1
|
Ueda I, Kohsaka S, Ikemura N, Kimura T, Katsumata Y, Takemura R, Suzuki M, Takatsuki S, Koide D, Fukuda K. Patient concern regarding bleeding side effects from oral anticoagulation therapy for atrial fibrillation: an analysis from the multicentre KiCS-AF registry. Eur J Cardiovasc Nurs 2024; 23:358-366. [PMID: 37694609 DOI: 10.1093/eurjcn/zvad094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 09/12/2023]
Abstract
AIMS The purpose of this study is to utilize patient-reported outcomes to determine the percentage of patients concerned about mild to moderate bleeding side effects of anticoagulants. METHODS AND RESULTS We consecutively enrolled 3312 newly diagnosed or referred patients for atrial fibrillation (AF) management from 11 sites within the Keio interhospital Cardiovascular Studies-Atrial Fibrillation registry between September 2012 and May 2018. Of these patients, 2636 (79.5%) were taking oral anticoagulants at enrollment. Using the Atrial Fibrillation Effect on Quality-of-life questionnaire (AFEQT), the patients who responded '1: not at all bothered' or '2: hardly bothered' on the seven-point scale regarding bleeding side effects were classified as the 'no OAC concern' group while those responding '3: a little bothered' to '7: extremely bothered' were classified as the 'OAC concern' group. On baseline analysis, 29.3% (n = 772) were 'concerned' about bleeding side effects. The proportion of women and patients with AF-related symptoms was higher in the oral anticoagulant (OAC) concern vs. no OAC concern group (36.9% vs. 29.8%, P < 0.0004 and 66.2% vs. 56.7%, P < 0.0001, respectively). The CHADS2 scores ≥ 2 were comparable between groups. Of the 430 patients in the 1-year follow-up analysis, the proportion of the continued OAC concern group (1 year from enrollment) was 41.6%. The dabigatran, rivaroxaban, and apixaban usage rates were comparable between the two groups in baseline and 1-year follow-up analysis. CONCLUSION Approximately one-third of all patients with AF on anticoagulant therapy were concerned regarding bleeding from short- and long-term anticoagulant use.
Collapse
Affiliation(s)
- Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo 1608582, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo 1608582, Japan
| | - Nobuhiro Ikemura
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo 1608582, Japan
| | - Takehiro Kimura
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo 1608582, Japan
| | - Yoshinori Katsumata
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo 1608582, Japan
| | - Ryo Takemura
- Clinical and Translational Research Center, Keio University Hospital, 35 Shinanomachi, Shinju-ku, Tokyo 1608582, Japan
| | - Masahiro Suzuki
- Department of Cardiology, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama 351-0102, Japan
| | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo 1608582, Japan
| | - Daisuke Koide
- Department of Biostatistics & Bioinformatics, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo 1608582, Japan
| |
Collapse
|
2
|
Bufalino VJ, Bleser WK, Singletary EA, Granger BB, O'Brien EC, Elkind MSV, Hamilton Lopez M, Saunders RS, McClellan MB, Brown N. Frontiers of Upstream Stroke Prevention and Reduced Stroke Inequity Through Predicting, Preventing, and Managing Hypertension and Atrial Fibrillation: A Call to Action From the Value in Healthcare Initiative's Predict & Prevent Learning Collaborative. Circ Cardiovasc Qual Outcomes 2020; 13:e006780. [PMID: 32683982 DOI: 10.1161/circoutcomes.120.006780] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.
Collapse
Affiliation(s)
| | - William K Bleser
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Elizabeth A Singletary
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Bradi B Granger
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Emily C O'Brien
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY (M.S.V.E.)
| | - Marianne Hamilton Lopez
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Robert S Saunders
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Mark B McClellan
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (W.K.B., E.A.S., B.B.G., E.C.O., M.H.L., R.S.S., M.B.M.)
| | - Nancy Brown
- American Heart Association, Dallas, TX (N.B.)
