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Vijay A, Mohanan PP, Kondal D, Baldridge A, Davies D, Devarajan R, Unni G, Abdullakutty J, Natesan S, Joseph J, Jayagopal PB, Joseph S, Gopinath R, Prabhakaran D, Huffman MD, Agarwal A. Polypill Eligibility for Patients with Heart Failure With Reduced Ejection Fraction in South India: A Secondary Analysis of a Prospective, Interrupted Time Series Study. J Am Heart Assoc 2021; 10:e021676. [PMID: 34612082 PMCID: PMC8751873 DOI: 10.1161/jaha.121.021676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Aishwarya Vijay
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | | | - Dimple Kondal
- Centre for Chronic Disease Control New Delhi Delhi India
| | - Abigail Baldridge
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | | | - Raji Devarajan
- Centre for Chronic Disease Control New Delhi Delhi India
| | - Govindan Unni
- Jubilee Mission Medical College and Hospital Thrissur Kerala India
| | | | | | | | | | - Stigi Joseph
- Little Flower Hospital and Research Centre Angamaly Kerala India
| | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control New Delhi Delhi India.,The Public Health Foundation of India Gurugram Haryana India
| | - Mark D Huffman
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL.,Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.,The George Institute for Global Health University of New South Wales Sydney New South Wales Australia
| | - Anubha Agarwal
- Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
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Agarwal A, Mohanan PP, Kondal D, Chopra A, Baldridge AS, Davies D, Devarajan R, Unni G, Abdullakutty J, Natesan S, Joseph J, Jayagopal PB, Joseph S, Gopinath R, Prabhakaran D, Huffman MD. Presentation, Management, and In-Hospital Outcomes of Patients with Acute Heart Failure in South India by Sex: A Secondary Analysis of a Prospective, Interrupted Time Series Study. Glob Heart 2021; 16:63. [PMID: 34692388 PMCID: PMC8485866 DOI: 10.5334/gh.1043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/25/2021] [Indexed: 11/20/2022] Open
Abstract
Background Sex differences in presentation, management, and outcomes of heart failure (HF) have been observed, but it is uncertain whether these differences exist in South India. Objective We describe sex differences in presentation, management, and in-hospital outcomes in patients hospitalized with HF in South India and explore sex-based differences in the effect of the quality improvement intervention in a secondary analysis of a prospective, interrupted time series study. Methods The Heart Failure Quality Improvement in Kerala (HF QUIK) study evaluated the effect of a quality improvement toolkit on process of care measures and clinical outcomes in patients hospitalized with HF in eight hospitals in Kerala using an interrupted time series design from February 2018 to August 2018. The primary outcome was guideline-directed medical therapy (GDMT) at hospital discharge for patients with HF with reduced ejection fraction (HFrEF). We performed sex-stratified analyses using mixed effect logistic regression models. Results Among 1,400 patients, 536 (38.3%) were female. Female patients were older (69.6 vs. 65 years, p < 0.001), were less likely to have an ischemic etiology of HF (control period: 78.2% vs. 87.5%; intervention period: 83.6% vs. 91.5%; p < 0.05 for both) and were less likely to undergo coronary angiography or percutaneous coronary intervention. The quality improvement intervention had similar effects on the odds of GDMT at discharge in females with HFrEF (adjusted OR 1.79, 95% CI 0.92, 3.47) and males with HFrEF (adjusted OR 1.68, 95% CI 1.07, 2.64, pinteraction = 0.69). Conclusions We observed sex-specific differences in presentation and procedural management of patients with HF but no differences in the effect of the quality improvement intervention on discharge GDMT rates. Both male and female patients with HFrEF remained undertreated in the study intervention period, demonstrating the need for implementation strategies to close the HFrEF treatment gap in South India.
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Affiliation(s)
- Anubha Agarwal
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | | | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, Delhi, IN
| | - Aashima Chopra
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Abigail S. Baldridge
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | | | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, Delhi, IN
| | - Govindan Unni
- Jubilee Mission Medical College and Hospital, Thrissur, Kerala, IN
| | | | | | | | | | - Stigi Joseph
- Little Flower Hospital and Research Centre, Angamaly, Kerala, IN
| | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, Delhi, IN
- The Public Health Foundation of India, Gurugram, Haryana, IN
| | - Mark D. Huffman
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, AU
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Masood MQ, Singh K, Kondal D, Ali MK, Mawani M, Devarajan R, Menon U, Varthakavi P, Viswanathan V, Dharmalingam M, Bantwal G, Sahay R, Khadgawat R, Desai A, Prabhakaran D, Narayan KMV, Tandon N. Factors affecting achievement of glycemic targets among type 2 diabetes patients in South Asia: Analysis of the CARRS trial. Diabetes Res Clin Pract 2021; 171:108555. [PMID: 33242515 PMCID: PMC7854496 DOI: 10.1016/j.diabres.2020.108555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/12/2020] [Accepted: 11/10/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the predictors of achieving and maintaining guideline-recommended glycemic control in people with poorly controlled type 2 diabetes. METHODS We analyzed data from the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) Trial (n = 1146), to identify groups that achieved guideline-recommended glycemic control (HbA1c < 7%) and those that remained persistently poorly controlled (HbA1c > 9%) over a median of 28 months of follow-up. We used generalized estimation equations (GEE) analysis for each outcome i.e. achieving guideline-recommended control and persistently poorly controlled and constructed four regression models (demographics, disease-related, self-care, and other risk factors) separately to identify predictors of HbA1c < 7% and HbA1c > 9% at the end of the trial, adjusting for trial group assignment and site. RESULTS In the final multivariate model, adherence to prescribed medications (RR: 1.46, 95%CI: 1.09, 1.95), adherence to diet plans (RR: 1.79, 95% CI: 1.43, 2.23) and middle-aged: 50-64 years (RR: 1.32; 95% CI: 1.02-1.71) were associated with achieving guideline-recommended control (HbA1c < 7%). Presence of microvascular complications (RR: 0.70; 95%CI: 0.53-0.92) reduced the probability of achieving guideline-recommended glycemic control (HbA1c 7%). Further, longer duration of diabetes (>15 years), RR: 1.41; 95% CI: 1.15, 1.72, hyperlipidemia, RR: 1.19; 95% CI: 1.06, 1.34 and younger age group (35-49 years vs. >64 years: RR: 0.61; 95% CI: 0.47-0.79) were associated with persistently poor glycemic control (HbA1c > 9%). CONCLUSION To achieve and maintain guideline-recommended glycemic control, care delivery models must put additional emphasis and effort on patients with longer disease duration, younger people and those having microvascular complications and hyperlipidemia.
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Affiliation(s)
- Muhammad Q Masood
- Aga Khan University, Department of Medicine, Section of Endocrinology and Diabetes, Stadium Road, Karachi 74800, Pakistan.
| | - Kavita Singh
- Public Health Foundation of India, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon 122 002, Haryana, India.
| | - Dimple Kondal
- Public Health Foundation of India, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon 122 002, Haryana, India.
| | - Mohammed K Ali
- Emory University, Rollins School of Public Health, 1518 Clifton Road, Rm CNR 701, Atlanta, GA 30322, USA.
| | - Minaz Mawani
- Aga Khan University, Department of Medicine, Section of Endocrinology and Diabetes, Stadium Road, Karachi 74800, Pakistan.
| | - Raji Devarajan
- Center of Excellence - Center for CArdio-metabolic Risk Reduction in South Asia, Public Health Foundation of India, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon 122 002, Haryana, USA.
| | - Usha Menon
- Amrita Institute of Medical Sciences, Department of Endocrinology & Diabetes, AIMS Ponekkara P.O., Kochi 682 041, Kerala, India.
| | - Premlata Varthakavi
- TNM College & BYL Nair Charity Hospital, Department of Endocrinology, Dr. A. L. Nair Road, Mumbai Central, Mumbai 400 008, Maharashtra, India.
| | - Vijay Viswanathan
- MV Hospital for Diabetes & Diabetes Research Centre, No 4, West Madha Church Street, Royapuram, Chennai 600 013, Tamil Nadu, India.
| | - Mala Dharmalingam
- Bangalore Endocrinology & Diabetes Research Centre, #35, 5th Cross, Malleswaram Circle, Bangalore 560 003, Karantaka, India.
| | - Ganapathi Bantwal
- St. John's Medical College & Hospital, Department of Endocrinology, Sarjapur Road, Koramangala, Bangalore 560 034, Karantaka, India.
| | - Rakesh Sahay
- Osmania General Hospital, Department of Endocrinology, 2nd Floor, Golden Jubilee Block, Afzalgunj, Hyderabad 500 012, Telangana, India.
| | - Rajesh Khadgawat
- All India Institute of Medical Sciences, Department of Endocrinology & Metabolism, Biotechnology Block, 3rd Floor, Ansari Nagar, New Delhi 110 029, India.
| | - Ankush Desai
- Goa Medical College, Endocrine Unit, Department of Medicine, Bambolim, Goa 403202, India.
| | - Dorairaj Prabhakaran
- Public Health Foundation of India, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon 122 002, Haryana, India.
| | - K M Venkat Narayan
- Emory University, Rollins School of Public Health, 1518 Clifton Road, Rm CNR 7049, Atlanta, GA 30322, USA.
| | - Nikhil Tandon
- All India Institute of Medical Sciences, Department of Endocrinology & Metabolism, Biotechnology Block, 3rd Floor, Rm #312, Ansari Nagar, New Delhi 110 029, India.
