Questions/Answers

Worldwide bile duct cancer is rare but is most common in Thailand. Early cancer can be operable but asymptomatic and almost all patients came with late stage which are deadly and incurable. It is caused mainly by liver fluke. Risk groups of people are mostly underprivileged with habits of eating raw fresh water fishes living in remote and rural areas. The only standard screening method is computerized tomography scan which is very expensive and can only be performed in large hospital with some radiation hazard, and mostly inaccessible. For the first time in Thailand, Phanomphrai Hospital has introduced nurse-performed ultrasound screening integrated to comprehensive strategy plan to eliminate liver fluke and bile duct cancer. Aims to include underprivileged people in rural and remote areas, it is innovative and affordable services to all to increase access and coverage of bile duct cancer screenings especially in low-resource settings. Phanomphrai Hospital strives for cooperation and been endorsed to conduct nurse sonographer training course with integrated quality assurance and supervision system. Expert consulting systems to increase effectiveness and efficiency has been also established with support from Chulabhorn and Roi Et Hospitals which are cancer specialized institutions. These innovative and comprehensive approach has reformed and transformed liver fluke and bile duct cancer control program. Phanomphrai Hospital has also been working with many organizations such as Khon Kaen University, Department of Disease Control, Ministry of Public Health and successfully push liver fluke and bile duct cancer control into the National Agenda which has been endorsed by the National Health Assembly Year 2014 and the Cabinet approved a 10-year plan to eliminate liver fluke and bile duct from 2016 to 2025, and ultrasound screening is one of the key elements of the strategy which put health equality and equity at the heart of this people centric services.

Phanomphrai Hospital’s innovative nurse sonographer screening and liver fluke control makes bile duct cancer control more comprehensive. With the objective of ‘leaving no one behind’ in mind, trained nurses worked with village health volunteers and can provide ultrasound services at district and sub-district facilities. Integration and transformation of ultrasound service delivery mechanisms help reduce people’s out-of-pocket expense and increase screening coverage to the most vulnerable. ‘Bring services to the people’ shall represent the principle of the program and helps increase access to quality and affordable services at community level which make the program more inclusive and equitable for all.

Phanomphrai Hospital’s nurse sonographer services can increase access to bile duct cancer screening at community level. People in remote and rural areas who usually were underprivileged can now access to early detection of cancer services and have increased chances for successful treatment. Up to now more than 15,000 people within the district have been screened with more than 8 lives saved. With improving the health of people and increasing life expectancy, the Sustainable Development Goal 3: Ensure healthy lives and promote wellbeing for all at all ages can be achieved. Nurse sonographer scheme can contribute to SDG 1: End poverty in all its forms everywhere - because it is provided free of charge. Bile duct cancer screening program can help achieving SDG Goal 5: Achieve gender equality and empower all women and girls - because bile duct cancer is the second most common among female cancers in Thailand. Phanomphrai Hospital’s comprehensive bile duct cancer control program also involved and engaged stakeholders from all level such as active participation of the Phanomphrai Organic Agriculture Network which are built on a foundation of trust, social networks and knowledge exchange to save the planet with sustainable agriculture and farming.

Ultrasound service has relative very low operating cost, nurse sonographer program can be provided free of charge, maintain and administrate as business on a day-to-day basis. The examination is simple and non-invasive with no radiation hazard so it is very well accepted by target population and environment-friendly. By using appropriate technology with the most effective usage of resources, nurse sonographer scheme is well aligned with His Majesty King Bhumibol’s Philosophy of Sufficiency Economy: moderation, reasonableness, and self-immunity. Phanomphrai Hospital can now run the program by its own budget therefore it is sustainable in terms of social, economy and environment.

Under Thailand’s Universal Health Coverage Scheme has made possible availability of ‘one hospital for every district and one health center for every sub-district (Tambon).’ However, the problem of maldistribution of health care providers among rural and urban areas still exists and affected equity in people’s access to care (https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---soc_sec/documents/publication/wcms_secsoc_6612.pdf). Number of populations per doctor is highest in northeast Thailand which is the poorest region and workloads are lower for the doctors who worked in other ministry hospitals or private hospitals rather than in Ministry of Public Health hospitals. Like most district hospitals, Phanomphrai Hospital has no radiologist. This is one of fundamental causes why socioeconomic status and health disparities has persisted over time. There is a social gradient in health – the lower a person’s social position, the worse his or her health. Phanomphrai Hospital’s nurse sonographer scheme and comprehensive liver fluke and bile duct cancer control plan has focused on reducing this gradient in health. With the principle ‘leaving no one behind’ in mind, nurse sonographer scheme at Phanomphrai Hospital aims to reach the underprivileged in remote and rural areas thus it can mitigate workforce crisis in rural and remote area like Phanomphrai District.