| | | |
Collapse
|
3
|
Pokorney SD, Gersh BJ, Ahmad A, Al-Khatib SM, Blank M, Coylewright M, DiBattiste P, Healey JS, Hedrich O, Hylek EM, Kline-Rogers E, Peterson ED, Mendys P, Mirro MJ, Naccarelli G, Patel P, Ruff CT, Rutman H, Stockbridge N, Temple R, Granger CB. Stroke prevention in atrial fibrillation: Closing the gap. Am Heart J 2019; 210:29-38. [PMID: 30731371 DOI: 10.1016/j.ahj.2018.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/12/2018] [Indexed: 10/28/2022]
|
4
|
Yu AYX, Malo S, Svenson LW, Wilton SB, Hill MD. Temporal Trends in the Use and Comparative Effectiveness of Direct Oral Anticoagulant Agents Versus Warfarin for Nonvalvular Atrial Fibrillation: A Canadian Population-Based Study. J Am Heart Assoc 2017; 6:JAHA.117.007129. [PMID: 29080863 PMCID: PMC5721787 DOI: 10.1161/jaha.117.007129] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are noninferior to warfarin for stroke prevention in atrial fibrillation (AF). We aimed to determine the population risk of stroke and death in incident AF, stratified by anticoagulation status and type, and the temporal trends of oral anticoagulation practice in the post-DOAC approval period. METHODS AND RESULTS We conducted a population-based cohort study of incident nonvalvular AF cases using administrative health data in Alberta, Canada. We used Cox proportional hazards modeling with anticoagulation status as a time-varying exposure and adjusted for age (continuous), sex, congestive heart failure, hypertension, diabetes mellitus, prior transient ischemic attack or ischemic stroke, myocardial infarction, peripheral artery disease, and chronic kidney disease. Primary outcome was the composite of stroke and death. Among 34 965 patients with incident AF (56.0% male, median age 73 years), relative to warfarin, DOAC use was associated with decreased risk of all stroke and death (hazard ratio: 0.90; 95% confidence interval, 0.83-0.97) and decreased hemorrhagic stroke (hazard ratio: 0.60; 95% confidence interval, 0.40-0.91]) but a similar risk of ischemic stroke (hazard ratio: 1.12; 95% confidence interval, 0.94-1.34]). During this time period, DOAC use increased rapidly, surpassing warfarin, but the total oral anticoagulation use in the population remained stable, even in the subgroup with the highest thromboembolic risk. CONCLUSIONS In a real-world population-based study of patients with incident AF, anticoagulation with DOACs was associated with decreased risk of stroke and death compared with warfarin. Despite a rapid uptake of DOACs in clinical practice, the total proportion of AF patients on anticoagulation has remained stable, even in high-risk patients.
Collapse
Affiliation(s)
- Amy Y X Yu
- University of Calgary, Calgary, AB, Canada
| | | | - Lawrence W Svenson
- University of Calgary, Calgary, AB, Canada.,Alberta Health, Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | | | | |
Collapse
|
5
|
Vinereanu D, Lopes RD, Bahit MC, Xavier D, Jiang J, Al-Khalidi HR, He W, Xian Y, Ciobanu AO, Kamath DY, Fox KA, Rao MP, Pokorney SD, Berwanger O, Tajer C, de Barros E Silva PGM, Roettig ML, Huo Y, Granger CB. A multifaceted intervention to improve treatment with oral anticoagulants in atrial fibrillation (IMPACT-AF): an international, cluster-randomised trial. Lancet 2017; 390:1737-1746. [PMID: 28859942 DOI: 10.1016/s0140-6736(17)32165-7] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 07/20/2017] [Accepted: 07/26/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Oral anticoagulation is underused in patients with atrial fibrillation. We assessed the impact of a multifaceted educational intervention, versus usual care, on oral anticoagulant use in patients with atrial fibrillation. METHODS This study was a two-arm, prospective, international, cluster-randomised, controlled trial. Patients were included who had atrial fibrillation and an indication for oral anticoagulation. Clusters were randomised (1:1) to receive a quality improvement educational intervention (intervention group) or usual care (control group). Randomisation was carried out centrally, using the eClinicalOS electronic data capture system. The intervention involved education of providers and patients, with regular monitoring and feedback. The primary outcome was the change in the proportion of patients treated with oral anticoagulants from baseline assessment to evaluation at 1 year. The trial is registered at ClinicalTrials.gov, number NCT02082548. FINDINGS 2281 patients from five countries (Argentina, n=343; Brazil, n=360; China, n=586; India, n=493; and Romania, n=499) were enrolled from 48 clusters between June 11, 2014, and Nov 13, 2016. Follow-up was at a median of 12·0 months (IQR 11·8-12·2). Oral anticoagulant use increased in the intervention group from 68% (804 of 1184 patients) at baseline to 80% (943 of 1184 patients) at 1 year (difference 12%), whereas in the control group it increased from 64% (703 of 1092 patients) at