Quality of medical prescriptions in diabetes and hypertension management in Kerala and its associated factors

Factors associated with patients' healthcare-seeking behavior and related clinical outcomes under China's hierarchical healthcare delivery system

Introduction

The hierarchical healthcare delivery system is an important measure to improve the allocation of medical resources and promote equitable distribution of basic medical and health services. It is one of the key factors in the success or failure of China's medical reform. This study aims to analyze the factors influencing patients' healthcare-seeking behaviors, including socioeconomic and clinical outcomes, under China's hierarchical healthcare delivery system, and to provide potential solutions.

Methods

Patients receiving outpatient treatment in the past 14 days and inpatient care in the past 1 year were investigated. The multivariate logistic regression was used to analyze the influencing factors of patient's medical treatment behavior selection, and to compare whether the clinical outcomes of primary medical institutions and grade A hospitals are the same.

Results

Nine thousand and ninety-eight person-times were included in the study. Of these, 4,538 patients were outpatients, 68.27% of patients were treated in primary medical institutions; 4,560 patients were hospitalized, 58.53% chose to be hospitalized in grade A hospitals. Provinces and cities, urban and rural areas, occupation, education level, medical insurance type, income, whether there are comorbid diseases, and doctors' medical behavior are the factors affecting the choice of medical treatment behavior. Patients who choose primary medical institutions and grade A hospitals have different control levels and control rate for the blood pressure, blood lipids, blood glucose.

Conclusion

Under the hierarchical diagnosis and treatment system, the patients' choice of hospital is mainly affected by their level of education, medical insurance types, and the inpatients are also affected by whether there are comorbid conditions. Clinical outcomes of choosing different levels of hospitals were different.

R. L, S. S, Panniyammakal J, Lavis A. Patients', carers' and healthcare providers' views of patient-held health records in Kerala, India: A qualitative exploratory study

INTRODUCTION

Poor medical information transfer across healthcare visits and providers poses a potential threat to patient safety. Patient-held health records (PHRs) may be used to facilitate informational continuity, handover communication and patient self-management. However, there are conflicting opinions on the effectiveness of PHRs, other than in maternal and child care. Moreover, the experiences of users of PHRs in low- and middle-income countries are critical in policy decisions but have rarely been researched.

AIM

This study aimed to explore similarities and differences in the perspectives of patients, carers and healthcare providers (HCPs) on the current PHRs for diabetes and hypertension in Kerala.

METHODS

A qualitative design was used comprising semistructured interviews with patients with diabetes/hypertension (n = 20), carers (n = 15) and HCPs (n = 17) in Kerala, India. Data were analysed using thematic analysis.

RESULTS

Themes generated regarding the experiences with PHRs from each user group were compared and contrasted. The themes that arose were organized under three headings: use of PHRs in everyday practice; the perceived value of PHR and where practice and value conflict. We found that in the use of PHRs in everyday practice, multiple PHRs posed challenges for patients carrying records and for HCPs locating relevant information. Most carers carried all patients' past PHRs, while patients made decisions on which PHR to take along based on the purpose of the healthcare visit. HCPs appreciated having PHRs but documented limited details in them. The perceived value of PHRs by each group for themselves was different. While HCPs placed value on PHRs for enabling better clinical decision-making, preventing errors and patient safety, patients perceived them as transactional tools for diabetes and hypertension medications; carers highlighted their value during emergencies.

CONCLUSION

Our findings suggest that users find a variety of values for PHRs. However, these perceived values are different for each user group, suggesting minimal functioning of PHRs for informational continuity, handover communication and self-management.

PATIENT AND PUBLIC INVOLVEMENT

Patients and carers were involved during the pilot testing of topic guides, consent and study information sheets. Patients and carers gave their feedback on the materials to ensure clarity and appropriateness within the context.

Effectiveness of a community-based education and peer support led by women's self-help groups in improving the control of hypertension in urban slums of Kerala, India: a cluster randomised controlled pragmatic trial

BACKGROUND

With less than 20% of people with hypertension achieving their target blood pressure (BP) goals, uncontrolled hypertension remains a major public health problem in India. We conducted a study to assess the effectiveness of a community-based education and peer support programme led by women's self-help group (SHG) members in reducing the mean systolic BP among people with hypertension in urban slums of Kochi city, Kerala, India.

