The household economic burden of non-communicable diseases in 18 countries

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries. METHODS: Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China. RESULTS: The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs. CONCLUSIONS: Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs. (AU)

Digitalis for treatment of congestive heart failure in patients in sinus rhythm.

BACKGROUND: Digitalis glycosides have been in clinical use in the treatment of congestive heart failure (CHF) for more than 200 years. In recent years several trials have been conducted to address concerns about efficacy and toxicity. Although a systematic review of the literature was published in 1990, an update is required to include more current trials. OBJECTIVES: To examine the effectiveness of digitalis glycosides in treating CHF in patients with normal sinus rhythm. To examine the effect of digitalis in patients taking diuretics, angiotensin converting enzyme inhibitors, and beta-blockers; patients with varying severity and duration of disease; patients with prior exposure to digitalis vs. no prior exposure; and patients with "CHF due to systolic dysfunction" vs. "CHF with preserved systolic function." SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (CENTRAL) 2003 Issue 4, MEDLINE (1966 to December 2003) and EMBASE (1990 to December 2003) were searched. Dissertation Abstracts and annual meeting abstracts of the American Heart Association, American College of Cardiology, and European Society of Cardiology were also searched from 1996-2003. In addition, reference lists provided by the pharmaceutical industry (Glaxo Wellcome Inc.) were searched. SELECTION CRITERIA: Included were randomized placebo-controlled trials of 20 or more adult patients of either sex with symptomatic CHF who were studied for seven weeks or more. Excluded were trials in which the prevalence of atrial fibrillation was 2% or greater, or in which any arrhythmia that might compromise cardiac function or any potentially reversible cause of CHF such as acute ischemic heart disease or myocarditis was present. DATA COLLECTION AND ANALYSIS: Articles selected from the searches described above were evaluated as a joint effort of the coauthors. The staff of the Cochrane Heart Group ran searches on the Cochrane Central Register of Controlled Trials. MAIN RESULTS: Thirteen articles meeting the defined criteria were identified, and major endpoints of mortality, hospitalization, and clinical status, based respectively upon 8, 4, and 12 of these selected studies, were recorded and analyzed. The data show that there is no evidence of a difference in mortality between treatment and control groups, whereas digitalis therapy is associated with a lower rate of hospitalization and of clinical deterioration. REVIEWERS' CONCLUSIONS: The literature indicates that digitalis has a useful role in the treatment of patients with CHF who are in normal sinus rhythm.

Applying the results of trials and systematic reviews to individual patients.

Your patient is a 60-year-old hypertensive, alcoholic woman whose symptomless atrial fibrillation was first documented 3 months ago. An echocardiogram shows an enlarged left atrium, rendering successful cardioversion unlikely. She tells you that both of her parents had severe strokes that made the last years of their lives horrible, and she is terrified of having a stroke. You know that a meta-analysis of 5 randomized trials of warfarin in nonvalvular atrial fibrillation demonstrated a 68% relative risk reduction (RRR) in stroke (1). You consider prescribing warfarin for this patient but know that she would not have qualified for the study because alcoholism increases her risk for major hemorrhage (2).

Evaluation of the reproducibility and accuracy of apex beat measurement in the detection of echocardiographic left ventricular dilation.

OBJECTIVE: To develop a standardized method for measuring the width of the apex beat and to determine its precision and accuracy in detecting echocardiographically determined left ventricular dilation. DESIGN: In the reproducibility study, two cardiologists blinded to each other's findings measured the apex beat. To determine accuracy, blind, independent assessment of apex beat measurement was compared with left ventricular enlargement determined by echocardiogram. PATIENTS: One hundred and four patients referred for echocardiogram for a wide variety of suspected cardiac abnormalities. MEASUREMENTS: The apex beat was measured with patients in a 45 degrees left lateral decubitus position; medial and lateral aspects of the impulse and the width were identified using electrocardiographic callipers. Echocardiographic left ventricular dilation was defined as a measure exceeding the 95% prediction limits as determined for the patient's age and body surface area. RESULTS: The intraclass correlation measuring agreement on apex beat size between two cardiologists in 13 patients was 0.95. Of the 104 patients, 57 had a measurable apex beat of whom 50 had a technically adequate echocardiogram. The sensitivity of the measurement, using a cut-point of 40 mm, was 0.48 and the specificity 0.96.