101
|
Dodd R, Palagyi A, Guild L, Jha V, Jan S. The impact of out-of-pocket costs on treatment commencement and adherence in chronic kidney disease: a systematic review. Health Policy Plan 2019; 33:1047-1054. [PMID: 30247548 DOI: 10.1093/heapol/czy081] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2018] [Indexed: 01/31/2023] Open
Abstract
Chronic kidney disease (CKD) is a significant and growing driver of the global non-communicable diseases (NCD) burden, responsible for 1.2 million deaths in 2016. While previous research has estimated the out-of-pocket costs of CKD treatment and resulting levels of catastrophic health expenditures, less is known about the impact of such costs on access to, and maintenance of, care. Our study seeks to fill this gap by synthesizing available evidence on cost as a determinant of CKD treatment discontinuation. We searched for studies which considered the financial burden of treatment and medication for CKD patients and the extent to which this burden was associated with patients forgoing or discontinuing treatment. We identified 14 relevant studies, 5 from high-income countries and 9 from low-middle income countries. All suggest that cost adversely influences adherence to CKD medication and dialysis treatment. In poorer countries, those entering treatment programs were typically diagnosed late, under-dialysed and suffered very high levels of mortality. Identified studies present consistent findings regardless of study context: cost is barrier to treatment and a driver of non-adherence and discontinuation, with poorer households worst affected. This is in line with previous research. Major gaps in the literature remain, however, in relation to differential impact of the cost burden on men and women, the coping strategies of poor households and the effect of insurance coverage.
Collapse
Affiliation(s)
- Rebecca Dodd
- The George Institute for Global Health, University of New South Wales, Missenden Rd, Sydney, Australia
| | - Anna Palagyi
- The George Institute for Global Health, University of New South Wales, Missenden Rd, Sydney, Australia
| | - Laura Guild
- School of Professional Studies, Northwestern University, Chicago, 339 East Chicago Avenue, Chicago, Illinois, USA
| | - Vivekanand Jha
- The George Institute for Global Health, 311-312, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi, India
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Missenden Rd, Sydney, Australia
| |
Collapse
|
102
|
Gómez JF, Camacho PA, López-López J, López-Jaramillo P. Control y tratamiento de la hipertensión arterial: Programa 20-20. REVISTA COLOMBIANA DE CARDIOLOGÍA 2019. [DOI: 10.1016/j.rccar.2018.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
103
|
Oyando R, Njoroge M, Nguhiu P, Kirui F, Mbui J, Sigilai A, Bukania Z, Obala A, Munge K, Etyang A, Barasa E. Patient costs of hypertension care in public health care facilities in Kenya. Int J Health Plann Manage 2019; 34:e1166-e1178. [PMID: 30762904 PMCID: PMC6618067 DOI: 10.1002/hpm.2752] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 11/09/2022] Open
Abstract
Background Hypertension in low‐ and middle‐income countries, including Kenya, is of economic importance due to its increasing prevalence and its potential to present an economic burden to households. In this study, we examined the patient costs associated with obtaining care for hypertension in public health care facilities in Kenya. Methods We conducted a cross‐sectional study among adult respondents above 18 years of age, with at least 6 months of treatment in two counties. A total of 212 patients seeking hypertension care at five public facilities were interviewed, and information on care seeking and the associated costs was obtained. We computed both annual direct and indirect costs borne by these patients. Results Overall, the mean annual direct cost to patients was US$ 304.8 (95% CI, 235.7‐374.0). Medicines (mean annual cost, US$ 168.9; 95% CI, 132.5‐205.4), transport (mean annual cost, US$ 126.7; 95% CI, 77.6‐175.9), and user charges (mean annual cost, US$ 57.7; 95% CI, 43.7‐71.6) were the highest direct cost categories. Overall mean annual indirect cost was US$ 171.7 (95% CI, 152.8‐190.5). The incidence of catastrophic health care costs was 43.3% (95% CI, 36.8‐50.2) and increased to 59.0% (95% CI, 52.2‐65.4) when transport costs were included. Conclusions Hypertensive patients incur substantial direct and indirect costs. High rates of catastrophic costs illustrate the urgency of improving financial risk protection for these patients and strengthening primary care to ensure affordability of hypertension care.
