Outcomes measured in studies assessing health systems interventions for type 1 diabetes management: A scoping review.

AIMS: Describe the outcomes reported in research on health systems interventions for type 1 diabetes management in comparison to the outcomes proposed by a core outcome set (COS) for this condition, an essential list of outcomes that studies should measure. METHODS: Systematic search of studies published between 2010 and 2021 reporting health systems interventions directed to improve the management of type 1 diabetes using PubMed, EMBASE and CENTRAL. Information on the outcomes was extracted and classified according to a COS: self-management, level of clinical engagement, perceived control over diabetes, diabetes-related quality of life, diabetes burden, diabetes ketoacidosis, severe hypoglycemia, and glycated hemoglobin (HbA1C). RESULTS: 187 studies were included. Most of the studies included either children (n = 82/187) or adults (n = 82/187) living with type 1 diabetes. The most common outcome measured was HbA1C (n = 149/187), followed by self-management (n = 105/187). While the least measured ones were diabetes ketoacidosis (n = 15/187), and clinical engagement (n = 0/187). None of the studies measured all the outcomes recommended in the COS. Additionally, different tools were found to be used in measuring the same outcome. CONCLUSIONS: This study provides a description of what researchers are measuring when assessing health systems interventions to improve type 1 diabetes management. In contrast to a COS, it was found that there is a predominance of clinical-based outcomes over patient-reported outcome measures.

Co-creation process of an intervention to implement a multiparameter point-of-care testing device in a primary healthcare setting for non-communicable diseases in Peru.

BACKGROUND: Point-of-care testing (POCT) devices are diagnostic tools that can provide quick and accurate results within minutes, making them suitable for diagnosing non-communicable diseases (NCDs). However, these devices are not widely implemented in healthcare systems and for this reason is relevant to understand the implementation process. AIM: To describe the process and define a strategy to implement a multiparameter POCT device for diagnosing and managing NCDs in one region of Peru. METHODS: A descriptive and non-experimental study, using the participatory methodologies of co-creation process. It was conducted in one region of Peru (Tumbes) to design an intervention for implementing a multiparameter POCT device. Two co-creation sessions were conducted involving five groups: community members, primary healthcare workers, these groups in both rural and urban settings, and regional decision-makers. These sessions included activities to understand patient journeys in receiving care for NCDs, identify facilitators and barriers to POCT devices usage, and define an implementation strategy for POCT devices in both rural and urban settings of Tumbes. The research team analysed the data and summarized key topics for discussion after each session. RESULTS: A total of 78 participants were enrolled across the five groups. Among community members: 22.2% had only diabetes, 24.1% had only hypertension, and 18.5% had both diagnoses. In the patient journey, community members mentioned that it took at least three days to receive a diagnosis and treatment for an NCD. Most of the participants agreed that the POCT devices would be beneficial for their communities, but they also identified some concerns. The strategy for POCT devices implementation included healthcare workers training, POCT devices must be placed in the laboratory area and must be able to perform tests for glucose, glycated haemoglobin, cholesterol, and creatinine. Advertising about POCT devices should be displayed at the healthcare centres and the municipality using billboards and flyers. CONCLUSIONS: The co-creation process was useful to develop strategies for the implementation of multiparameter POCT devices for NCDs, involving the participation of different groups of stakeholders guided by moderators in both, rural and urban, settings in Peru.

Exploring medical students' perceptions of family medicine in Kyrgyzstan: a mixed method study.

BACKGROUND: Despite knowing that health systems with strong primary care improve overall health outcomes within a population, many countries are facing a global trend of declining interest and shortage of family doctors. This is the case of the Kyrgyz Republic, in which rural areas are struggling to attract and retain family medicine (FM) doctors. This study aims to explore how Kyrgyz medical students perceive FM and the factors that influence their specialty choice. METHODS: This study used a cross-sectional explanatory sequential design, including quantitative survey and focus group discussions that were carried out at the Kyrgyz State Medical Academy (KSMA) in Bishkek in 2017. Overall, 66% (953 out of 1449) of medical undergraduate students registered in year 1, 4 and 6 completed the survey, and 42 participated in the focus groups. The results were organized around 7 factors influencing perceptions and attitudes towards FM identified through a qualitative systematic review. RESULTS: The interest of Kyrgyz students for FM was the lowest of all specialties. Access to high medical technologies, career opportunities, salary, patient interaction and possibility to work abroad were the five most important factors influencing specialty choice. FM was perceived as a difficult profession, yet with poor prestige, insufficient remuneration, limited career possibilities and poor working conditions, especially in rural areas. The academic discourse, which disregards FM specialty had a negative influence on student's perceptions and prevented students' ability to identify with the practice of family medicine. However, students' awareness of their social accountability arose as a positive leverage to increase the choice of FM, provided other problems were solved. CONCLUSION: This study highlighted key factors responsible for the low number of students choosing to become FM in Kyrgyzstan. The first major factor, presumably specific to many low- and lower-middle- income countries was the poor working conditions in remote areas. The second factor, common to many countries, was the distorted image of FM and its specialty transmitted through the medical schools' institutional culture which does not value FM through positive role models. This study served as a basis to establish a strategy to promote FM within the KSMA and potentially at National level.

