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1.
Environ Int ; 133(Pt A): 105089, 2019 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-31654984

RESUMO

BACKGROUND: Previous epidemiological studies, largely conducted in high-income countries and cross-sectional, have suggested a relatively strong association between exposure to dichlorodiphenyldichloroethylene (DDE), a metabolite of the pesticide dichlorodiphenyltrichloroethane (DDT), and type 2 diabetes. DDT is widely used in India and the prevalence of type 2 diabetes there is increasing, but the association between these factors has not been explored to date. OBJECTIVE: The objective was to estimate the association of the p,p' isomer of DDE with incident type 2 diabetes in India. METHODS: A nested case-control study was conducted in a representative prospective cohort of adults from two cities in India. Participants were enrolled in 2010-11 (n = 12,271) and followed for annual assessment of chronic diseases including type 2 diabetes. Baseline plasma samples from incident cases of diabetes (n = 193) and sex-city-matched controls (n = 323) were selected for analysis of p,p-DDE. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using conditional logistic regression. RESULTS: At baseline, cases had higher p,p-DDE concentrations: geometric mean (95% CI) 330 (273-399) ng/g lipid compared to 223 (189-262) ng/g lipid among controls. Delhi participants had higher p,p-DDE concentrations: 579 (521-643) ng/g lipid compared to 122 (102-145) ng/g lipid in Chennai. In unadjusted models, being in the highest versus lowest quartile of p,p-DDE was associated with a more than doubling of the odds of diabetes: unadjusted OR (95% CI), 2.30 (1.19, 4.43). However, this effect was no longer significant after adjustment for age: adjusted (95% CI), 0.97 (0.46, 2.06). DISCUSSION: Results suggest that levels of p,p'-DDE in Delhi are exceptionally high, but we did not observe a significant association between p,p-DDE and incident type 2 diabetes. As this is the first study to evaluate this association in India, more studies are needed to inform our understanding of the association in this context, including potential routes of exposure.

2.
Lancet Glob Health ; 7(10): e1359-e1366, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31477545

RESUMO

BACKGROUND: Elevated blood pressure incurs a major health and economic burden, particularly in low-income and middle-income countries. The Triple Pill versus Usual Care Management for Patients with Mild-to-Moderate Hypertension (TRIUMPH) trial showed a greater reduction in blood pressure in patients using fixed-combination, low-dose, triple-pill antihypertensive therapy (consisting of amlodipine, telmisartan, and chlorthalidone) than in those receiving usual care in Sri Lanka. We aimed to assess the cost-effectiveness of the triple-pill strategy. METHODS: We did a within-trial (6-month) and modelled (10-year) economic evaluation of the TRIUMPH trial, using the health system perspective. Health-care costs, reported in 2017 US dollars, were determined from trial records and published literature. A discrete-time simulation model was developed, extrapolating trial findings of reduced systolic blood pressure to 10-year health-care costs, cardiovascular disease events, and mortality. The primary outcomes were the proportion of people reaching blood pressure targets (at 6 months from baseline) and disability-adjusted life-years (DALYs) averted (at 10 years from baseline). Incremental cost-effectiveness ratios were calculated to estimate the cost per additional participant achieving target blood pressure at 6 months and cost per DALY averted over 10 years. FINDINGS: The triple-pill strategy, compared with usual care, cost an additional US$9·63 (95% CI 5·29 to 13·97) per person in the within-trial analysis and $347·75 (285·55 to 412·54) per person in the modelled analysis. Incremental cost-effectiveness ratios were estimated at $7·93 (95% CI 6·59 to 11·84) per participant reaching blood pressure targets at 6 months and $2842·79 (-28·67 to 5714·24) per DALY averted over a 10-year period. INTERPRETATION: Compared with usual care, the triple-pill strategy is cost-effective for patients with mild-to-moderate hypertension. Scaled up investment in the triple pill for hypertension management in Sri Lanka should be supported to address the high population burden of cardiovascular disease. FUNDING: Australian National Health and Medical Research Council.