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Agarwal A, Mohanan PP, Kondal D, Baldridge A, Davies D, Devarajan R, Unni G, Abdullakutty J, Natesan S, Joseph J, Jayagopal PB, Joseph S, Gopinath R, Huffman MD, Prabhakaran D. Effect of a quality improvement intervention for acute heart failure in South India: An interrupted time series study. Int J Cardiol 2020; 329:123-129. [PMID: 33358838 DOI: 10.1016/j.ijcard.2020.12.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/16/2020] [Accepted: 12/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although quality improvement interventions for acute heart failure have been studied in high-income countries, none have been studied in low- or middle-income country settings where quality of care can be lower. We evaluated the effect of a quality improvement toolkit on process of care measures and clinical outcomes in patients hospitalized for acute heart failure in 8 hospitals in Kerala, India utilizing an interrupted time series design from February 2018 to August 2018. METHODS The quality improvement toolkit included checklists, audit-and-feedback reports, and patient education materials. The primary outcome was rate of discharge guideline-directed medical therapy for patients with heart failure with reduced ejection fraction. We used mixed effect logistic regression and interrupted time series models for analysis. RESULTS Among 1400 participants, mean (SD) age was 66.6 (12.2) years, and 38% were female. Mean (SD) left ventricular ejection fraction was 35.2% (9.7%). The primary outcome was observed in 41.3% of participants in the intervention period and 28.1% of participants in the control period (difference 13.2%; 95% CI 6.8, 19.0; adjusted OR = 1.70; 95% CI 1.17, 2.48). Interrupted time series model demonstrated highest rate of guideline-directed medical therapy at discharge in the initial weeks following intervention delivery with a concomitant decline over time. Improvements were observed in discharge process of care measures, including diet counseling, weight monitoring instructions, and scheduling of outpatient clinic follow-up but not hospital length of stay nor inpatient mortality. CONCLUSIONS Higher rates of guideline-directed medical therapy at discharge were observed in Kerala. Broader implementation of this quality improvement intervention may improve heart failure care in low- and middle-income countries.
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Affiliation(s)
- Anubha Agarwal
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | | | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, Delhi, India
| | - Abigail Baldridge
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Divin Davies
- WestFort Hi-Tech Hospital, Thrissur, Kerala, India
| | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, Delhi, India
| | - Govindan Unni
- Jubilee Mission Medical College and Hospital, Thrissur, Kerala, India
| | | | | | | | | | - Stigi Joseph
- Little Flower Hospital and Research Centre, Angamaly, Kerala, India
| | - Rajesh Gopinath
- Amala Institute of Medical Sciences, Thrissur, Kerala, India
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, Delhi, India; The Public Health Foundation of India, Gurugram, Haryana, India
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Prabhakaran D, Chandrasekaran AM, Singh K, Mohan B, Chattopadhyay K, Chadha DS, Negi PC, Bhat P, Sadananda KS, Ajay VS, Singh K, Praveen PA, Devarajan R, Kondal D, Soni D, Mallinson P, Manchanda SC, Madan K, Hughes AD, Chathurvedi N, Roberts I, Ebrahim S, Reddy KS, Tandon N, Pocock S, Roy A, Kinra S. Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial. J Am Coll Cardiol 2020; 75:1551-1561. [PMID: 32241371 PMCID: PMC7132532 DOI: 10.1016/j.jacc.2020.01.050] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly). OBJECTIVES This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial. METHODS The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life-5 Dimensions-5 Level visual analogue scale at 12 weeks. RESULTS MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes). CONCLUSIONS Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408).
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Affiliation(s)
- Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India; Public Health Foundation of India, New Delhi, India; London School of Hygiene and Tropical Medicine, London, United Kingdom; Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | | | - Kalpana Singh
- Centre for Chronic Disease Control, New Delhi, India
| | | | - Kaushik Chattopadhyay
- London School of Hygiene and Tropical Medicine, London, United Kingdom; The University of Nottingham, Nottingham, United Kingdom
| | | | | | - Prabhavathi Bhat
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | | | - Vamadevan S Ajay
- Centre for Chronic Disease Control, New Delhi, India; Public Health Foundation of India, New Delhi, India
| | - Kavita Singh
- Centre for Chronic Disease Control, New Delhi, India
| | - Pradeep A Praveen
- Centre for Chronic Disease Control, New Delhi, India; All India Institute of Medical Sciences, New Delhi, India
| | | | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, India
| | - Divya Soni
- Centre for Chronic Disease Control, New Delhi, India
| | - Poppy Mallinson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Alun D Hughes
- MRC Unit for Lifelong Health and Ageing at University College London, London, United Kingdom; Imperial College London, London, United Kingdom
| | - Nishi Chathurvedi
- MRC Unit for Lifelong Health and Ageing at University College London, London, United Kingdom; Imperial College London, London, United Kingdom
| | - Ian Roberts
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Shah Ebrahim
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Nikhil Tandon
- All India Institute of Medical Sciences, New Delhi, India
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ambuj Roy
- All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Kinra
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Shah MK, Kondal D, Patel SA, Singh K, Devarajan R, Shivashankar R, Ajay VS, Menon VU, Varthakavi PK, Viswanathan V, Dharmalingam M, Bantwal G, Sahay RK, Masood MQ, Khadgawat R, Desai A, Prabhakaran D, Narayan KMV, Tandon N, Ali MK. Effect of a multicomponent intervention on achievement and improvements in quality-of-care indices among people with Type 2 diabetes in South Asia: the CARRS trial. Diabet Med 2020; 37:1825-1831. [PMID: 31479537 PMCID: PMC7051882 DOI: 10.1111/dme.14124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2019] [Indexed: 11/30/2022]
Abstract
AIMS To evaluate whether and what combinations of diabetes quality metrics were achieved in a multicentre trial in South Asia evaluating a multicomponent quality improvement intervention that included non-physician care coordinators to promote adherence and clinical decision-support software to enhance physician practices, in comparision with usual care. METHODS Using data from the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, we evaluated the proportions of trial participants achieving specific and combinations of five diabetes care targets (HbA1c <53 mmol/mol [7%], blood pressure <130/80 mmHg, LDL cholesterol <2.6 mmol/L, non-smoking status, and aspirin use). Additionally, we examined the proportions of participants achieving the following risk factor improvements from baseline: ≥11-mmol/mol (1%) reduction in HbA1c , ≥10-mmHg reduction in systolic blood pressure, and/or ≥0.26-mmol/l reduction in LDL cholesterol. RESULTS Baseline characteristics were similar in the intervention and usual care arms. Overall, 12.3%, 29.4%, 36.5%, 19.5% and 2.2% of participants in the intervention group and 16.2%, 38.3%, 31.6%, 11.3% and 0.8% of participants in the usual care group achieved any one, two, three, four or five targets, respectively. We noted sizeable improvements in HbA1c , blood pressure and cholesterol, and found that participants in the intervention group were twice as likely to achieve improvements in all three indices at 12 months that were sustained over 28 months of the study [relative risk 2.1 (95% CI 1.5,2.8) and 1.8 (95% CI 1.5,2.3), respectively]. CONCLUSIONS The intervention was associated with significantly higher achievement of and greater improvements in composite diabetes quality care goals. However, among these higher-risk participants, very small proportions achieved the complete group of targets, which suggests that achievement of multiple quality-of-care goals is challenging and that other methods may be needed in closing care gaps.
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Affiliation(s)
- M K Shah
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - D Kondal
- Centre of Excellence, Centre for Cardiometabolic Risk Reduction in South Asia, Public Health Foundation of India, Gurgaon, India
| | - S A Patel
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - K Singh
- Centre of Excellence, Centre for Cardiometabolic Risk Reduction in South Asia, Public Health Foundation of India, Gurgaon, India
| | - R Devarajan
- Centre of Excellence, Centre for Cardiometabolic Risk Reduction in South Asia, Public Health Foundation of India, Gurgaon, India
| | - R Shivashankar
- Centre for Chronic Disease Control India, Public Health Foundation of India, Gurgaon, India
| | - V S Ajay
- Centre of Excellence, Centre for Cardiometabolic Risk Reduction in South Asia, Public Health Foundation of India, Gurgaon, India
| | - V U Menon
- Department of Endocrinology and Diabetes, Amrita Institute of Medical Sciences, Kerala, India
| | - P K Varthakavi
- Department of Endocrinology, TNM College and BYL Nair Charity Hospital, Mumbai, India
| | - V Viswanathan
- MV Hospital for Diabetes & Diabetes Research Centre, Chennai, India
| | - M Dharmalingam
- Bangalore Endocrinology and Diabetes Research Centre, Karnataka, India
| | - G Bantwal
- Department of Endocrinology, St John's Medical College and Hospital, Karnataka, India
| | - R K Sahay
- Department of Endocrinology, Osmania General Hospital, Hyderabad, India
| | - M Q Masood
- Department of Medicine, Section of Endocrinology and Diabetes, Aga Khan University, Karachi, Pakistan
| | - R Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - A Desai
- Department of Medicine Endocrine Unit, Goa Medical College, Goa, India
| | - D Prabhakaran
- Department of Medicine Endocrine Unit, Goa Medical College, Goa, India
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
| | - K M V Narayan
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - N Tandon
- Department of Medicine, Section of Endocrinology and Diabetes, Aga Khan University, Karachi, Pakistan
| | - M K Ali
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Affiliation(s)
- Shifalika Goenka
- Centre for Chronic Disease Control, New Delhi, India and Public Health Foundation of India, Gurugram, Haryana, India.