Phanomphrai Hospital institutionalized bile duct screening and enabling policy, structure and administrative capacities for their full implementation to fill gender gap in cancer care and control. Nurse sonographers provide better opportunities and working environment for women to ensure their role and leadership in the health sector. Comprehensive liver fluke and bile duct cancer control plan has also addressed reduction of poverty and inequality, and can prevent them from dying prematurely. Gender inequality is somewhat significant in bile duct cancer because in Thailand liver and bile duct cancer is second most common among female cancer, only after breast cancer (http://www.nci.go.th/th/cancer_record/cancer_rec1.html).

Most inhabitants in Phanomphrai District and northeastern Thailand have raw flesh water fishes as their favorite dishes. These groups usually are poor people living in remote and rural parts of Thailand like Phanomphrai District. Phanomphrai Hospital targets to reach this high-risk groups within the district. Criteria for enrolled into screening services are people aged 40 years or more, or those younger who had family history of bile duct cancer. Running with the aims to bring technology and services to the people, nurse sonographer scheme can help increase access to and coverage of bile duct cancer screenings. Action taken to reduce health inequalities will benefit society in many ways. It will have economic benefits in reducing losses from illness associated with health inequalities. These currently account for productivity losses, reduced tax revenue, higher welfare payments and increased treatment costs. Economic growth is not the most important measure of country’s success. The fair distribution of health, well-being and sustainability are important social goals. Tackling social inequalities in health and tackling climate change must go together. Phanomphrai Hospital has also been awarded for its GREEN & CLEAN Plus Hospital 2019 by Department of Health, Ministry of Public Health of Thailand.

Nurse sonographer and comprehensive liver fluke and bile duct cancer control strategy has been planned systematically with stepwise framework for action. First, finding new tools for bile duct cancer control. Results from early studies had shown that ultrasound can be used as screening modality and nurses can be trained to be sonographers and be competent for bile duct screenings. Second, bring services to the people by raising awareness and increase accessing care. Improving early diagnosis capacity is an important strategy to cancer control in all settings. After geographic considerations for people-centered approach, ultrasound services have been institutionalized and implemented as organized screening program at Phanomphrai Hospital. Because it was the first time ever in Thailand, quality assurance became an important issue. Delays in clinical diagnosis, including inaccessible diagnosis testing, pathology and staging were major barriers and have been minimized with staff from Chulabhorn and Roi Et Hospitals and aimed to reduce loss of follow-up. Phanomphrai Hospital had also been working with primary health care workers at community level to break barriers of poor health literacy, cancer stigma and limited access to primary care. Third, ensure access to quality treatment of bile duct cancer. Effective cancer care requires that services are accessible, well-coordinated and provided without delay. Phanomphrai Hospital with its partners addressed financial, geographic and logistical barriers, as well as sociocultural barriers. Strong referral mechanisms had been devised such as Liver Clinic set up. Last but not least, palliative care for advanced bile duct cancer was established and has formal financial support from the National Health Security Office (NHSO) through Long-Term Care benefit package under the Universal Health Coverage (UHC) scheme. Monitoring and evaluation activities for ongoing activities can be reached at https://cloud.cascap.in.th/ which is run by the Cholangiocarcinoma Screening and Care Program (CASCAP) at Khon Kaen University.

Professional and popular ideas about cancer screening and treatment can lead to needless worry and even hinder good prevention and treatment decisions. Research-based implementation at the first time to explore and found comparable effectiveness between radiologist-operated ultrasound studies and standard computerized tomography scans (CT Scan) among 839 clients. Then nurse-performed ultrasound screenings were explored and found similar effectiveness compared with CT Scan among 2,029 clients. All professional and organizational resistances and barriers had been then ameliorated. Myths and misconceptions about liver and bile duct cancer has been conquered by comprehensive and integrated approach with effective and people centric counselling.