Health system responses for type 1 diabetes: A scoping review.

AIMS: The focus of health system interventions for noncommunicable diseases and diabetes focus mainly on primary health care responses. However, existing interventions are not necessarily adapted for the complex management of type 1 diabetes (T1DM). We aimed to identify and describe health system interventions which have been developed to improve the management of T1DM globally. METHODS: We conducted a scoping review by searching MEDLINE, Embase, and Global Health using OVID for peer-review articles published in either English, Spanish, Portuguese or French in the last 10 years. We classified the intervention strategies according to the Effective Practice and Organization of Care (EPOC) taxonomy for health system interventions and the World Health Organization (WHO) health system building blocks. RESULTS: This review identified 159 health system interventions to improve T1DM management. Over half of the studies focused only on children or adolescents with type 1 diabetes. Only a small fraction of the studies were conducted in low-and-middle income countries (LMICs). According to the EPOC taxonomy, the most frequently studied category was delivery arrangement interventions, while implementation strategies and financial arrangements were less frequently studied. Also, governance arrangements domains were not studied. The most common combination of intervention strategies included self-management with either telemedicine, use of information and smart home technologies. CONCLUSIONS: There is a need to expand potential interventions to other EPOC strategies to assess their potential effect on health outcomes in people with T1DM, as well as to involve more LMIC settings as the impact may be greater in these settings.

Management of type 1 diabetes in low- and middle-income countries: Comparative health system assessments in Kyrgyzstan, Mali, Peru and Tanzania.

AIMS: To describe and compare the health system responses for type 1 diabetes in Kyrgyzstan, Mali, Peru and Tanzania. METHODS: The Rapid Assessment Protocol for Insulin Access, a multi-level assessment of the health system, was implemented in Kyrgyzstan, Mali, Peru and Tanzania using document reviews, site visits and interviews to assess the delivery of care and access to insulin. RESULTS: Despite the existence of noncommunicable or diabetes strategies and Universal Health Coverage policies including diabetes-related supplies, this has not necessarily translated into access to insulin or diabetes care for all. Insulin and related supplies were often unavailable and unaffordable. Across the four countries test strips and insulin, when paid for by the individual, represented respectively 48-82% and 25-36% of total costs. Care was mainly delivered at tertiary-level hospitals by specialists. Only Kyrgyzstan had data collection systems integrated into the Ministry of Health structure. In addition, issues with healthcare worker training and education and empowerment of people with diabetes were present in these health systems. CONCLUSIONS: People with type 1 diabetes in these countries face different barriers, including the cost of insulin and care. Given the renewed attention to diabetes on the global health agenda tailored health system responses for type 1 diabetes are needed. Insulin should be prioritized as it is the foundation of type 1 diabetes care, but other elements of care and support need to be fostered by different actors.

Changes in prevalence and the cascade of care for type 2 diabetes over ten years (2005-2015): results of two nationally representative surveys in Mozambique.

BACKGROUND: Sub-Saharan Africa is predicted to have the steepest increase in the prevalence of diabetes in the next 25 years. The latest Mozambican population-based STEPS survey (STEPS 2005) estimated a 2.9% prevalence of diabetes in the adult population aged 25-64 years. We aimed to assess the change in prevalence, awareness, and management of diabetes in the national STEPS survey from 2014/2015 compared to 2005. METHODS: We conducted an observational, quantitative, cross-sectional study following the WHO STEPS surveillance methodology in urban and rural settings, targeting the adult population of Mozambique in 2015. We collected sociodemographic data, anthropometric, and 12 hour fasting glucose blood samples in a sample of 1321 adults. The analysis consisted of descriptive measures of the prevalence of impaired fasting glucose (IFG), diabetes and related risk factors by age group, sex, and urban/rural residence and compared the findings to those of the 2005 survey results. RESULTS: The prevalence of IFG and diabetes was 4.8% (95CI: 3.6-6.3) and 7.4% (95CI: 5.5-10.0), respectively. These prevalence of IFG and diabetes did not differ significantly between women and men. The prevalence of diabetes in participants classified with overweight/obesity [10.6% (95CI: 7.5-14.6)] and with central obesity (waist hip ratio) [11.0% (95CI: 7.4-16.1)] was almost double the prevalence of their leaner counterparts, [6.3% (95CI, 4.0-9.9)] and [5.2% (95CI: 3.2-8.6)], respectively. Diabetes prevalence increased with age. There were 50% more people with diabetes in urban areas than in rural. Only 10% of people with diabetes were aware of their disease, and only 44% of those taking oral glucose-lowering drugs. The prevalence of IFG over time [2.0% (95CI: 1.1-3.5) vs 4.8% (95CI: 3.6-6.3)] and diabetes [2.9% (95CI: 2.0-4.2) vs 7.4% (95CI: 5.5-10.0)] were more than twofold higher in 2014/2015 than in 2005. However, awareness of disease and being on medication decreased by 3% and by 50%, respectively. Though this was not statistically significant. CONCLUSIONS: While the prevalence of diabetes in Mozambique has increased from 2005 to 2015, awareness and medication use have declined considerably. There is an urgent need to improve the capacity of primary health care and communities to detect, manage and prevent the occurrence of NCDs and their risk factors.

