Comparison of Indian clinical practice guidelines for the management of hypertension with the World Health Organization, International Society of Hypertension, American, and European guidelines.

Hypertension is the leading risk factor for preventable cardiovascular diseases and all-cause mortality globally, with majority of the hypertension-attributed deaths occurring in low- and middle-income countries like India. Several international and national clinical practice guidelines (CPGs) provide evidence-informed recommendations to achieve optimal control. CPGs produced by the World Health Organization, International Society for Hypertension, American (AHA/ACC-2017), and European (ESC/ESH-2018) are "major" as they are widely used and are highly cited. We compared the main recommendations for the pharmacological management of hypertension among the major CPGs and the two existing Indian CPGs for similarities and shortcomings. Several deviations from the major CPGs were observed among Indian CPGs. Important shortcomings pertain to Indian CPGs' low priority for initial combination therapy and the use of single pill combinations. Having multiple CPGs providing conflicting recommendations might discourage the adoption of evidence-based practices. There is a need for updating Indian CPGs based on up-to-date evidence.

Standardized treatment protocols for hypertension: global availability, characteristics, and alignment with the hypertension guideline recommendations.

BACKGROUND: Hypertension control is suboptimal globally. Implementing evidence-based, simple, standardized treatment protocols (STPs) has been instrumental in effectively and efficiently improving treatment and control of hypertension. We aimed to identify, characterize, and critically appraise hypertension STPs. METHODS: We defined STP as a series of steps for the pharmacological treatment of primary hypertension, with information on target population, BP threshold for treatment initiation, target BP, specific drugs/classes/doses, and follow-up frequency. STPs for adult patients were identified from the websites of relevant health organizations, Google search, and through expert consultations (until July 2023). STPs for secondary, gestational, or malignant hypertension or those that were templates/samples were excluded. Included STPs were critically appraised using HEARTS in the Americas Checklist for hypertension management in primary care and compared with the 2021 WHO hypertension management guideline recommendations. RESULTS: Fifty STPs were identified. All STPs had a stepwise treatment approach, involved guideline-recommended first-line drugs, and 98% consisted of at least four steps. Majority (54%) recommended monotherapy with calcium channel blockers as first-line treatment. Only 44% STPs recommended treatment initiation with combination therapy, and 16% recommended single-pill combinations. Most (62%) had dose-intensification as the second step. Most (74%) STPs did not provide complete dosing information. Only one STP mentioned a target time for achieving BP control. On average, STPs scored a performance of 68% on the HEARTS Checklist. CONCLUSION: Several STPs are available globally; however, most of them have enormous scope for improvement through interventions aimed at alignment with the latest evidence-based guidelines and multistakeholder engagement.

Salt intake and salt-reduction strategies in South Asia: From evidence to action.

The World Health Organization recommends salt reduction as a cost-effective intervention to prevent noncommunicable diseases. Salt-reduction interventions are best tailored to the local context, taking into consideration the varying baseline salt-intake levels, population's knowledge, attitude, and behaviors. Fundamental to reduction programs is the source of dietary salt-intake. In South Asian countries, there is a paucity of such baseline evidence around factors that contribute to community salt intake. Upon reviewing the electronic literature databases and government websites through March 31, 2021, we summarized dietary salt intake levels and aimed to identify major sources of sodium in the diet. Information on the current salt reduction strategies in eight South Asian countries were summarized, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. One hundred twelve publications (out of identified 640) met our inclusion-exclusion criteria for full text review. Twenty-one studies were included in the review. Quality of the included studies was assessed using the US National Heart, Lung, and Blood Institute assessment tool. The primary result revealed that mean salt intake of South Asian countries was approximately twice (10 g/day) compared to WHO recommended intake (< 5 g/day). The significant proportion of salt intake is derived from salt additions during cooking and/or discretionary use at table. In most South Asian countries, there is limited data on population sodium intake based on 24-h urinary methods and sources of dietary salt in diet. While salt reduction initiatives have been proposed in these countries, they are yet to be fully implemented and evaluated. Proven salt reduction strategies in high-income countries could possibly be replicated in South Asian countries; however, further community-health promotion studies are necessary to test the effectiveness and scalability of those strategies in the local context.

Effectiveness of blended learning in pharmacy education: A systematic review and meta-analysis.