Innovative nurse sonographer services are organized screenings of bile duct cancer for the first time by Phanomphrai Hospital. Normally in Thailand ultrasound examination can be performed only by radiologist or trained physician. Along with applying appropriate technology for underprivileged people in rural and remote areas, these services had put people at the heart of care. Digital data systems through local area network and the Picture Archiving and Communication System (PACS) made no waste of printed paper. Radiologists at referral hospitals can easily access this PACS and make suggestion for further management. This helps improve communication and reduce unnecessary visits.

Comprehensive liver fluke and bile duct cancer control has His Majesty the late King Bhumibol the Great’s Philosophy of Sufficiency Economy as guiding star: moderation, reasonableness, and self-immunity. Nurse provider training course for VIA & cryotherapy had been used as a model for nurse sonographer. Inspiration was also from Sir Michael Marmot lectures on health inequalities and social determinants of health: IF YOU’RE DOING NOTHING, DO SOMETHING. IF YOU’RE DOING A LITTLE, DO MORE. IF YOU’RE DOING A LOT, DO BETTER. Why treat people and send them back to the conditions that make them sick?

Phanomphrai Hospital’s nurse sonographer and comprehensive liver fluke and bile duct cancer control has been used as a model course for training in other districts in Roi Et Province. At present all districts in Roi Et Province can run ultrasound services by nurse sonographers. Other provinces such as Sakonnakhon, Mahasarakham and Khon Kaen have also been training nurse sonographers for bile duct cancer screening with partly supports from Chulabhorn, Roi Et and Phanomphrai Hospitals. Most of them run services using PACS and DICOM equipment like Phanomphrai Hospital, too. A few hospitals with no PACS have to print out ultrasound images and scan into computer to upload for further processes. Comprehensive liver fluke and bile duct cancer control plan has been endorsed by all District Health Boards (DHB) within Roi Et Province and are under monitoring and evaluation system of Roi Et Provincial Governor Office. Curriculum for health literacy to combat liver fluke and bile duct cancer are expanding among primary and secondary schools and in communities over the entire province to ensure the sustainability of good health habit.

The Medical Sonography School is the first sonographer school in Thailand since 2016. The school is a component of the Chulabhorn Royal Academy with a mandate to produce qualified sonographers in response to increasing needs all over the country including bile duct cancer screening. It has been established with partly experience and inspiration from the collaboration between Phanomphrai and Chulabhorn Hospitals. This school can produce much more sonographers to respond to increasing needs for ultrasound services all over the country including bile duct cancer screening.

From the very outset Phanomphrai Hospital had run nurse sonographer services as a research-based implementation with budget supported from the Office of Permanent Secretary to Ministry of Public Health of Thailand. Afterward the program has been integrated into routine services with supported by its own regular budget called the Promotion, Prevention and Protection (PPP) benefit package under the UHC scheme from NHSO. Nurse personnel are allocated and workloads are considered as regular shift. Ultrasound machines were supported by Roi Et Provincial Health Office. Liver fluke control activities are supported by local governmental organizations within corresponding areas.

Very low operating cost and safety of ultrasound services make nurse sonographer affordable and more sustainable over time. Nurses from all levels of health care facilities with different backgrounds can attend the training course. Nurse sonographer scheme is a good model for self-reliance and effective use of resources to enable the best possible outcomes. Ultrasound screening is non-invasive, have no radiation hazard and very user-friendly. With application of appropriate technology such as PACS and DICOM equipment under digital government policy, nurse sonographer services at Phanomphrai Hospital is paperless and environment-friendly and is well accepted by target population.

Yes

A cross sectional study was performed to explore the inter-rater agreement between radiologists and nurse sonographers in the screening for liver and bile duct cancer. Seven nurses had attended a 5-day training course at Chulabhorn Hospital and a 5-day practical workshop at Roi Et Hospital. Two experienced radiologists from Chulabhorn and Roi Et Hospitals had conducted ultrasound examination of hepatobiliary system and abdomen upon 229 people against seven trained nurse sonographers at Phanomphrai Hospital between February and June 2014. Diagnostic work up such as computerized tomography scan was performed at Roi Et Hospital for definite diagnosis.

Target population were people aged 50 years or more without previous diagnosis or treatment of liver and bile duct cancer. Enrolled participants were inhabitants within Phanomphrai and Nonghi Districts, Roi Et Province, Thailand. Ultrasound machines were installed and used as screening tools. Indicator findings include liver parenchyma, liver surface, liver lesion, bile duct dilatation, gall bladder, gall bladder polyp and gall stone. The agreement between radiologists and nurse sonographers were interpreted using Cohen’s Kappa. The agreement was classified according to Cohen’s Kappa coefficient values as: Good agreement (>0.700), Moderate (0.500 – 0.700), Fair (0.300 – 0.499), and Poor (<0.300).

