Study protocol on Enhanced Primary Healthcare (EnPHC) interventions: a quasi-experimental controlled study on diabetes and hypertension management in primary healthcare clinics

Estimating the prevalence of select non-communicable diseases in Saudi Arabia using a population-based sample: econometric analysis with natural language processing

BACKGROUND

Non-communicable diseases (NCDs) are a major public health challenge globally, including in Saudi Arabia. However, measuring the true extent of NCD prevalence has been hampered by a paucity of nationally representative epidemiological studies.

OBJECTIVES

Assess the prevalence of selected NCDs, using population-based electronic health records and applying novel analytical methods to identify cases of NCDs.

DESIGN

Retrospective.

SETTINGS

A large healthcare network in Saudi Arabia.

PATIENTS AND METHODS

We included all beneficiaries aged 16 years or older (n=650 835[a]) and used the International Classification of Disease (ICD-10) codes, laboratory results, and associated medications to identify individuals with diabetes, obesity, hypertension, dyslipidemia, mental disorders, and injuries. For diabetes and hypertension, we used natural language processing (NLP) on clinical notes in the electronic health records. The prevalence of multimorbidity across age groups was also tabulated, and logistic regression was used to examine its association with glycemic control.

MAIN OUTCOME MEASURES

The primary outcomes measured were the prevalence of diabetes, hypertension, and multimorbidity, and their association with glycemic control.

SAMPLE SIZE

650 835 individuals aged 16 years or older.

RESULTS

The study population was relatively young, with 41.2% aged between 26 and 45 years, and around two-thirds were married. The prevalence of diabetes and hypertension was 18.5% (95% CI: 18.5-18.7) and 13.0% (95% CI: 12.9-13.1), respectively. Approximately 26.7% (95% CI: 26.7-26.8) of the population had multimorbidity, with levels increasing to 62.9% for those aged 65 or older. Multimorbidity was associated with a four-fold increase in the likelihood of poor glycemic control. NLP analysis suggested that the prevalence of diabetes or hypertension may be underestimated by no more than 1.5%.

CONCLUSIONS

The study suggests a higher prevalence of NCDs than earlier national estimates. Electronic health records with regular analysis provide an opportunity to estimate changes in the prevalence of NCDs in Saudi Arabia. Health policies and interventions are needed to address the high levels of multimorbidity, which adversely impact glycemic control.

LIMITATIONS

Retrospective design and reliance on electronic health records, which may not capture all cases of NCDs.

The Effectiveness of Enhanced Primary Healthcare (EnPHC) interventions on Type 2 diabetes management in Malaysia: Difference-in-differences (DID) analysis

AIMS

To evaluate the effectiveness of the Enhanced Primary Healthcare (EnPHC) interventions on process of care and intermediate clinical outcomes among type 2 diabetes patients.

METHODS

This was a quasi-experimental controlled study conducted in 20 intervention and 20 control public primary care clinics in Malaysia from November 2016 to June 2019. Type 2 diabetes patients aged 30 years and above were selected via systematic random sampling. Outcomes include process of care and intermediate clinical outcomes. Difference-in-differences analyses was conducted.

RESULTS

We reviewed 12,017 medical records of patients with type 2 diabetes. Seven process of care measures improved: HbA1c tests (odds ratio (OR) 3.31, 95% CI 2.13, 5.13); lipid test (OR 4.59, 95% CI 2.64, 7.97), LDL (OR 4.33, 95% CI 2.16, 8.70), and urine albumin (OR 1.99, 95% CI 1.12, 3.55) tests; BMI measured (OR 15.80, 95% CI 4.78, 52.24); cardiovascular risk assessment (OR 174.65, 95% CI 16.84, 1810.80); and exercise counselling (OR 1.18, 95% CI 1.04, 1.33). We found no statistically significant changes in intermediate clinical outcomes (i.e. HbA1c, LDL, HDL and BP control).

CONCLUSIONS

EnPHC interventions was successful in enhancing the quality of care, in terms of process of care, by changing healthcare providers behaviour.

Growing Up Unequal: Disparities of Childhood Overweight and Obesity in Indonesia's 514 Districts

BACKGROUND

Childhood obesity is a major public health concern as it increases the risk of premature death and adult disability. Globally, the latest estimates showed that more than 340 million children and adolescents between the ages of 5 and 19 were overweight or obese in 2016. This study aimed to investigate the disparities in childhood overweight and obesity across 514 districts in Indonesia, based on geographic and socioeconomic factors.

METHODS

Geospatial and quantitative analyses were performed using the latest Indonesian Basic Health Survey data from 2018. Dependent variables were rates of overweight and obesity among children aged 5-17 years including by gender.