BACKGROUND & OBJECTIVE: Though blended learning (BL), is widely adopted in higher education, evaluating effectiveness of BL is difficult because the components of BL can be extremely heterogeneous. Purpose of this study was to evaluate the effectiveness of BL in improving knowledge and skill in pharmacy education. METHODS: PubMed/MEDLINE, Scopus and the Cochrane Library were searched to identify published literature. The retrieved studies from databases were screened for its title and abstracts followed by the full-text in accordance with the pre-defined inclusion and exclusion criteria. Methodological quality was appraised by modified Ottawa scale. Random effect model used for statistical modelling. KEY FINDINGS: A total of 26 studies were included for systematic review. Out of which 20 studies with 4525 participants for meta-analysis which employed traditional teaching in control group. Results showed a statistically significant positive effect size on knowledge (standardized mean difference [SMD]: 1.35, 95% confidence interval [CI]: 0.91 to 1.78, p<0.00001) and skill (SMD: 0.68; 95% CI: 0.19 to 1.16; p = 0.006) using a random effect model. Subgroup analysis of cohort studies showed, studies from developed countries had a larger effect size (SMD: 1.54, 95% CI: 1.01 to 2.06), than studies from developing countries(SMD: 0.44, 95% CI: 0.23 to 0.65, studies with MCQ pattern as outcome assessment had larger effect size (SMD: 2.81, 95% CI: 1.76 to 3.85) than non-MCQs (SMD 0.53, 95% CI 0.33 to 0.74), and BL with case studies (SMD 2.72, 95% CI 1.86-3.59) showed better effect size than non-case-based studies (SMD: 0.22, CI: 0.02 to 0.41). CONCLUSION: BL is associated with better academic performance and achievement than didactic teaching in pharmacy education.

Health System Capacity and Access Barriers to Diagnosis and Treatment of CVD and Diabetes in Nepal.

Background: Universal access to essential medicines and routine diagnostics is required to combat the growing burden of cardiovascular disease (CVD) and diabetes. Evaluating health systems and various access dimensions availability, affordability, accessibility, acceptability, and quality is crucial yet rarely performed, especially in low- and middle-income countries. Objective: To evaluate health system capacity and barriers in accessing diagnostics and essential medicines for CVD and diabetes in Nepal. Methods: We conducted a WHO/HAI nationally-representative survey in 45 health-facilities (public-sector: 11; private-sector: 34) in Nepal to collect availability and price data for 21 essential medicines for treating CVD and diabetes, during MayJuly 2017. Data for 13 routine diagnostics was obtained in 12 health facilities. Medicines were considered unaffordable if the lowest paid worker spends >1 days wage to purchase a monthly supply. To evaluate accessibility, we conducted facility exit interviews among 636 CVD patients. Accessibility (e.g., private-public health facility mix, travel to hospital/pharmacy) and acceptability (i.e. Nepals adoption of WHO Essential Medicine List, and patient medication adherence) were summarized using descriptive statistics, and we conducted a systematic review of relevant literature. We did not evaluate medicine quality. Results: We found that mean availability of generic medicines is low (<50%) in both public and private sectors, and less than one-third medicines met WHOs availability target (80%). Mean (SD) availability of diagnostics was 73.1% (26.8%). Essential medicines appear locally unaffordable. On average, the lowest-paid worker would spend 1.03 (public-sector) and 1.26 (private-sector) days wages to purchase a monthly supply. For a person undergoing CVD secondary preventive-interventions in the private sector, the associated expenditure would be 7.511.2% of monthly household income. Exit-interviews suggest that a long/expensive commute to health-facilities and poor medicine affordability constrain access. Conclusions: This study highlights critical gaps in Nepals health system capacity to offer basic health services to CVD and diabetes patients, owing to low availability, poor affordability and accessibility of essential medicines and diagnostics. Research and policy initiatives are needed to ensure uninterrupted supply of affordable essential medicines and diagnostics.