The agreement between radiologists and nurse sonographers ranged from poor agreement with Kappa of 0.145 to good agreement with Kappa of 0.758. The agreement of nurse sonographers and radiologists for liver lesion was 0.585 (p<0.001) which was moderate. For gall bladder findings the agreement was good (0.746; p<0.001). The agreement on gall stone detection was good (Cohen’s Kappa Coefficient 0.758; p<0.001). Liver cancer were found in seven cases which five patients were cholangiocarcinoma or bile duct cancer and the other two were hepatocellular carcinoma. The agreement between radiologists and nurse sonographers in screening for liver and bile duct cancer was varied regarding part of liver screening. Further diagnostic study should be performed for evaluating the validity of nurse sonography in screening for liver and bile duct cancer.

Phanomphrai Hospital has institutionalized and operationalized nurse sonographer and comprehensive liver fluke and bile duct cancer control as research-based activities with routine services. Nurse personnel has been officially allocated for ultrasound services. The initiative has been run as ongoing implementation and improvement. Informed consent forms have been collected after counselling. Advanced laboratory services have also been established with supports from Chulabhorn Hospital such as biomarkers and tissue banking. Biospecimens have been collected and sent for long term storage and future study at Chulabhorn Hospital in Bangkok. Phanomphrai Hospital has also been challenged as a population-based epidemiological laboratory. At the same time, Ministry of Public Health of Thailand has response to the manifest that Roi Et Province is among provinces with highest incidence and mortality of bile duct cancer. Roi Et Hospital has been appointed and named as general cancer center. The Chulabhorn Hospital Collaborating Center for Comprehensive Cancer Control at Roi Et Province has been established at Roi Et Hospital. Advanced oncology service and treatment modalities have been developed and set up at this referral hospital such as surgical oncology - especially hepatobiliary surgery, chemotherapy unit, and radiation therapy both linear accelerator and brachytherapy, and palliative care.

Phanomphrai Hospital takes part in many collaborations. Actions involving delivering policy objectives has been shown by local and central governments. Phanomphrai District Health Board (DHB) has approved and endorsed comprehensive liver fluke and bile duct cancer control plan as district agenda. Phanomphrai District Governor has signed memorandum of understandings with every local administrative organization within the district to ensure the Plan be implemented in pursuit of healthy standard of living for all. The National Agenda for Liver Fluke and Bile Duct Cancer Control has been endorsed by the National Health Assembly 2014 and a 10-year Strategic Plan for Liver Fluke and Bile Duct Cancer Control was approved by the Cabinet in 2016. This plan ensures bile duct cancer control and health equity in all policies. Phanomphrai Hospital has been working continuously with local communities to strengthen effective service delivery by active participation of decision-makers at all levels by empowering individuals and communities. Phanomphrai Hospital has also engaged stakeholders from Chulabhorn and Roi Et Hospitals. Radiologists, pathologist and surgeons have actively participated as trainers and evaluators. Consultation has been made through LINE application. Fast tract referral system has been also established and help reduce patient waiting times and unnecessary visits.

Many lessons have been learned from nurse sonographer and comprehensive bile duct cancer prevention and control program at Phanomphrai Hospital. First, strong leadership and inspiration is very important. The late King Bhumibol the Great’s Philosophy of Sufficiency Economy provides a guiding star: moderation, reasonableness and self-immunity and principles underpinning the 2030 Agenda: leaving no one behind, must be followed and should be applied at all stages of program from planning, designing, service delivery, implementation, to monitor and evaluation phases. Second, establish multi-stakeholder partnerships for mobilizing and sharing knowledge, expertise, technology and resources. Engagement of both people and providers are as important for the success of the program. Third, interprofessional education and collaborative practice plays an important role in mitigating the health workforce crisis. Continuous professional learning and improvement activities are essential. Forth, people-centric services by reforming and transforming existing services. Ongoing adaptation and services alignment such as One-Stop Service Liver Clinic and Government Easy Contact Center that facilitate harmonization, collaboration and digitalized public services are all helpful. Phanomphrai Hospital plans to make the initiative more inclusive and equitable for all in the future with application of artificial intelligence and imaging technologies to enhance effectiveness and efficiency.