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Abrahams-Gessel S, Beratarrechea A, Irazola V, Gulayin P, Gutierrez L, Mahoney M, Gaziano T. Managing high cardiovascular disease risk among adults in Argentina using a multicomponent strategy linking key aspects of care: A two-arm cluster-randomized clinical trial (PRIMECare) protocol. Contemp Clin Trials 2023; 134:107357. [PMID: 37852532 PMCID: PMC10842453 DOI: 10.1016/j.cct.2023.107357] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/28/2023] [Accepted: 10/15/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) imposes a significant burden on the Argentinian population. Management of its leading risk factors can significantly reduce the CVD burden in high-resource settings, but there is insufficient evidence for effective implementation of evidence-based interventions in lower-resource settings like Argentina. METHODS In this two-arm cluster-randomized trial we seek to compare the effective implementation, of a multicomponent intervention, versus usual care, to improve the management of high CVD risk across the care continuum in three provinces of Argentina. The multicomponent intervention strategy links five primary components of the CVD care continuum to improve its management: (1) a data management system linking a digital mHealth (mobile health) screening tool used by community health workers (CHWs), (2) an electronic appointment scheduler that is integrated with the primary care center electronic appointment system, (3) point of care testing for lipid profiles, (4) a clinical decision support (CDS) system for medication initiation, and (5) a text message (SMS) reminder system to improve treatment adherence and life-style changes. The primary outcome is the mean change in Framingham laboratory-based, 10-year absolute CVD risk score between the study arms from baseline to twelve months after enrollment. CONCLUSIONS This protocol describes the development of a multicomponent intervention to implement effective management of CVD, developed with partners at the National and provincial Departments of Health in Argentina, with the goal of understanding its effective implementation in a primary health care system strengthened by universal health coverage, provision of free health care services, and provision of free medication.
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Affiliation(s)
| | | | - Vilma Irazola
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Pablo Gulayin
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Laura Gutierrez
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Margaret Mahoney
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas Gaziano
- Harvard TH Chan School of Public Health, Boston, MA, USA; Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Nogueira ACC, Barreto J, Moura FA, Luchiari B, Abuhab A, Bonilha I, Nadruz W, Gaziano JM, Gaziano T, de Carvalho LSF, Sposito AC. Comparative effectiveness and cost-effectiveness of cardioprotective glucose-lowering therapies for type 2 diabetes in Brazil: a Bayesian network model. Health Econ Rev 2023; 13:50. [PMID: 37878108 PMCID: PMC10599033 DOI: 10.1186/s13561-023-00466-3] [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] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 10/16/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND The escalating prevalence of type 2 diabetes (T2DM) poses an unparalleled economic catastrophe to developing countries. Cardiovascular diseases remain the primary source of costs among individuals with T2DM, incurring expenses for medications, hospitalizations, and surgical interventions. Compelling evidence suggests that the risk of cardiovascular outcomes can be reduced by three classes of glucose-lowering therapies (GLT), including SGLT2i, GLP-1A, and pioglitazone. However, an evidence-based and cost-effective protocol is still unavailable for many countries. The objective of the current study is to compare the effectiveness and cost-effectiveness of GLT in individuals with T2DM in Brazil. METHODS We employed Bayesian Networks to calculate the incremental cost-effectiveness ratios (ICER), expressed in international dollars (Int$) per disease-adjusted life years [DALYs] averted. To determine the effectiveness of GLT, we conducted a systematic review with network meta-analysis (NMA) to provide insights for our model. Additionally, we obtained cardiovascular outcome incidence data from two real-world cohorts comprising 851 and 1337 patients in primary and secondary prevention, respectively. Our cost analysis took into account the perspective of the Brazilian public health system, and all values were converted to Int$. RESULTS In the NMA, SGLT2i [HR: 0.81 (95% CI 0.69-0.96)], GLP-1A [HR: 0.79 (95% CI 0.67-0.94)], and pioglitazone [HR: 0.73 (95% CI 0.59-0.91)] demonstrated reduced relative risks of non-fatal cardiovascular events. In the context of primary prevention, pioglitazone yielded 0.2339 DALYs averted, with an ICER of Int$7,082 (95% CI 4,521-10,770) per DALY averted when compared to standard care. SGLT2i and GLP-1A also increased effectiveness, resulting in 0.261 and 0.259 DALYs averted, respectively, but with higher ICERs of Int$12,061 (95% CI: 7,227-18,121) and Int$29,119 (95% CI: 23,811-35,367) per DALY averted. In the secondary prevention scenario, all three classes of treatments were deemed cost-effective at a maximum willingness-to-pay threshold of Int$26,700. Notably, pioglitazone consistently exhibited the highest probability of being cost-effective in both scenarios. CONCLUSIONS In Brazil, pioglitazone presented a higher probability of being cost-effective both in primary and secondary prevention, followed by SGLT2i and GLP-1A. Our findings support the use of cost-effectiveness models to build optimized and hierarchical therapeutic strategy in the management of T2DM. TRIAL REGISTRATION CRD42020194415.
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Affiliation(s)
- Ana Claudia Cavalcante Nogueira
- Cardiology Division, Unicamp Medical School, São Paulo, SP, Brazil
- Escola Superior de Ciências da Saúde (ESCS), Brasília, Distrito Federal, Brazil
| | - Joaquim Barreto
- Cardiology Division, Unicamp Medical School, São Paulo, SP, Brazil
| | - Filipe A Moura
- Cardiology Division, Unicamp Medical School, São Paulo, SP, Brazil
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Beatriz Luchiari
- Cardiology Division, Unicamp Medical School, São Paulo, SP, Brazil
| | - Abrão Abuhab
- Heart Institute (InCor), Do Hospital das Clínicas - FMUSP, Sao Paulo, Brazil
| | - Isabella Bonilha
- Cardiology Division, Unicamp Medical School, São Paulo, SP, Brazil
| | - Wilson Nadruz
- Cardiology Division, Unicamp Medical School, São Paulo, SP, Brazil
| | | | - Thomas Gaziano
- Department of Cardiovascular Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - Luiz Sergio F de Carvalho
- Cardiology Division, Unicamp Medical School, São Paulo, SP, Brazil
- Clarity Healthcare Intelligence, Jundiaí, SP, Brasil
| | - Andrei C Sposito
- Cardiology Division, Unicamp Medical School, São Paulo, SP, Brazil.
- Atherosclerosis and Vascular Biology Laboratory (Atherolab), State University of Campinas (Unicamp), Sao Paulo, Campinas, 13084-971, Brazil.
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Ordunez P, Tajer C, Gaziano T, Rodriguez YA, Rosende A, Jaffe MG. Authors’ response to the letter “Concerning The HEARTS app: a clinical tool for cardiovascular risk and hypertension management in primary health care”. Rev Panam Salud Publica 2022; 46:e91. [PMID: 35795158 PMCID: PMC9250130 DOI: 10.26633/rpsp.2022.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Pedro Ordunez
- Pan American Health Organization, Washington DC, United States of America. ORCID 0000-0002-9871-6845
| | - Carlos Tajer
- Hospital El Cruce Néstor Kirchner, Buenos Aires, Argentina. ORCID 0000-0002-6787-6651
| | - Thomas Gaziano
- Harvard T.H. Chan School of Public Health, Boston, United States of America. ORCID 0000-0002-5985-345X
| | - Yenny A. Rodriguez
- Pan American Health Organization, Washington DC, United States of America. ORCID 0000-0003-2026-572X
| | - Andres Rosende
- Pan American Health Organization, Washington DC, United States of America. ORCID 0000-0001-8173-0686
| | - Marc G. Jaffe
- Kaiser Permanente San Francisco Medical Center, San Francisco, United States of America. ORCID 0000-0002-5049-7815
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Abrahams-Gessel S, Wilde P, Zhang FF, Lizewski L, Sy S, Liu J, Ruan M, Lee Y, Mozaffarian D, Micha R, Gaziano T. Implementing federal food service guidelines in federal and private worksite cafeterias in the United States leads to improved health outcomes and is cost saving. J Public Health Policy 2022; 43:266-280. [PMID: 35379921 PMCID: PMC9197963 DOI: 10.1057/s41271-022-00344-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 12/17/2022]
Abstract
Poor diet increases cardiometabolic disease risk, yet the impact of food service guidelines on employee health and its cost effectiveness is poorly understood. Federal food service guidelines (FFSG) aim to provide United States (U.S.) government employees with healthier food options. Using microsimulation modeling, we estimated changes in the incidence of cardiometabolic disease, related mortality, and the cost effectiveness of implementing FFSG in nationally representative model populations of government and private company employees across 5 years and lifetime. We based estimates on changes in workplace intake of six FFSG dietary targets and showed lifetime reductions of heart attacks (- 107/million), strokes (- 30/million), diabetes (- 134/million), ischemic heart disease deaths (- 56/million), and stroke deaths (- 8/million). FFSG is cost saving overall, with total savings in discounted healthcare costs from $4,611,026 (5 years) to $539,809,707 (lifetime) $U.S. This study demonstrates that FFSG improves health outcomes and is cost saving.
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Affiliation(s)
- Shafika Abrahams-Gessel
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T. H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, 02115, USA
| | - Parke Wilde
- Friedman School of Nutrition Science and Policy, Tufts University, Jaharis Building - 150 Harrison Avenue, Boston, MA, 02111, USA
| | - Fang Fang Zhang
- Friedman School of Nutrition Science and Policy, Tufts University, Jaharis Building - 150 Harrison Avenue, Boston, MA, 02111, USA
| | - Lauren Lizewski
- National Institute of Allergy and Infectious Disease, Vaccine Research Center, National Institutes of Health, 5601 Fishers Lane, Rockville, MD, 20852, USA
| | - Stephen Sy
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T. H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, 02115, USA
| | - Junxiu Liu
- Friedman School of Nutrition Science and Policy, Tufts University, Jaharis Building - 150 Harrison Avenue, Boston, MA, 02111, USA
| | - Mengyuan Ruan
- School of Medicine, Tufts University School of Medicine, 136 Harrison Ave, Boston, MA, 02111, USA
| | - Yujin Lee
- Department of Food and Nutrition, Myongji University, 116 Myongji-ro, Cheoin-gu, Yongin-si, 17058, Gyunggi-do, Korea
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Jaharis Building - 150 Harrison Avenue, Boston, MA, 02111, USA
| | - Renata Micha
- Friedman School of Nutrition Science and Policy, Tufts University, Jaharis Building - 150 Harrison Avenue, Boston, MA, 02111, USA
| | - Thomas Gaziano
- Department of Health Policy and Management, Center for Health Decision Science, Harvard T. H. Chan School of Public Health, 718 Huntington Avenue, Boston, MA, 02115, USA.