COVID-19's impact on type 1 diabetes management: A mixed-methods study exploring the Peruvian experience.

INTRODUCTION: The COVID-19 pandemic has negatively impacted health services, especially in low-and-middle-income countries, where care for chronic conditions such as diabetes was disrupted. Our study aims to describe the challenges faced by people living with Type 1 diabetes mellitus (T1DM) to access care during the COVID-19 pandemic in Peru. METHODS: A sequential explanatory mixed-method study was conducted between May and September 2020 including health professionals involved in T1DM care, people with T1DM and their caregivers. The study consisted of a quantitative strand to gather general information through electronic surveys and a qualitative strand that involved in-depth interviews. RESULTS: For the quantitative study, we included 105 people with T1DM, 50 caregivers and 76 health professionals. The qualitative study included a total of 31 interviews; 16 people with T1DM, 14 health care professionals, and one representative from the Peruvian Ministry of Health (MoH). People with T1DM faced difficulties accessing consultations, insulin, monitoring devices and laboratory testing during the pandemic. Different phases of the Peruvian health system response were found. Firstly, an initial informal response to addressing T1DM care during the pandemic characterised by local initiatives to ensure continuity of care for people with T1DM. Following from this, a formal response was implemented by the MoH which focussed on reinforcing the primary level of care. Measures included teleconsultations and delivery of medicines, although these were not implemented in all health care establishments. Throughout the pandemic patient associations played an important role in organising and helping to counteract the impact of COVID-19 on people with T1DM. CONCLUSIONS: The Peruvian health care system slowly adapted to the COVID-19 pandemic to provide care for people with T1DM. However, people with T1DM had difficulties to access care. Thus, reinforcement of interventions such as communication between levels of care, teleconsultations and delivery of medicines was urgently needed. Patient associations' capacity to respond should be considered by local authorities and civil society should be part of the health system response.

A global perspective on the issue of access to insulin.

The discovery of insulin in 1921 changed the prognosis for people with type 1 diabetes. A century later, availability and affordability of insulin remain a challenge in many parts of the globe. Using the WHO's framework on understanding the life cycle of medicines, this review details the global and national challenges that affect patients' abilities to access and afford insulin. Current research and development in diabetes has seen some innovations, but none of these have truly been game-changing. Currently, three multinational companies control over 95% of global insulin supply. The inclusion of insulin on the WHO's Prequalification Programme is an opportunity to facilitate entry of new companies into the market. Many governments lack policies on the selection, procurement, supply, pricing and reimbursement of insulin. Moreover, mark-ups in the supply chain also affect the final price to the consumer. Whilst expenses related to diabetes are mostly covered by insurance in high-income countries, many patients from low- and middle-income countries have to pay out of their own pockets. The organisation of diabetes management within the healthcare system also affects patient access to insulin. The challenges affecting access to insulin are complex and require a wide range of solutions. Given that 2021 marks the centenary of the discovery of insulin, there is need for global advocacy to ensure that the benefits of insulin and innovations in diabetes care reach all individuals living with diabetes.

Type 1 diabetes in 2017: global estimates of incident and prevalent cases in children and adults.