METHODS

A cluster randomised controlled pragmatic trial was conducted where 20 slums were randomised to either the intervention or the control arms. In each slum, participants who had elevated BP (>140/90) or were on antihypertensive medications were recruited. The intervention was delivered through women's SHG members (1 per 20-30 households) who provided (1) assistance in daily hypertension management, (2) social and emotional support to encourage healthy behaviours and (3) referral to the primary healthcare system. Those in the control arm received standard of care. The primary outcome was change in mean systolic BP (SBP) after 6 months.

RESULTS

A total of 1952 participants were recruited-968 in the intervention arm and 984 in the control arm. Mean SBP was reduced by 6.26 mm Hg (SE 0.69) in the intervention arm compared with 2.16 mm Hg (SE 0.70) in the control arm; the net difference being 4.09 (95% CI 2.15 to 4.09), p<0.001.

CONCLUSION

This women's SHG members led community intervention was effective in reducing SBP among people with hypertension compared with those who received usual care, over 6 months in urban slums of Kerala, India.

TRIAL REGISTRATION NUMBER

CTRI/2019/12/022252.

Hypertension control in Kerala, India: a prescription-based study at primary and secondary level health care institutions

Objective

We undertook a prescription-based study to identify the provider and institution-level factors related to achieving guideline-recommended control of hypertension and diabetes mellitus in Kerala, India.

Methods

This cross-sectional study in primary and secondary care hospitals in Kerala included both public and private institutions. One practitioner was selected from each institution. Data on institutional and provider factors were collected using a structured questionnaire. Prescriptions were photographically captured and data on disease status and drugs prescribed were recorded. Factors associated with disease control were identified using binary logistic regression.

Results

Totally 4679 prescriptions were included for analysis. For hypertension-only patients, control levels were 31.5% and was significantly higher in public hospitals (Adjusted odds ratio (AOR) 1.96, 95% confidence intervals (CI) 1.50–2.57). Among patients with diabetes only, diabetes control was seen in 36.6%. When both conditions were present, control was achieved in only 17.0% patients. Being prescribed two or more drugs indicated lower control, whatever the respective condition. Among antihypertensive prescriptions rationality of 26.7% were questioned, such as lack of Renin Angiotensin System (RAS) inhibitor in diabetic hypertensives, dual RAS blockage, and indication for beta-blocker monotherapy.

Conclusions

In this prescription-based study in Kerala, India, a majority of hypertensive patients did not have controlled blood pressure levels, particularly if diabetes coexisted. This has serious implications as Kerala is the state with the highest burden of hypertension in India. Several prescription patterns were of questionable rationality. Further research and actions on rationality of anti-hypertensive prescriptions and barriers to treatment intensification is warranted.

Availability, price and affordability of essential medicines for managing cardiovascular diseases and diabetes: a statewide survey in Kerala, India

OBJECTIVE

Limited access to essential medicines (EMs) for cardiovascular disease (CVD) and diabetes is a major concern in low- and middle-income countries. We aimed to generate data on availability, price and affordability of EMs for CVD and diabetes in India.

METHODS

Using WHO/HAI survey methodology, we evaluated availability and prices of 23 EMs in 30 public sector facilities (government hospitals and semi-public/government-subsidised-discount-pharmacies (GSDPs)) and 60 private retail pharmacies across six districts in Kerala state, India (November 2018 - May 2019). Median Price Ratios (MPRs) were calculated by comparing consumer prices with international reference prices. We also analysed data (collected in July 2020) on six anti-hypertensive fixed-dose-combinations (FDCs) that were designated as 'essential' by the WHO in 2019.

RESULTS

Mean availability of surveyed generic EMs was 45.7% in government hospitals, 64.7% in GSDPs and 72.0% in private retail pharmacies. On average, the most-sold and highest-priced generics, respectively, were 6.6% and 8.9% costlier than the lowest-priced generics (LPG). Median MPR for LPG was 2.71 in private retail and 2.25 in GSDPs. Monthly supply of LPG would cost the lowest-paid worker 1.11 and 0.79 days' wages in private retail and GSDPs, respectively. Mean availability of the surveyed FDCs was poor (private retail: 15-85%; GSDPs: 8.3-66.7%), and the private retail prices of FDCs were comparable to the sum of corresponding constituent monotherapies.

CONCLUSION

Availability of CVD and diabetes EMs fall short of WHO's 80% target in both sectors. Although availability in the private retail pharmacies was near-optimal, prices appear unaffordable compared to GSDPs. Initiatives such as mandating generic prescribing, adding the WHO-approved FDCs in local EM lists, improving price transparency, and streamlining medicine supply to ensure equitable access to EMs, especially in the public sector, are crucial in tackling Kerala's ever-increasing CVD burden.