Collapse
Affiliation(s)
- Robinson Oyando
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Martin Njoroge
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Peter Nguhiu
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Fredrick Kirui
- Clinical Unit, KEMRI Centre for Clinical Research, Nairobi, Kenya
| | - Jane Mbui
- Clinical Unit, KEMRI Centre for Clinical Research, Nairobi, Kenya
| | - Antipa Sigilai
- Epidemiology and Demography, KEMRI Centre for Geographic Medicine Research, Coast, Kilifi, Kenya
| | - Zipporah Bukania
- Public health nutrition, maternal and child health unit, KEMRI Centre for Public Health Research, Nairobi, Kenya
| | - Andrew Obala
- Medical Microbiology and Parasitology, Moi University, Eldoret, Kenya
| | - Kenneth Munge
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Anthony Etyang
- Epidemiology and Demography, KEMRI Centre for Geographic Medicine Research, Coast, Kilifi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
104
|
Lamy A, Lonn E, Tong W, Swaminathan B, Jung H, Gafni A, Bosch J, Yusuf S. The cost implication of primary prevention in the HOPE 3 trial. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 5:266-271. [DOI: 10.1093/ehjqcco/qcz001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 12/17/2018] [Accepted: 01/15/2019] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
The Heart Outcomes Prevention Evaluation-3 (HOPE-3) found that rosuvastatin alone or with candesartan and hydrochlorothiazide (HCT) (in a subgroup with hypertension) significantly lowered cardiovascular events compared with placebo in 12 705 individuals from 21 countries at intermediate risk and without cardiovascular disease. We assessed the costs implications of implementation in primary prevention in countries at different economic levels.
Methods and results
Hospitalizations, procedures, study and non-study medications were documented. We applied country-specific costs to the healthcare resources consumed for each patient. We calculated the average cost per patient in US dollars for the duration of the study (5.6 years). Sensitivity analyses were also performed with cheapest equivalent substitutes. The combination of rosuvastatin with candesartan/HCT reduced total costs and was a cost-saving strategy in United States, Canada, Europe, and Australia. In contrast, the treatments were more expensive in developing countries even when cheapest equivalent substitutes were used. After adjustment for gross domestic product (GDP), the costs of cheapest equivalent substitutes in proportion to the health care costs were higher in developing countries in comparison to developed countries.
Conclusion
Rosuvastatin and candesartan/HCT in primary prevention is a cost-saving approach in developed countries, but not in developing countries as both drugs and their cheapest equivalent substitutes are relatively more expensive despite adjustment by GDP. Reductions in costs of these drugs in developing countries are essential to make statins and blood pressure lowering drugs affordable and ensure their use.
Clinical trial registration
HOPE-3 ClinicalTrials.gov number, NCT00468923.
Collapse
Affiliation(s)
- Andre Lamy
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
- Hamilton Health Sciences, 237 Barton St. East, Hamilton, ON, Canada
- McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Eva Lonn
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
- Hamilton Health Sciences, 237 Barton St. East, Hamilton, ON, Canada
- McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Wesley Tong
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
| | - Balakumar Swaminathan
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
| | - Hyejung Jung
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
| | - Amiram Gafni
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
- McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
- McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, DBCVSRI, 20 Copeland Avenue, Hamilton, ON, Canada
- Hamilton Health Sciences, 237 Barton St. East, Hamilton, ON, Canada
- McMaster University, 1280 Main St W, Hamilton, ON, Canada
| |
Collapse
|
105
|
Joseph P, Pais P, Dans AL, Bosch J, Xavier D, Lopez-Jaramillo P, Yusoff K, Santoso A, Talukder S, Gamra H, Yeates K, Lopez PC, Tyrwhitt J, Gao P, Teo K, Yusuf S. The International Polycap Study-3 (TIPS-3): Design, baseline characteristics and challenges in conduct. Am Heart J 2018; 206:72-79. [PMID: 30342297 PMCID: PMC6299262 DOI: 10.1016/j.ahj.2018.07.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/18/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND It is hypothesized that in individuals without clinical cardiovascular disease (CVD), but at increased CVD risk, a 50% to 60% reduction in CVD risk could be achieved using fixed dose combination (FDC) therapy (usually comprised of multiple blood-pressure agents and a statin [with or without aspirin]) in a single "polypill". However, the impact of a polypill in preventing clinical CV events has not been evaluated in a large randomized controlled trial. METHODS TIPS-3 is a 2x2x2 factorial randomized controlled trial that will examine the effect of a FDC polypill on major CV outcomes in a primary prevention population. This study aims to determine whether the Polycap (comprised of atenolol, ramipril, hydrochlorothiazide, and a statin) reduces CV events in persons without a history of CVD, but who are at least at intermediate CVD risk. Additional interventions in the factorial design of the study will compare the effect of (1) aspirin versus placebo on CV events (and cancer), (2) vitamin D versus placebo on the risk of fractures, and (3) the combined effect of aspirin and the Polycap on CV events. RESULTS The study has randomized 5713 participants across 9 countries. Mean age of the study population is 63.9 years, and 53% are female. Mean INTERHEART risk score is 16.8, which is consistent with a study population at intermediate CVD risk. CONCLUSION Results of the TIP-3 study will be key to determining the appropriateness of FDC therapy as a strategy in the global prevention of CVD.