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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Ordunez P, Tajer C, Gaziano T, Rodríguez YA, Rosende A, Jaffe MG. [The HEARTS app: a clinical tool for cardiovascular risk and hypertension management in primary health careO aplicativo HEARTS: uma ferramenta clínica para o gerenciamento de risco cardiovascular e hipertensão na atenção primária à saúde]. Rev Panam Salud Publica 2022; 46:e46. [PMID: 35573118 PMCID: PMC9097924 DOI: 10.26633/rpsp.2022.46] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 01/06/2022] [Indexed: 11/25/2022] Open
Abstract
HEARTS en las Américas es la adaptación regional de la iniciativa Global HEARTS de la Organización Mundial de la Salud, que será el modelo para el manejo del riesgo de las enfermedades cardiovasculares (ECV) en la atención primaria de salud en la Región de las Américas para el año 2025. Ya se ha implementado en 21 países y 1045 centros de atención primaria de salud en toda América Latina y el Caribe. Se ha adoptado un enfoque de salud pública y de sistemas de salud para introducir sistemáticamente intervenciones simplificadas en el nivel de la atención primaria de salud que se centran en el control de la hipertensión como punto de entrada clínico. En este artículo se presenta una aplicación nueva y mejorada cuyo componente principal es la calculadora de riesgo de ECV y de manejo de la hipertensión. Se resume el enfoque de evaluación del riesgo y la metodología utilizada por la Organización Mundial de la Salud para actualizar sus tablas de riesgo cardiovascular del 2019; se describe la aplicación, su uso, su funcionalidad y su proceso de validación; y se presenta un conjunto de recomendaciones prácticas para optimizar el manejo del riesgo de ECV y de la hipertensión, mediante el uso de la aplicación en la práctica clínica. La aplicación HEARTS es una herramienta sólida para mejorar la calidad de la atención prestada en los centros de atención primaria. La creación y difusión de la aplicación HEARTS es un paso esencial en el camino hacia la eliminación de las ECV prevenibles en la Región de las Américas.
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Affiliation(s)
- Pedro Ordunez
- Organización Panamericana de la Salud Washington D.C. Estados Unidos de América Organización Panamericana de la Salud, Washington D.C., Estados Unidos de América. ORCID 0000-0002-9871-6845; ORCID 0000-0003-2026-572X; ORCID 0000-0001-8173-0686
| | - Carlos Tajer
- Hospital El Cruce Néstor Kirchner Buenos Aires Argentina Hospital El Cruce Néstor Kirchner, Buenos Aires, Argentina ORCID 0000-0002-6787-66511
| | - Thomas Gaziano
- Harvard T.H. Chan School of Public Health Boston Estados Unidos de América Harvard T.H. Chan School of Public Health, Boston, Estados Unidos de América. ORCID 0000-0002-5985-345X
| | - Yenny A Rodríguez
- Organización Panamericana de la Salud Washington D.C. Estados Unidos de América Organización Panamericana de la Salud, Washington D.C., Estados Unidos de América. ORCID 0000-0002-9871-6845; ORCID 0000-0003-2026-572X; ORCID 0000-0001-8173-0686
| | - Andrés Rosende
- Organización Panamericana de la Salud Washington D.C. Estados Unidos de América Organización Panamericana de la Salud, Washington D.C., Estados Unidos de América. ORCID 0000-0002-9871-6845; ORCID 0000-0003-2026-572X; ORCID 0000-0001-8173-0686
| | - Marc G Jaffe
- Kaiser Permanente San Francisco Medical Center San Francisco Estados Unidos de América Kaiser Permanente San Francisco Medical Center, San Francisco, Estados Unidos de América. ORCID 0000-0002-5049-7815
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6
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Ordunez P, Tajer C, Gaziano T, Rodriguez YA, Rosende A, Jaffe MG. The HEARTS app: a clinical tool for cardiovascular risk and hypertension management in primary health care. Rev Panam Salud Publica 2022; 46:e12. [PMID: 35355690 PMCID: PMC8959249 DOI: 10.26633/rpsp.2022.12] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 01/06/2022] [Indexed: 12/14/2022] Open
Abstract
HEARTS in the Americas is the regional adaptation of the World Health Organization’s Global Hearts Initiative, which will be the model for risk management for cardiovascular disease (CVD) in primary health care in the Region of the Americas by 2025. It has already been implemented in 21 countries and 1045 primary health care centers throughout Latin America and the Caribbean. It takes a public health and health systems approach to systematically introduce simplified interventions at the primary health care level and focuses on hypertension as a clinical entry point. This paper introduces a new, improved application (app), the main component of which is the calculator for CVD risk and hypertension management. The paper summarizes the risk assessment approach and the methodology used by the World Health Organization to update its cardiovascular risk charts in 2019; describes the app, its use, functionality and validation process; and provides a set of practical recommendations for optimizing CVD risk and hypertension management by using the app in clinical practice. The HEARTS app is a powerful tool to improve the quality of care provided in primary health settings. The creation and dissemination of the HEARTS app is an essential step in the journey towards eliminating preventable CVD in the Americas.
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Affiliation(s)
- Pedro Ordunez
- Pan American Health Organization Washington, DC United States of America ORCID 0000-0002-9871-6845 ORCID 0000-0003-2026-572X ORCID 0000-0001-8173-0686 Pan American Health Organization, Washington, DC, United States of America; ORCID 0000-0002-9871-6845; ORCID 0000-0003-2026-572X; ORCID 0000-0001-8173-0686
| | - Carlos Tajer
- Hospital El Cruce Néstor Kirchner Buenos Aires Argentina ORCID 0000-0002-6787-6651 Hospital El Cruce Néstor Kirchner, Buenos Aires, Argentina; ORCID 0000-0002-6787-6651
| | - Thomas Gaziano
- Harvard T.H. Chan School of Public Health Boston United States of America ORCID 0000-0002-5985-345X Harvard T.H. Chan School of Public Health, Boston, United States of America; ORCID 0000-0002-5985-345X
| | - Yenny A Rodriguez
- Pan American Health Organization Washington, DC United States of America ORCID 0000-0002-9871-6845 ORCID 0000-0003-2026-572X ORCID 0000-0001-8173-0686 Pan American Health Organization, Washington, DC, United States of America; ORCID 0000-0002-9871-6845; ORCID 0000-0003-2026-572X; ORCID 0000-0001-8173-0686
| | - Andres Rosende
- Pan American Health Organization Washington, DC United States of America ORCID 0000-0002-9871-6845 ORCID 0000-0003-2026-572X ORCID 0000-0001-8173-0686 Pan American Health Organization, Washington, DC, United States of America; ORCID 0000-0002-9871-6845; ORCID 0000-0003-2026-572X; ORCID 0000-0001-8173-0686
| | - Marc G Jaffe
- Kaiser Permanente San Francisco Medical Center San Francisco United States of America ORCID 0000-0002-5049-7815 Kaiser Permanente San Francisco Medical Center, San Francisco, United States of America; ORCID 0000-0002-5049-7815
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Blood A, Chaney K, Miller A, Nichols H, Crossen J, Matta L, Gordon W, Gaziano T, Scirica B, Plutzky J, Cannon C. STATIN INTOLERANCE: A REMOTE, NAVIGATOR-LED STRATEGY TO COMBAT A COMMON CHALLENGE. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)04620-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Blood A, Chaney K, Zelle D, Matta L, Nichols H, Crossen J, Gordon W, Gaziano T, Cannon C, Scirica B, Fisher N. TIME TO CONTROL: ROUTINE CLINICAL CARE VS. VIRTUAL HYPERTENSION MANAGEMENT. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02841-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Fuller JM, Ho YX, Morse R, Fix G, Cutrona SL, Gaziano T, Connolly SL, Hass R, Jackson J, McInnes DK. A Mobile Health Tool for Peer Support of Individuals Reentering Communities After Incarceration. J Health Care Poor Underserved 2021; 32:148-165. [PMID: 35574220 PMCID: PMC9097827 DOI: 10.1353/hpu.2021.0055] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Individuals just released from prison, or returning citizens (RCs), face high mortality rates during the reentry period, with cardiovascular disease (CVD) being a leading cause. Peer mentors can support RCs' health, but they traditionally work in person, which may not always be feasible, particularly during pandemic outbreaks such as COVID-19. We used human-centered design to build a prototype of RCPeer, a web/mobile application (app) to support peer-led reentry efforts through CVD risk screening, action planning, linkage to resources addressing reintegration needs (e.g., housing, transportation), and goal-setting. We assessed feasibility, acceptability, and usability of RCPeer using mixed-methods. System Usability Scale (SUS) scores were 68 for peers and 66 for RCs, indicating good usability. Qualitative data suggests that RCPeer can support reentry tasks through RCs and peers sharing data, strengthen RC-peer relationships, and facilitate RCs meeting their goals. Future work is needed to enhance usability for RCs with limited technology experience.
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Affiliation(s)
| | | | | | - Gemmae Fix
- Center for Health Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA
| | - Sarah L Cutrona
- Center for Health Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA
| | - Thomas Gaziano
- Department of Cardiovascular Medicine, Brigham & Women's Hospital, Boston, MA
| | - Samantha L Connolly
- Center for Health Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Boston, MA
| | | | | | - D Keith McInnes
- Center for Health Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA
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Desai AS, Maclean T, Blood AJ, Bosque-Hamilton J, Dunning J, Fischer C, Fera L, Smith KV, Wagholikar K, Zelle D, Gaziano T, Plutzky J, Scirica B, MacRae CA. Remote Optimization of Guideline-Directed Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction. JAMA Cardiol 2020; 5:1430-1434. [PMID: 32936209 DOI: 10.1001/jamacardio.2020.3757] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [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: 01/30/2023]
Abstract
Importance Optimal treatment of heart failure with reduced ejection fraction (HFrEF) is scripted by treatment guidelines, but many eligible patients do not receive guideline-directed medical therapy (GDMT) in clinical practice. Objective To determine whether a remote, algorithm-driven, navigator-administered medication optimization program could enhance implementation of GDMT in HFrEF. Design, Setting, and Participants In this case-control study, a population-based sample of patients with HFrEF was offered participation in a quality improvement program directed at GDMT optimization. Treating clinicians in a tertiary academic medical center who were caring for patients with heart failure and an ejection fraction of 40% or less (identified through an electronic health record-based search) were approached for permission to adjust medical therapy according to a sequential titration algorithm modeled on the current American College of Cardiology/American Heart Association heart failure guidelines. Navigators contacted participants by telephone to direct medication adjustment and conduct longitudinal surveillance of laboratory tests, blood pressure, and symptoms under supervision of a pharmacist, nurse practitioner, and heart failure cardiologist. Patients and clinicians declining to participate served as a control group. Exposures Navigator-led remote optimization of GDMT compared with usual care. Main Outcomes and Measures Proportion of patients receiving GDMT in the intervention and control groups at 3 months. Results Of 1028 eligible patients (mean [SD] values: age, 68 [14] years; ejection fraction, 32% [8%]; and systolic blood pressure, 122 [18] mm Hg; 305 women (30.0%); 892 individuals [86.8%] in New York Heart Association class I and II), 197 (19.2%) participated in the medication optimization program, and 831 (80.8%) continued with usual care as directed by their treating clinicians (585 [56.9%] general cardiologists; 443 [43.1%] heart failure specialists). At 3 months, patients participating in the remote intervention experienced significant increases from baseline in use of renin-angiotensin system antagonists (138 [70.1%] to 170 [86.3%]; P < .001) and β-blockers (152 [77.2%] to 181 [91.9%]; P < .001) but not mineralocorticoid receptor antagonists (51 [25.9%] to 60 [30.5%]; P = .14). Doses for each category of GDMT also increased from baseline in the intervention group. Among the usual-care group, there were no changes from baseline in the proportion of patients receiving GDMT or the dose of GDMT in any category. Conclusions and Relevance Remote titration of GDMT by navigators using encoded algorithms may represent an efficient, population-level strategy for rapidly closing the gap between guidelines and clinical practice in patients with HFrEF.