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

OBJECTIVE: Limited access to essential medicines (EMs) for cardiovascular disease (CVD) and diabetes is a major concern in low- and middle-income countries. We aimed to generate data on availability, price and affordability of EMs for CVD and diabetes in India. METHODS: Using WHO/HAI survey methodology, we evaluated availability and prices of 23 EMs in 30 public sector facilities (government hospitals and semi-public/government-subsidised-discount-pharmacies (GSDPs)) and 60 private retail pharmacies across six districts in Kerala state, India (November 2018 - May 2019). Median Price Ratios (MPRs) were calculated by comparing consumer prices with international reference prices. We also analysed data (collected in July 2020) on six anti-hypertensive fixed-dose-combinations (FDCs) that were designated as 'essential' by the WHO in 2019. RESULTS: Mean availability of surveyed generic EMs was 45.7% in government hospitals, 64.7% in GSDPs and 72.0% in private retail pharmacies. On average, the most-sold and highest-priced generics, respectively, were 6.6% and 8.9% costlier than the lowest-priced generics (LPG). Median MPR for LPG was 2.71 in private retail and 2.25 in GSDPs. Monthly supply of LPG would cost the lowest-paid worker 1.11 and 0.79 days' wages in private retail and GSDPs, respectively. Mean availability of the surveyed FDCs was poor (private retail: 15-85%; GSDPs: 8.3-66.7%), and the private retail prices of FDCs were comparable to the sum of corresponding constituent monotherapies. CONCLUSION: Availability of CVD and diabetes EMs fall short of WHO's 80% target in both sectors. Although availability in the private retail pharmacies was near-optimal, prices appear unaffordable compared to GSDPs. Initiatives such as mandating generic prescribing, adding the WHO-approved FDCs in local EM lists, improving price transparency, and streamlining medicine supply to ensure equitable access to EMs, especially in the public sector, are crucial in tackling Kerala's ever-increasing CVD burden.

OBJECTIF: L'accès limité aux médicaments essentiels (ME) pour les maladies cardiovasculaires (MCV) et le diabète est une préoccupation majeure dans les pays à revenu faible et intermédiaire. Nous visions à générer des données sur la disponibilité, le prix et l'aspect abordable des ME pour les MCV et le diabète en Inde. MÉTHODES: En utilisant la méthodologie OMS/HAI, nous avons évalué la disponibilité et les prix de 23 ME dans 30 établissements du secteur public (hôpitaux publics et pharmacies semi-publiques/à discompte subventionnées par le gouvernement (GSDP)) et 60 pharmacies de détail privées dans 6 districts de l'Etat du Kerala, en Inde. Les ratios de prix médians (RPM) ont été calculés en comparant les prix des consommateurs aux prix de référence internationaux. Nous avons également analysé les données de six combinaisons à dose fixe (CDF) d'antihypertensives désignées ''essentielles'' par l'OMS en 2019. RÉSULTATS: La disponibilité moyenne des ME génériques étudiés était de 45,7% dans les hôpitaux publics, de 64,7% dans les GSDP et de 72,0% dans le commerce de détail privé. En moyenne, les génériques les plus vendus et les plus chers, respectivement, étaient de 6,6% et 8,9% plus chers que les génériques les moins chers (GMC). Le RPM pour les (GMC) était de 2,71 dans le secteur privé et de 2,25 dans les GSDP. L'approvisionnement mensuel en GMC coûterait au travailleur le moins payé le salaire de 1,11 et 0,79 jour de travail dans le secteur de la vente au détail privé et dans les GSDP, respectivement. La disponibilité moyenne des CDF était faible (vente au détail privée: 15% - 85%; GSDP: 8,3%-66,7%), avec des prix de détail privés comparables à la somme des monothérapies constituantes correspondantes. CONCLUSION: La disponibilité des ME pour les MCV et le diabète est inférieure à l'objectif de 80% de l'OMS dans les deux secteurs. Bien que la disponibilité dans les pharmacies de détail privées soit presque optimale, les prix semblent inabordables par rapport aux GSDP. Des initiatives telles que la prescription de médicaments génériques, l'inscription des CDF sous ME, l'amélioration de la transparence des prix, la rationalisation de l'approvisionnement en médicaments pour assurer un accès équitable aux ME, en particulier dans le secteur public, sont essentielles pour faire face à la charge toujours croissante des MCV dans le Kerala.

Effects of sedative-hypnotics on sleep quality among patients with insomnia: evidence from an observational, pre-post study in India.