Collapse
Affiliation(s)
- Philip Joseph
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Prem Pais
- St. John's Medical College, Bangalore, India
| | - Antonio L Dans
- College of Medicine, University of the Philippines, Manila, Philippines
| | - Jackie Bosch
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | | | - Patricio Lopez-Jaramillo
- Research Institute and Clinic of Metabolic Syndrome and Diabetes, Fundacion Oftalmologica de Santander FOSCAL, Universidad de Santander UDES, Bucaramanga, Colombia
| | - Khalid Yusoff
- UiTM Selayang, Selangor and UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Anwar Santoso
- Universitas Indonesia and Department of Cardiology - Vascular Medicine, National Cardiovascular Centre, Harapan Kita Hospital, Jakarta, Indonesia
| | | | - Habib Gamra
- Fattouma Bourguiba University Hospital and University of Monastir, Tunisia
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Paul Camacho Lopez
- Research Institute and Clinic of Metabolic Syndrome and Diabetes, Fundacion Oftalmologica de Santander FOSCAL, Universidad de Santander UDES, Bucaramanga, Colombia
| | - Jessica Tyrwhitt
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Peggy Gao
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
106
|
DiPette DJ, Skeete J, Ridley E, Campbell NRC, Lopez-Jaramillo P, Kishore SP, Jaffe MG, Coca A, Townsend RR, Ordunez P. Fixed-dose combination pharmacologic therapy to improve hypertension control worldwide: Clinical perspective and policy implications. J Clin Hypertens (Greenwich) 2018; 21:4-15. [PMID: 30480368 DOI: 10.1111/jch.13426] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 09/15/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Donald J DiPette
- University of South Carolina School of Medicine, University of South Carolina, Columbia, South Carolina
| | - Jamario Skeete
- University of South Carolina School of Medicine, University of South Carolina, Columbia, South Carolina.,Palmetto Health, Columbia, South Carolina
| | | | - Norm R C Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Patricio Lopez-Jaramillo
- FOSCAL, UDES, Bucaramanga, Colombia.,Eugenio Espejo Medical Sciences Faculty, UTE, Quito, Ecuador
| | - Sandeep P Kishore
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York.,Young Professionals Chronic Disease Network, New York, New York
| | - Marc G Jaffe
- Resolve to Save Lives, New York, New York.,Kaiser Permanente South, San Francisco Medical Center South, San Francisco, California
| | | | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pedro Ordunez
- Department of Non-Communicable Diseases and Mental Health, The Pan-American Health Organization, Washington, District of Columbia
| |
Collapse
|
107
|
Ferrario A. Availability and affordability of medicines: towards an evidence base for routine assessment. Lancet Diabetes Endocrinol 2018; 6:759-761. [PMID: 30170948 DOI: 10.1016/s2213-8587(18)30258-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Alessandra Ferrario
- Department of Population Medicine, Harvard Medical School, Boston, MA 02215, USA.
| |
Collapse
|
108
|
Chow CK, Ramasundarahettige C, Hu W, AlHabib KF, Avezum A, Cheng X, Chifamba J, Dagenais G, Dans A, Egbujie BA, Gupta R, Iqbal R, Ismail N, Keskinler MV, Khatib R, Kruger L, Kumar R, Lanas F, Lear S, Lopez-Jaramillo P, McKee M, Mohammadifard N, Mohan V, Mony P, Orlandini A, Rosengren A, Vijayakumar K, Wei L, Yeates K, Yusoff K, Yusuf R, Yusufali A, Zatonska K, Zhou Y, Islam S, Corsi D, Rangarajan S, Teo K, Gerstein HC, Yusuf S. Availability and affordability of essential medicines for diabetes across high-income, middle-income, and low-income countries: a prospective epidemiological study. Lancet Diabetes Endocrinol 2018; 6:798-808. [PMID: 30170949 DOI: 10.1016/s2213-8587(18)30233-x] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/22/2018] [Accepted: 07/23/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Data are scarce on the availability and affordability of essential medicines for diabetes. Our aim was to examine the availability and affordability of metformin, sulfonylureas, and insulin across multiple regions of the world and explore the effect of these on medicine use. METHODS In the Prospective Urban Rural Epidemiology (PURE) study, participants aged 35-70 years (n=156 625) were recruited from 110 803 households, in 604 communities and 22 countries; availability (presence of any dose of medication in the pharmacy on the day of audit) and medicine cost data were collected from pharmacies with the Environmental Profile of a Community's Health audit tool. Our primary analysis was to describe the availability and affordability of metformin and insulin and also commonly used and prescribed combinations of two medicines for diabetes management (two oral drugs, metformin plus a sulphonylurea [either glibenclamide (also known as glyburide) or gliclazide] and one oral drug plus insulin [metformin plus insulin]). Medicines were defined as affordable if the cost of medicines was less than 20% of capacity-to-pay (the household income minus food expenditure). Our analyses included data collected in pharmacies and data from representative samples of households. Data on availability were ascertained during the pharmacy audit, as were data on cost of medications. These cost data were used to estimate the cost of a month's supply of essential medicines for diabetes. We estimated affordability of medicines using income data from household surveys. FINDINGS Metformin was available in 113 (100%) of 113 pharmacies from high-income countries, 112 (88·2%) of 127 pharmacies in upper-middle-income countries, 179 (86·1%) of 208 pharmacies in lower-middle-income countries, 44 (64·7%) of 68 pharmacies in low-income countries (excluding India), and 88 (100%) of 88 pharmacies in India. Insulin was available in 106 (93·8%) pharmacies in high-income countries, 51 (40·2%) pharmacies in upper-middle-income countries, 61 (29·3%) pharmacies in lower-middle-income countries, seven (10·3%) pharmacies in lower-income countries, and 67 (76·1%) of 88 pharmacies in India. We estimated 0·7% of households in high-income countries and 26·9% of households in low-income countries could not afford metformin and 2·8% of households in high-income countries and 63·0% of households in low-income countries could not afford insulin. Among the 13 569 (8·6% of PURE participants) that reported a diagnosis of diabetes, 1222 (74·0%) participants reported diabetes medicine use in high-income countries compared with 143 (29·6%) participants in low-income countries. In multilevel models, availability and affordability were significantly associated with use of diabetes medicines. INTERPRETATION Availability and affordability of essential diabetes medicines are poor in low-income and middle-income countries. Awareness of these global differences might importantly drive change in access for patients with diabetes. FUNDING Full funding sources listed at the end of the paper (see Acknowledgments).
Collapse
Affiliation(s)
- Clara K Chow
- Faculty of Medicine and Health, University of Sydney, The George Institute for Global Health and Westmead Hospital, Sydney, NSW, Australia; Population Health Research Institute, Hamilton, ON, Canada.
| | | | - Weihong Hu
- Population Health Research Institute, Hamilton, ON, Canada
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alvaro Avezum
- Research Division, Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | - Xiaoru Cheng
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jephat Chifamba
- College of Health Sciences, Physiology Department, University of Zimbabwe, Harare, Zimbabwe
| | - Gilles Dagenais
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Université Laval, QC, Canada
| | - Antonio Dans
- Department of Medicine, University of the Philippines-Manila, Ermita, Manila, Philippines
| | - Bonaventure A Egbujie
- School of PublicHealth, University of the Western Cape, Bellville, Cape Town, Western Cape Province, South Africa
| | - Rajeev Gupta
- Eternal Heart Care Centre and Research Institute, Jawahar Circle, Jaipur, India
| | - Romaina Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Noorhassim Ismail
- Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Mirac V Keskinler
- Department of Internal Medicine, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Rasha Khatib
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lanthé Kruger
- Faculty of Health Science, North-West University, Potchefstroom Campus, Potchefstroom, South Africa
| | - Rajesh Kumar
- Post Graduate Institute of Medical Education and Research, School of Public Health, Chandigarh, India
| | - Fernando Lanas
- Department of Medicine, Universidad de La Frontera, Francisco Salazar, Temuco, Chile
| | - Scott Lear
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | | | - Martin McKee
- London School of Hygiene & Tropical Medicine, London, UK
| | - Noushin Mohammadifard
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Prem Mony
- Division of Epidemiology and Population Health, St John's Medical College and Research Institute, Bangalore India
| | | | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Östra Hospital, Gothenburg, Sweden
| | | | - Li Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Karen Yeates
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Khalid Yusoff
- Department of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; University College Sedaya International (UCSI) University, Cheras, Selangor, Malaysia
| | - Rita Yusuf
- School of Life Sciences, Independent University, Bangladesh, Bashundhara, Dhaka, Bangladesh
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority, Dubai Medical University, Dubai, United Arab Emirates
| | - Katarzyna Zatonska
- Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Yihong Zhou
- Wujin DistrictCenter for Disease Control and Prevention, Changzhou, Jiangsu Province, China
| | - Shariful Islam
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Daniel Corsi
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Koon Teo