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Affiliation(s)
- Akshay S Desai
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Taylor Maclean
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Alexander J Blood
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joshua Bosque-Hamilton
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jacqueline Dunning
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christina Fischer
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Liliana Fera
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Katelyn V Smith
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - David Zelle
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts
| | - Thomas Gaziano
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jorge Plutzky
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Benjamin Scirica
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Calum A MacRae
- Cardiovascular Medicine Innovation Program, Brigham and Women's Hospital, Boston, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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Ferro E, Abrahams-Gessel S, Wagner R, Montana L, Gomez-Olive X, Tollman S, Gaziano T. Defining the electrocardiographic and echocardiographic abnormalities in a population of older adults with cardiovascular disease in rural south africa. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/13/2022] Open
Abstract
Abstract
Background
The African continent is undergoing an epidemiologic transition from infectious to cardiovascular (CV) diseases. National health systems face a critical shortage of population-level data to target the growing burden of hypertension (HTN). Very little is known on the impact of HTN on the rural population in many African countries, where over 85% of the rural population will migrate to cities and shape the modern CV disease spectrum of Africa in the next decade.
Purpose
To characterize the prevalence of HTN and HTN-related EKG and TTE abnormalities in a rural cohort in South Africa (n=5,059).
Methods
Between 2014 and 2015, 804 EKGs and 158 TTEs were performed on participants aged 40 or older randomly sampled from a longitudinal cohort residing in the Agincourt sub-district of rural South Africa. EKGs and TTEs were interpreted by two blinded physicians, and clinically meaningful variables defined using the Minnesota code (EKG) and European Association of Cardiovascular Imaging guidelines (TTE). Chi-square tests were conducted to define the association of EKG/TTE abnormalities with HTN, and stratify by gender.
Results
Over 55% of the sample (n=810) met blood pressure criteria for HTN, with a high prevalence of obesity (29%). On EKG, 36.5% participants had left ventricular hypertrophy (LVH), 13.6% T wave abnormalities, 7.5% Q wave abnormalities and 18.8% prolonged QT interval. Males (n=291) had more LVH (45% vs 30.8%, p<0.01) and Q wave abnormalities (10% vs 5.9%, p=0.04) than females. Instead, females (n=438) had more prolonged QT intervals (28.8% vs 21%, p=0.02). Compared to those without HTN, participants with HTN had more LVH (45.4% vs 22.1%, p<0.01), ST segment abnormalities (17.4% vs 10.7%, p<0.01) and prolonged QT interval (23.4% vs 11.4%, p<0.01). On TTE, there was a high prevalence of moderate (31%) / severe (25.8%) diastolic dysfunction, and concentric LVH (31.6%). Females had more concentric LVH (40.8% vs 13.5%, p<0.01), and high relative wall thickness (70% vs 18.1%, p<0.01) than males. Participants with HTN had more concentric LVH (42.5% vs 8.2%, p<0.01), LV mass (58.5% vs 20.4%, p<0.01) and LV mass index (52.8% vs 30.6%, p<0.01), than those without HTN.
Conclusions
The rural population in South Africa is already affected by a high burden of HTN and high obesity levels. Within this cohort, patients with HTN have significantly more EKG and TTE abnormalities that predict adverse CV outcomes. EKG and TTE evaluation can be used to identify high-risk groups that national health systems should prioritize with frequent monitoring and more aggressive medical treatment.
Funding Acknowledgement
Type of funding source: Private hospital(s). Main funding source(s): Brigham and Women's Hospital
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Affiliation(s)
- E.G Ferro
- Brigham and Women'S Hospital, Harvard Medical School, Boston, United States of America
| | - S Abrahams-Gessel
- Brigham and Women'S Hospital, Harvard Medical School, Boston, United States of America
| | - R Wagner
- University of the Witwatersrand, Johannesburg, South Africa
| | - L Montana
- Harvard T. H. Chan School of Public Health, Boston, United States of America
| | - X Gomez-Olive
- University of the Witwatersrand, Johannesburg, South Africa
| | - S Tollman
- University of the Witwatersrand, Johannesburg, South Africa
| | - T Gaziano
- Brigham and Women'S Hospital, Harvard Medical School, Boston, United States of America
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12
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Marklund M, Lee Y, Liu J, Sy S, Abrahams-Gessel S, Wilde P, Mozaffarian D, Gaziano T, Micha R. Health Impact and Cost-Effectiveness of Financing Fruit and Vegetable Subsidies with a Sugar-Sweetened Beverage Tax in the US: A Micro-Simulation Study. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa064_011] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Financial incentives and disincentives are effective tools for improving food purchases and health. Healthy food subsidies have only been considered for vulnerable populations and can be costly, while sugar-sweetened beverage (SSB) taxes can be considered financially regressive and punitive. The potential joint health and economic impacts of combining these approaches at a national scale have not been evaluated.
Methods
A validated microsimulation model, CVD PREDICT, was used to estimate reductions in CVD events, diabetes cases, gains in quality-adjusted life-years (QALYs), costs, and cost-effectiveness of a national U.S. fruit and vegetable subsidy fully or partly financed by SSB excise tax revenue ($0.01/tsp of added sugar). For the fully financed subsidy, cost could not exceed net tax revenue; while for the partly financed subsidy, costs were greater and ensured that taxes paid did not exceed subsidies received in either low or high income subgroups. Model inputs included national demographic and dietary data from NHANES 2009–2014; policy effects on consumer intakes, industry responses, and diet-disease effects from meta-analyses; and policy costs (tax and subsidy implementation, subsidy costs, industry reformulation), and health-related costs (formal/informal healthcare costs, productivity costs) from published sources. Findings were evaluated over 10 years and lifetime, with costs (in constant 2019 USD) and QALYs discounted at 3% annually.
Results
Both the fully and partly financed joint intervention was estimated to be cost-saving, compared to a base-case scenario accounting for gradual voluntary SSB industry reformulation. At 10 years, the fully financed intervention would prevent approximately 1.11M CVD events, 0.14M CVD deaths, and 0.34M diabetes cases, gain 0.87M QALYs, generate 1.49B net revenue, and save $56B in formal healthcare costs. Corresponding values for the partially financed intervention were 1.42M, 0.17M, 0.34M, 1.18M, −13.9B, and $65B. Estimated benefits and cost-savings were approximately 4–15 fold higher over a lifetime.
Conclusions
A joint national strategy combining revenue from an SSB excise tax to fully or partially finance fruit and vegetable subsidies could generate substantial health gains and cost-savings for the US, while minimizing government spending.
Funding Sources
NIH, NHLBI.
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Affiliation(s)
- Matti Marklund
- Friedman School of Nutrition Science and Policy, Tufts University; The George Institute for Global Health, UNSW
| | - Yujin Lee
- Friedman School of Nutrition Science and Policy, Tufts University
| | - Junxiu Liu
- Friedman School of Nutrition Science and Policy, Tufts University
| | | | | | - Parke Wilde
- Friedman School of Nutrition Science and Policy, Tufts University
| | | | - Thomas Gaziano
- Brigham & Women's Hospital; Harvard T.H. Chan School of Public Health
| | - Renata Micha
- Friedman School of Nutrition Science and Policy, Tufts University
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13
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Wade AN, Crowther N, Gomez-Olive FX, Wagner RG, Manne-Goehler J, Berkman L, Salomon JA, George J, Gaziano T, Cappola AR, Tollman S. SUN-616 Poor Diagnostic Concordance Between Fasting Plasma Glucose and Glycosylated Hemoglobin in a Black South African Population. J Endocr Soc 2020. [PMCID: PMC7208058 DOI: 10.1210/jendso/bvaa046.1258] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: While elevations in fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c) are both recognized by the American Diabetes Association (ADA) as diagnostic of hyperglycemia, previous comparisons of these tests have demonstrated discordant individual classifications and population estimates. This may be due to additional postprandial glycemia reflected by HbA1c and, in African-descent populations, to non-glycemic factors that contribute to higher HbA1c at any given level of glycemia. We hypothesized that glycemic classifications based on FPG or HbA1c would differ in a Black South African population and investigated factors associated with discordance. Methods: 889 Black adults with previously undiagnosed diabetes, aged 40-79 years, from the population-based Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) cohort were included. Concordance between ADA FPG (normoglycemia [NG] <100 mg/dl, prediabetes [pre-DM] 100-125 mg/dl, diabetes [DM] ≥ 126 mg/dl) and HbA1c (NG <5.7%, pre-DM 5.7-6.4%, DM ≥ 6.5%) classifications was assessed using Cohen’s kappa statistic and logistic regression models were used to identify predictors of discordance. Results: Median age was 55 years (IQR 49-62) and 49.3% of the sample was male. Median glucose was 86.4 mg/dl and median HbA1c was 5.4%. Pre-DM, as defined by HbA1c, was present in 204 participants (22.9%), while FPG-defined pre-DM was present in 122 (13.7%). DM defined by HbA1c was present in 146 (16.4%), while FPG-defined DM was present in 36 (4.0%). Concordance between the two tests was poor (kappa statistic 0.18; 95%CI 0.13-0.24). Self-reported history of tuberculosis (OR 1.90, p=0.026) and higher HbA1c (OR 4.70, p<0.001) were associated with increased likelihood of discordance, whereas higher fasting glucose was associated with decreased likelihood of discordance (OR 0.58, p<0.001). There was no association between discordance and hemoglobin, HIV status, BMI, waist circumference or hip circumference. Conclusion: FPG and HbA1c exhibit poor concordance in classifying hyperglycemia in this Black South African population, with HbA1c-based definitions identifying higher prevalences of pre-DM and DM. Further work is needed to confirm whether these discrepancies are due solely to elevations in postprandial glucose. In the interim, clinicians should consider confirming elevated HbA1c concentrations with oral glucose tolerance testing, particularly in those with a history of tuberculosis, prior to making a diagnosis of DM in this population.
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Affiliation(s)
- Alisha N Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit, Univ of the Witwatersrand, Johannesburg, South Africa
| | - Nigel Crowther
- Department of Chemical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - F Xavier Gomez-Olive
- MRC/Wits Rural Public Health and Health Transitions Research Unit, Univ of the Witwatersrand, Johannesburg, South Africa
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit, Univ of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Berkman
- Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Joshua A Salomon
- Center for Health Policy, Stanford University, Stanford, CA, USA
| | - Jaya George
- Department of Chemical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Thomas Gaziano
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Anne Rentoumis Cappola
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Perelman School of Medicine, Univ of Pennsylvania, Philadelphia, PA, USA
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit, Univ of the Witwatersrand, Johannesburg, South Africa
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14
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Houle B, Gaziano T, Farrell M, Gómez-Olivé FX, Kobayashi LC, Crowther NJ, Wade AN, Montana L, Wagner RG, Berkman L, Tollman SM. Cognitive function and cardiometabolic disease risk factors in rural South Africa: baseline evidence from the HAALSI study. BMC Public Health 2019; 19:1579. [PMID: 31775713 PMCID: PMC6882146 DOI: 10.1186/s12889-019-7938-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 11/11/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Evidence on cognitive function in older South Africans is limited, with few population-based studies. We aimed to estimate baseline associations between cognitive function and cardiometabolic disease risk factors in rural South Africa. METHODS We use baseline data from "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI), a population-based study of adults aged 40 and above in rural South Africa in 2015. Cognitive function was measured using measures of time orientation, immediate and delayed recall, and numeracy adapted from the Health and Retirement Study cognitive battery (overall total cognitive score range 0-26). We used multiple linear regression to estimate associations between cardiometabolic risk factors (including BMI, hypertension, dyslipidemia, diabetes, history of stroke, alcohol frequency, and smoking status) and the overall cognitive function score, adjusted for potential confounders. RESULTS In multivariable-adjusted analyses (n = 3018; male = 1520; female = 1498; median age 59 (interquartile range 50-67)), cardiometabolic risk factors associated with lower cognitive function scores included: diabetes (b = - 1.11 [95% confidence interval: - 2.01, - 0.20] for controlled diabetes vs. no diabetes); underweight BMI (b = - 0.87 [CI: - 1.48, - 0.26] vs. normal BMI); and current and past smoking history compared to never smokers. Factors associated with higher cognitive function scores included: obese BMI (b = 0.74 [CI: 0.39, 1.10] vs. normal BMI); and controlled hypertension (b = 0.53 [CI: 0.11, 0.96] vs. normotensive). CONCLUSIONS We provide an important baseline from rural South Africa on the associations between cardiometabolic disease risk factors and cognitive function in an older, rural South African population using standardized clinical measurements and cut-offs and widely used cognitive assessments. Future studies are needed to clarify temporal associations as well as patterns between the onset and duration of cardiometabolic conditions and cognitive function. As the South African population ages, effective management of cardiometabolic risk factors may be key to lasting cognitive health.