3.
BMJ Open ; 9(9): e027134, 2019 Sep 08.
Artigo em Inglês | MEDLINE | ID: mdl-31501100

RESUMO

OBJECTIVE: Recent data on sustained hypertension and obesity among school-going children and adolescents in India are limited. This study evaluates the prevalence of sustained hypertension and obesity and their risk factors among urban and rural adolescents in northern India. SETTING: A school-based, cross-sectional survey was conducted in the urban and rural areas of Ludhiana, Punjab, India using standardised measurement tools. PARTICIPANTS: A total of 1959 participants aged 11-17 years (urban: 849; rural: 1110) were included in this school-based survey. PRIMARY AND SECONDARY OUTCOME MEASURES: To measure sustained hypertension among school children, two distinct blood pressure (BP) measurements were recorded at an interval of 1 week. High BP was defined and classified into three groups as recommended by international guidelines: (1) normal BP: <90th percentile compared with age, sex and height percentile in each age group; (2) prehypertension: BP=90th-95th percentile; and (3) hypertension: BP >95th percentile. The Indian Academy of Pediatrics classification was used to define underweight, normal, overweight and obesity as per the body mass index (BMI) for specific age groups. RESULTS: The prevalence of sustained hypertension among rural and urban areas was 5.7% and 8.4%, respectively. The prevalence of obesity in rural and urban school children was 2.7% and 11.0%, respectively. The adjusted multiple regression model found that urban area (relative risk ratio (RRR): 1.7, 95% CI 1.01 to 2.93), hypertension (RRR: 7.4, 95% CI 4.21 to 13.16) and high socioeconomic status (RRR: 38.6, 95% CI 16.54 to 90.22) were significantly associated with an increased risk of obesity. However, self-reported regular physical activity had a protective effect on the risk of obesity among adolescents (RRR: 0.4, 95% CI 0.25 to 0.62). Adolescents who were overweight (RRR: 2.66, 95% CI 1.49 to 4.40) or obese (RRR: 7.21, 95% CI 4.09 to 12.70) and reported added salt intake in their diet (RRR: 4.90, 95% CI 2.83 to 8.48) were at higher risk of hypertension. CONCLUSION: High prevalence of sustained hypertension and obesity was found among urban school children and adolescents in a northern state in India. Hypertension among adolescents was positively associated with overweight and obesity (high BMI). Prevention and early detection of childhood obesity and high BP should be strengthened to prevent the risk of cardiovascular diseases in adults.

4.
Indian Heart J ; 71(3): 235-241, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31543196

RESUMO

OBJECTIVE: Heart failure is a leading cause of death worldwide and in India, yet the qualitative data regarding heart failure care are limited. To fill this gap, we studied the facilitators and barriers of heart failure care in Kerala, India. METHODS AND RESULTS: During January 2018, we conducted a qualitative study using in-depth, semi-structured interviews with 21 health-care providers and quality administrators from 8 hospitals in Kerala to understand the context, facilitators, and barriers of heart failure care. We developed a theoretical framework using iteratively developed codes from these data to identify 6 key themes of heart failure care in Kerala: (1) need for comprehensive patient and family education on heart failure; (2) gaps between guideline-directed clinical care for heart failure and clinical practice; (3) national hospital accreditation contributing to a culture of systematically improving quality and safety of in-hospital care; (4) limited system-level attention toward improving heart failure care compared with other cardiovascular conditions; (5) application of existing personnel and technology to improve heart failure care; and (6) longitudinal and recurrent costs as barriers for optimal heart failure care. CONCLUSIONS: Key themes emerged regarding heart failure care in Kerala in the context of a health system that is increasingly emphasizing health-care quality and safety. Targeted in-hospital quality improvement interventions for heart failure should account for these themes to improve cardiovascular outcomes in the region.

6.
BMC Oral Health ; 19(1): 191, 2019 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-31429749

RESUMO

BACKGROUND: Studies in high-income countries have reported associations between oral health and diabetes. There is however a lack of evidence on this association from low and middle-income countries, especially India. The current study aimed to assess the prevalence of common oral diseases and their association with diabetes. METHODS: This cross-sectional study was nested within the second Cardiometabolic Risk Reduction in South Asia Surveillance Study. A subset of study participants residing in Delhi were administered the World Health Organization's Oral Health Assessment Questionnaire and underwent oral examination for caries experience and periodontal health assessment using standard indices. Diabetes status was ascertained by fasting blood glucose, glycosylated hemoglobin values or self-reported medication use. Information was captured on co-variates of interest. The association between oral health and diabetes was investigated using Multivariable Zero-Inflated Poisson (ZIP) regression analysis. RESULTS: Out of 2045 participants, 47% were women and the mean age of study participants was 42.17 (12.8) years. The age-standardised prevalence (95% confidence interval) estimates were 78.9% (75.6-81.7) for dental caries, 35.9% (32.3-39.6) for periodontitis. Nearly 85% participants suffered from at least one oral disease. Compared to diabetes-free counterparts, participants with diabetes had more severe caries experience [Mean Count Ratio (MCR) = 1.07 (1.03-1.12)] and attachment loss [MCR = 1.10 (1.04-1.17)]. Also, the adjusted prevalence of periodontitis was significantly higher among participants with diabetes [42.3%(40.0-45.0)] compared to those without diabetes [31.3%(30.3-32.2)]. CONCLUSION: We found that eight out of ten participants in urban Delhi suffered from some form of oral disease and participants with diabetes had worse oral health. This highlights the need for public health strategies to integrate oral health within the existing Non-Communicable Disease control programs.