AIMS/HYPOTHESIS: Data on type 1 diabetes incidence and prevalence are limited, particularly for adults. This study aims to estimate global numbers of incident and prevalent cases of type 1 diabetes in 2017 for all age groups, by country and areas defined by income and region. METHODS: Incidence rates of type 1 diabetes in children (available from 94 countries) from the IDF Atlas were used and extrapolated to countries without data. Age-specific incidence rates in adults (only known across full age range for fewer than ten countries) were obtained by applying scaling ratios for each adult age group relative to the incidence rate in children. Age-specific incidence rates were applied to population estimates to obtain incident case numbers. Duration of diabetes was estimated from available data and adjusted using differences in childhood mortality rate between countries from United Nations demographic data. Prevalent case numbers were derived by modelling the relationship between prevalence, incidence and disease duration. Sensitivity analyses were performed to quantify the impact of alternative assumptions and model inputs. RESULTS: Global numbers of incident and prevalent cases of type 1 diabetes were estimated to be 234,710 and 9,004,610, respectively, in 2017. High-income countries, with 17% of the global population, accounted for 49% of global incident cases and 52% of prevalent cases. Asia, which has the largest proportion of the world's population (60%), had the largest number of incident (32%) and prevalent (31%) cases of type 1 diabetes. Globally, 6%, 35%, 43% and 16% of prevalent cases were in the age groups 0-14, 15-39, 40-64 and 65+ years, respectively. Based on sensitivity analyses, the estimates could deviate by ±15%. CONCLUSIONS/INTERPRETATION: Globally, type 1 diabetes represents about 2% of the estimated total cases of diabetes, ranging from less than 1% in certain Pacific countries to more than 15% in Northern European populations in 2017. This study provides information for the development of healthcare and policy approaches to manage type 1 diabetes. The estimates need further validation due to limitations and assumptions related to data availability and estimation methods.

Nationwide survey of the availability and affordability of asthma and COPD medicines in Nigeria.

OBJECTIVE(S): To determine the availability and affordability of asthma and COPD medicines across Nigeria. METHODS: This was a cross-sectional survey conducted in 128 pharmacies (51 in public sector hospitals, 51 private sector community pharmacies and 26 charity or big private hospitals) across the six geopolitical zones of Nigeria using the WHO/Health Action Initiative method. The proportion of pharmacies where medicines were available, the median retail prices of originator and generics and affordability were analysed. A medicine was available if found in ≥ 80% of surveyed pharmacies. Unaffordability was defined as paying> 1 day's wage (> US$1.68) for a standard 30-day supply of the medicine. RESULTS: The available medicines were oral corticosteroids and oral salbutamol which are not on the WHO Essential Medicine List. Medicines were found more frequently in private than public pharmacies and in the southern than northern zones. Inhalable corticosteroid was not available at any public pharmacy nationwide. None of the EML medicines were affordable. The least number of days' wages for a 30-day supply of any inhalable corticosteroid-containing medication was 3.5 days. CONCLUSIONS: There are very limited availability and affordability of recommended asthma and COPD medicines across Nigeria with disparity across regions. Medicines that were available and affordable are not recommended and are harmful for long-term use. This underpins the need for engagement of all stakeholders for the review of existing policies regarding access to asthma and COPD medicines to improve availability and affordability.

Why Are Individuals With Diabetes Less Active? The Mediating Role of Physical, Emotional, and Cognitive Factors.

BACKGROUND: Despite the key role of physical activity in the management of diabetes, many individuals with diabetes do not engage in the recommended levels of physical activity. However, our knowledge of the mechanisms underlying the relationship between diabetes and physical inactivity is limited. PURPOSE: To investigate the associations between diabetes and the levels and evolution of physical activity across aging, and to determine whether physical, emotional, and cognitive factors mediate these associations. METHODS: Data from 105,622 adults aged 50-96 years from the Survey of Health, Ageing and Retirement in Europe (SHARE) were used in adjusted linear mixed models to examine whether diabetes was associated with physical activity levels and variations across aging. The potential mediators were subjective energy, muscle strength, physical and cognitive disability, sleep problems, depressive symptoms, and cognitive functions. The variables were measured up to seven times over a 13-year period. RESULTS: Individuals with diabetes demonstrated a lower level and a steeper decrease in physical activity across aging than individual without diabetes. Mediators explained ~53% and 94% of the association of diabetes with the level of physical activity and with the linear evolution of physical activity across aging, respectively. All mediators were significantly associated with physical activity. Physical and cognitive disability as well as depressive symptoms were the strongest mediators, while sleep was the lowest one. CONCLUSIONS: These findings suggest that the etiology of physical inactivity in individuals with diabetes can result from several physical, emotional, and cognitive changes associated with the emergence of this disease.

Development of a target product profile for a point-of-care cardiometabolic device.