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Affiliation(s)
- Brian Houle
- School of Demography, The Australian National University, ACT, Canberra, Australia.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa.,Institute of Behavioral Science, University of Colorado Boulder, Boulder, CO, USA
| | - Thomas Gaziano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Harvard University, Boston, MA, USA
| | - Meagan Farrell
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
| | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa.,Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA.,INDEPTH Network, East Legon, Accra, Ghana
| | - Lindsay C Kobayashi
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Nigel J Crowther
- Department of Chemical Pathology, National Health Laboratory Service, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Alisha N Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Livia Montana
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa.,INDEPTH Network, East Legon, Accra, Ghana.,Centre for Global Health Research, Umeå University, Umeå, Sweden
| | - Lisa Berkman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa.,Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Departments of Social and Behavioral Sciences and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Stephen M Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa. .,INDEPTH Network, East Legon, Accra, Ghana. .,Centre for Global Health Research, Umeå University, Umeå, Sweden.
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15
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Lee Y, Mozaffarian D, Liu J, Sy S, Abrahams-Gessel S, Wilde P, Gaziano T, Micha R. Health Impact and Cost-effectiveness of Volume, Tiered, and Sugar Content Sugar-sweetened Beverage Tax Policies in the US: A Micro-simulation Study (OR28-04-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz042.or28-04-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Sugar-sweetened beverage (SSB) intake is linked to weight gain, type 2 diabetes, and cardiovascular disease (CVD). SSBs taxes are a policy tool to reduce intake, and volume-based taxes have been passed in the US. Yet, the comparative health and economic impacts of volume-based, tiered, or sugar content-based SSB taxes have not been quantified. We aimed to estimate the health and economic impacts of these varying SSB tax designs in the US.
Methods
A validated microsimulation model, CVD PREDICT, was used to estimate reductions in CVD events, diabetes cases, gains in quality-adjusted life-years (QALYs), costs, and cost-effectiveness of three SSB tax designs in US adults: (1) volume tax ($0.01/oz), (2) tiered tax (no tax for <5 g of added sugar/8 oz; $0.01/oz for 5–20 g/8 oz; and $0.02/oz for >20 g/8 oz, and (3) sugar content tax ($0.01/tsp of added sugar). Model inputs included national demographic and dietary data from NHANES 2009–2014; policy effects on consumer intakes, industry responses, and SSB-disease effects from meta-analyses; and policy costs (tax implementation, industry reformulation) and health-related costs (formal/informal healthcare costs, productivity costs) from established sources. Findings were evaluated over 10 years and a lifetime, with costs inflated to constant 2018 USD, and costs and QALYs discounted at 3% annually.
Results
All SSB tax designs were cost-saving from all perspectives, compared to a base-case scenario accounting for voluntary industry reformulation (Table). At 10 years, the volume tax would prevent 0.24 M CVD events, 0.11 M CVD deaths, and 0.03 M diabetes cases, gain 0.22 M QALYs, generate $35.18bn tax revenue, and save $14.45bn in formal healthcare costs. Corresponding values for the tiered tax were 0.46 M, 0.22 M, 0.06 M, 0.42 M, $54.99bn and $27.88bn; and for the sugar content tax, 0.37 M, 0.16 M, 0.05 M, 0.27 M, $19.97bn and $20.54bn. Projected benefits increased over a lifetime, and economic benefits were less from health and societal perspectives, excluding tax revenue.
Conclusions
Implementing SSB taxes would generate substantial health gains and cost-savings for the US population. Taxing SSBs based on a tiered tax, followed by grams of sugar content, would be a more effective strategy than a volume tax to generate health and economic benefits.
Funding Sources
NIH, NHLBI.
Supporting Tables, Images and/or Graphs
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Affiliation(s)
- Yujin Lee
- Friedman School of Nutrition Science & Policy, Tufts University
| | | | - Junxiu Liu
- Friedman School of Nutrition Science & Policy, Tufts University
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health
| | | | - Parke Wilde
- Friedman School of Nutrition Science & Policy, Tufts University
| | | | - Renata Micha
- Friedman School of Nutrition Science & Policy, Tufts University
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16
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Liu J, Mozaffarian D, Lee Y, Sy S, Abrahams-Gessel S, Wilde P, Gaziano T, Micha R. Cost-Effectiveness of the U.S. Federal Restaurant Menu Calorie Labeling Law for Improving Diet and Health: A Microsimulation Modeling Study (P22-014-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz042.p22-014-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Excess caloric intake is linked to weight gain, obesity and related diseases including type 2 diabetes and cardiovascular disease (CVD). Obesity incidence has been on the rise, with almost 2 of 3 people being overweight or obese in the US. In 2018, the US federal government passed a law mandating the labeling of calories on all menu items across chain restaurants, as a strategy to support informed consumer choice and reduce caloric intake. Yet, potential health and economic impacts of this policy remain unclear.
Methods
We used a validated microsimulation model (CVD-PREDICT) to estimate reductions in CVD events, diabetes cases, gains in quality-adjusted life-years (QALYs), costs, and cost-effectiveness of two policy scenarios: (1) implementation of the federal menu calorie labelling (menu calorie label), and (2) further accounting for corresponding industry reformulation (menu calorie label + reformulation). The model utilized nationally representative demographic and dietary data from NHANES 2009–2016; policy effects on consumer intake and BMI-disease effects from published meta-analyses; and policy effects on industry reformulation, policy costs (policy administration, industry compliance and reformulation) and health-related costs (formal and informal healthcare costs, productivity costs) from established sources. We conservatively modeled change in calories to change in weight using an established dynamic weight-change model. Findings were evaluated over 10 years and lifetime from a healthcare and societal perspective. Costs were inflated to constant 2018 USD, and costs and QALYs were discounted at 3% annually. We performed probabilistic analyses and a range of one-way sensitivity and subgroup analyses to assess the robustness of our findings.
Results
Sample statistics were shown (Table). American adults (35+) consume ∼21% calorie from restaurants (Figure) that would be reduced by 2% due to this law at the population level. Government administration costs were estimated at 11.6$M, industry compliance costs at 652$M, and industry reformulation costs at 9.2$B. Findings for all other analyses will be presented at the meeting.
Conclusions
These findings will provide much needed evidence on the health and economic impacts of the US menu calorie labeling law.
Funding Sources
NIH, AHA.
Supporting Tables, Images and/or Graphs
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Affiliation(s)
- Junxiu Liu
- Friedman School of Nutrition Science & Policy, Tufts University
| | | | - Yujin Lee
- Friedman School of Nutrition Science & Policy, Tufts University
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health
| | | | | | | | - Renata Micha
- Friedman School of Nutrition Science & Policy, Tufts University
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17
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Manne‐Goehler J, Siedner MJ, Montana L, Harling G, Geldsetzer P, Rohr J, Gómez‐Olivé F, Goehler A, Wade A, Gaziano T, Kahn K, Davies JI, Tollman S, Bärnighausen TW. Hypertension and diabetes control along the HIV care cascade in rural South Africa. J Int AIDS Soc 2019; 22:e25213. [PMID: 30916897 PMCID: PMC6436499 DOI: 10.1002/jia2.25213] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [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: 04/19/2018] [Accepted: 11/02/2018] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Participation in antiretroviral therapy (ART) programmes has been associated with greater utilization of care for hypertension and diabetes in rural South Africa. The objective of this study was to assess whether people living with HIV on ART with comorbid hypertension or diabetes also have improved chronic disease management indicators. METHODS The Health and Aging in Africa: a longitudinal study of an INDEPTH Community in South Africa (HAALSI) is a cohort of 5059 adults >40 years old. Enrollment took place between November 2014 and November 2015. The study collected population-based data on demographics, healthcare utilization, height, weight, blood pressure (BP) and blood glucose as well as HIV infection, HIV-1 RNA viral load (VL) and ART exposure. We used regression models to determine whether HIV care cascade stage (HIV-negative, HIV+ /No ART, ART/Detected HIV VL, and ART/Undetectable VL) was associated with diagnosis or treatment of hypertension or diabetes, and systolic blood pressure and glucose among those with diagnosed hypertension or diabetes. ART use was measured from drug level testing on dried blood spots. RESULTS AND DISCUSSION Compared to people without HIV, ART/Undetectable VL was associated with greater awareness of hypertension diagnosis (adjusted risk ratio (aRR) 1.18, 95% CI: 1.09 to 1.28) and treatment of hypertension (aRR 1.24, 95% CI: 1.10 to 1.41) among those who met hypertension diagnostic criteria. HIV care cascade stage was not significantly associated with awareness of diagnosis or treatment of diabetes. Among those with diagnosed hypertension or diabetes, ART/Undetectable VL was associated with lower mean systolic blood pressure (5.98 mm Hg, 95% CI: 9.65 to 2.32) and lower mean glucose (3.77 mmol/L, 95% CI: 6.85 to 0.69), compared to being HIV-negative. CONCLUSIONS Participants on ART with an undetectable VL had lower systolic blood pressure and blood glucose than the HIV-negative participants. HIV treatment programmes may provide a platform for health systems strengthening for cardiometabolic disease.