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Yoo SGK, Davies D, Mohanan PP, Baldridge AS, Charles PM, Schumacher M, Bhalla S, Devarajan R, Hirschhorn LR, Prabhakaran D, Huffman MD. Hospital-Level Cardiovascular Management Practices in Kerala, India. Circ Cardiovasc Qual Outcomes 2020; 12:e005251. [PMID: 31092020 DOI: 10.1161/circoutcomes.118.005251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Hospital management practices are associated with cardiovascular process of care measures and patient outcomes. However, management practices related to acute cardiac care in India has not been studied. Methods and Results We measured management practices through semistructured, in-person interviews with hospital administrators, physician managers, and nurse managers in Kerala, India between October and November 2017 using the adapted World Management Survey. Trained interviewers independently scored management interview responses (range: 1-5) to capture management practices ranging from performance data tracking to setting targets. We performed univariate regression analyses to assess the relationship between hospital-level factors and management practices. Using Pearson correlation coefficients and mixed-effect logistic regression models, we explored the relationship between management practices and 30-day major adverse cardiovascular events defined as all-cause mortality, reinfarction, stroke, or major bleeding. Ninety managers from 37 hospitals participated. We found suboptimal management practices across 3 management levels (mean [SD]: 2.1 [0.5], 2.0 [0.3], and 1.9 [0.3] for hospital administrators, physician managers, and nurse managers, respectively [ P=0.08]) with lowest scores related to setting organizational targets. Hospitals with existing healthcare quality accreditation, more cardiologists, and private ownership were associated with higher management scores. In our exploratory analysis, higher physician management practice scores related to operation, performance, and target management were correlated with lower 30-day major adverse cardiovascular event. Conclusions Management practices related to acute cardiac care in participating Kerala hospitals were suboptimal but were correlated with clinical outcomes. We identified opportunities to strengthen nonclinical practices to improve patient care.
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Affiliation(s)
- Sang Gune K Yoo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.G.K.Y., A.S.B., M.D.H.)
| | - Divin Davies
- WestFort Hi-Tech Hospital Ltd, Thrissur, India (D.D., P.P.M.)
| | | | - Abigail S Baldridge
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.G.K.Y., A.S.B., M.D.H.)
| | | | - Mark Schumacher
- Northwestern Memorial Healthcare, Chicago, IL (P.M.C., M.S.)
| | - Sandeep Bhalla
- Public Health Foundation of India, Gurgaon, India (S.B., D.P.)
| | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, India (R.D., D.P.)
| | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL (L.R.H.)
| | - Dorairaj Prabhakaran
- Public Health Foundation of India, Gurgaon, India (S.B., D.P.).,Centre for Chronic Disease Control, New Delhi, India (R.D., D.P.).,London School of Hygiene and Tropical Medicine, London, United Kingdom (D.P.)
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.G.K.Y., A.S.B., M.D.H.)
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Devarajan R, Prabhakaran D, Goenka S. Built environment for physical activity-An urban barometer, surveillance, and monitoring. Obes Rev 2020; 21:e12938. [PMID: 31701653 PMCID: PMC6916279 DOI: 10.1111/obr.12938] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 12/19/2022]
Abstract
The Lancet Commission on Obesity (LCO), also known as the "syndemic commission," states that radical changes are required to harness the common drivers of "obesity, undernutrition, and climate change." Urban design, land use, and the built environment are few such drivers. Holding individuals responsible for obesity detracts from the obesogenic built environments. Pedestrian priority and dignity, wide pavements with tree canopies, water fountains with potable water, benches for the elderly at regular intervals, access to open-green spaces within 0.5-km radius and playgrounds in schools are required. Facilities for physical activity at worksite, prioritization of staircases and ramps in building construction, redistribution of land use, and access to quality, adequate capacity, comfortable, and well-networked public transport, which are elderly and differently abled sensitive with universal design are some of the interventions that require urgent implementation and monitoring. An urban barometer consisting of valid relevant indicators aligned to the sustainable development goals (SDGs), UN-Habitat-3 and healthy cities, should be considered a basic human right and ought to be mounted for purposes of surveillance and monitoring. A "Framework Convention on Built Environment and Physical Activity" needs to be taken up by WHO and the UN for uptake and implementation by member countries.
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Affiliation(s)
- Raji Devarajan
- Department of Physical Activity and Obesity Prevention, Centre for Chronic Disease Control, New Delhi, India
| | - Dorairaj Prabhakaran
- Executive Director, Centre for Chronic Disease Control, New Delhi, India.,Centre for Chronic Conditions & Injuries, Public Health Foundation of India, Gurugram, India.,Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Shifalika Goenka
- Department of Physical Activity and Obesity Prevention, Centre for Chronic Disease Control, New Delhi, India.,Centre for Chronic Conditions & Injuries, Public Health Foundation of India, Gurugram, India.,Department of Social and Behavioral Sciences, Indian Institute of Public Health-Delhi, Gurugram, India
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10
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Mohanan PP, Huffman MD, Baldridge AS, Devarajan R, Kondal D, Zhao L, Ali M, Joseph J, Eapen K, Krishnan MN, Menon J, Thomas M, Lloyd-Jones DM, Harikrishnan S, Prabhakaran D. Microeconomic Costs, Insurance, and Catastrophic Health Spending Among Patients With Acute Myocardial Infarction in India: Substudy of a Randomized Clinical Trial. JAMA Netw Open 2019; 2:e193831. [PMID: 31099866 PMCID: PMC6537817 DOI: 10.1001/jamanetworkopen.2019.3831] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Ischemic heart disease is the leading cause of death in India, and treatment can be costly. OBJECTIVE To evaluate individual- and household-level costs and impoverishing effects of acute myocardial infarction among patients in Kerala, India. DESIGN, SETTING, AND PARTICIPANTS This investigation was a prespecified substudy of the Acute Coronary Syndrome Quality Improvement in Kerala study, a stepped-wedge, cluster randomized clinical trial conducted between November 2014 and November 2016 across 63 hospitals in Kerala, India. In this cross-sectional substudy, individual- and household-level cost data were collected 30 days after hospital discharge from a sample of 2114 respondents from November 2014 to July 2016. Data were analyzed from July through October 2018 and in March 2019. EXPOSURES Health insurance status. MAIN OUTCOMES AND MEASURES The primary outcomes were detailed direct and indirect cost data associated with acute myocardial infarction and respondent ability to pay as well as catastrophic health spending and distress financing. Catastrophic health spending was defined as 40% or more of household expenditures minus food costs spent on health, and distress financing was defined as borrowing money or selling assets to cover health costs. Hierarchical regression models were used to evaluate the association between health insurance and measures of financial risk. Costs were converted from Indian rupees to international dollars (represented herein as "$"). RESULTS Among 2114 respondents, the mean (SD) age was 62.3 (12.7) years, 1521 (71.9%) were men, 1144 (54.1%) presented with an ST-segment elevation myocardial infarction, and 1600 (75.7%) had no health insurance. The median (interquartile range) expenditure among respondents was $480.4 ($112.5-$1733.0) per acute myocardial infarction encounter, largely driven by in-hospital expenditures. There was greater than 15-fold variability between the 25th and 75th percentiles. Individuals with or without health insurance had similar monthly incomes and annual household expenditures, yet individuals without health insurance had approximately $400 higher out-of-pocket cardiovascular health care costs (median [interquartile range] total cardiovascular expenditures among uninsured, $560.3 [$134.1-$1733.6] vs insured, $161.4 [$23.2-$1726.9]; P < .001). Individuals without health insurance also had a 24% higher risk of catastrophic health spending (adjusted risk ratio, 1.24; 95% CI, 1.07-1.43) and 3-fold higher risk of distress financing (adjusted risk ratio; 3.05; 95% CI, 1.45-6.44). CONCLUSIONS AND RELEVANCE The results of this study indicate that acute myocardial infarction carries substantial financial risk for patients in Kerala. Expansion of health insurance may be an important strategy for financial risk protection to disrupt the poverty cycle associated with cardiovascular diseases in India.
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Affiliation(s)
| | - Mark D. Huffman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Raji Devarajan
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Dimple Kondal
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Lihui Zhao
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mumtaj Ali
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Johny Joseph
- Department of Cardiology, Caritas Hospital, Kottyam, India
| | - Koshy Eapen
- Department of Cardiology, Samaritan Hospital, Pazhangad, India
| | | | - Jaideep Menon
- Department of Cardiology, Sree Narayana Institute of Medical Sciences, Ernakulam, India
| | - Manoj Thomas
- Department of Cardiology, St Joseph’s Hospital, Dharmagiri, India
| | | | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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11
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Singh K, Ali MK, Devarajan R, Shivashankar R, Kondal D, Ajay VS, Menon VU, Varthakavi PK, Viswanathan V, Dharmalingam M, Bantwal G, Sahay RK, Masood MQ, Khadgawat R, Desai A, Prabhakaran D, Narayan KMV, Phillips VL, Tandon N. Rationale and protocol for estimating the economic value of a multicomponent quality improvement strategy for diabetes care in South Asia. Glob Health Res Policy 2019; 4:7. [PMID: 30923749 PMCID: PMC6421672 DOI: 10.1186/s41256-019-0099-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Economic dimensions of implementing quality improvement for diabetes care are understudied worldwide. We describe the economic evaluation protocol within a randomised controlled trial that tested a multi-component quality improvement (QI) strategy for individuals with poorly-controlled type 2 diabetes in South Asia. METHODS/DESIGN This economic evaluation of the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) randomised trial involved 1146 people with poorly-controlled type 2 diabetes receiving care at 10 diverse diabetes clinics across India and Pakistan. The economic evaluation comprises both a within-trial cost-effectiveness analysis (mean 2.5 years follow up) and a microsimulation model-based cost-utility analysis (life-time horizon). Effectiveness measures include multiple risk factor control (achieving HbA1c < 7% and blood pressure < 130/80 mmHg and/or LDL-cholesterol< 100 mg/dl), and patient reported outcomes including quality adjusted life years (QALYs) measured by EQ-5D-3 L, hospitalizations, and diabetes related complications at the trial end. Cost measures include direct medical and non-medical costs relevant to outpatient care (consultation fee, medicines, laboratory tests, supplies, food, and escort/accompanying person costs, transport) and inpatient care (hospitalization, transport, and accompanying person costs) of the intervention compared to usual diabetes care. Patient, healthcare system, and societal perspectives will be applied for costing. Both cost and health effects will be discounted at 3% per year for within trial cost-effectiveness analysis over 2.5 years and decision modelling analysis over a lifetime horizon. Outcomes will be reported as the incremental cost-effectiveness ratios (ICER) to achieve multiple risk factor control, avoid diabetes-related complications, or QALYs gained against varying levels of willingness to pay threshold values. Sensitivity analyses will be performed to assess uncertainties around ICER estimates by varying costs (95% CIs) across public vs. private settings and using conservative estimates of effect size (95% CIs) for multiple risk factor control. Costs will be reported in US$ 2018. DISCUSSION We hypothesize that the additional upfront costs of delivering the intervention will be counterbalanced by improvements in clinical outcomes and patient-reported outcomes, thereby rendering this multi-component QI intervention cost-effective in resource constrained South Asian settings. TRIAL REGISTRATION ClinicalTrials.gov: NCT01212328.