INTRODUCTION: Multi-parameter diagnostic devices can simplify cardiometabolic disease diagnosis. However, existing devices may not be suitable for use in low-resource settings, where the burden of non-communicable diseases is high. Here we describe the development of a target product profile (TPP) for a point-of-care multi-parameter device for detection of biomarkers for cardiovascular disease and metabolic disorders, including diabetes, in primary care settings in low- and middle-income countries (LMICs). METHODS: A draft TPP developed by an expert group was reviewed through an online survey and semi-structured expert interviews to identify device characteristics requiring refinement. The draft TPP included 41 characteristics with minimal and optimal requirements; characteristics with an agreement level for either requirement of ≤ 85% in either the survey or among interviewees were further discussed by the expert group and amended as appropriate. RESULTS: Twenty people responded to the online survey and 18 experts participated in the interviews. Twenty-two characteristics had an agreement level of ≤ 85% in either the online survey or interviews. The final TPP defines the device as intended to be used for basic diagnosis and management of cardiometabolic disorders (lipids, glucose, HbA1c, and creatinine) as minimal requirement, and offering an expanded test menu for wider cardiometabolic disease management as optimal requirement. To be suitable, the device should be intended for level 1 healthcare settings or lower, used by minimally trained healthcare workers and allow testing using self-contained cartridges or strips without the need for additional reagents. Throughput should be one sample at a time in a single or multi-analyte cartridge, or optimally enable testing of several samples and analytes in parallel with random access. CONCLUSION: This TPP will inform developers of cardiometabolic multi-parameter devices for LMIC settings, and will support decision makers in the evaluation of existing and future devices.

Diagnostics and monitoring tools for noncommunicable diseases: a missing component in the global response.

A key component of any health system is the capacity to accurately diagnose individuals. One of the six building blocks of a health system as defined by the World Health Organization (WHO) includes diagnostic tools. The WHO's Noncommunicable Disease Global Action Plan includes addressing the lack of diagnostics for noncommunicable diseases, through multi-stakeholder collaborations to develop new technologies that are affordable, safe, effective and quality controlled, and improving laboratory and diagnostic capacity and human resources. Many challenges exist beyond price and availability for the current tools included in the Package of Essential Noncommunicable Disease Interventions (PEN) for cardiovascular disease, diabetes and chronic respiratory diseases. These include temperature stability, adaptability to various settings (e.g. at high altitude), need for training in order to perform and interpret the test, the need for maintenance and calibration, and for Blood Glucose Meters non-compatible meters and test strips. To date the issues surrounding access to diagnostic and monitoring tools for noncommunicable diseases have not been addressed in much detail. The aim of this Commentary is to present the current landscape and challenges with regards to guidance from the WHO on diagnostic tools using the WHO REASSURED criteria, which define a set of key characteristics for diagnostic tests and tools. These criteria have been used for communicable diseases, but so far have not been used for noncommunicable diseases. Diagnostic tools have played an important role in addressing many communicable diseases, such as HIV, TB and neglected tropical diseases. Clearly more attention with regards to diagnostics for noncommunicable diseases as a key component of the health system is needed.

How to bring research evidence into policy? Synthesizing strategies of five research projects in low-and middle-income countries.

BACKGROUND: Addressing the uptake of research findings into policy-making is increasingly important for researchers who ultimately seek to contribute to improved health outcomes. The aims of the Swiss Programme for Research on Global Issues for Development (r4d Programme) initiated by the Swiss National Science Foundation and the Swiss Agency for Development and Cooperation are to create and disseminate knowledge that supports policy changes in the context of the 2030 Agenda for Sustainable Development. This paper reports on five r4d research projects and shows how researchers engage with various stakeholders, including policy-makers, in order to assure uptake of the research results. METHODS: Eleven in-depth interviews were conducted with principal investigators and their research partners from five r4d projects, using a semi-structured interview guide. The interviews explored the process of how stakeholders and policy-makers were engaged in the research project. RESULTS: Three key strategies were identified as fostering research uptake into policies and practices: (S1) stakeholders directly engaged with and sought evidence from researchers; (S2) stakeholders were involved in the design and throughout the implementation of the research project; and (S3) stakeholders engaged in participatory and transdisciplinary research approaches to coproduce knowledge and inform policy. In the first strategy, research evidence was directly taken up by international stakeholders as they were actively seeking new evidence on a very specific topic to up-date international guidelines. In the second strategy, examples from two r4d projects show that collaboration with stakeholders from early on in the projects increased the likelihood of translating research into policy, but that the latter was more effective in a supportive and stable policy environment. The third strategy adopted by two other r4d projects demonstrates the benefits of promoting colearning as a way to address potential power dynamics and working effectively across the local policy landscape through robust research partnerships. CONCLUSIONS: This paper provides insights into the different strategies that facilitate collaboration and communication between stakeholders, including policy-makers, and researchers. However, it remains necessary to increase our understanding of the interests and motivations of the different actors involved in the process of influencing policy, identify clear policy-influencing objectives and provide more institutional support to engage in this complex and time-intensive process.

Global Inequality in Type 1 Diabetes: a Comparison of Switzerland and Low-and Middle-Income Countries.

