RT Journal Article SR Electronic T1 Designing and implementing an integrated non-communicable disease primary care intervention in rural Nepal JF BMJ Global Health JO BMJ Global Health FD BMJ Publishing Group Ltd SP e001343 DO 10.1136/bmjgh-2018-001343 VO 4 IS 2 A1 Anirudh Kumar A1 Dan Schwarz A1 Bibhav Acharya A1 Pawan Agrawal A1 Anu Aryal A1 Nandini Choudhury A1 David Citrin A1 Binod Dangal A1 Grace Deukmedjian A1 Meghnath Dhimal A1 Santosh Dhungana A1 Bikash Gauchan A1 Tula Gupta A1 Scott Halliday A1 Dhiraj Jha A1 SP Kalaunee A1 Biraj Karmacharya A1 Sandeep Kishore A1 Bhagawan Koirala A1 Lal Kunwar A1 Ramesh Mahar A1 Sheela Maru A1 Stephen Mehanni A1 Isha Nirola A1 Sachit Pandey A1 Bhaskar Pant A1 Mandeep Pathak A1 Sanjaya Poudel A1 Irina Rajbhandari A1 Anant Raut A1 Pragya Rimal A1 Ryan Schwarz A1 Archana Shrestha A1 Aradhana Thapa A1 Poshan Thapa A1 Roshan Thapa A1 Lena Wong A1 Duncan Maru YR 2019 UL http://gh.bmj.com/content/4/2/e001343.abstract AB Low-income and middle-income countries are struggling with a growing epidemic of non-communicable diseases. To achieve the Sustainable Development Goals, their healthcare systems need to be strengthened and redesigned. The Starfield 4Cs of primary care—first-contact access, care coordination, comprehensiveness and continuity—offer practical, high-quality design options for non-communicable disease care in low-income and middle-income countries. We describe an integrated non-communicable disease intervention in rural Nepal using the 4C principles. We present 18 months of retrospective assessment of implementation for patients with type II diabetes, hypertension and chronic obstructive pulmonary disease. We assessed feasibility using facility and community follow-up as proxy measures, and assessed effectiveness using singular ‘at-goal’ metrics for each condition. The median follow-up for diabetes, hypertension and chronic obstructive pulmonary disease was 6, 6 and 7 facility visits, and 10, 10 and 11 community visits, respectively (0.9 monthly patient touch-points). Loss-to-follow-up rates were 16%, 19% and 22%, respectively. The median time between visits was approximately 2 months for facility visits and 1 month for community visits. ‘At-goal’ status for patients with chronic obstructive pulmonary disease improved from baseline to endline (p=0.01), but not for diabetes or hypertension. This is the first integrated non-communicable disease intervention, based on the 4C principles, in Nepal. Our experience demonstrates high rates of facility and community follow-up, with comparatively low lost-to-follow-up rates. The mixed effectiveness results suggest that while this intervention may be valuable, it may not be sufficient to impact outcomes. To achieve the Sustainable Development Goals, further implementation research is urgently needed to determine how to optimise non-communicable disease interventions.