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Affiliation(s)
- Jennifer Manne‐Goehler
- Division of Infectious DiseasesMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
- Department of Global Health & PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Mark J Siedner
- Massachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Livia Montana
- Harvard Center for Population & Development StudiesHarvard UniversityCambridgeMAUSA
| | - Guy Harling
- Harvard Center for Population & Development StudiesHarvard UniversityCambridgeMAUSA
- Africa Health Research Institute (AHRI)MtubatubaSouth Africa
- Institute for Global HealthUniversity College LondonLondonUK
| | - Pascal Geldsetzer
- Department of Global Health & PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Julia Rohr
- Harvard Center for Population & Development StudiesHarvard UniversityCambridgeMAUSA
| | - F Xavier Gómez‐Olivé
- Medical Research Council/Wits Rural Public Health & Health Transitions Research UnitSchool of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- INDEPTH NetworkAccraGhana
| | - Alexander Goehler
- Department of Radiology, Brigham & Women's HospitalHarvard Medical SchoolBostonMAUSA
| | - Alisha Wade
- Medical Research Council/Wits Rural Public Health & Health Transitions Research UnitSchool of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Thomas Gaziano
- Department of Cardiovascular MedicineBrigham & Women's HospitalHarvard Medical SchoolBostonMAUSA
- Center for Health Decision ScienceHarvard Medical SchoolBostonMAUSA
| | - Kathleen Kahn
- Medical Research Council/Wits Rural Public Health & Health Transitions Research UnitSchool of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- INDEPTH NetworkAccraGhana
| | - Justine I Davies
- Medical Research Council/Wits Rural Public Health & Health Transitions Research UnitSchool of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- Centre for Global HealthKing's College LondonLondonUK
| | - Stephen Tollman
- Medical Research Council/Wits Rural Public Health & Health Transitions Research UnitSchool of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- INDEPTH NetworkAccraGhana
| | - Till W Bärnighausen
- Department of Global Health & PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
- Africa Health Research Institute (AHRI)MtubatubaSouth Africa
- Institute of Public HealthUniversity of HeidelbergHeidelbergGermany
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18
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Wilde P, Huang Y, Sy S, Abrahams-Gessel S, Jardim TV, Paarlberg R, Mozaffarian D, Micha R, Gaziano T. Cost-Effectiveness of a US National Sugar-Sweetened Beverage Tax With a Multistakeholder Approach: Who Pays and Who Benefits. Am J Public Health 2019; 109:276-284. [PMID: 30571305 PMCID: PMC6336039 DOI: 10.2105/ajph.2018.304803] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To estimate the health impact and cost-effectiveness of a national penny-per-ounce sugar-sweetened beverage (SSB) tax, overall and with stratified costs and benefits for 9 distinct stakeholder groups. METHODS We used a validated microsimulation model (CVD PREDICT) to estimate cardiovascular disease reductions, quality-adjusted life years gained, and cost-effectiveness for US adults aged 35 to 85 years, evaluating full and partial consumer price pass-through. RESULTS From health care and societal perspectives, the SSB tax was highly cost-saving. When we evaluated health gains, taxes paid, and out-of-pocket health care savings for 6 distinct consumer categories, incremental cost-effectiveness ratios ranged from $20 247 to $42 662 per quality-adjusted life year for 100% price pass-through (incremental cost-effectiveness ratios similar with 50% pass-through). For the beverage industry, net costs were $0.92 billion with 100% pass-through (largely tax-implementation costs) and $49.75 billion with 50% pass-through (largely because of partial industry coverage of the tax). For government, the SSB tax positively affected both tax revenues and health care cost savings. CONCLUSIONS This stratified analysis improves on unitary approaches, illuminating distinct costs and benefits for stakeholders with political influence over SSB tax decisions.
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Affiliation(s)
- Parke Wilde
- Parke Wilde, Yue Huang, Dariush Mozaffarian, and Renata Micha are with the Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. Stephen Sy, Shafika Abrahams-Gessel, Thiago Veiga Jardim, and Thomas Gaziano are with the Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston. T. Veiga Jardim and T. Gaziano are also with the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston. Robert Paarlberg is with the Harvard Kennedy School, Cambridge, MA
| | - Yue Huang
- Parke Wilde, Yue Huang, Dariush Mozaffarian, and Renata Micha are with the Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. Stephen Sy, Shafika Abrahams-Gessel, Thiago Veiga Jardim, and Thomas Gaziano are with the Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston. T. Veiga Jardim and T. Gaziano are also with the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston. Robert Paarlberg is with the Harvard Kennedy School, Cambridge, MA
| | - Stephen Sy
- Parke Wilde, Yue Huang, Dariush Mozaffarian, and Renata Micha are with the Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. Stephen Sy, Shafika Abrahams-Gessel, Thiago Veiga Jardim, and Thomas Gaziano are with the Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston. T. Veiga Jardim and T. Gaziano are also with the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston. Robert Paarlberg is with the Harvard Kennedy School, Cambridge, MA
| | - Shafika Abrahams-Gessel
- Parke Wilde, Yue Huang, Dariush Mozaffarian, and Renata Micha are with the Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. Stephen Sy, Shafika Abrahams-Gessel, Thiago Veiga Jardim, and Thomas Gaziano are with the Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston. T. Veiga Jardim and T. Gaziano are also with the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston. Robert Paarlberg is with the Harvard Kennedy School, Cambridge, MA
| | - Thiago Veiga Jardim
- Parke Wilde, Yue Huang, Dariush Mozaffarian, and Renata Micha are with the Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. Stephen Sy, Shafika Abrahams-Gessel, Thiago Veiga Jardim, and Thomas Gaziano are with the Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston. T. Veiga Jardim and T. Gaziano are also with the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston. Robert Paarlberg is with the Harvard Kennedy School, Cambridge, MA
| | - Robert Paarlberg
- Parke Wilde, Yue Huang, Dariush Mozaffarian, and Renata Micha are with the Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. Stephen Sy, Shafika Abrahams-Gessel, Thiago Veiga Jardim, and Thomas Gaziano are with the Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston. T. Veiga Jardim and T. Gaziano are also with the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston. Robert Paarlberg is with the Harvard Kennedy School, Cambridge, MA
| | - Dariush Mozaffarian
- Parke Wilde, Yue Huang, Dariush Mozaffarian, and Renata Micha are with the Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. Stephen Sy, Shafika Abrahams-Gessel, Thiago Veiga Jardim, and Thomas Gaziano are with the Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston. T. Veiga Jardim and T. Gaziano are also with the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston. Robert Paarlberg is with the Harvard Kennedy School, Cambridge, MA
| | - Renata Micha
- Parke Wilde, Yue Huang, Dariush Mozaffarian, and Renata Micha are with the Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. Stephen Sy, Shafika Abrahams-Gessel, Thiago Veiga Jardim, and Thomas Gaziano are with the Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston. T. Veiga Jardim and T. Gaziano are also with the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston. Robert Paarlberg is with the Harvard Kennedy School, Cambridge, MA
| | - Thomas Gaziano
- Parke Wilde, Yue Huang, Dariush Mozaffarian, and Renata Micha are with the Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. Stephen Sy, Shafika Abrahams-Gessel, Thiago Veiga Jardim, and Thomas Gaziano are with the Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston. T. Veiga Jardim and T. Gaziano are also with the Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston. Robert Paarlberg is with the Harvard Kennedy School, Cambridge, MA
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Gómez-Olivé FX, Montana L, Wagner RG, Kabudula CW, Rohr JK, Kahn K, Bärnighausen T, Collinson M, Canning D, Gaziano T, Salomon JA, Payne CF, Wade A, Tollman SM, Berkman L. Cohort Profile: Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI). Int J Epidemiol 2018; 47:689-690j. [PMID: 29325152 PMCID: PMC6005147 DOI: 10.1093/ije/dyx247] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/29/2017] [Accepted: 01/02/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
- INDEPTH Network, East Legon, Accra, Ghana
| | - Livia Montana
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
- Centre for Global Health Research, Umeå University, Umeå, Sweden
- INDEPTH Network, East Legon, Accra, Ghana
| | - Chodziwadziwa W Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- INDEPTH Network, East Legon, Accra, Ghana
| | - Julia K Rohr
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
- Centre for Global Health Research, Umeå University, Umeå, Sweden
- INDEPTH Network, East Legon, Accra, Ghana
| | - Till Bärnighausen
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
- Department of Global Health and Population
| | - Mark Collinson
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
- Centre for Global Health Research, Umeå University, Umeå, Sweden
- INDEPTH Network, East Legon, Accra, Ghana
| | - David Canning
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
- Department of Global Health and Population
| | - Thomas Gaziano
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Joshua A Salomon
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
- Department of Global Health and Population
| | - Collin F Payne
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
| | - Alisha Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Stephen M Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
- Centre for Global Health Research, Umeå University, Umeå, Sweden
- INDEPTH Network, East Legon, Accra, Ghana
| | - Lisa Berkman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
- Department of Global Health and Population
- Departments of Social and Behavioral Sciences and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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20
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Prabhakaran D, Anand S, Watkins D, Gaziano T, Wu Y, Mbanya JC, Nugent R. Cardiovascular, respiratory, and related disorders: key messages from Disease Control Priorities, 3rd edition. Lancet 2018; 391:1224-1236. [PMID: 29108723 PMCID: PMC5996970 DOI: 10.1016/s0140-6736(17)32471-6] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [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] [Received: 01/26/2017] [Revised: 08/04/2017] [Accepted: 09/05/2017] [Indexed: 12/11/2022]
Abstract
Cardiovascular, respiratory, and related disorders (CVRDs) are the leading causes of adult death worldwide, and substantial inequalities in care of patients with CVRDs exist between countries of high income and countries of low and middle income. Based on current trends, the UN Sustainable Development Goal to reduce premature mortality due to CVRDs by a third by 2030 will be challenging for many countries of low and middle income. We did systematic literature reviews of effectiveness and cost-effectiveness to identify priority interventions. We summarise the key findings and present a costed essential package of interventions to reduce risk of and manage CVRDs. On a population level, we recommend tobacco taxation, bans on trans fats, and compulsory reduction of salt in manufactured food products. We suggest primary health services be strengthened through the establishment of locally endorsed guidelines and ensured availability of essential medications. The policy interventions and health service delivery package we suggest could serve as the cornerstone for the management of CVRDs, and afford substantial financial risk protection for vulnerable households. We estimate that full implementation of the essential package would cost an additional US$21 per person in the average low-income country and $24 in the average lower-middle-income country. The essential package we describe could be a starting place for low-income and middle-income countries developing universal health coverage packages. Interventions could be rolled out as disease burden demands and budgets allow. Our outlined interventions provide a pathway for countries attempting to convert the UN Sustainable Development Goal commitments into tangible action.
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Affiliation(s)
- Dorairaj Prabhakaran
- Public Health Foundation of India, Gurgaon, India; Centre for Chronic Disease Control, New Delhi, India; Department of Non-communicable Disease Epidemiology, London School of Hygiene Tropical Medicine, London, UK; Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Shuchi Anand
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - David Watkins
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Thomas Gaziano
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Center for Health Decision Science, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Yangfeng Wu
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China
| | - Jean Claude Mbanya
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaounde, Cameroon
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21
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Petersen I, Bhana A, Folb N, Thornicroft G, Zani B, Selohilwe O, Petrus R, Mntambo N, Georgeu-Pepper D, Kathree T, Lund C, Lombard C, Bachmann M, Gaziano T, Levitt N, Fairall L. Collaborative care for the detection and management of depression among adults with hypertension in South Africa: study protocol for the PRIME-SA randomised controlled trial. Trials 2018; 19:192. [PMID: 29566730 PMCID: PMC5863904 DOI: 10.1186/s13063-018-2518-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 09/08/2017] [Indexed: 12/15/2022] Open
Abstract
Background The high co-morbidity of mental disorders, particularly depression, with non-communicable diseases (NCDs) such as cardiovascular disease (CVD), is concerning given the rising burden of NCDs globally, and the role depression plays in confounding prevention and treatment of NCDs. The objective of this randomised control trial (RCT) is to determine the real-world effectiveness of strengthened depression identification and management on depression outcomes in hypertensive patients attending primary health care (PHC) facilities in South Africa (SA). Methods/design The study design is a pragmatic, two-arm, parallel-cluster RCT, the unit of randomisation being the clinics, with outcomes being measured for individual participants. The 20 largest eligible clinics from one district in the North West Province are enrolled in the trial. Equal numbers of hypertensive patients (n = 50) identified as having depression using the Patient Health Questionnaire (PHQ-9) are enrolled from each clinic, making up a total of 1000 participants with 500 in each arm. The nurse clinicians in the control facilities receive the standard training in Primary Care 101 (PC101), a clinical decision support tool for integrated chronic care that includes guidelines for hypertension and depression care. Referral pathways available include referrals to PHC physicians, clinical or counselling psychologists and outpatient psychiatric and psychological services. In the intervention clinics, this training is supplemented with strengthened training in the depression components of PC101 as well as training in clinical communication skills for nurse-led chronic care. Referral pathways are strengthened through the introduction of a facility-based behavioural health counsellor, trained to provide structured manualised counselling for depression and adherence counselling for all chronic conditions. The primary outcome is defined as at least 50% reduction in PHQ-9 score measured at 6 months. Discussion This trial should provide evidence of the real world effectiveness of strengtheneddepression identification and collaborative management on health outcomes of hypertensive patients withcomorbid depression attending PHC facilities in South Africa. Trial registration South African National Clinical Trial Register: SANCTR (http://www.sanctr.gov.za/SAClinicalTrials) (DOH-27-0916-5051). Registered on 9 April 2015. ClinicalTrials.gov: ID: NCT02425124. Registered on 22 April 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2518-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa.