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Salim Yusuf
- Population Health Research Institute, Hamilton, ON, Canada
| | | |
Collapse
|
109
|
Soetedjo NNM, McAllister SM, Ugarte-Gil C, Firanescu AG, Ronacher K, Alisjahbana B, Costache AL, Zubiate C, Malherbe ST, Koesoemadinata RC, Laurence YV, Pearson F, Kerry-Barnard S, Ruslami R, Moore DAJ, Ioana M, Kleynhans L, Permana H, Hill PC, Mota M, Walzl G, Dockrell HM, Critchley JA, van Crevel R. Disease characteristics and treatment of patients with diabetes mellitus attending government health services in Indonesia, Peru, Romania and South Africa. Trop Med Int Health 2018; 23:1118-1128. [PMID: 30106222 DOI: 10.1111/tmi.13137] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To describe the characteristics and management of Diabetes mellitus (DM) patients from low- and middle-income countries (LMIC). METHODS We systematically characterised consecutive DM patients attending public health services in urban settings in Indonesia, Peru, Romania and South Africa, collecting data on DM treatment history, complications, drug treatment, obesity, HbA1c and cardiovascular risk profile; and assessing treatment gaps against relevant national guidelines. RESULTS Patients (median 59 years, 62.9% female) mostly had type 2 diabetes (96%), half for >5 years (48.6%). Obesity (45.5%) and central obesity (females 84.8%; males 62.7%) were common. The median HbA1c was 8.7% (72 mmol/mol), ranging from 7.7% (61 mmol/mol; Peru) to 10.4% (90 mmol/mol; South Africa). Antidiabetes treatment included metformin (62.6%), insulin (37.8%), and other oral glucose-lowering drugs (34.8%). Disease complications included eyesight problems (50.4%), EGFR <60 ml/min (18.9%), heart disease (16.5%) and proteinuria (14.7%). Many had an elevated cardiovascular risk with elevated blood pressure (36%), LDL (71.0%) and smoking (13%), but few were taking antihypertensive drugs (47.1%), statins (28.5%) and aspirin (30.0%) when indicated. Few patients on insulin (8.0%), statins (8.4%) and antihypertensives (39.5%) reached treatment targets according to national guidelines. There were large differences between countries in terms of disease profile and medication use. CONCLUSION DM patients in government clinics in four LMIC with considerable growth of DM have insufficient glycaemic control, frequent macrovascular and other complications, and insufficient preventive measures for cardiovascular disease. These findings underline the need to identify treatment barriers and secure optimal DM care in such settings.
Collapse
Affiliation(s)
- Nanny N M Soetedjo
- Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Susan M McAllister
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Cesar Ugarte-Gil
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Adela G Firanescu
- Clinic of Diabetes Nutrition and Metabolic Diseases, Clinical County Emergency Hospital, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Katharina Ronacher
- South African Medical Research Council Centre for TB Research, Stellenbosch University, Stellenbosch, South Africa.,Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Bachti Alisjahbana
- Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia.,TB-HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Anca L Costache
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Human Genomics Laboratory, University of Medicine and Pharmacy of Craiova, Craiova, Romania.,Regional Centre for Human Genetics, Dolj, Emergency Clinical County Hospital, Craiova, Romania
| | - Carlos Zubiate
- Servicio de Endocrinologia, Hospital Maria Auxiliadora, Lima, Peru
| | - Stephanus T Malherbe
- South African Medical Research Council Centre for TB Research, Stellenbosch University, Stellenbosch, South Africa
| | - Raspati C Koesoemadinata
- TB-HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia.,Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Yoko V Laurence
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Fiona Pearson
- Population Health Research Institute, St George's University of London, London, UK
| | - Sarah Kerry-Barnard
- Population Health Research Institute, St George's University of London, London, UK
| | - Rovina Ruslami
- TB-HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia.,Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - David A J Moore
- Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Mihai Ioana
- Human Genomics Laboratory, University of Medicine and Pharmacy of Craiova, Craiova, Romania.,Regional Centre for Human Genetics, Dolj, Emergency Clinical County Hospital, Craiova, Romania
| | - Leanie Kleynhans
- South African Medical Research Council Centre for TB Research, Stellenbosch University, Stellenbosch, South Africa
| | - Hikmat Permana
- Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Philip C Hill
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Maria Mota
- Clinic of Diabetes Nutrition and Metabolic Diseases, Clinical County Emergency Hospital, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Gerhard Walzl