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Affiliation(s)
- Kavita Singh
- Public Health Foundation of India, Center of Excellence - Center for CArdio-metabolic Risk Reduction in South Asia, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon, Haryana 122 002 India
- Centre for Chronic Disease Control, C 1/52, Second Floor, Safdarjung Development Area, New Delhi, 110016 India
| | - Mohammed K. Ali
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Rm CNR 7041, Atlanta, GA 30322 USA
| | - Raji Devarajan
- Public Health Foundation of India, Center of Excellence - Center for CArdio-metabolic Risk Reduction in South Asia, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon, Haryana 122 002 India
- Centre for Chronic Disease Control, C 1/52, Second Floor, Safdarjung Development Area, New Delhi, 110016 India
| | - Roopa Shivashankar
- Centre for Chronic Disease Control, C 1/52, Second Floor, Safdarjung Development Area, New Delhi, 110016 India
| | - Dimple Kondal
- Public Health Foundation of India, Center of Excellence - Center for CArdio-metabolic Risk Reduction in South Asia, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon, Haryana 122 002 India
- Centre for Chronic Disease Control, C 1/52, Second Floor, Safdarjung Development Area, New Delhi, 110016 India
| | - Vamadevan S. Ajay
- Public Health Foundation of India, Center of Excellence - Center for CArdio-metabolic Risk Reduction in South Asia, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon, Haryana 122 002 India
- Centre for Chronic Disease Control, C 1/52, Second Floor, Safdarjung Development Area, New Delhi, 110016 India
| | - V. Usha Menon
- Department of Endocrinology & Diabetes, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Ponekkara P.O., Kochi, Kerala 682 041 India
| | - Premlata K. Varthakavi
- Department of Endocrinology, TNM College & BYL Nair Charity Hospital, Dr. A. L. Nair Road, Mumbai Central, Mumbai, Maharashtra 400 008 India
| | - Vijay Viswanathan
- MV Hospital for Diabetes & Diabetes Research Centre, No 4, West Madha Church Street, Royapuram, Chennai, Tamil Nadu 600 013 India
| | - Mala Dharmalingam
- Bangalore Endocrinology & Diabetes Research Centre, #35, 5th Cross, Malleswaram Circle, Bangalore, Karnataka 560 003 India
| | - Ganapati Bantwal
- Department of Endocrinology, St. John’s Medical College & Hospital, Sarjapur Road, Koramangala, Bangalore, Karnataka 560 034 India
| | - Rakesh Kumar Sahay
- Department of Endocrinology, Osmania General Hospital, 2nd Floor, Golden Jubilee Block, Afzalgunj, Hyderabad, Telangana 500 012 India
| | - Muhammad Qamar Masood
- Department of Medicine, Section of Endocrinology and Diabetes, Aga Khan University, Stadium Road, Karachi, 74800 Pakistan
| | - Rajesh Khadgawat
- Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, Biotechnology Block, 3rd Floor, Ansari Nagar, New Delhi, 110 029 India
| | - Ankush Desai
- Endocrine Unit, Department of Medicine, Goa Medical College, Bambolim, Goa 403202 India
| | - Dorairaj Prabhakaran
- Public Health Foundation of India, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon, Haryana 122 002 India
- Centre for Chronic Disease Control, C 1/52, Second Floor, Safdarjung Development Area, New Delhi, 110016 India
- London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - K. M. Venkat Narayan
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Rm CNR 7049, Atlanta, GA 30322 USA
| | - Victoria L. Phillips
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322 USA
| | - Nikhil Tandon
- Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, Biotechnology Block, 3rd Floor, Rm #312, Ansari Nagar, New Delhi, 110 029 India
| | - On behalf of the CARRS Trial Group
- Public Health Foundation of India, Center of Excellence - Center for CArdio-metabolic Risk Reduction in South Asia, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon, Haryana 122 002 India
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Rm CNR 7041, Atlanta, GA 30322 USA
- Department of Endocrinology & Diabetes, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Ponekkara P.O., Kochi, Kerala 682 041 India
- Department of Endocrinology, TNM College & BYL Nair Charity Hospital, Dr. A. L. Nair Road, Mumbai Central, Mumbai, Maharashtra 400 008 India
- MV Hospital for Diabetes & Diabetes Research Centre, No 4, West Madha Church Street, Royapuram, Chennai, Tamil Nadu 600 013 India
- Bangalore Endocrinology & Diabetes Research Centre, #35, 5th Cross, Malleswaram Circle, Bangalore, Karnataka 560 003 India
- Department of Endocrinology, St. John’s Medical College & Hospital, Sarjapur Road, Koramangala, Bangalore, Karnataka 560 034 India
- Department of Endocrinology, Osmania General Hospital, 2nd Floor, Golden Jubilee Block, Afzalgunj, Hyderabad, Telangana 500 012 India
- Department of Medicine, Section of Endocrinology and Diabetes, Aga Khan University, Stadium Road, Karachi, 74800 Pakistan
- Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, Biotechnology Block, 3rd Floor, Ansari Nagar, New Delhi, 110 029 India
- Endocrine Unit, Department of Medicine, Goa Medical College, Bambolim, Goa 403202 India
- Public Health Foundation of India, 4th Floor, Plot No. 47, Sector 44, Institutional Area, Gurgaon, Haryana 122 002 India
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Rm CNR 7049, Atlanta, GA 30322 USA
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA 30322 USA
- Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, Biotechnology Block, 3rd Floor, Rm #312, Ansari Nagar, New Delhi, 110 029 India
- Centre for Chronic Disease Control, C 1/52, Second Floor, Safdarjung Development Area, New Delhi, 110016 India
- London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
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12
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Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, Brinsden H, Calvillo A, De Schutter O, Devarajan R, Ezzati M, Friel S, Goenka S, Hammond RA, Hastings G, Hawkes C, Herrero M, Hovmand PS, Howden M, Jaacks LM, Kapetanaki AB, Kasman M, Kuhnlein HV, Kumanyika SK, Larijani B, Lobstein T, Long MW, Matsudo VKR, Mills SDH, Morgan G, Morshed A, Nece PM, Pan A, Patterson DW, Sacks G, Shekar M, Simmons GL, Smit W, Tootee A, Vandevijvere S, Waterlander WE, Wolfenden L, Dietz WH. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Lancet 2019; 393:791-846. [PMID: 30700377 DOI: 10.1016/s0140-6736(18)32822-8] [Citation(s) in RCA: 1142] [Impact Index Per Article: 228.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/10/2018] [Accepted: 10/29/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Boyd A Swinburn
- School of Population Health, University of Auckland, Auckland, New Zealand; Global Obesity Centre, School of Health & Social Development, Deakin University, Geelong, VIC, Australia.