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa.,Health Systems Research Unit, South African Medical Research Council, Durban, South Africa
| | - Naomi Folb
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Graham Thornicroft
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, UK
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - One Selohilwe
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa
| | - Ruwayda Petrus
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa
| | - Ntokozo Mntambo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa
| | | | - Tasneem Kathree
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa
| | - Crick Lund
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, UK.,Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Max Bachmann
- Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Thomas Gaziano
- Department of Health Policy and Management, Harvard University, Cambridge, USA
| | - Naomi Levitt
- Department of Diabetic Medicine and Endocrinology, University of Cape Town, Cape Town, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
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22
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Jamison DT, Alwan A, Mock CN, Nugent R, Watkins D, Adeyi O, Anand S, Atun R, Bertozzi S, Bhutta Z, Binagwaho A, Black R, Blecher M, Bloom BR, Brouwer E, Bundy DAP, Chisholm D, Cieza A, Cullen M, Danforth K, de Silva N, Debas HT, Donkor P, Dua T, Fleming KA, Gallivan M, Garcia PJ, Gawande A, Gaziano T, Gelband H, Glass R, Glassman A, Gray G, Habte D, Holmes KK, Horton S, Hutton G, Jha P, Knaul FM, Kobusingye O, Krakauer EL, Kruk ME, Lachmann P, Laxminarayan R, Levin C, Looi LM, Madhav N, Mahmoud A, Mbanya JC, Measham A, Medina-Mora ME, Medlin C, Mills A, Mills JA, Montoya J, Norheim O, Olson Z, Omokhodion F, Oppenheim B, Ord T, Patel V, Patton GC, Peabody J, Prabhakaran D, Qi J, Reynolds T, Ruacan S, Sankaranarayanan R, Sepúlveda J, Skolnik R, Smith KR, Temmerman M, Tollman S, Verguet S, Walker DG, Walker N, Wu Y, Zhao K. Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition. Lancet 2018; 391:1108-1120. [PMID: 29179954 PMCID: PMC5996988 DOI: 10.1016/s0140-6736(17)32906-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [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] [Received: 08/10/2017] [Revised: 11/01/2017] [Accepted: 11/15/2017] [Indexed: 12/23/2022]
Abstract
The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.
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Affiliation(s)
- Dean T Jamison
- University of California, San Francisco, San Francisco, CA, USA.
| | - Ala Alwan
- University of Washington, Seattle, WA, USA
| | | | | | | | | | | | - Rifat Atun
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | | | | | | | - Robert Black
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mark Blecher
- National Treasury of South Africa, Cape Town, South Africa
| | - Barry R Bloom
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Dan Chisholm
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | | | | | | | | | - Haile T Debas
- University of California, San Francisco, San Francisco, CA, USA
| | - Peter Donkor
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Tarun Dua
- World Health Organization, Geneva, Switzerland
| | - Kenneth A Fleming
- Center for Global Health, National Cancer Institute, Bethesda, MD, USA; University of Oxford, Oxford, UK
| | | | | | - Atul Gawande
- Harvard T. H. Chan School of Public Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas Gaziano
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
| | | | - Roger Glass
- Fogarty International Center, US National Institutes of Health, Bethesda, MD, USA
| | | | - Glenda Gray
- University of the Witwatersrand, Johannesburg, South Africa
| | - Demissie Habte
- International Clinical Epidemiology Network, New Delhi, India
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Carol Medlin
- Praxis Social Impact Consulting, Washington, DC, USA
| | - Anne Mills
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Zachary Olson
- University of California, Berkeley, Berkeley, CA, USA
| | | | | | - Toby Ord
- University of Oxford, Oxford, UK
| | | | - George C Patton
- Murdoch Childrens Research Institute, Melbourne, VIC, Australia; University of Melbourne, Melbourne, VIC, Australia
| | - John Peabody
- University of California, San Francisco, San Francisco, CA, USA
| | - Dorairaj Prabhakaran
- London School of Hygiene & Tropical Medicine, London, UK; Public Health Foundation of India, New Delhi, India
| | - Jinyuan Qi
- Princeton, University, Princeton, NJ, USA
| | | | | | | | - Jaime Sepúlveda
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Kirk R Smith
- University of California, Berkeley, Berkeley, CA, USA
| | | | | | | | | | - Neff Walker
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Kun Zhao
- China National Health Development Research Center, Beijing, China
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Gaziano T, Cho S, Sy S, Pandya A, Levitt NS, Steyn K. Increasing Prescription Length Could Cut Cardiovascular Disease Burden And Produce Savings In South Africa. Health Aff (Millwood) 2017; 34:1578-85. [PMID: 26355061 DOI: 10.1377/hlthaff.2015.0351] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
South Africa's rates of statin use are among the world's lowest, despite statins' demonstrated effectiveness for people with a high blood cholesterol level or history of cardiovascular disease. Almost 5 percent of the country's total mortality has been attributed to high cholesterol levels, fueled in part by low levels of statin adherence. Drawing upon experience elsewhere, we used a microsimulation model of cardiovascular disease to investigate the health and economic impacts of increasing prescription length from the standard thirty days to either sixty or ninety days, for South African adults on a stable statin regimen. Increasing prescription length to sixty or ninety days could save 1,694 or 2,553 lives per million adults, respectively. In addition, annual per patient costs related to cardiovascular disease would decrease by $152.41 and $210.29, respectively. Savings would largely accrue to patients in the form of time savings and reduced transportation costs, as a result of less frequent trips to the pharmacy. Increasing statin prescription length would both save resources and improve health outcomes in South Africa.
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Affiliation(s)
- Thomas Gaziano
- Thomas Gaziano is an assistant professor in the Cardiovascular Division of Brigham and Women's Hospital, in Boston, Massachusetts
| | - Sylvia Cho
- Sylvia Cho is a research assistant in the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health, in Boston
| | - Stephen Sy
- Stephen Sy is a programmer at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health
| | - Ankur Pandya
- Ankur Pandya is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health
| | - Naomi S Levitt
- Naomi S. Levitt is director of the Division of Diabetes and the Chronic Diseases Initiative for Africa, both at Old Groote Schuur Hospital, in Cape Town, South Africa
| | - Krisela Steyn
- Krisela Steyn is associate director of the Chronic Diseases Initiative for Africa, at Old Groote Schuur Hospital
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Gaziano T, Abrahams-Gessel S, Surka S, Sy S, Pandya A, Denman CA, Mendoza C, Puoane T, Levitt NS. Cardiovascular Disease Screening By Community Health Workers Can Be Cost-Effective In Low-Resource Countries. Health Aff (Millwood) 2017; 34:1538-45. [PMID: 26355056 DOI: 10.1377/hlthaff.2015.0349] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In low-resource settings, a physician is not always available. We recently demonstrated that community health workers-instead of physicians or nurses-can efficiently screen adults for cardiovascular disease in South Africa, Mexico, and Guatemala. In this analysis we sought to determine the health and economic impacts of shifting this screening to community health workers equipped with either a paper-based or a mobile phone-based screening tool. We found that screening by community health workers was very cost-effective or even cost-saving in all three countries, compared to the usual clinic-based screening. The mobile application emerged as the most cost-effective strategy because it could save more lives than the paper tool at minimal extra cost. Our modeling indicated that screening by community health workers, combined with improved treatment rates, would increase the number of deaths averted from 15,000 to 110,000, compared to standard care. Policy makers should promote greater acceptance of community health workers by both national populations and health professionals and should increase their commitment to treating cardiovascular disease and making medications available.
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Affiliation(s)
- Thomas Gaziano
- Thomas Gaziano is an assistant professor in the Cardiovascular Division of Brigham and Women's Hospital, in Boston, Massachusetts
| | - Shafika Abrahams-Gessel
- Shafika Abrahams-Gessel is a research manager at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health, in Boston
| | - Sam Surka
- Sam Surka is a researcher in the Chronic Diseases Initiative for Africa at Old Groote Schuur Hospital, in Cape Town, South Africa
| | - Stephen Sy
- Stephen Sy is a programmer at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health
| | - Ankur Pandya
- Ankur Pandya is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health
| | - Catalina A Denman
- Catalina A. Denman is a professor in the Centro de Estudios en Salud y Sociedad at El Colegio de Sonora, in Hermosillo, Mexico
| | - Carlos Mendoza
- Carlos Mendoza is a coinvestigator at the Instituto de Nutricion de Centro America y Panama, in Guatemala City, Guatemala
| | - Thandi Puoane
- Thandi Puoane is a professor in the School of Public Health at the University of the Western Cape, in Bellville, South Africa
| | - Naomi S Levitt
- Naomi S. Levitt is director of the Division of Diabetes and the Chronic Diseases Initiative for Africa, both at Old Groote Schuur Hospital
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Manne-Goehler J, Montana L, Gomez-Olive X, Rohr J, Wagner R, Kabudula C, Wade A, Kahn K, Tollman S, Berkman L, Barnighausen T, Gaziano T. Human Immunodeficiency Virus (HIV) Infection, Antiretroviral Therapy (ART) Use and Access to Care for Diabetes and Hypertension in Agincourt, South Africa. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw194.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Livia Montana
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
| | - Xavier Gomez-Olive
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
| | - Julia Rohr
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
| | - Ryan Wagner
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit, Agincourt, South Africa
| | | | - Alisha Wade
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen Tollman
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa Berkman
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
| | - Till Barnighausen
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, Boston, Massachusetts
| | - Thomas Gaziano
- Department of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Pearson-Stuttard J, Bandosz P, Rehm C, Afshin A, Penalvo J, Whitsel I, Micha R, Danaei G, Gaziano T, Conrad Z, Lloyd-Williams F, Mozaffarian D, Capewell S, O’Flaherty M. OP83 Comparing the impact of price change and mass media campaigns on reducing cardiovascular disease mortality and disparities in the US. Br J Soc Med 2016. [DOI: 10.1136/jech-2016-208064.83] [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: 11/03/2022]
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Irazola VE, Gutierrez L, Bloomfield G, Carrillo-Larco RM, Dorairaj P, Gaziano T, Levitt NS, Miranda JJ, Ortiz AB, Steyn K, Wu Y, Xavier D, Yan LL, He J, Rubinstein A. Hypertension Prevalence, Awareness, Treatment, and Control in Selected LMIC Communities: Results From the NHLBI/UHG Network of Centers of Excellence for Chronic Diseases. Glob Heart 2016; 11:47-59. [PMID: 27102022 PMCID: PMC4843831 DOI: 10.1016/j.gheart.2015.12.008] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 12/17/2015] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Hypertension is the leading cause of cardiovascular disease and premature death worldwide. The prevalence of this public health problem is increasing in low- and middle-income countries (LMICs) in both urban and rural communities. OBJECTIVE The aim of this study was to examine hypertension prevalence, awareness, treatment, and control in adults 35 to 74 years of age from urban and rural communities in LMICs in Africa, Asia, and South America. METHODS The authors analyzed data from 7 population-based cross-sectional studies in selected communities in 9 LMICs that were conducted between 2008 and 2013. Age- and sex-standardized prevalence rates of pre-hypertension and hypertension were calculated. The prevalence rates of awareness, treatment, and control of hypertension were estimated overall and by subgroups of age, sex, and educational level. RESULTS In selected communities, age- and sex-standardized prevalence rates of hypertension among men and women 35 to 74 years of age were 49.9% (95% confidence interval [CI]: 42.3% to 57.4%) in Kenya, 54.9% (95% CI: 51.3% to 58.4%) in South Africa, 52.5% (95% CI: 50.1% to 54.8%) in China, 32.5% (95% CI: 31.7% to 33.3%) in India, 42.3% (95% CI: 40.4% to 44.2%) in Pakistan, 45.4% (95% CI: 43.6% to 47.2%) in Argentina, 39.9% (95% CI: 37.8% to 42.1%) in Chile, 19.2% (95% CI: 17.8% to 20.5%) in Peru, and 44.1% (95% CI: 41.6% to 46.6%) in Uruguay. The proportion of awareness varied from 33.5% in India to 69.0% in Peru, the proportion of treatment among those who were aware of their hypertension varied from 70.8% in South Africa to 93.3% in Pakistan, and the proportion of blood pressure control varied from 5.3% in China to 45.9% in Peru. CONCLUSIONS The prevalence of hypertension varies widely in different communities. The rates of awareness, treatment, and control also differ in different settings. There is a clear need to focus on increasing hypertension awareness and control in LMICs.