8.
Glob Heart ; 14(2): 165-172, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31324371

RESUMO

BACKGROUND: Appropriate strategies and key stakeholder engagement are the keys to successful implementation of new health care interventions. OBJECTIVES: The study sought to articulate the key strategies used for scaling up a research-based intervention, mPower Heart electronic Clinical Decision Support System (e-CDSS), for state-wide implementation at health facilities in Tripura. METHODS: Multiple strategies were used for statewide implementation of mPower Heart e-CDSS at noncommunicable diseases clinics across the government health facilities in Tripura: formation of a technical coordination-cum-support unit, change management, enabling environment, adapting the intervention with user focus, and strengthening the Health Information System. RESULTS: The effective delivery of a new health system intervention requires engagement at multiple levels including political leadership, health administrators, and health professionals, which can be achieved by forming a technical coordination-cum-support unit. It is important to specify the role and responsibilities of existing manpower and provide a structured training program. Enabling environment at health facilities (providing essential equipment, space and time, etc.) is also crucial. Successful implementation also requires that patients, health care providers, the health system, and leadership recognize the immediate and long-term benefits of the new intervention and have a buy-in in the intervention. With constant encouragement and nudge from administrative authorities and by using multiple strategies, 40 government health facilities adopted the mPower Heart e-CDSS. From its launch in May 2017 until November 20, 2018, a total of 100,810 eligible individuals were screened and enrolled, with 35,884 treated for hypertension, 9,698 for diabetes, and 5,527 for both hypertension and diabetes. CONCLUSIONS: Multiple strategies, based on implementation principles, are required for successful scaling up of research-based interventions.

9.
Artigo em Inglês | MEDLINE | ID: mdl-31315297

RESUMO

: Background: Numerous epidemiological studies indicated high levels of particulate matter less than2.5 µm diameter (PM2.5) as a major cardiovascular risk factor. Most of the studies have been conducted in high-income countries (HICs), where average levels of PM2.5 are far less compared to low- and middle- income countries (LMICs), and their socio-economic profile, disease burden, and PM speciation/composition are very different. We systematically reviewed the association of long-term exposure to PM2.5 and cardio-metabolic diseases (CMDs) in LMICs. METHODS: Multiple databases were searched for English articles with date limits until March 2018. We included studies investigating the association of long-term exposure to PM2.5 (defined as an annual average/average measure for 3 more days of PM2.5 exposure) and CMDs, such as hospital admissions, prevalence, and deaths due to CMDs, conducted in LMICs as defined by World Bank. We excluded studies which employed exposure proxy measures, studies among specific occupational groups, and specific episodes of air pollution. RESULTS: A total of 5567 unique articles were identified, of which only 17 articles were included for final review, and these studies were from Brazil, Bulgaria, China, India, and Mexico. Outcome assessed were hypertension, type 2 diabetes mellitus and insulin resistance, and cardiovascular disease (CVD)-related emergency room visits/admissions, death, and mortality. Largely a positive association between exposure to PM2.5 and CMDs was found, and CVD mortality with effect estimates ranging from 0.24% to 6.11% increased per 10 µg/m3 in PM2.5. CVD-related hospitalizations and emergency room visits increased by 0.3% to 19.6%. Risk factors like hypertension had an odds ratio of 1.14, and type 2 diabetes mellitus had an odds ratio ranging from 1.14-1.32. Diversity of exposure assessment and health outcomes limited the ability to perform a meta-analysis. CONCLUSION: Limited evidence on the association of long-term exposure to PM2.5 and CMDs in the LMICs context warrants cohort studies to establish the association.