| | - Vivica I Kraak
- Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, VA, USA
| | - Steven Allender
- Global Obesity Centre, School of Health & Social Development, Deakin University, Geelong, VIC, Australia
| | | | - Phillip I Baker
- Institute for Physical Activity and Nutrition, Deakin University, Melbourne, VIC, Australia
| | - Jessica R Bogard
- Commonwealth Scientific and Industrial Research Organisation, Brisbane, QLD, Australia
| | | | | | - Olivier De Schutter
- Institute for Interdisciplinary Research in Legal Sciences, Catholic University of Louvain, Louvain-la-Neuve, Belgium
| | - Raji Devarajan
- Public Health Foundation of India, Centre for Chronic Disease Control, New Delhi, India
| | - Majid Ezzati
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Sharon Friel
- School of Regulation and Global Governance, Australian National University, Canberra, ACT, Australia
| | - Shifalika Goenka
- Public Health Foundation of India, Centre for Chronic Disease Control, New Delhi, India
| | - Ross A Hammond
- Center on Social Dynamics & Policy, The Brookings Institution, Washington, DC, USA; Public Health & Social Policy Department, Brown School, Washington University in St Louis, St Louis, MO, USA
| | - Gerard Hastings
- Institute for Social Marketing, University of Stirling, Stirling, UK
| | - Corinna Hawkes
- Centre for Food Policy, City University, University of London, London, UK
| | - Mario Herrero
- Commonwealth Scientific and Industrial Research Organisation, Brisbane, QLD, Australia
| | - Peter S Hovmand
- Social System Design Lab, Brown School, Washington University in St Louis, St Louis, MO, USA
| | - Mark Howden
- Climate Change Institute, Australian National University, Canberra, ACT, Australia
| | - Lindsay M Jaacks
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Ariadne B Kapetanaki
- Department of Marketing and Enterprise, Hertfordshire Business School, University of Hertfordshire, Hatfield, UK
| | - Matt Kasman
- Center on Social Dynamics & Policy, The Brookings Institution, Washington, DC, USA
| | - Harriet V Kuhnlein
- Centre for Indigenous Peoples' Nutrition and Environment, McGill University, Montreal, QC, Canada
| | | | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Michael W Long
- Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Victor K R Matsudo
- Physical Fitness Research Laboratory of São Caetano do Sul, São Caetano do Sul, São Paulo, Brazil
| | - Susanna D H Mills
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Alexandra Morshed
- Prevention Research Center, Brown School, Washington University in St Louis, St Louis, MO, USA
| | | | - An Pan
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | - Gary Sacks
- Global Obesity Centre, School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Meera Shekar
- Health, Nutrition, and Population Global Practice, The World Bank, Washington, DC, USA
| | | | - Warren Smit
- African Centre for Cities, University of Cape Town, Cape Town, South Africa
| | - Ali Tootee
- Diabetes Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Stefanie Vandevijvere
- School of Population Health, University of Auckland, Auckland, New Zealand; Scientific Institute of Public Health (Sciensano), Brussels, Belgium
| | - Wilma E Waterlander
- Department of Public Health Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Luke Wolfenden
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - William H Dietz
- Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
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13
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Huffman MD, Mohanan PP, Devarajan R, Baldridge AS, Kondal D, Zhao L, Ali M, Spertus JA, Chan PS, Natesan S, Abdullakutty J, Krishnan MN, Tp A, Renga S, Punnoose E, Unni G, Prabhakaran D, Lloyd-Jones DM. Health-Related Quality of Life at 30 Days Among Indian Patients With Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2019; 12:e004980. [PMID: 30755027 DOI: 10.1161/circoutcomes.118.004980] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite a high cardiovascular disease burden, data on patient-reported health status outcomes among individuals with cardiovascular disease in India are limited. METHODS AND RESULTS Between November 2014 and November 2016, we collected health-related quality of life data among 1261 participants in the ACS QUIK trial (Acute Coronary Syndrome Quality Improvement in Kerala). We used a translated, validated version of the Seattle Angina Questionnaire administered 30 days after discharge for acute myocardial infarction, wherein higher scores represent better health status. We compared results across sex, myocardial infarction type, and randomization status using regression models that account for clustering and temporal trends. Mean (SD) age was 60.8 (13.7) years, 62% were men, and 63% presented with ST-segment-elevation myocardial infarction. More than 2 out of 5 respondents (44%) experienced angina 30 days after hospitalization, but most (68% of respondents with angina; 27% of the total sample) experienced it less than once per week (Seattle Angina Questionnaire angina frequency score 60). Respondents rated high median (interquartile range [IQR]) scores for angina frequency (100.0 [80.0-100.0]) overall with similar unadjusted scores by sex, but between-hospitality variability was high. Median (IQR) physical limitation scale response was 58.3 (41.7-77.8), which is consistent with limitations in moderate- and high-intensity activities at 30-day follow-up. Older respondents had more angina frequency and physical limitations and lower treatment satisfaction and quality of life. Women had greater physical limitations (median [IQR], 52.8 [38.9-72.2] for women versus median [IQR], 61.1 [44.4-80.6] for men; P<0.01). Overall treatment satisfaction was high with median (IQR) score, 81.3 (75.0-93.8), but overall quality of life was lower with median (IQR) score, 66.7 (50.0-83.3). Allocation to the quality improvement intervention group had the strongest direct association with higher quality of life (difference, 4.2; P=0.03), but overall effects were modest. CONCLUSIONS This study represents the largest report of quality of life among myocardial infarction survivors in India with variability across age, sex, and quality improvement intervention status. Wide variability demonstrated across hospitals warrants further study. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT02256657.
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Affiliation(s)
- Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (M.D.H., A.S.B., L.Z., D.M.L.-J.)
| | - Padinhare P Mohanan
- Department of Cardiology, WestFort Hi-Tech Hospital, Ltd, Thrissur, India (P.P.M.)
| | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, India (R.D., D.K., M.A., D.P.).,Public Health Foundation of India, Gurgaon (R.D., D.K., M.A., D.P.)
| | - Abigail S Baldridge
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (M.D.H., A.S.B., L.Z., D.M.L.-J.)
| | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, India (R.D., D.K., M.A., D.P.).,Public Health Foundation of India, Gurgaon (R.D., D.K., M.A., D.P.)
| | - Lihui Zhao
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (M.D.H., A.S.B., L.Z., D.M.L.-J.)
| | - Mumtaj Ali
- Centre for Chronic Disease Control, New Delhi, India (R.D., D.K., M.A., D.P.).,Public Health Foundation of India, Gurgaon (R.D., D.K., M.A., D.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S., P.S.C.).,University of Missouri-Kansas City (J.A.S., P.S.C.)
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S., P.S.C.).,University of Missouri-Kansas City (J.A.S., P.S.C.)
| | | | | | | | - Abhilash Tp
- Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, India (A.T.P.)
| | - Sujay Renga
- Bishop Benziger Hospital, Kollam, India (S.R.)
| | - Eapen Punnoose
- Malankara Orthodox Syrian Church Medical College, Ernakulam, India (E.P.)
| | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India (R.D., D.K., M.A., D.P.).,Public Health Foundation of India, Gurgaon (R.D., D.K., M.A., D.P.).,London School of Hygiene and Tropical Medicine, United Kingdom (D.P.)
| | - Donald M Lloyd-Jones
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (M.D.H., A.S.B., L.Z., D.M.L.-J.)
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14
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Singh K, Devarajan R, Mohanan PP, Baldridge AS, Kondal D, Victorson DE, Karmali KN, Zhao L, Lloyd-Jones DM, Prabhakaran D, Goenka S, Huffman MD. Implementation and acceptability of a heart attack quality improvement intervention in India: a mixed methods analysis of the ACS QUIK trial. Implement Sci 2019; 14:12. [PMID: 30728053 PMCID: PMC6364470 DOI: 10.1186/s13012-019-0857-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 01/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ACS QUIK trial showed that a multicomponent quality improvement toolkit intervention resulted in improvements in processes of care for patients with acute myocardial infarction in Kerala but did not improve clinical outcomes in the context of background improvements in care. We describe the development of the ACS QUIK intervention and evaluate its implementation, acceptability, and sustainability. METHODS We performed a mixed methods process evaluation alongside a cluster randomized, stepped-wedge trial in Kerala, India. The ACS QUIK intervention aimed to reduce the rate of major adverse cardiovascular events at 30 days compared with usual care across 63 hospitals (n = 21,374 patients). The ACS QUIK toolkit intervention, consisting of audit and feedback report, admission and discharge checklists, patient education materials, and guidelines for the development of code and rapid response teams, was developed based on formative qualitative research in Kerala and from systematic reviews. After four or more months of the center's participation in the toolkit intervention phase of the trial, an online survey and physician interviews were administered. Physician interviews focused on evaluating the implementation and acceptability of the toolkit intervention. A framework analysis of transcripts incorporated context and intervening mechanisms. RESULTS Among 63 participating hospitals, 22 physicians (35%) completed online surveys. Of these, 17 (77%) respondents reported that their hospital had a cardiovascular quality improvement team, 18 (82%) respondents reported having read an audit report, admission checklist, or discharge checklist, and 19 (86%) respondents reported using patient education materials. Among the 28 interviewees (44%), facilitators of toolkit intervention implementation were physicians' support and leadership, hospital administrators' support, ease-of-use of checklists and patient education materials, and availability of training opportunities for staff. Barriers that influenced the implementation or acceptability of the toolkit intervention for physicians included time and staff constraints, Internet access, patient volume, and inadequate understanding of the quality improvement toolkit intervention. CONCLUSIONS Implementation and acceptability of the ACS QUIK toolkit intervention were enhanced by hospital-level management support, physician and team support, and usefulness of checklists and patient education materials. Wider and longer-term use of the toolkit intervention and its expansion to potentially other cardiovascular conditions or other locations where the quality of care is not as high as in the ACS QUIK trial may be useful for improving acute cardiovascular care in Kerala and beyond. TRIAL REGISTRATION NCT02256657.
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Affiliation(s)
- Kavita Singh
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - Padinhare P Mohanan
- Westfort Hi-Tech Hospital, Ltd, Thrissur, India
- Cardiological Society of India - Kerala Chapter, Kerala, India
| | - Abigail S Baldridge
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - David E Victorson
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Kunal N Karmali
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Lihui Zhao
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Donald M Lloyd-Jones
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
- London School of Hygiene and Tropical Medicine, London, UK
| | - Shifalika Goenka
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
- Indian Institute of Public Health-Delhi, New Delhi, India
| | - Mark D Huffman
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA.