Globally it is estimated that over 1 million children and adolescents have Type 1 diabetes with large variations in incidence between different contexts. Health systems need to provide a variety of elements to ensure appropriate diabetes care, such as service delivery; healthcare workforce; information; medical products and technologies; financing and leadership and governance. Describing these elements between Geneva, Switzerland, a high-income country with high spending on healthcare and a large density of doctors, and low- and middle-income countries this article aims to highlight the global inequality of diabetes care. Type 1 diabetes can serve as a litmus as we move towards the centenary of the discovery of insulin and beyond as there is a need for a global movement to ensure that innovation in the management of diabetes benefits the whole diabetes community and not just a select few.

Access to insulin: applying the concept of security of supply to medicines.

Security of supply of medicines is fundamental to ensure health for all. Furthermore, improving access to medicines is included in sustainable development goal 3. However, the concept of security of supply has mostly been applied to food, water and energy. Diversity of supply, vulnerability to disruption, expenditure, infrastructure, stability of exporting countries, ownership of production, price stability, access and equity, affordability, intellectual property, safety and reliability of supply, and countries' capacity to adapt to market changes are all elements of security of supply. Based on these elements, we assessed security of supply for insulin, since access to insulin is a global problem. We found that three multinational companies, in Denmark, France and Germany, control 99% of the value of the global insulin market. Prices and affordability of insulin and access to it vary considerably between countries. Some countries are vulnerable to insulin shortage because they import insulin from only one source. Many countries spend large amounts of money on insulin and costs are increasing. Some countries lack an adequate infrastructure for procurement, supply chain management and distribution of insulin. Applying the security of supply concept to insulin showed that diversification of suppliers needs to be fostered. Global health actors should adopt a security of supply approach to identify medicines that are susceptible to supply issues and address this concern by strategic promotion of local production, strengthening regulatory harmonization, and adding local products to the World Health Organization's programme on prequalification of medicines.

La sécurité de l'approvisionnement en médicaments est fondamentale pour garantir une bonne santé pour tous. De plus, l'amélioration de l'accès aux médicaments figure dans l'Objectif de développement durable n°3. Or, le concept de sécurité d'approvisionnement a jusqu'à présent été principalement appliqué aux aliments, aux boissons et à l'énergie. La diversité d'approvisionnement, la vulnérabilité face aux perturbations de la chaîne d'approvisionnement, les infrastructures, la stabilité des pays exportateurs, la propriété des moyens de production, la stabilité des prix, l'accès et l'équité, l'accessibilité des prix, la propriété intellectuelle, la sûreté et la fiabilité de l'approvisionnement ainsi que la capacité des pays à s'adapter aux évolutions du marché sont autant de notions inhérentes à la sécurité d'approvisionnement. À partir de ces éléments, nous avons évalué la sécurité d'approvisionnement pour l'insuline, étant donné que l'accès à l'insuline constitue un enjeu mondial. Nous avons constaté que trois multinationales (au Danemark, en France et en Allemagne) contrôlent 99% de la valeur du marché mondial de l'insuline. Les prix, leur accessibilité ainsi que l'accès à l'insuline varient considérablement d'un pays à un autre. Certains pays sont vulnérables face aux pénuries d'insuline, car ils n'importent l'insuline qu'auprès d'une seule source. De nombreux pays dépensent énormément d'argent pour l'insuline, et les coûts sont en augmentation. Certains pays n'ont pas d'infrastructures appropriées pour les achats, la gestion de la chaîne d'approvisionnement et la distribution de l'insuline. L'application du concept de sécurité d'approvisionnement à l'insuline nous a montré que la diversification des fournisseurs doit être encouragée. Les acteurs mondiaux de la santé devraient adopter une approche de sécurité d'approvisionnement pour identifier les médicaments susceptibles de connaître des problèmes d'approvisionnement et répondre à cet enjeu par la promotion stratégique d'une production locale, le renforcement de l'harmonisation réglementaire et l'ajout de produits locaux dans le programme de l'Organisation mondiale de la Santé sur la préqualification des médicaments.