- South African Medical Research Council Centre for TB Research, Stellenbosch University, Stellenbosch, South Africa
| | - Hazel M Dockrell
- Department of Immunology & Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - Julia A Critchley
- Population Health Research Institute, St George's University of London, London, UK
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | |
Collapse
|
110
|
Rationale and design of a cluster randomized trial of a multifaceted intervention in people with hypertension: The Heart Outcomes Prevention and Evaluation 4 (HOPE-4) Study. Am Heart J 2018; 203:57-66. [PMID: 30015069 DOI: 10.1016/j.ahj.2018.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/03/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death throughout the world, with the majority of deaths occurring in low- and middle-income countries. Despite clear evidence for the benefits of blood pressure reduction and availability of safe and low-cost medications, most individuals are either unaware of their condition or not adequately treated. OBJECTIVE The primary objective of this study is to evaluate whether a community-based, multifaceted intervention package primarily provided by nonphysician health workers can improve long-term cardiovascular risk in people with hypertension by addressing identified barriers at the patient, health care provider, and health system levels. METHODS/DESIGN HOPE-4 is a community-based, parallel-group, cluster randomized controlled trial involving 30 communities (1,376 participants) in Colombia and Malaysia. Participants ≥50 years old and with newly diagnosed or poorly controlled hypertension were included. Communities were randomized to usual care or to a multifaceted intervention package that entails (1) detection, treatment, and control of cardiovascular risk factors by nonphysician health workers in the community, who use tablet-based simplified management algorithms, decision support, and counseling programs; (2) free dispensation of combination antihypertensive and cholesterol-lowering medications, supervised by local physicians; and (3) support from a participant-nominated treatment supporter (either a friend or family member). The primary outcome is the change in Framingham Risk Score after 12 months between the intervention and control communities. Secondary outcomes including change in blood pressure, lipid levels, and Interheart Risk Score will be evaluated. SIGNIFICANCE If successful, the study could serve as a model to develop low-cost, effective, and scalable strategies to reduce cardiovascular risk in people with hypertension.
Collapse
|
111
|
Abstract
Type 2 diabetes is a major and accelerating public health challenge. Between 1980 and 2014, a period of just 35 years, the number of adults with diabetes globally is estimated to have increased from 108 to 422 million, due not only to sharply rising obesity rates, but also to increasing population size, longer life expectancy, and rising prevalence of diabetes worldwide. Overall, worldwide age-standardized adult diabetes prevalence doubled from 4.3% to 9.0% in men and from 5.0% to 7.9% in women. The largest increases in diabetes type 2 have been demonstrated in low- and middle-income countries, whilst rises in high-income countries have been less marked, or even flat. Diabetes type 2 rates in low- and middle-income countries now in many instances surpass those in high-income countries, in response to changes in lifestyle. One factor of particular concern are the large relative increases in type 2 diabetes amongst young individuals observed in many countries, their higher overall risk factor burden, long exposure to hyperglycaemia and greater risk of complications over the life course. Type 2 diabetes is increasingly found to be a heterogeneous condition, where risk of cardiovascular disease that traditionally has been estimated at 2-4 times that of the nondiabetic population varies substantially with diabetes phenotype and accordingly diabetes does not confer the same increase in relative or absolute risk in all people. New research shows that excess risk varies substantially with type of outcome, age, glycaemic control, the presence of renal complications and other factors. Heart failure, previously less recognized that other cardiovascular conditions, is increasingly coming into focus, because of strong links with poor glycaemic control and obesity. The knowledge about risk of cardiovascular disease in diabetes is almost entirely derived from high-income countries, whereas there is comparatively very little data from low- and middle income countries, where the majority of persons with type 2 diabetes live, and where management in many cases is far from optimal. The reductions in cardiovascular disease incidence and mortality now observed in high-income countries are encouraging, because this reinforces the fact that improvement is possible and that a near-normal, or even normal life-expectancy can be achieved in subtypes of type 2 diabetes.