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Chandrasekaran AM, Kinra S, Ajay VS, Chattopadhyay K, Singh K, Singh K, Praveen PA, Soni D, Devarajan R, Kondal D, Manchanda SC, Hughes AD, Chaturvedi N, Roberts I, Pocock S, Ebrahim S, Reddy KS, Tandon N, Prabhakaran D. Effectiveness and cost-effectiveness of a Yoga-based Cardiac Rehabilitation (Yoga-CaRe) program following acute myocardial infarction: Study rationale and design of a multi-center randomized controlled trial. Int J Cardiol 2019; 280:14-18. [PMID: 30661847 DOI: 10.1016/j.ijcard.2019.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/20/2018] [Accepted: 01/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cardiac rehabilitation (CR) is a standard treatment for secondary prevention of acute myocardial infarction (AMI) in high income countries (HICs), but it is inaccessible to most patients in India due to high costs and skills required for multidisciplinary CR teams. We developed a low-cost and scalable CR program based on culturally-acceptable practice of yoga (Yoga-CaRe). In this paper, we report the rationale and design for evaluation of its effectiveness and cost-effectiveness. METHODS This is a multi-center, single-blind, two-arm parallel-group randomized controlled trial across 22 cardiac care hospitals in India. Four thousand patients aged 18-80 years with AMI will be recruited and randomized 1:1 to receive Yoga-CaRe program (13 sessions supervised by an instructor and encouragement to self-practice daily) or enhanced standard care (3 sessions of health education) delivered over a period of three months. Participants will be followed 3-monthly till the end of the trial. The co-primary outcomes are a) time to occurrence of first cardiovascular event (composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke and emergency cardiovascular hospitalization), and b) quality of life (Euro-QoL-5L) at 12 weeks. Secondary outcomes include need for revascularization procedures, return to pre-infarct activities, tobacco cessation, medication adherence, and cost-effectiveness of the intervention. CONCLUSION This trial will alone contribute >20% participants to existing meta-analyses of randomized trials of CR worldwide. If Yoga-CaRe is found to be effective, it has the potential to save millions of lives and transform care of AMI patients in India and other low and middle income country settings.
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Affiliation(s)
| | - Sanjay Kinra
- London School of Hygiene and Tropical Medicine, London, UK
| | - Vamadevan S Ajay
- Centre for Chronic Disease Control, New Delhi, India; Public Health Foundation of India, Gurgaon, India
| | - Kaushik Chattopadhyay
- London School of Hygiene and Tropical Medicine, London, UK; The University of Nottingham, Nottingham, UK
| | - Kalpana Singh
- Centre for Chronic Disease Control, New Delhi, India
| | - Kavita Singh
- Centre for Chronic Disease Control, New Delhi, India; Public Health Foundation of India, Gurgaon, India
| | - Pradeep A Praveen
- Centre for Chronic Disease Control, New Delhi, India; All India Institute of Medical Sciences, New Delhi, India
| | - Divya Soni
- Centre for Chronic Disease Control, New Delhi, India
| | | | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, India; Public Health Foundation of India, Gurgaon, India
| | | | - Alun D Hughes
- University College London, London, UK; Imperial College London, London, UK
| | - Nishi Chaturvedi
- University College London, London, UK; Imperial College London, London, UK
| | - Ian Roberts
- London School of Hygiene and Tropical Medicine, London, UK
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Shah Ebrahim
- London School of Hygiene and Tropical Medicine, London, UK
| | - Kolli S Reddy
- Centre for Chronic Disease Control, New Delhi, India; Public Health Foundation of India, Gurgaon, India
| | - Nikhil Tandon
- All India Institute of Medical Sciences, New Delhi, India
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India; London School of Hygiene and Tropical Medicine, London, UK; Public Health Foundation of India, Gurgaon, India; Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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Singh K, Johnson L, Devarajan R, Shivashankar R, Sharma P, Kondal D, Ajay VS, Narayan KMV, Prabhakaran D, Ali MK, Tandon N. Acceptability of a decision-support electronic health record system and its impact on diabetes care goals in South Asia: a mixed-methods evaluation of the CARRS trial. Diabet Med 2018; 35:1644-1654. [PMID: 30142228 DOI: 10.1111/dme.13804] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 02/03/2023]
Abstract
AIMS To describe physicians' acceptance of decision-support electronic health record system and its impact on diabetes care goals among people with Type 2 diabetes. METHODS We analysed data from participants in the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, who received the study intervention (care coordinators and use of a decision-support electronic health record system; n=575) using generalized estimating equations to estimate the association between acceptance/rejection of decision-support system prompts and outcomes (mean changes in HbA1c , blood pressure and LDL cholesterol) considering repeated measures across all time points available. We conducted in-depth interviews with physicians to understand the benefits, challenges and value of the decision-support electronic health record system and analysed physicians' interviews using Rogers' diffusion of innovation theory. RESULTS At end-of-trial, participants with diabetes for whom glycaemic, systolic blood pressure, diastolic blood pressure and LDL cholesterol decision-support electronic health record prompts were accepted vs rejected, experienced no reduction in HbA1c [mean difference: -0.05 mmol/mol (95% CI -0.22, 0.13); P=0.599], but statistically significant improvements were observed for systolic blood pressure [mean difference: -11.6 mmHg (95% CI -13.9, -9.3); P ≤ 0.001], diastolic blood pressure [mean difference: -5.2 mmHg (95% CI -6.5, -3.8); P ≤ 0.001] and LDL cholesterol [mean difference: -0.7 mmol/l (95% CI -0.6, -0.8); P ≤0.001], respectively. The relative advantages and compatibility of the decision-support electronic health record system with existing clinic set-ups influenced physicians' acceptance of it. Software complexities and data entry challenges could be overcome by task-sharing. CONCLUSION Wider adherence to decision-support electronic health record prompts could potentially improve diabetes goal achievement, particularly when accompanied by assistance from a non-physician health worker.
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Affiliation(s)
- K Singh
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
- Centre for Chronic Disease Control, New Delhi, India
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| | - L Johnson
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - R Devarajan
- Centre for Control of Chronic Conditions, New Delhi, India
- Centre of Excellence - Centre for Cardio-metabolic Risk Reduction in South Asia
| | - R Shivashankar
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| | - P Sharma
- St. Georges Medical University of London, London, UK
- Plovdiv Medical University, Plovdiv, Bulgaria
| | - D Kondal
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| | - V S Ajay
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| | - K M V Narayan
- Centre for Control of Chronic Conditions, New Delhi, India
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - D Prabhakaran
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
- Centre for Chronic Disease Control, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
| | - M K Ali
- Centre for Control of Chronic Conditions, New Delhi, India
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - N Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
- Centre for Control of Chronic Conditions, New Delhi, India
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Devarajan R, Singh K, Kondal D, Shivashankar R, Narayan K, Prabhakaran D, Tandon N, Ali M. MS02.9 Association of Body Mass Index and Other Cardiovascular Risk Factors With Diabetic Retinopathy Among People With Poorly-Controlled Type 2 Diabetes Mellitus In South Asia: The CARRS Trial. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Soni D, Singh K, Ambalam C, Vamadevan A, Kinra S, Singh K, PA P, Devarajan R, Mohan B, Chadha DS, Negi PC, Prabhavati, Kumar S, Sadananda KS, Manchanda SC, Sarma PVR, Chandra S, MR P, Dorairaj P. A16184 Clinical profile of acute myocardial infarction patients with and without hypertension. J Hypertens 2018. [DOI: 10.1097/01.hjh.0000548938.68524.7b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sarma S, Harikrishnan S, Baldridge AS, Devarajan R, Mehta A, Selvaraj S, Ali MK, Mohanan PP, Prabhakaran D, Huffman MD. Availability, Sales, and Affordability of Tobacco Cessation Medicines in Kerala, India. Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.117.004108. [PMID: 29150536 DOI: 10.1161/circoutcomes.117.004108] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/23/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND India is the world's second largest consumer of tobacco, but tobacco cessation remains uncommon due, at least in part, to underutilization of cessation pharmacotherapy. We evaluated the availability, sales, and affordability of nicotine replacement therapy, bupropion, and varenicline in the South Indian state of Kerala to understand potential reasons for underutilization. METHODS AND RESULTS From November 2016 to April 2017, we collected data on availability, inventory, and pricing of cessation medication through a cross-sectional survey of 199 public, semiprivate (Karunya), and private pharmacies across 5 districts in Kerala using World Health Organization/Health Action International methodology. Revenue and sales data were obtained from the latest Pharmatrac medication database. We assessed affordability using individual- and household-level income and expenditure data collected from November 2014 to November 2016 through the Acute Coronary Syndrome Quality Improvement in Kerala randomized trial. Cessation medications were not available in public hospitals (0%, n=58) nor in public specialty centers (0%, n=10) including those designated to provide cessation services. At least 1 cessation medicine was available at 63% of private pharmacies (n=109) and 27% of Karunya (semiprivate) pharmacies (n=22). Among the 75 pharmacies that stocked cessation medications, 96% had nicotine replacement therapy, 28% had bupropion, and 1% had varenicline. No outlets had sufficient inventory for a patient to purchase a 12-week treatment regimen. There were an estimated 253 270 treatment regimens sold throughout India and 14 092 in Kerala in 2013 to 2014. Treatment regimens cost 1.9 to 13.0× the median amount spent on smoked tobacco and between 8% and 52% of nonsubsistence income. CONCLUSIONS Tobacco cessation medications are unavailable in the Kerala public sector and have limited availability in the private and semiprivate sectors. When available, medications are unaffordable for most patients. Addition of tobacco cessation medication onto national and state essential medicines lists may help increase access. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02256657.
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Affiliation(s)
- Smitha Sarma
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Sivadasanpillai Harikrishnan
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Abigail S Baldridge
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Raji Devarajan
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Aashna Mehta
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Sakhtivel Selvaraj
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Mohammed K Ali
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Padinhare P Mohanan
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Dorairaj Prabhakaran
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.)
| | - Mark D Huffman
- From the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL (S. Sarma, A.S.B., M.D.H.); Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India (S.H.); Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, Haryana, India (R.D., D.P.); Public Health Foundation of India, Gurgaon, Haryana, India (A.M.); Public Health Foundation of India, Delhi, India (S. Selvaraj); Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA (M.K.A.); and Department of Cardiology, Westfort Hi-Tech Hospital Ltd, Thrissur, Kerala, India (P.P.M.).