La seguridad en el suministro de medicamentos es fundamental para garantizar la salud de todos. Además, la mejora del acceso a los medicamentos está incluida en el objetivo de desarrollo sostenible 3. Sin embargo, el concepto de seguridad en el suministro se ha aplicado principalmente a los alimentos, el agua y la energía. La diversidad del suministro, la vulnerabilidad a las perturbaciones, el gasto, la infraestructura, la estabilidad de los países exportadores, la propiedad de la producción, la estabilidad de los precios, el acceso y la equidad, la asequibilidad, la propiedad intelectual, la seguridad y la fiabilidad del suministro y la capacidad de los países para adaptarse a los cambios del mercado son todos elementos que se incluyen en la seguridad en el suministro. Con base en estos elementos, se ha evaluado la seguridad del suministro de insulina, ya que el acceso a esta es un problema mundial. Se ha descubierto que tres empresas multinacionales, en Dinamarca, Francia y Alemania, controlan el 99 % del valor de mercado mundial de insulina. Los precios y la asequibilidad de la insulina y el acceso a ella varían considerablemente de un país a otro. Algunos países son vulnerables a la escasez de insulina porque la importan de una sola fuente. Muchos países gastan grandes cantidades de dinero en insulina y los costes aumentan. Algunos países carecen de una infraestructura adecuada para la adquisición, la gestión de la cadena de suministro y la distribución de insulina. La aplicación del concepto de seguridad en el suministro a la insulina demostró que es necesario fomentar la diversificación de los proveedores. Los agentes de la salud mundial deberían adoptar un enfoque de seguridad en el suministro para identificar los medicamentos que son susceptibles de problemas de suministro y abordar esta preocupación mediante la promoción estratégica de la producción local, el fortalecimiento de la armonización de los reglamentos y la incorporación de los productos locales al programa de la Organización Mundial de la Salud sobre la precalificación de los medicamentos.

Interventions targeting hypertension and diabetes mellitus at community and primary healthcare level in low- and middle-income countries:a scoping review.

BACKGROUND: Hypertension (HTN) and diabetes mellitus (DM) are highly prevalent in low- and middle-income countries (LMIC) and a leading cause of morbidity and mortality. Recent evidence on effectiveness of primary care interventions has attracted renewed calls for their implementation. This review aims to synthesize evidence pertaining to primary care interventions on these two diseases, evaluated and tested in LMICs. METHODS: Two reviewers conducted an electronic search of three databases (Pubmed, EMBASE and Web of Science) and screened for eligible articles. Interventions covering health promotion, prevention, treatment, or rehabilitation activities at the PHC or community level were included. Studies published in English, French, Portuguese and Spanish, from January 2007 to January 2017, were included. Key extraction variables included the 12 criteria identified by the Template for Intervention Description and Replication (TIDieR) checklist and guide. The Innovative Care for Chronic Conditions Framework (ICCCF) was used to guide analysis and reporting of results. RESULTS: 198 articles were analyzed. The strategies focused on healthcare service organization (76.5%), community level (9.7 %), creating a positive policy environment (3.6%) and strategies covering multiple domains (10.2%). Studies included related to the following topics: description or testing of interventions (n=81; 41.3%), implementation or evaluation projects (n=42; 21.4%), quality improvement initiatives (n=15; 7.7%), screening and prevention efforts (n=26; 13.2%), management of HTN or DM (n=13; 6.6%), integrated health services (n=10; 5.1%), knowledge and attitude surveys (n=5; 2.5%), cost-effective lab tests (n=2; 1%) and policy making efforts (n=2; 1%). Most studies reported interventions by non-specialists (n=86; 43.4%) and multidisciplinary teams (n=49; 25.5%). CONCLUSION: Only 198 articles were found over a 10 year period which demonstrates the limited published research on highly prevalent diseases in LMIC. This review shows the variety and complexity of approaches that have been tested to address HTN and DM in LMICs and highlights the elements of interventions needed to be addressed in order to strengthen delivery of care. Most studies reported little information regarding implementation processes to allow replication. Given the need for multi-component complex interventions, study designs and evaluation techniques will need to be adapted by including process evaluations versus simply effectiveness or outcome evaluations.

Evidence-Based Clinical Criteria for Computed Tomography Imaging in Odontogenic Infections.

PURPOSE: Odontogenic infections are a common problem in emergency departments and impose a burden on hospital budgets and provider time. Compounding this is the lack of evidence guiding the patient's initial evaluation. The purpose of this study was to derive evidence-based guidelines for the use of computed tomographic (CT) imaging in the management of odontogenic infections. MATERIALS AND METHODS: A prospective cohort study was designed. Patients with an odontogenic infection presenting to the emergency department from November 1, 2016 to November 30, 2017 were eligible for inclusion. The outcome variable was need for CT imaging, which was based on the location of the abscess. The potential predictor variables were demographics, history items, examination findings, and laboratory values. The association between the outcome and predictor variables was determined using classification and regression tree analysis and standard logistic regression analysis. RESULTS: There were 129 patients who met the inclusion criteria and consented to participation. The patients were 53.5% men and the mean age was 42.5 years. The most common fascial spaces involved were vestibular (58.2%), submandibular (18.6%), pterygomandibular (6.2%), buccal (5.4%), and lateral pharyngeal (5.4%). The classification and regression tree analysis identified mandibular inferior border blunting at the body as the best predictor for necessitating a CT scan and identified a mouth opening smaller than 25 mm as the second best predictor. These 2 predictors had an accuracy of 96.9% for needing a CT scan. The logistic regression analysis identified these 2 variables and odynophagia, floor of mouth induration, and white blood cell count as relevant predictors for needing CT imaging. CONCLUSION: The 2 physical examination findings of mandibular inferior border blunting at the body and restricted mouth opening were found to be strongly associated with the need for CT imaging. Further studies should be directed at validating these criteria in larger multicenter studies.