baseline to 67% (732 of 1092 patients) at 1 year (difference 3%). Absolute difference in the change between groups was 9·1% (95% CI 3·8-14·4); odds ratio of change in the use of oral anticoagulation between groups was 3·28 (95% CI 1·67-6·44; adjusted p value=0·0002). Kaplan-Meier estimates showed a reduction in the secondary outcome of stroke in the intervention versus control groups (HR 0·48, 95% CI 0·23-0·99; log-rank p value=0·0434). INTERPRETATION A multifaceted and multilevel educational intervention, aimed to improve use of oral anticoagulation in patients with atrial fibrillation and at risk for stroke, resulted in a significant increase in the proportion of patients treated with oral anticoagulants. Such an intervention has the potential to improve stroke prevention around the world for patients with atrial fibrillation. FUNDING Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, and Pfizer.
Collapse
Affiliation(s)
- Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA; Federal University of São Paulo, São Paulo, Brazil; Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil
| | - M Cecilia Bahit
- INECO Neurociencias, Rosario, Argentina; Argentine Clinical Research Group (ACRG), Rosario, Argentina
| | - Denis Xavier
- St John's Medical College and Research Institute, Bangalore, India
| | - Jie Jiang
- Peking University First Hospital, Beijing, China
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Wensheng He
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Ying Xian
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA; Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Andrea O Ciobanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania
| | - Deepak Y Kamath
- St John's Medical College and Research Institute, Bangalore, India
| | - Kathleen A Fox
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Meena P Rao
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Sean D Pokorney
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Otavio Berwanger
- Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil; Research Institute HCor, Heart Hospital (Hospital do Coração), Sao Paulo-SP, Brazil
| | | | - Pedro G M de Barros E Silva
- Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil; Research Institute HCor, Heart Hospital (Hospital do Coração), Sao Paulo-SP, Brazil
| | - Mayme L Roettig
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Yong Huo
- Peking University First Hospital, Beijing, China
| | | |
Collapse
|
6
|
Vinereanu D, Al-Khalidi HR, Rao MP, He W, Lopes RD, Bahit CM, Ciobanu AO, Fox KA, Pokorney SD, Xian Y, Jiang J, Kamath DY, Berwanger O, Tajer C, Huo Y, Xavier D, Granger CB. Regional differences in presentation and antithrombotic treatment of patients with atrial fibrillation: Baseline characteristics from a clustered randomized trial to IMProve treatment with AntiCoagulanTs in patients with atrial fibrillation (IMPACT-AF). Am Heart J 2017; 192:38-47. [PMID: 28938962 DOI: 10.1016/j.ahj.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/12/2017] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. However, there are few contemporary comparative data on AF from middle-income countries. METHODS Baseline characteristics of the IMPACT-AF trial were analyzed to assess regional differences in presentation and antithrombotic treatment of AF from 5 middle-income countries (Argentina, Brazil, China, India, and Romania) and factors associated with antithrombotic treatment prescription. RESULTS IMPACT-AF enrolled 2281 patients (69 ± 11 years, 47% women) at 48 sites. Overall, 66% of patients were on anticoagulation at baseline, ranging from 38% in China to 91% in Brazil. The top 3 reasons for not prescribing an anticoagulant were patient preference/refusal (26%); concomitant antiplatelet therapy (15%); and risks outweighing the benefits, as assessed by the physician (13%). In a multivariable model, the most significant factors associated with prescription of oral anticoagulants were no prior major bleeding (odds ratio [OR] = 4.34; 95% CI = 2.22-8.33), no alcohol abuse (OR = 2.27; 95% CI = 1.12-4.55), and history of rheumatic valvular heart disease (OR = 2.10; 95% CI = 1.36-3.26), with a strong predictive accuracy (c statistic = 0.85), whereas the most significant factors associated with prescription of a combination of oral anticoagulants and antiplatelet drugs were prior coronary revascularization (OR = 5.10; 95% CI = 2.88-9.05), prior myocardial infarction (OR = 2.24; 95% CI = 1.38-3.63), and no alcohol abuse (OR = 2.22; 95% CI = 1.11-4.55), with a good predictive accuracy (c statistic = 0.76). CONCLUSIONS IMPACT-AF provides contemporary data from 5 middle-income countries regarding antithrombotic treatment of AF. Lack of prior major bleeding and coronary revascularization were the most important factors associated with prescription of oral anticoagulants and their combination with antiplatelet drugs, respectively.