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Huffman MD, Mohanan PP, Devarajan R, Baldridge AS, Kondal D, Zhao L, Ali M, Krishnan MN, Natesan S, Gopinath R, Viswanathan S, Stigi J, Joseph J, Chozhakkat S, Lloyd-Jones DM, Prabhakaran D. Effect of a Quality Improvement Intervention on Clinical Outcomes in Patients in India With Acute Myocardial Infarction: The ACS QUIK Randomized Clinical Trial. JAMA 2018; 319:567-578. [PMID: 29450524 PMCID: PMC5838631 DOI: 10.1001/jama.2017.21906] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Wide heterogeneity exists in acute myocardial infarction treatment and outcomes in India. OBJECTIVE To evaluate the effect of a locally adapted quality improvement tool kit on clinical outcomes and process measures in Kerala, a southern Indian state. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized, stepped-wedge clinical trial conducted between November 10, 2014, and November 9, 2016, in 63 hospitals in Kerala, India, with a last date of follow-up of December 31, 2016. During 5 predefined steps over the study period, hospitals were randomly selected to move in a 1-way crossover from the control group to the intervention group. Consecutively presenting patients with acute myocardial infarction were offered participation. INTERVENTIONS Hospitals provided either usual care (control group; n = 10 066 participants [step 0: n = 2915; step 1: n = 2649; step 2: n = 2251; step 3: n = 1422; step 4; n = 829; step 5: n = 0]) or care using a quality improvement tool kit (intervention group; n = 11 308 participants [step 0: n = 0; step 1: n = 662; step 2: n = 1265; step 3: n = 2432; step 4: n = 3214; step 5: n = 3735]) that consisted of audit and feedback, checklists, patient education materials, and linkage to emergency cardiovascular care and quality improvement training. MAIN OUTCOMES AND MEASURES The primary outcome was the composite of all-cause death, reinfarction, stroke, or major bleeding using standardized definitions at 30 days. Secondary outcomes included the primary outcome's individual components, 30-day cardiovascular death, medication use, and tobacco cessation counseling. Mixed-effects logistic regression models were used to account for clustering and temporal trends. RESULTS Among 21 374 eligible randomized participants (mean age, 60.6 [SD, 12.0] years; n = 16 183 men [76%] ; n = 13 689 [64%] with ST-segment elevation myocardial infarction), 21 079 (99%) completed the trial. The primary composite outcome was observed in 5.3% of the intervention participants and 6.4% of the control participants. The observed difference in 30-day major adverse cardiovascular event rates between the groups was not statistically significant after adjustment (adjusted risk difference, -0.09% [95% CI, -1.32% to 1.14%]; adjusted odds ratio, 0.98 [95% CI, 0.80-1.21]). The intervention group had a higher rate of medication use including reperfusion but no effect on tobacco cessation counseling. There were no unexpected adverse events reported. CONCLUSIONS AND RELEVANCE Among patients with acute myocardial infarction in Kerala, India, use of a quality improvement intervention compared with usual care did not decrease a composite of 30-day major adverse cardiovascular events. Further research is needed to understand the lack of efficacy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02256657.
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Affiliation(s)
- Mark D. Huffman
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Raji Devarajan
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | | | - Dimple Kondal
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Lihui Zhao
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | - Mumtaj Ali
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
| | | | | | | | | | | | | | | | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, Gurgaon, India
- Public Health Foundation of India, Gurgaon, India
- London School of Hygiene and Tropical Medicine, London, England
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El-Hadi M, D'Costa J, DeVogel C, Devarajan R, Otite U. Sugar and Stones; How Does Diabetes Affect Biochemical and Surgical Outcomes in Surgically Managed Urolithiasis? Int J Surg 2017. [DOI: 10.1016/j.ijsu.2017.08.521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Zhang K, Myllymäki SM, Gao P, Devarajan R, Kytölä V, Nykter M, Wei GH, Manninen A. Oncogenic K-Ras upregulates ITGA6 expression via FOSL1 to induce anoikis resistance and synergizes with αV-Class integrins to promote EMT. Oncogene 2017; 36:5681-5694. [PMID: 28604746 PMCID: PMC5658677 DOI: 10.1038/onc.2017.177] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 04/11/2017] [Accepted: 05/04/2017] [Indexed: 12/17/2022]
Abstract
In many cancer types, integrin-mediated signaling regulates proliferation, survival and invasion of tumorigenic cells. However, it is still unclear how integrins crosstalk with oncogenes to regulate tumorigenesis and metastasis. Here we show that oncogenic K-RasV12 upregulates α6-integrin expression in Madin–Darby canine kidney (MDCK) cells via activation of the mitogen-activated protein kinase/extracellular signal-regulated kinase (ERK)/Fos-related antigen 1-signaling cascade. Activated α6-integrins promoted metastatic capacity and anoikis resistance, and led to perturbed growth of MDCK cysts. Transcriptomic analysis of K-RasV12-transformed MDCK cells also revealed robust downregulation of αV-class integrins. Re-expression of αV-integrin in K-RasV12-transformed MDCK cells synergistically upregulated the expression of Zinc finger E-box-binding homeobox 1 and Twist-related protein 1 and triggered epithelial-mesenchymal transition leading to induced cell motility and invasion. These results delineate the signaling cascades connecting oncogenic K-RasV12 with α6- and αV-integrin functions to modulate cancer cell survival and tumorigenesis, and reveal new possible strategies to target highly oncogenic K-RasV12 mutants.
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Affiliation(s)
- K Zhang
- Biocenter Oulu, Centre of Excellence in Cell-Extracellular Matrix Research, Faculty of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
| | - S-M Myllymäki
- Biocenter Oulu, Centre of Excellence in Cell-Extracellular Matrix Research, Faculty of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
| | - P Gao
- Biocenter Oulu, Centre of Excellence in Cell-Extracellular Matrix Research, Faculty of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
| | - R Devarajan
- Biocenter Oulu, Centre of Excellence in Cell-Extracellular Matrix Research, Faculty of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
| | - V Kytölä
- Prostate Cancer Research Center, Institute of Biomedical Technology and BioMediTech, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - M Nykter
- Prostate Cancer Research Center, Institute of Biomedical Technology and BioMediTech, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - G-H Wei
- Biocenter Oulu, Centre of Excellence in Cell-Extracellular Matrix Research, Faculty of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
| | - A Manninen
- Biocenter Oulu, Centre of Excellence in Cell-Extracellular Matrix Research, Faculty of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
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Huffman MD, Mohanan PP, Devarajan R, Baldridge AS, Kondal D, Zhao L, Ali M, Lloyd-Jones DM, Prabhakaran D. Acute coronary syndrome quality improvement in Kerala (ACS QUIK): Rationale and design for a cluster-randomized stepped-wedge trial. Am Heart J 2017; 185:154-160. [PMID: 28267469 DOI: 10.1016/j.ahj.2016.10.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/06/2016] [Indexed: 12/12/2022]
Abstract
Ischemic heart disease is the leading cause of death in India, and there are likely more myocardial infarctions in India than in any other country in the world. We have previously reported heterogeneous care for patients with myocardial infarction in Kerala, a state in southern India, including both gaps in optimal care and inappropriate care. Based on that prior work, limitations from previous nonrandomized quality improvement studies and promising gains in process of care measures demonstrated from previous randomized trials, we and the Cardiological Society of India-Kerala chapter sought to develop, implement, and evaluate a quality improvement intervention to improve process of care measures and clinical outcomes for these patients. In this article, we report the rationale and study design for the ACS QUIK cluster-randomized stepped-wedge clinical trial (NCT02256657) in which we aim to enroll 15,750 participants with acute coronary syndromes across 63 hospitals. To date, most participants are men (76%) and have ST-segment elevation myocardial infarction (63%). The primary outcome is 30-day major adverse cardiovascular events defined as death, recurrent infarction, stroke, or major bleeding. Our secondary outcomes include health-related quality of life and individual- and household-level costs. We also describe the principal features and limitations of the stepped-wedge study design, which may be important for other investigators or sponsors considering cluster-randomized stepped-wedge trials.
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Ali MK, Singh K, Kondal D, Devarajan R, Patel SA, Shivashankar R, Ajay VS, Unnikrishnan AG, Menon VU, Varthakavi PK, Viswanathan V, Dharmalingam M, Bantwal G, Sahay RK, Masood MQ, Khadgawat R, Desai A, Sethi B, Prabhakaran D, Narayan KMV, Tandon N. Effectiveness of a Multicomponent Quality Improvement Strategy to Improve Achievement of Diabetes Care Goals: A Randomized, Controlled Trial. Ann Intern Med 2016; 165:399-408. [PMID: 27398874 PMCID: PMC6561084 DOI: 10.7326/m15-2807] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Achievement of diabetes care goals is suboptimal globally. Diabetes-focused quality improvement (QI) is effective but remains untested in South Asia. OBJECTIVE To compare the effect of a multicomponent QI strategy versus usual care on cardiometabolic profiles in patients with poorly controlled diabetes. DESIGN Parallel, open-label, pragmatic randomized, controlled trial. (ClinicalTrials.gov: NCT01212328). SETTING Diabetes clinics in India and Pakistan. PATIENTS 1146 patients (575 in the intervention group and 571 in the usual care group) with type 2 diabetes and poor cardiometabolic profiles (glycated hemoglobin [HbA1c] level ≥8% plus systolic blood pressure [BP] ≥140 mm Hg and/or low-density lipoprotein cholesterol [LDLc] level ≥130 mg/dL). INTERVENTION Multicomponent QI strategy comprising nonphysician care coordinators and decision-support electronic health records. MEASUREMENTS Proportions achieving HbA1c level less than 7% plus BP less than 130/80 mm Hg and/or LDLc level less than 100 mg/dL (primary outcome); mean risk factor reductions, health-related quality of life (HRQL), and treatment satisfaction (secondary outcomes). RESULTS Baseline characteristics were similar between groups. Median diabetes duration was 7.0 years; 6.8% and 39.4% of participants had preexisting cardiovascular and microvascular disease, respectively; mean HbA1c level was 9.9%; mean BP was 143.3/81.7 mm Hg; and mean LDLc level was 122.4 mg/dL. Over a median of 28 months, a greater percentage of intervention participants achieved the primary outcome (18.2% vs. 8.1%; relative risk, 2.24 [95% CI, 1.71 to 2.92]). Compared with usual care, intervention participants achieved larger reductions in HbA1c level (-0.50% [CI, -0.69% to -0.32%]), systolic BP (-4.04 mm Hg [CI, -5.85 to -2.22 mm Hg]), diastolic BP (-2.03 mm Hg [CI, -3.00 to -1.05 mm Hg]), and LDLc level (-7.86 mg/dL [CI, -10.90 to -4.81 mg/dL]) and reported higher HRQL and treatment satisfaction. LIMITATION Findings were confined to urban specialist diabetes clinics. CONCLUSION Multicomponent QI improves achievement of diabetes care goals, even in resource-challenged clinics. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute and UnitedHealth Group.