[Insulin: prices, availability, and affordability in public and private Peruvian pharmaciesPreço, disponibilidade e acessibilidade à insulina em farmácias públicas e privadas no Peru]. / Precios, disponibilidad y asequibilidad de insulina en farmacias públicas y privadas en Perú.

OBJECTIVE: Measure and compare the price, availability, and affordability of insulin and metformin in public and private pharmacies in six regions of Peru. METHODS: Cross-sectional study using the World Health Organization/Health Action International (WHO/HAI) revised methodology. Public and private pharmacies in six regions of Peru were surveyed. Data were collected on availability and prices for insulin (all types) and 850 mg metformin. Availability is expressed as percentages and prices are reported in medians. Affordability is defined as the number of days that a person must work at minimum wage to cover the cost of one month of treatment. RESULTS: Availability in public pharmacies is 63.2% for regular insulin and 68.4% for NPH (isophane) insulin, but differences in availability were observed between levels of care and between regions. Private pharmacies have a greater variety of insulin, but availability is less than 11%. The median price of human insulin was three to four times higher in private pharmacies than in public pharmacies. In comparison, availability of metformin was 89.5% in public pharmacies and 77.7% in private ones. Affordability in public pharmacies for one month of treatment with human insulin or generic metformin is less than one day's wages. CONCLUSIONS: The price for human insulin and generic metformin in public pharmacies is affordable. However, efforts are needed to improve their availability in the different regions and levels of care.

OBJETIVO: Avaliar o preço, a disponibilidade e a acessibilidade à insulina e metformina, como comparativo, em farmácias públicas e privadas em seis regiões do Peru. MÉTODOS: Estudo transversal conduzido com metodologia adaptada da Organização Mundial da Saúde/Ação Internacional para a Saúde (OMS/AIS). Farmácias públicas e privadas foram pesquisadas em seis regiões do Peru com a coleta de dados sobre a disponibilidade e os preços da insulina (de todos os tipos) e metformina na apresentação de 850 mg. A disponibilidade é expressa em porcentagem e os preços estão descritos como mediana. A acessibilidade foi definida no estudo como o número de dias que um indivíduo que ganha salário mínimo precisa trabalhar para arcar com o custo de um mês de tratamento. RESULTADOS: A disponibilidade em farmácias públicas da insulina regular foi de 63,2% e da insulina isófana (NPH) foi de 68,4%, porém se observou diferença de disponibilidade entre os níveis de atenção e as regiões. Nas farmácias privadas, a variedade de insulinas é maior, mas a disponibilidade é inferior a 11%. A mediana de preços para a insulina humana nas farmácias privadas é 3 a 4 vezes maior que nas farmácias públicas. Comparativamente, a disponibilidade da metformina foi de 89,5% nas farmácias públicas e 77,7% nas farmácias privadas. A acessibilidade nas farmácias públicas para um mês de tratamento com insulina humana ou metformina genérica é inferior à remuneração de um dia de trabalho. CONCLUSÕES: As insulinas humanas e a metformina genérica têm preço acessível nas farmácias públicas. Porém, esforços devem ser empreendidos para aumentar a disponibilidade destes medicamentos nos níveis de atenção e nas regiões.

Availability and Affordability of Essential Medicines: Implications for Global Diabetes Treatment.

PURPOSE OF REVIEW: The purpose of this review is to highlight the key issues with regard to the value, affordability, and availability of diabetes treatments. RECENT FINDINGS: Many of the medicines needed to manage diabetes are available as generics and, if purchased appropriately, can be made affordable to many individuals and systems. With new treatments for diabetes, additional costs to individuals and systems need to be assessed in terms of added clinical benefit and financial impact. As healthcare finances are limited, increased spending on diabetes medicines means fewer resources for other areas of diabetes care or for the population as a whole. This increased expenditure is driven by rising prevalence as well as the cost of newer treatments. With an increasing burden of disease and changing patterns of medicines in the market, we stress the need to focus attention on ensuring access for individuals to essential medicines. Universal health care offers unique opportunity to address the issue of access to medicines and the wider issues surrounding access to diabetes care, but this will require concerted action bringing together governments, civil society and the private sector.