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Affiliation(s)
- Vilma E Irazola
- Centro de Excelencia en Salud Cardiovascular para el Cono Sur, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
| | - Laura Gutierrez
- Centro de Excelencia en Salud Cardiovascular para el Cono Sur, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | | | - Rodrigo M Carrillo-Larco
- CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Prabhakaran Dorairaj
- Public Health Foundation of India, Gurgaon, India; Centre for Chronic Disease Control, Gurgaon, India
| | - Thomas Gaziano
- Division of Cardiovascular Medicine, Brigham & Women's Hospital, Boston, MA, USA; Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Naomi S Levitt
- Chronic Disease Initiative for Africa, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Division of Diabetic Medicine and Endocrinology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - J Jaime Miranda
- CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Antonio Bernabe Ortiz
- CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Krisela Steyn
- Chronic Disease Initiative for Africa, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China; Peking University Clinical Research Institute, Department of Epidemiology and Biostatistics, Peking University School of Public Health, Beijing, China
| | - Denis Xavier
- St. John's Medical College and Research Institute, St. John's National Academy of Health Sciences, Bangalore, India
| | - Lijing L Yan
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China; Duke Global Health Institute and Global Health Research Center, Duke Kunshan University, Kunshan, China
| | - Jiang He
- Department of Epidemiology, Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Adolfo Rubinstein
- Centro de Excelencia en Salud Cardiovascular para el Cono Sur, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
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Pearson-Stuttard J, Bandosz P, Rehm C, Afshin A, Penalvo J, Whitsel L, Danaei G, Gaziano T, Mozaffarian D, O’Flaherty M, Capewell S. OP51 Comparing the effectiveness of price reduction and mass media campaigns in reducing cvd mortality by targeting fruit and vegetables intake. Br J Soc Med 2015. [DOI: 10.1136/jech-2015-206256.50] [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: 11/03/2022]
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Guzman-Castillo M, Pearson-Stuttard J, Penalvo J, Rehm C, Afshin A, Danaei G, Gaziano T, Mozaffarian D, O’Flaherty M, Capewell S. OP03 Predicting cardiovascular disease mortality rates in the united states in 2030: prospective modelling approaches. Br J Soc Med 2015. [DOI: 10.1136/jech-2015-206256.3] [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: 11/04/2022]
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Riviello ED, Letchford S, Cook EF, Waxman AB, Gaziano T. Improving decision making for massive transfusions in a resource poor setting: a preliminary study in Kenya. PLoS One 2015; 10:e0127987. [PMID: 26020935 PMCID: PMC4447346 DOI: 10.1371/journal.pone.0127987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 04/22/2015] [Indexed: 11/18/2022] Open
Abstract
Background The reality of finite resources has a real-world impact on a patient’s ability to receive life-saving care in resource-poor settings. Blood for transfusion is an example of a scarce resource. Very few studies have looked at predictors of survival in patients requiring massive transfusion. We used data from a rural hospital in Kenya to develop a prediction model of survival among patients receiving massive transfusion. Methods Patients who received five or more units of whole blood within 48 hours between 2004 and 2010 were identified from a blood registry in a rural hospital in Kenya. Presenting characteristics and in-hospital survival were collected from charts. Using stepwise selection, a logistic model was developed to predict who would survive with massive transfusion versus those who would die despite transfusion. An ROC curve was created from this model to quantify its predictive power. Results Ninety-five patients with data available met inclusion criteria, and 74% survived to discharge. The number of units transfused was not a predictor of mortality, and no threshold for futility could be identified. Preliminary results suggest that initial blood pressure, lack of comorbidities, and indication for transfusion are the most important predictors of survival. The ROC curve derived from our model demonstrates an area under the curve (AUC) equal to 0.757, with optimism of 0.023 based on a bootstrap validation. Conclusions This study provides a framework for making prioritization decisions for the use of whole blood in the setting of massive bleeding. Our analysis demonstrated an overall survival rate for patients receiving massive transfusion that was higher than clinical perception. Our analysis also produced a preliminary model to predict survival in patients with massive bleeding. Prediction analyses can contribute to more efficient prioritization decisions; these decisions must also include other considerations such as equity, acceptability, affordability and sustainability.
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Affiliation(s)
- Elisabeth D. Riviello
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- * E-mail:
| | | | - Earl Francis Cook
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Aaron B. Waxman
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Thomas Gaziano
- Harvard School of Public Health, Boston, Massachusetts, United States of America
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
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Peer N, Steyn K, Lombard C, Gaziano T, Levitt N. Alarming rise in prevalence of atherogenic dyslipidaemia in the black population of Cape Town: the Cardiovascular Risk in Black South Africans (CRIBSA) study. Eur J Prev Cardiol 2013; 21:1549-56. [PMID: 23881149 DOI: 10.1177/2047487313497865] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [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: 11/17/2022]
Abstract
OBJECTIVES To determine the prevalence, determinants, and management of dyslipidaemia in the 25-74-year-old urban black population of Cape Town and examine the changes between 1990 and 2008/09 in the 25-64-year-old sample. METHODS In 2008/09, a representative cross-sectional sample, stratified for age and sex, was randomly selected from the same townships sampled in 1990. Cardiovascular disease (CVD) risk factors were determined by questionnaires, clinical measurements, and fasting biochemical analyses. Survey logistic regression analysis assessed the determinants of raised low-density lipoprotein cholesterol (LDL-C). RESULTS There were 1099 participants in 2008/09 (392 men and 707 women; response rate 86%). The prevalence of raised total cholesterol (TC), raised LDL-C, and reduced high-density lipoprotein cholesterol (HDL-C) were 25.2% (95% confidence interval, CI, 20.0-31.3), 37.8% (95% CI 32.5-43.4), and 55.2% (95% CI 49.9-60.4) in men and 23.1% (95% CI 20.0-26.5), 47.0% (95% CI 43.1-50.9), and 66.8% (95% CI 62.9-70.5) in women, respectively. Between 1990 and 2008/09, raised LDL-C and reduced HDL-C prevalence increased significantly with no change for raised TC. Among participants with raised LDL-C, only 2.6% were aware of their diagnosis, 2.7% were on treatment, and 1.5% had LDL-C <3 mmol/l. In the logistic model, increasing age (odds ratio, OR, 1.04, 95% CI 1.03-1.05; p < 0.001), rising body mass index (OR 1.03, 95% CI 1.01-1.05; p = 0.003), and fat intake ≥30% of diet (OR 1.37, 95% CI 1.02-1.85; p = 0.035) were significantly associated with LDL-C ≥3 mmol/l but not sex, physical activity, or urbanization. CONCLUSIONS The dyslipidaemia pattern in this population requires full lipogram screening in high-risk individuals and demands improved management using a total CVD risk approach.
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Affiliation(s)
- Nasheeta Peer
- Medical Research Council, Durban and Cape Town, South Africa
| | | | - Carl Lombard
- Medical Research Council, Durban and Cape Town, South Africa
| | | | - Naomi Levitt
- University of Cape Town, Cape Town, South Africa
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Patel D, Lambert EV, da Silva R, Greyling M, Kolbe-Alexander T, Noach A, Conradie J, Nossel C, Borresen J, Gaziano T. Participation in fitness-related activities of an incentive-based health promotion program and hospital costs: a retrospective longitudinal study. Am J Health Promot 2011; 25:341-8. [PMID: 21534837 DOI: 10.4278/ajhp.100603-quan-172] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE A retrospective, longitudinal study examined changes in participation in fitness-related activities and hospital claims over 5 years amongst members of an incentivized health promotion program offered by a private health insurer. DESIGN A 3-year retrospective observational analysis measuring gym visits and participation in documented fitness-related activities, probability of hospital admission, and associated costs of admission. SETTING A South African private health plan, Discovery Health and the Vitality health promotion program. PARTICIPANTS 304,054 adult members of the Discovery medical plan, 192,467 of whom registered for the health promotion program and 111,587 members who were not on the program. INTERVENTION Members were incentivised for fitness-related activities on the basis of the frequency of gym visits. MEASURES Changes in electronically documented gym visits and registered participation in fitness-related activities over 3 years and measures of association between changes in participation (years 1-3) and subsequent probability and costs of hospital admission (years 4-5). Hospital admissions and associated costs are based on claims extracted from the health insurer database. ANALYSIS The probability of a claim modeled by using linear logistic regression and costs of claims examined by using general linear models. Propensity scores were estimated and included age, gender, registration for chronic disease benefits, plan type, and the presence of a claim during the transition period, and these were used as covariates in the final model. RESULTS There was a significant decrease in the prevalence of inactive members (76% to 68%) over 5 years. Members who remained highly active (years 1-3) had a lower probability (p < .05) of hospital admission in years 4 to 5 (20.7%) compared with those who remained inactive (22.2%). The odds of admission were 13% lower for two additional gym visits per week (odds ratio, .87; 95% confidence interval [CI], .801-.949). CONCLUSION We observed an increase in fitness-related activities over time amongst members of this incentive-based health promotion program, which was associated with a lower probability of hospital admission and lower hospital costs in the subsequent 2 years.