RESULTS

This study found that the rates of overweight were 17.2%, 17.6%, and 16.8% among all children, boys, and girls, while the rates of obesity were 7.0%, 7.9%, and 6.1%, respectively. Boys were 1.30 times more likely to be obese than girls, while overweight was similar between both sexes. Urban cities had significantly higher prevalence of childhood overweight and obesity compared with rural districts by up to 1.26 and 1.32 times, respectively. In addition, the most developed region had significantly higher prevalence of childhood overweight and obesity than the least developed region by up to 1.37 and 1.38 times, respectively. With regard to socioeconomic factors, our analysis demonstrated a notable disparity in the prevalence of childhood overweight and obesity across income quintiles. Specifically, the wealthiest districts exhibited a 1.18 times higher prevalence of overweight and obesity among all children compared with the poorest districts. This association was particularly pronounced among boys; in the richest quintile, the prevalence of overweight and obesity was 1.24 and 1.26 times higher, respectively, in comparison to the poorest income quintile. In contrast, district-level education appears to exhibit an inverse relationship with the prevalence of childhood overweight and obesity, although the findings were not statistically significant.

Does the Disparity Patterning Differ between Diagnosed and Undiagnosed Hypertension among Adults? Evidence from Indonesia

Background: Healthcare systems in many low- and middle-income countries (LMICs) are not yet designed to tackle the high and increasing burden of non-communicable diseases (NCDs), including hypertension. As a result, a large proportion of people with disease or risk factors are undiagnosed. Policymakers need to understand the disparity better to act. However, previous analyses on the disparity in undiagnosed hypertension, especially from LMICs, are lacking. Our study assessed the geographic and socioeconomic disparity in undiagnosed hypertension and compared it with diagnosed hypertension. Methods: We used the Basic Health Survey (Riskesdas) 2018 and performed geospatial and quantitative analyses across 514 districts in Indonesia. Dependent variables included diagnosed and undiagnosed hypertension among adults (18+ years) and by gender. Results: A high prevalence of undiagnosed hypertension at 76.3% was found, with different patterns of disparity observed between diagnosed and undiagnosed hypertension. Diagnosed hypertension was 1.87 times higher in females compared with males, while undiagnosed hypertension rates were similar between genders. Urban areas had up to 22.6% higher rates of diagnosed hypertension, while undiagnosed hypertension was 11.4% more prevalent among females in rural areas. Districts with higher education rates had up to 25% higher diagnosed hypertension rates, while districts with lower education rates had 6% higher rates of undiagnosed hypertension among females. The most developed regions had up to 76% and 40% higher prevalence of both diagnosed and undiagnosed hypertension compared with the least developed regions. Conclusion: The disparity patterning differs between diagnosed and undiagnosed hypertension among adults in Indonesia. This highlights the need for effective measures, including healthcare system reforms to tackle NCDs in LMICs.

District-Level Inequalities in Hypertension among Adults in Indonesia: A Cross-Sectional Analysis by Sex and Age Group

BACKGROUND

An estimated 1.28 billion adults 30-79 years old had hypertension globally in 2021, of which two-thirds lived in low- and middle-income countries (LMICs). Previous studies on geographic and socioeconomic inequalities in hypertension among adults have limitations: (a) most studies used individual-level data, while evidence from locality-level data is also crucial for policymaking; (b) studies from LMICs are limited. Thus, our study examines geographic and socioeconomic inequalities in hypertension among adults across districts in Indonesia.

METHODS

We combined geospatial and quantitative analyses to assess the inequalities in hypertension across 514 districts in Indonesia. Hypertension data were obtained from the Indonesian Basic Health Survey (Riskesdas) 2018. Socioeconomic data were obtained from the World Bank. Six dependent variables included hypertension prevalence among all adults (18+ years), male adults, female adults, young adults (18-24 years), adults (25-59 years), and older adults (60+ years).

RESULTS

We also found significant geographic and socioeconomic inequalities in hypertension among adults across 514 districts. All hypertension indicators were higher in the most developed region than in the least developed region. Districts in the Java region had up to 50% higher prevalence of hypertension among all adults, males, females, young adults, adults, and older adults. Notably, districts in the Kalimantan region had the highest prevalence of hypertension, even compared to those in Java. Moreover, income level was positively associated with hypertension; the wealthiest districts had higher hypertension than the poorest districts by up to 30%, but only among males and older adults were statistically significant.

CONCLUSIONS

There were significant inequalities in hypertension among adults across 514 districts in the country. Policies to reduce such inequalities may need to prioritize more affluent urban areas and rural areas with a higher burden.

Disparities in Obesity Rates among Adults: Analysis of 514 Districts in Indonesia

BACKGROUND

Globally, it was estimated that over 650 million adults 18 years old and older were obese in 2016. It is an increasing global health challenge with a significant health and economic impact. Thus, understanding geographic and socioeconomic disparities in obesity among adults is crucial.