Collapse
Affiliation(s)
- Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania.
| | | | - Meena P Rao
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Wensheng He
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Federal University of São Paulo, São Paulo, Brazil; Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil
| | | | - Andrea O Ciobanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania
| | - Kathleen A Fox
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Sean D Pokorney
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Ying Xian
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC
| | - Jie Jiang
- Peking University First Hospital, Beijing, China
| | - Deepak Y Kamath
- St John's Medical College and Research Institute, Bangalore, India
| | - Otavio Berwanger
- Federal University of São Paulo, São Paulo, Brazil; Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil
| | | | - Yong Huo
- Peking University First Hospital, Beijing, China
| | - Denis Xavier
- St John's Medical College and Research Institute, Bangalore, India
| | | |
Collapse
|
7
|
Murphy A, Biringanine M, Roberts B, Stringer B, Perel P, Jobanputra K. Diabetes care in a complex humanitarian emergency setting: a qualitative evaluation. BMC Health Serv Res 2017. [PMID: 28645279 PMCID: PMC5481869 DOI: 10.1186/s12913-017-2362-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Evidence is urgently needed from complex emergency settings to support efforts to respond to the increasing burden of diabetes mellitus (DM). We conducted a qualitative study of a new model of DM health care (Integrated Diabetic Clinic within an Outpatient Department [IDC-OPD]) implemented by Médecins Sans Frontières (MSF) in Mweso Hospital in eastern Democratic Republic of Congo (DRC). We aimed to explore patient and provider perspectives on the model in order to identify factors that may support or impede it. Methods We used focus group discussions (FGDs; two discussions, each with eight participants) and individual semi-structured qualitative interviews (seven patients and 10 staff) to explore experience of and perspectives on the IDC-OPD. Participants were recruited purposively to represent a range of DM disease severity and staff functions respectively, and to ensure the age and gender distribution was representative of the population of DM patients registered in the clinic. Data were coded in NVivo10© and analysed using an inductive thematic approach. Results There appears to be little awareness surrounding DM in patient communities, resulting in delays presenting to hospital. Patients describe their first reactions to symptoms as fear and confusion, often assuming symptoms are of another disease (e.g. HIV/AIDS). They often express disbelief that they could have DM (e.g. stating DM is a ‘rich man’s disease’) and lack acceptance that there is no cure. Patients experienced difficulty travelling to appointments, exacerbated by flare-ups in the conflict. Providing psycho-social and sensitisation activities in a group setting appears to offer an opportunity for patients to support each other in their effort to adhere to drug treatment and follow-up appointments. All patients reported great difficulty in adhering to the recommended diet, which was viewed as unaffordable and unavailable, and fear that this would be the biggest obstacle to maintaining their drug treatment (as treatment must be taken with food). Conclusion Our findings emphasize the importance of community awareness of DM and the value of treatment support, including psychosocial and educational support to DM patients and their families, and culturally sensitive, low-cost dietary advice, to ensuring the adoption and maintenance of DM treatment. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2362-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Adrianna Murphy
- The Centre for Health and Social Change, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK.
| | | | - Bayard Roberts
- The Centre for Health and Social Change, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK
| | - Beverley Stringer
- Médecins Sans Frontières (MSF), Manson Unit, 10 Furnival Street, EC4A 1AB, London, UK
| | - Pablo Perel
- Department of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, UK
| | - Kiran Jobanputra
- Médecins Sans Frontières (MSF), Manson Unit, 10 Furnival Street, EC4A 1AB, London, UK
| |
Collapse
|