BACKGROUND: Insomnia continues to be neglected globally, despite its high prevalence. Guidelines by the health regulatory agencies call for studies to evaluate the effect of sedative-hypnotics on sleep quality. METHODS: We conducted a pre-post observational study to evaluate sleep quality among 186 inpatients receiving short-term oral sedative-hypnotic therapy in a tertiary care teaching hospital in Kozhikode (Kerala), India. Using Pittsburgh Sleep Quality Index_Past-Week (PSQI_PW) questionnaire, patients were interviewed upon hospital admission and at follow up after ≥1-week of sedative-hypnotic therapy. Additionally, we interviewed 36 physicians to understand the current clinical perception about sedative-hypnotics. RESULTS: Mean (SD) age of the study patients was 59 (7.5) years. Majority (63.4%) of the patients were men. Of the various primary diagnoses for hospitalization, cardiovascular disease was the most common (22.6%, n = 49). Sedative-hypnotic therapy improved the mean (SD) PSQI_PW overall score by 6.79 points (pre: 12.70 (3.5) vs. post: 5.91 (2.8); p < 0.0001). Statistically significant improvements in sleep duration, latency, efficacy, and day dysfunction were observed. Higher proportion of study patients were prescribed benzodiazepines (73.7%) compared to zolpidem (26.3%). Patients treated with zolpidem reported higher improvements in mean overall PSQI_PW scores compared to those treated with benzodiazepines, however these differences were not statistically significant upon adjusting for age, gender and primary diagnosis for hospitalization. Qualitative interviews indicate that that physicians consider zolpidem to be safer and more efficacious. CONCLUSIONS: In our study, sedative-hypnotic therapy helped improve sleep quality among the hospitalized patients. More studies evaluating the comparative efficacy and safety of zolpidem vs. benzodiazepines - including among patient groups with varying demographic and clinical characteristics - are needed. India must develop evidence-based treatment guidelines to inform the clinical practice around the use of sedative-hypnotics.

Challenges constraining availability and affordability of insulin in Bengaluru region (Karnataka, India): evidence from a mixed-methods study.

INTRODUCTION: Considering limited global access to affordable insulin, we evaluated insulin access in public and private health sectors in Bengaluru, India. METHODS: Employing modified WHO/HAI methodology, we used mixed-methods analysis to study insulin access and factors influencing insulin supply and demand in Bengaluru in December 2017. We assessed insulin availability, price and affordability in a representative sample of 5 public-sector hospitals, 5 private-sector hospitals and 30 retail pharmacies. We obtained insulin price data from websites of government Jan Aushadhi scheme (JAS) and four online private-sector retail pharmacies. We interviewed wholesalers in April 2018 to understand insulin market dynamics. RESULTS: Mean availability of insulins on India's 2015 Essential Medicine List was 66.7% in the public sector, lower than private-sector retail (76.1%) and hospital pharmacies (93.3%). Among private retailers, mean availability was higher among chain (96.7%) than independent pharmacies (68.3%). Non-Indian companies supplied 67.3% products in both sectors. 79.1% products were manufactured in India, of which 60% were marketed by non-Indian companies.In private retail pharmacies, median consumer prices of human insulin cartridges and pens were 2.5 and 3.6 times, respectively, that of human insulin vials. Analogues depending on delivery device were twice as expensive as human insulin. Human insulin vials were 18.3% less expensive in JAS pharmacies than private retail pharmacies. The lowest paid unskilled worker would pay 1.4 to 9.3 days' wages for a month's supply, depending on insulin type and health sector. Wholesaler interviews suggest that challenges constraining patient insulin access include limited market competition, physicians' preference for non-Indian insulins, and the ongoing transition from human to analogue insulin. Rising popularity of online and chain pharmacies may influence insulin access. CONCLUSION: Insulin availability in Bengaluru's public sector falls short of WHO's 80% target. Insulin remains unaffordable in both private and public sectors. To improve insulin availability and affordability, government should streamline insulin procurement and supply chains at different levels, mandate biosimilar prescribing, educate physicians to pursue evidence-based prescribing, and empower pharmacists with brand substitution. Patients must be encouraged to shop around for lower prices from subsidized schemes like JAS. While non-Indian companies dominate Bengaluru's insulin market, rising market competition from Indian companies may improve access.