METHODS

We combined geospatial and quantitative analyses to assess the disparity in obesity across 514 districts in Indonesia. We used the Basic Health Survey (Riskesdas) 2018 for obesity data and the World Bank database for socioeconomic data. Dependent variables included obesity prevalence among all adults (18+ years), males, females, young adults (18-24 years), adults (25-59 years), and older adults (60+ years).

RESULTS

We found significant geographic and socioeconomic disparities in adult obesity in Indonesia. In terms of region, districts in Java and Bali had a significantly higher prevalence of obesity than those in Papua, Maluku, and Nusa Tenggara. Districts in Java had 29%, 32%, 60%, and 28% higher prevalence of obesity among all adults, female adults, young adults, and adults. By income, compared to the poorest ones, most affluent districts had a significantly higher prevalence of obesity; they had a 36%, 39%, 34%, 42%, 33%, and 73% higher prevalence of obesity among all adults, males, females, young adults, adults, and older adults. Similarly, by education, compared to the least educated ones, the most educated districts had a significantly higher prevalence of obesity; they had a 34%, 42%, 29%, 36%, and 80% higher prevalence of obesity among all adults, males, females, adults, and older adults.

CONCLUSIONS

There are significant disparities in adult obesity among 514 districts in Indonesia. Efforts by policymakers and stakeholders are needed to reduce obesity among adults, especially within districts with high prevalence.

Medication Regimen Complexity and Medication Burden Among Patients With Type 2 Diabetes Mellitus: A Retrospective Analysis

Introduction: Most type 2 diabetes mellitus (T2DM) patients with chronic conditions require multiple medications to achieve and maintain good glycemic control. Objective: This study assessed medication burden, regimen complexity, and adherence among T2DM patients and evaluate its association with glycemic control. Method: We analyzed data of 2,696 T2DM patients at public health clinics in Malaysia from January 2018 until May 2019. Medication burden was based on medication count, regimen complexity was measured using the validated Medication Regimen Complexity Index (MRCI) tool, and adherence was measured using proportion of days covered (PDC) formula. Logistic regression models were used to compute unadjusted and adjusted odds ratio (aOR) with 95% confidence interval (CI) for association between the medication parameters and glycemic control (HbA1c ≤ 7.0%) over a 90-day period. Results: The cohort mean age was 60.4 years old (±10.8) and 62.9% were female. Overall, the average medication count was 4.8 with MRCI score of 15.1. Mean adherence score (PDC) was 90%. High medication count and MRCI scores were associated with lower odds of achieving good glycemic control (aOR 0.88; 95% CI 0.82, 0.94 and aOR 0.89; 95% CI 0.87, 0.92, respectively) while inverse association was observed between adherence and HbA1c level (aOR 2.7, 95% CI 1.66, 5.19). Similar findings were observed for diabetes-specific measures. Conclusions: High medication count, high regimen complexity, and low medication adherence were associated with poor glycemic control over the 3-month follow-up period. These parameters could be used to identify patients with complex pharmacotherapy regimens so that targets for intervention can be taken to achieve optimum outcomes and ease of self-care.

Optimal cut-off points for adherence measure among patients with type 2 diabetes in primary care clinics: a retrospective analysis

Background

Medication adherence measures are often dichotomized to classify patients into those with good or poor adherence using a cut-off value ⩾80%, but this cut-off may not be universal across diseases or medication classes. This study aimed to examine the cut-off value that optimally distinguish good and poor adherence by using the medication possession ratio (MPR) and proportion of days covered (PDC) as adherence measures and glycated hemoglobin (HbA1c) as outcome measure among type 2 diabetes mellitus (T2DM) patients.

Method

We used pharmacy dispensing data of 1461 eligible T2DM patients from public primary care clinics in Malaysia treated with oral antidiabetic drugs between January 2018 and May 2019. Adherence rates were calculated during the period preceding the HbA1c measurement. Adherence cut-off values for the following conditions were compared: adherence measure (MPR versus PDC), assessment period (90-day versus 180-day), and HbA1c target (⩽7.0% versus ⩽8.0%).

Results

The optimal adherence cut-offs for MPR and PDC in predicting HbA1c ⩽7.0% ranged between 86.1% and 98.3% across the two assessment periods. In predicting HbA1c ⩽8.0%, the optimal adherence cut-offs ranged from 86.1% to 92.8%. The cut-off value was notably higher with PDC as the adherence measure, shorter assessment period, and a stricter HbA1c target (⩽7.0%) as outcome.

Conclusion

We found that optimal adherence cut-off appeared to be slightly higher than the conventional value of 80%. The adherence thresholds may vary depending on the length of assessment period and outcome definition but a reasonably wise cut-off to distinguish good versus poor medication adherence to be clinically meaningful should be at 90%.