Collapse
Affiliation(s)
- A Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
112
|
Webster R, Salam A, de Silva HA, Selak V, Stepien S, Rajapakse S, Amarasekara S, Amarasena N, Billot L, de Silva AP, Fernando M, Guggilla R, Jan S, Jayawardena J, Maulik PK, Mendis S, Mendis S, Munasinghe J, Naik N, Prabhakaran D, Ranasinghe G, Thom S, Tisserra N, Senaratne V, Wijekoon S, Wijeyasingam S, Rodgers A, Patel A. Fixed Low-Dose Triple Combination Antihypertensive Medication vs Usual Care for Blood Pressure Control in Patients With Mild to Moderate Hypertension in Sri Lanka: A Randomized Clinical Trial. JAMA 2018; 320:566-579. [PMID: 30120478 PMCID: PMC6583010 DOI: 10.1001/jama.2018.10359] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Poorly controlled hypertension is a leading global public health problem requiring new treatment strategies. OBJECTIVE To assess whether a low-dose triple combination antihypertensive medication would achieve better blood pressure (BP) control vs usual care. DESIGN, SETTING, AND PARTICIPANTS Randomized, open-label trial of a low-dose triple BP therapy vs usual care for adults with hypertension (systolic BP >140 mm Hg and/or diastolic BP >90 mm Hg; or in patients with diabetes or chronic kidney disease: >130 mm Hg and/or >80 mm Hg) requiring initiation (untreated patients) or escalation (patients receiving monotherapy) of antihypertensive therapy. Patients were enrolled from 11 urban hospital clinics in Sri Lanka from February 2016 to May 2017; follow-up ended in October 2017. INTERVENTIONS A once-daily fixed-dose triple combination pill (20 mg of telmisartan, 2.5 mg of amlodipine, and 12.5 mg of chlorthalidone) therapy (n = 349) or usual care (n = 351). MAIN OUTCOMES AND MEASURES The primary outcome was the proportion achieving target systolic/diastolic BP (<140/90 mm Hg or <130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 months. Secondary outcomes included mean systolic/diastolic BP difference during follow-up and withdrawal of BP medications due to an adverse event. RESULTS Among 700 randomized patients (mean age, 56 years; 58% women; 29% had diabetes; mean baseline systolic/diastolic BP, 154/90 mm Hg), 675 (96%) completed the trial. The triple combination pill increased the proportion achieving target BP vs usual care at 6 months (70% vs 55%, respectively; risk difference, 12.7% [95% CI, 3.2% to 22.0%]; P < .001). Mean systolic/diastolic BP at 6 months was 125/76 mm Hg for the triple combination pill vs 134/81 mm Hg for usual care (adjusted difference in postrandomization BP over the entire follow-up: systolic BP, -9.8 [95% CI, -7.9 to -11.6] mm Hg; diastolic BP, -5.0 [95% CI, -3.9 to -6.1] mm Hg; P < .001 for both comparisons). Overall, 419 adverse events were reported in 255 patients (38.1% for triple combination pill vs 34.8% for usual care) with the most common being musculoskeletal pain (6.0% and 8.0%, respectively) and dizziness, presyncope, or syncope (5.2% and 2.8%). There were no significant between-group differences in the proportion of patient withdrawal from BP-lowering therapy due to adverse events (6.6% for triple combination pill vs 6.8% for usual care). CONCLUSIONS AND RELEVANCE Among patients with mild to moderate hypertension, treatment with a pill containing low doses of 3 antihypertensive drugs led to an increased proportion of patients achieving their target BP goal vs usual care. Use of such medication as initial therapy or to replace monotherapy may be an effective way to improve BP control. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12612001120864; slctr.lk Identifier: SLCTR/2015/020.
Collapse
Affiliation(s)
- Ruth Webster
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Abdul Salam
- The George Institute for Global Health, University of New South Wales, Hyderabad, India
| | - H. Asita de Silva
- Clinical Trials Unit, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Vanessa Selak
- Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Sandrine Stepien
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Senaka Rajapakse
- Department of Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | | | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Arjuna P. de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | | | - Rama Guggilla
- General Directorate of Health Affairs in Jizan, Ministry of Health, Sabya, Saudi Arabia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Pallab K. Maulik
- The George Institute for Global Health, University of New South Wales, New Delhi, India
| | | | | | | | - Nitish Naik
- All India Institute of Medical Sciences, New Delhi
| | | | | | - Simon Thom
- International Centre for Circulatory Health, Imperial College London, London, England
| | | | | | - Sanjeewa Wijekoon
- Department of Medicine, Faculty of Medical Sciences, University of Sri Jayawardenapura, Nugegoda, Sri Lanka
| | | | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Anushka Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| |
Collapse
|
113
|
Stock JK. Navigating the highlights of EAS Congress Lisbon. Atherosclerosis 2018; 275:387-389. [PMID: 29945722 DOI: 10.1016/j.atherosclerosis.2018.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 10/14/2022]
Affiliation(s)
- Jane K Stock
- European Atherosclerosis Society, World Trade Center Göteborg, Box 5243, Mässans Gata 10, SE-402 24, Göteborg, Sweden.
