settings around the world (Nandasena et al., 2013). Transition to safer cooking practices may, therefore, improve respiratory health, and should be enforced in mountainous terrains such as Naryn. Second, high-altitude locations in Kyrgyzstan, pioneering family practice implementation, may need corrected syllabuses for family doctors who are training to address the needs of local populations in the order of priority. At present, medical doctors' training in Kyrgyzstan does not take into account the essential differences in the overall management of the healthcare system for remote and high-altitude locations. Existing syllabuses ignore high-altitude aspects of patients' management, evacuation, referral system, as well as evidence-based diagnosis and treatment of specific high-altitude conditions. High-altitude medicine, including physiological acclimatization, acute mountain sickness detection, prevention, and treatment, as well as the clinical characteristics of nonaltitude-related chronic conditions at altitude are covered only within two or three lectures in the course of the internal diseases class, and moreover, neglected in emergency care. Despite colossal experience and academic achievements with a long-lasting history of the National Center of Cardiology, specialized in high-altitude medicine, medical school graduates feel almost unprepared to consult patients in high-altitude provinces of Kyrgyzstan on graduation. This study is the first to support syllabus adaptation for medical school graduates to address the medical needs of high-altitude locations in Kyrgyzstan.
Conclusions
In summary, this is the first evidence for the high-altitude province in Kyrgyzstan to demonstrate the gaps in the primary care system and quality service delivery, showing the need to better address possibly greater prevalent musculoskeletal and chest pain problems in Naryn compared with Bishkek. Higher prevalence of a number of conditions with the opposite trend with others may disclose significant misclassification of diagnoses and reasons for admission, caused by lack in training. These study findings must call for urgent medical school curriculum revision, as well as incite a broader discussion on the quality of service in primary care at high altitude, which may suffer from misdiagnoses.
Footnotes
Acknowledgments
The authors thank all the team of data collectors in both Naryn and Bishkek, including Aisuluu Atakanova and Nargiza Ibraimova. They also thank the managers of the included primary care outpatient facilities in Bishkek and Naryn for their support. This survey was funded by the “Medical Education Reforms in Kyrgyzstan” project.
Author Disclosure statement
No competing financial interests exist.