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Affiliation(s)
- Deepak Patel
- UCT/MRC Research Unit for Exercise Science and Sports Medicine, University of Cape Town, Cape Town South Africa
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Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, Baugh V, Bekedam H, Billo N, Casswell S, Cecchini M, Colagiuri R, Colagiuri S, Collins T, Ebrahim S, Engelgau M, Galea G, Gaziano T, Geneau R, Haines A, Hospedales J, Jha P, Keeling A, Leeder S, Lincoln P, McKee M, Mackay J, Magnusson R, Moodie R, Mwatsama M, Nishtar S, Norrving B, Patterson D, Piot P, Ralston J, Rani M, Reddy KS, Sassi F, Sheron N, Stuckler D, Suh I, Torode J, Varghese C, Watt J. Priority actions for the non-communicable disease crisis. Lancet 2011; 377:1438-47. [PMID: 21474174 DOI: 10.1016/s0140-6736(11)60393-0] [Citation(s) in RCA: 1021] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US$9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.
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Patel D, Lambert EV, da Silva R, Greyling M, Noach A, Scott A, Nossel C, Borresen J, Kolbe-Alexander T, Gaziano T. Engagement In Fitness-related Activities Of An Incentivised Health Promotion Program And Long-term Health Costs. Med Sci Sports Exerc 2010. [DOI: 10.1249/01.mss.0000386643.76536.e2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Patel DN, Lambert EV, da Silva R, Greyling M, Nossel C, Noach A, Derman W, Gaziano T. The association between medical costs and participation in the vitality health promotion program among 948,974 members of a South African health insurance company. Am J Health Promot 2010; 24:199-204. [PMID: 20073387 DOI: 10.4278/090217-quan-68r2.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Examine the association between the levels of participation in an incentive-based health promotion program (Vitality) and inpatient medical claims among members of a major health insurer. DESIGN A 1-year, cross-sectional, correlational analyses of engagement with a health promotion program and hospital claims experience (admissions costs, days in hospital, and admission rate) of members of a national private health insurer. SETTING Adult members of South Africa's largest national private health insurer, Discovery Health. Insured members were also eligible for voluntary membership in an insurance-linked incentivized health promotion program, Vitality. SUBJECTS The study sample included 948,974 adult members of the Discovery Health plan for the year 2006. Of these, 591,134 (62.3%) were also members of the Vitality health promotion program. MEASURES The study sample was grouped based on registration and the level of engagement with the Vitality health promotion program into the following: not registered (37.5%), registered but not engaged with any health promotion activity (21.9%), low engagement (30.9%), and high engagement (9.5%). High engagement was defined a priori by the accumulation of an arbitrary number of points on the Vitality program, allocated against specific activities (knowledge, fitness-related activities, assessment and screening, and healthy choices). Hospital admission costs, the number of days in hospital, and hospital admission rates were compared among highly engaged members and those members who were not enrolled in the program, nonengaged, and lowly engaged. Data were normalized for age, gender, plan type, and chronic disease status. RESULTS Highly engaged members had lower costs per patient, shorter stays in hospital, and fewer admissions compared with other groups (p < .001). Low or no engagement was not associated with lower hospital costs. Admission rates were also 7.4% lower for cardiovascular disease, 13.2% lower for cancers, and 20.7% lower for endocrine and metabolic diseases in the highly engaged group compared with any of the other groups (p < .01). CONCLUSIONS Engagement in an incentive-based wellness program, offered by a health insurer, was associated with lower health care costs.
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Lambert EV, da Silva R, Fatti L, Patel D, Kolbe-Alexander T, Derman W, Noach A, Nossel C, Gaziano T. Fitness-related activities and medical claims related to hospital admissions - South Africa, 2006. Prev Chronic Dis 2009; 6:A120. [PMID: 19754996 PMCID: PMC2774634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION We report on the effect of an incentive-based wellness program on medical claims and hospital admissions among members of a major health insurer. The focus of this investigation was specifically on fitness-related activities in this insured population. METHODS Adult members of South Africa's largest private health insurer (n = 948,974) were grouped, a priori, on the basis of documented participation in fitness-related activities, including gym visits, into inactive (80%, equivalent to < or =3 gym visits/y), low active (7.0%, 4-23 gym visits/y), moderate active (5.2%, 24-48 gym visits/y), and high active (7.4%, >48 gym visits/y) groups. We compared medical claims data related to hospital admissions between groups after adjustment for age, sex, medical plan, and chronic illness benefits. RESULTS Hospitalization costs per member were lower in each activity group compared with the inactive group. This same pattern was demonstrated for admissions rates. There was good agreement between level of participation in fitness-related activities and in other wellness program offerings; 90% of people only nominally engaged in the wellness program also were low active or inactive, whereas 84% of those in the high active group also had the highest overall participation in the wellness program. CONCLUSION Participation in fitness-related activities within an incentive-based health insurance wellness program was associated with lower health care costs. However, involvement in fitness-related activities was generally low, and further research is required to identify and address barriers to participation in such programs.
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Affiliation(s)
- Estelle V. Lambert
- UCT/MRC Research Unit for Exercise Science and Sports Medicine, University of Cape Town
| | | | - Libero Fatti
- University of the Witwatersrand, Johannesburg, South Africa
| | - Deepak Patel
- University of Cape Town, Cape Town, South Africa, and Discovery Health, Johannesburg, South Africa
| | | | - Wayne Derman
- University of Cape Town, Cape Town, South Africa
| | - Adam Noach
- Discovery Health, Johannesburg, South Africa
| | | | - Thomas Gaziano
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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Patel D, Lambert EV, de Silva R, Liberto F, Nossel C, Gaziano T. Fitness-related activities as part of an Incentive-based Wellness Program and Chronic Medical Claims and Admissions: Vitality Insured Persons. Med Sci Sports Exerc 2008. [DOI: 10.1249/01.mss.0000321912.78292.51] [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: 11/21/2022]
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Garg P, Cohen DJ, Gaziano T, Mauri L. Balancing the Risks of Restenosis and Stent Thrombosis in Bare-Metal Versus Drug-Eluting Stents. J Am Coll Cardiol 2008; 51:1844-53. [DOI: 10.1016/j.jacc.2008.01.042] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Revised: 11/29/2007] [Accepted: 01/06/2008] [Indexed: 01/01/2023]
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Norman R, Bradshaw D, Steyn K, Gaziano T. Estimating the burden of disease attributable to high cholesterol in South Africa in 2000. S Afr Med J 2007; 97:708-715. [PMID: 17952228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVES To estimate the burden of disease attributable to high cholesterol in adults aged 30 years and older in South Africa in 2000. DESIGN World Health Organization comparative risk assessment (CRA) methodology was followed. Small community studies were used to derive the prevalence by population group. Population-attributable fractions were calculated and applied to revised burden of disease estimates for the relevant disease categories for each population group. The total attributable burden for South Africa in 2000 was obtained by adding the burden attributed to high cholesterol for the four population groups. Monte Carlo simulation-modelling techniques were used for uncertainty analysis. SETTING South Africa. SUBJECTS Black African, coloured, white and Indian adults aged 30 years and older. OUTCOME MEASURES Mortality and disability-adjusted life years (DALYs) from ischaemic heart disease (IHD) and ischaemic stroke. RESULTS Overall, about 59% of IHD and 29% of ischaemic stroke burden in adult males and females (30+ years) were attributable to high cholesterol (>or= 3.8 mmol/l), with marked variation by population group. High cholesterol was estimated to have caused 24,144 deaths (95% uncertainty interval 22,404 - 25,286) or 4.6% (95% uncertainty interval 4.3 - 4.9%) of all deaths in South Africa in 2000. Since most cholesterol-related cardiovascular disease events occurred in middle or old age, the loss of life years comprised a smaller proportion of the total: 222,923 DALYs (95% uncertainty interval 206,712 - 233,460) or 1.4% of all DALYs (95% uncertainty interval 1.3 - 1.4%) in South Africa in 2000. CONCLUSIONS High cholesterol is an important cardiovascular risk factor in all population groups in South Africa.
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Affiliation(s)
- Rosana Norman
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Cape Town.
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Norman R, Gaziano T, Laubscher R, Steyn K, Bradshaw D. Estimating the burden of disease attributable to high blood pressure in South Africa in 2000. S Afr Med J 2007; 97:692-698. [PMID: 17952226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVES To estimate the burden of disease attributable to high blood pressure (BP) in adults aged 30 years and older in South Africa in 2000. DESIGN World Health Organization comparative risk assessment (CRA) methodology was followed. Mean systolic BP (SBP) estimates by age and sex were obtained from the 1998 South African Demographic and Health Survey adult data. Population-attributable fractions were calculated and applied to revised burden of disease estimates for the relevant disease categories for South Africa in 2000. Monte Carlo simulation-modelling techniques were used for uncertainty analysis. SETTING South Africa. SUBJECTS Adults aged 30 years and older. OUTCOME MEASURES Mortality and disability-adjusted life years (DALYs) from ischaemic heart disease (IHD), stroke, hypertensive disease and other cardiovascular disease (CVD). RESULTS High BP was estimated to have caused 46,888 deaths (95% uncertainty interval 44,878 - 48,566) or 9% (95% uncertainty interval 8.6 - 9.3%) of all deaths in South Africa in 2000, and 390,860 DALYs (95% uncertainty interval 377,955 - 402,256) or 2.4% of all DALYs (95% uncertainty interval 2.3 - 2.5%) in South Africa in 2000. Overall, 50% of stroke, 42% of IHD, 72% of hypertensive disease and 22% of other CVD burden in adult males and females (30+ years) were attributable to high BP (systolic BP >or= 115 mmHg). CONCLUSIONS High BP contributes to a considerable burden of CVD in South Africa and results indicate that there is considerable potential for health gain from implementing BP-lowering interventions that are known to be highly costeffective.
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Affiliation(s)
- Rosana Norman
- Burden of Disease Research Unit, Medical Research Council of South Africa, Tygerberg, Cape Town.
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Zimetbaum P, Reynolds MR, Ho KKL, Gaziano T, McDonald MJ, McClennen S, Berezin R, Josephson ME, Cohen DJ. Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs. Am J Cardiol 2003; 92:677-81. [PMID: 12972105 DOI: 10.1016/s0002-9149(03)00821-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Health care resource utilization is high for patients presenting with acute atrial fibrillation (AF). The potential for treatment algorithms to safely reduce resource consumption in this setting has not been prospectively evaluated. We designed and implemented a practice guideline for the management of patients presenting to the emergency department (ED) with the primary diagnosis of AF, with emphasis on appropriate cardioversion, use of oral rate-controlling medications, and expedited referral to an outpatient AF clinic. We prospectively collected clinical and resource utilization data on all such patients for 14 months before and after institution of the guideline. Institution of the guideline was associated with a decreased rate of hospital admission (from 74% to 38%), with no differences in ED return visits or hospital readmission within 30 days. No strokes or deaths were observed. This large decrease in resource utilization during the intervention phase of the study translated to an average decrease in 30-day total direct health care costs of approximately $1,400 US dollars per patient. Our clinical and cost outcomes were minimally affected after statistical adjustment for baseline differences between study groups. We conclude that the implementation of our practice guideline was feasible, safe, and effective. Widespread adoption of such practices may have large financial implications for the health care system.
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Affiliation(s)
- Peter Zimetbaum
- Division of Cardiology, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA.
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