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Affiliation(s)
- Mohammed K Ali
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Kavita Singh
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Dimple Kondal
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Raji Devarajan
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Shivani A Patel
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Roopa Shivashankar
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Vamadevan S Ajay
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - A G Unnikrishnan
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - V Usha Menon
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Premlata K Varthakavi
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Vijay Viswanathan
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Mala Dharmalingam
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Ganapati Bantwal
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Rakesh Kumar Sahay
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Muhammad Qamar Masood
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Rajesh Khadgawat
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Ankush Desai
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Bipin Sethi
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Dorairaj Prabhakaran
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - K M Venkat Narayan
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Nikhil Tandon
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
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Devarajan R, Singh K, Kondal D, Shivashankar R, Narayan K, Prabhakaran D, Tandon N, Ali M. PT316 Associations Between Blood Pressure- and Lipid-Lowering Medications Use and Cardiac Risk Factor Control: Findings From the Carrs Trial. Glob Heart 2016. [DOI: 10.1016/j.gheart.2016.03.633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Devarajan R, Singh K, Kondal D, Shivashankar R, Narayan K, Prabhakaran D, Tandon N, Ali M. PT315 Effects of a Multicomponent Intervention Strategy on Processes of Care and Cardiac Risk Factor Control in Poorly Controlled Type 2 Diabetes Patients: The Carrs Trial. Glob Heart 2016. [DOI: 10.1016/j.gheart.2016.03.632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Arunkalaivanan AS, Kaur H, Devarajan R. Management of complex vault prolapse with hydronephrosis by using porcine mesh (SIS) sacrocolpopexy and colposuspension. J OBSTET GYNAECOL 2006; 26:179-81. [PMID: 16483994 DOI: 10.1080/01443610500473565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- A S Arunkalaivanan
- Departments of Obstetrics and Gynaecology, Staffordshire General Hospital, Stafford, UK.
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Mahomoud S, Arunkalaivanan AS, Devarajan R, Kaur H. Vesicocervical fistula--a rare complication secondary to caesarean section. Int Urogynecol J 2004; 15:439-41. [PMID: 15309282 DOI: 10.1007/s00192-004-1211-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2004] [Accepted: 07/06/2004] [Indexed: 11/28/2022]
Abstract
We report a case of vesicocervical fistula secondary to caesarean section. This is a rare complication of caesarean section, which was not recognised intraoperatively. Diagnosis was made clinically, radiologically and endoscopically during the post-operative period. Conservative management with indwelling catheterisation for 3 weeks failed. Hence the fistula was repaired surgically by an abdominal approach.
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Affiliation(s)
- S Mahomoud
- Department of Obstetrics and Gynaecology, City Hospital, Dudley Road, Birmingham, B18 7QH, UK
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Devarajan R, Jaganathan RS, Harriss DR, Chua CB, Bishop MC. Combined transurethral prostatectomy and inguinal hernia repair: a retrospective audit and literature review. BJU Int 1999; 84:637-9. [PMID: 10510107 DOI: 10.1046/j.1464-410x.1999.00250.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To audit the results of combined transurethral resection of the prostate (TURP) and inguinal hernia repair, often carried out under the same anaesthetic (because bladder outlet obstruction from prostatic disease and inguinal hernia are both common conditions in elderly men), to avoid two separate operations. PATIENTS AND METHODS The study included 85 patients who underwent primary inguinal hernia repair with TURP in the urology unit of Nottingham City hospital between 1989 and 1995, and who were recalled to a special clinic. The type of hernia and repair carried out were recorded and complications audited with specific reference to recurrence of hernia and wound infection. RESULTS The 85 patients underwent 88 primary inguinal hernia repairs with TURP (three were bilateral). Maloney's darn repair was used on 55 and a Bassini repair on 33 occasions, respectively. Two patients developed mild wound infection after surgery, but only two patients (2%) had recurrence of hernia. CONCLUSIONS The recurrence rate after primary inguinal herniorraphy with conventional methods of repair, performed with TURP, was comparable with published results of hernia repairs alone, before the introduction of Lichtenstein's mesh repair.
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Affiliation(s)
- R Devarajan
- Department of Urology, Walsgrave Hospital, Walsgrave, Coventry, UK
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Abstract
OBJECTIVE To assess the success of holmium:YAG lasertripsy in the management of ureteric calculi and to audit the complications of the procedure, with special reference to strictures in the ureter. PATIENTS AND METHODS A total of 300 ureteroscopic laser procedures were carried out on 265 patients (204 male and 61 female, median age 51 years, range 2-95) with ureteric calculi. At ureteroscopy, the calculi were present in the upper ureter in 44%, mid-ureter in 37% and lower ureter in 19% of patients; most calculi were > 5 mm. A 7.5 F Wolf semi-rigid ureteroscope was used and the holmium:YAG laser energy delivered using the Sharplan ML210 device at 0.8-1.0 J/pulse. The patients were followed up at approximately 6 weeks with limited intravenous urography or ultrasonography to assess clearance and the incidence of strictures. RESULTS Stones were completely cleared in 90% of the patients, with the best results in the lower and mid-ureter (97% and 96%, respectively) followed by the upper ureter (89%). Alternative procedures were required in only 17 (7%) patients; extracorporeal shock-wave lithotripsy in 13, percutaneous nephrolithotomy in two and open pyelolithotomy in two patients. Complications with ureteric perforation in 11 patients, including laparotomy for peritonitis in one, serious sepsis in two and strictures in 10 patients. Strictures were more common in association with impacted calculi in the upper ureter early in the series. CONCLUSIONS Holmium:YAG lasertripsy is a highly effective treatment for ureteric calculi, with strictures related to the treatment of difficult upper ureteric calculi.
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Affiliation(s)
- R Devarajan
- Department of Urology, King's Mill Hospital, Sutton-in-Ashfield, UK
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Devarajan R, Bishop MC, Sands KA. Hepatic abscess: a tertiary complication of Mitrofanoff continent urinary diversion. Br J Urol 1997; 79:137-8. [PMID: 9043519 DOI: 10.1046/j.1464-410x.1997.129034.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- R Devarajan
- Department of Urology, Nottingham City Hospital, UK
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Devarajan R, Arunachalam V, Jayakumar E, Selvi P. Water-soluble polymers. I. Synthesis of N-succinimido (N) thiocarbonyl acrylamide and its polymerization: Grafting of this monomer and acrylamide onto poly(vinyl alcohol). J Appl Polym Sci 1993. [DOI: 10.1002/app.1993.070480516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Devarajan R, Arunachalam V, Kumaraswamy MDK, Tajuddin I, Joghee T. Darzen's glycidic ester condensation reaction on poly(N-vinyl pyrrolidone). J Appl Polym Sci 1992. [DOI: 10.1002/app.1992.070440817] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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McAllister DF, Carver D, Devarajan R, Harrison L, Pietenpol JL, Yang SH. An interactive computer graphics system for the design of molded and orthopedic shoe lasts. J Rehabil Res Dev 1991; 28:39-46. [PMID: 1941648 DOI: 10.1682/jrrd.1991.10.0039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The Department of Computer Science at North Carolina State University, with support from the Department of Veterans Affairs and National Aeronautics and Space Administration (NASA) Langley Research Center, has developed an interactive graphics program for the development of shoe lasts from digitized images of feet or digitized images of commercial shoe lasts. The program runs on a Sun 3/260 computer with a TAAC-1 graphics accelerator. The program contains operations for region addition and deletion, techniques for narrowing the ankle area, methods for toe extension, operations to allow for shoe inserts, etc. Once the operations by the user are complete, the program will resample the resulting last in a 512 x 512 array. The user is then allowed to select an error tolerance which will guide a data reduction program to represent the last as Coons patches. These patches are then transmitted to a milling machine which will cut the last.
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Affiliation(s)
- D F McAllister
- Department of Computer Science, North Carolina State University, Raleigh 27695-8206
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Devarajan R, Balakrishnan T, Santappa M. A novel method of preparing some new αα-disubstituted vinyl monomers and their polymerizability. I. Synthesis of methyl α-phenoxymethylacrylate and its polymerizability. ACTA ACUST UNITED AC 1980. [DOI: 10.1002/pol.1980.170180332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Devarajan R, Balakrishnan T. The preparation of a new series of ?, ?-disubstituted vinyl monomers. Polym Bull (Berl) 1979. [DOI: 10.1007/bf00284416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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