| |
Collapse
|
114
|
Rockers PC, Laing RO, Wirtz VJ. Equity in access to non-communicable disease medicines: a cross-sectional study in Kenya. BMJ Glob Health 2018; 3:e000828. [PMID: 29989082 PMCID: PMC6035514 DOI: 10.1136/bmjgh-2018-000828] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/24/2018] [Accepted: 05/26/2018] [Indexed: 01/12/2023] Open
Abstract
Introduction Wealth-based inequity in access to medicines is an impediment to achieving universal health coverage in many low-income and middle-income countries. We explored the relationship between household wealth and access to medicines for non-communicable diseases (NCDs) in Kenya. Methods We administered a cross-sectional survey to a sample of patients prescribed medicines for hypertension, diabetes or asthma. Data were collected on medicines available in the home, including the location and cost of purchase. Household asset information was used to construct an indicator of wealth. We analysed the relationship between household wealth and various aspects of access, including the probability of having NCD medicines at home and price paid. Results Among 639 patients interviewed, hypertension was the most prevalent NCD (69.6%), followed by diabetes (22.2%) and asthma (20.2%). There was a positive and statistically significant association between wealth and having medicines for patients with hypertension (p=0.020) and asthma (p=0.016), but not for diabetes (p=0.160). Poorer patients lived farther from their nearest health facility (p=0.050). There was no relationship between household wealth and the probability that the nearest public or non-profit health facility had key NCD medicines in stock, though less poor patients were significantly more likely to purchase medicines at better stocked private outlets. The relationship between wealth and median price paid for metformin by patients with diabetes was strongly u-shaped, with the middle quintile paying the lowest prices and the poorest and least poor paying higher prices. Patients with asthma in the poorest wealth quintile paid more for salbutamol than those in all other quintiles. Conclusion The poorest in Kenya appear to face increased barriers to accessing NCD medicines as compared with the less poor. To achieve universal health coverage, the country will need to consider pro-poor policies for improving equity in access.
Collapse
Affiliation(s)
- Peter C Rockers
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Richard O Laing
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA.,Department of Demography and Population Studies, University of the Witwatersrand, Johannesburg, South Africa
| | - Veronika J Wirtz
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
115
|
Abstract
PURPOSE OF REVIEW Outline recent epidemiologic data regarding hypertension in developing countries, distinguish differences from developed countries, and identify challenges in management and future perspectives. RECENT FINDINGS Increased sugar intake, air and noise pollution, and low birth weight are emerging hypertension risk factors. The major challenges in management are difficulties in accurate diagnosis of hypertension and adequate blood pressure control. In contrast to developed countries, hypertension prevalence rates are on the rise in developing countries with no improvement in awareness or control rates. The increasing burden of hypertension is largely attributable to behavioral factors, urbanization, unhealthy diet, obesity, social stress, and inactivity. Health authorities, medical societies, and drug industry can collaborate to improve hypertension control through education programs, public awareness campaigns, legislation to limit salt intake, encourage generic drugs, development and dissemination of national guidelines, and involving nurses and pharmacists in hypertension management. More epidemiologic data are needed in the future to identify reasons behind increased prevalence and poor blood pressure control and examine trends in prevalence, awareness, treatment, and control. National programs for better hypertension control based on local culture, economic characteristics, and available resources in the population are needed. The role of new tools for hypertension management should be tested in developing world.
Collapse
Affiliation(s)
- M Mohsen Ibrahim
- Cardiology Department, Faculty of Medicine, Cairo University, 1 El-Sherifein Street, Abdeen, Cairo, 11111, Egypt.
| |
Collapse
|
116
|
Abstract
PURPOSE OF REVIEW This article introduces the haemodynamic principles that underpin the pathophysiology of hypertension and introduces a rational physiological approach to appropriate pharmacologic treatment. RECENT FINDINGS Outdated understanding of haemodynamics based on previous measurement systems can no longer be applied to our understanding of the circulation. We question the current view of hypertension as defined by a predominantly systolic blood pressure and introduce the concept of vasogenic, cardiogenic and mixed-origin hypertension. We postulate that failure to identify the individual's haemodynamic pattern may lead to the use of inappropriate medication, which in turn may be a major factor in patient non-compliance with therapeutic strategies. A population-based approach to treatment of hypertension may lead to suboptimal functional dynamics in the individual patient. Finally, we question the validity of current guidelines and published evidence relating morbidity and mortality to the future treatment of hypertension. The importance of individual haemodynamic profiles may be pivotal in the understanding, diagnosis and treatment of hypertension if optimal control with minimal adverse effects is to be achieved. Research based on individual haemodynamic patterns is overdue.
Collapse
|
117
|
Beyond availability and affordability: how access to medicines affects non-communicable disease outcomes. LANCET PUBLIC HEALTH 2017; 2:e390-e391. [PMID: 29253405 DOI: 10.1016/s2468-2667(17)30168-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 08/14/2017] [Indexed: 11/22/2022]
|