10.
PLoS One ; 14(7): e0217834, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31283784

RESUMO

BACKGROUND: Although most Indians live in rural settings, data on cardiovascular disease risk factors in these groups are limited. We describe the association between socioeconomic position and cardiovascular disease risk factors in a large rural population in north India. METHODS: We performed representative, community-based sampling from 2013 to 2014 of Solan district in Himachal Pradesh. We used education, occupation, household income, and household assets as indicators of socioeconomic position. We used tobacco use, alcohol use, low physical activity, obesity, hypertension, and diabetes as risk factors for cardiovascular disease. We performed hierarchical multivariable logistic regression, adjusting for age, sex and clustering of the health sub-centers, to evaluate the cross-sectional association of socioeconomic position indicators and cardiovascular disease risk factors. RESULTS: Among 38,457 participants, mean (SD) age was 42.7 (15.9) years, and 57% were women. The odds of tobacco use was lowest in participants with graduate school and above education (adjusted OR 0.11, 95% CI 0.09, 0.13), household income >15,000 INR (adjusted OR 0.35, 95% CI 0.29, 0.43), and highest quartile of assets (adjusted OR 0.28, 95% CI 0.24, 0.34) compared with other groups but not occupation (skilled worker adjusted OR 0.93, 95% CI 0.74, 1.16). Alcohol use was lower among individuals in the higher quartile of income (adjusted OR 0.75, 95% CI 0.64, 0.88) and assets (adjusted OR 0.70, 95% CI 0.59, 0.82). The odds of obesity was highest in participants with graduate school and above education (adjusted OR 2.33, 95% CI 1.85, 2.94), household income > 15,000 Indian rupees (adjusted OR 1.89, 95% CI 1.63, 2.19), and highest quartile of household assets (adjusted OR 2.87, 95% CI 2.39, 3.45). The odds of prevalent hypertension and diabetes were also generally higher among individuals with higher socioeconomic position. CONCLUSIONS: Individuals with lower socioeconomic position in Himachal Pradesh were more likely to have abnormal behavioral risk factors, and individuals with higher socioeconomic position were more likely to have abnormal clinical risk factors.

12.
Eur Heart J ; 40(25): 2006-2017, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31041440

RESUMO

AIMS: Raised blood pressure (BP) is the biggest contributor to mortality and disease burden worldwide and fewer than half of those with hypertension are aware of it. May Measurement Month (MMM) is a global campaign set up in 2017, to raise awareness of high BP and as a pragmatic solution to a lack of formal screening worldwide. The 2018 campaign was expanded, aiming to include more participants and countries. METHODS AND RESULTS: Eighty-nine countries participated in MMM 2018. Volunteers (≥18 years) were recruited through opportunistic sampling at a variety of screening sites. Each participant had three BP measurements and completed a questionnaire on demographic, lifestyle, and environmental factors. Hypertension was defined as a systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, or taking antihypertensive medication. In total, 74.9% of screenees provided three BP readings. Multiple imputation using chained equations was used to impute missing readings. 1 504 963 individuals (mean age 45.3 years; 52.4% female) were screened. After multiple imputation, 502 079 (33.4%) individuals had hypertension, of whom 59.5% were aware of their diagnosis and 55.3% were taking antihypertensive medication. Of those on medication, 60.0% were controlled and of all hypertensives, 33.2% were controlled. We detected 224 285 individuals with untreated hypertension and 111 214 individuals with inadequately treated (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) hypertension. CONCLUSION: May Measurement Month expanded significantly compared with 2017, including more participants in more countries. The campaign identified over 335 000 adults with untreated or inadequately treated hypertension. In the absence of systematic screening programmes, MMM was effective at raising awareness at least among these individuals at risk.

13.
Lancet Glob Health ; 7(6): e761-e771, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31097278

RESUMO

BACKGROUND: Task sharing for the management of hypertension could be useful for understaffed and resource-poor health systems. We assessed the effectiveness of task-sharing interventions in improving blood pressure control among adults in low-income and middle-income countries. METHODS: We searched the Cochrane Library, PubMed, Embase, and CINAHL for studies published up to December 2018. We included intervention studies involving a task-sharing strategy for management of blood pressure and other cardiovascular risk factors. We extracted data on population, interventions, blood pressure, and task sharing groups. We did a meta-analysis of randomised controlled trials. FINDINGS: We found 3012 references, of which 54 met the inclusion criteria initially. Another nine studies were included following an updated search. There were 43 trials and 20 before-and-after studies. We included 31 studies in our meta-analysis. Systolic blood pressure was decreased through task sharing in different groups of health-care workers: the mean difference was -5·34 mm Hg (95% CI -9·00 to -1·67, I2=84%) for task sharing with nurses, -8·12 mm Hg (-10·23 to -6·01, I2=57%) for pharmacists, -4·67 mm Hg (-7·09 to -2·24, I2=0%) for dietitians, -3·67 mm Hg (-4·58 to -2·77, I2=24%) for community health workers, and -4·85 mm Hg (-6·12 to -3·57, I2=76%) overall. We found a similar reduction in diastolic blood pressure (overall mean difference -2·92 mm Hg, -3·75 to -2·09, I2=80%). The overall quality of evidence based on GRADE criteria was moderate for systolic blood pressure, but low for diastolic blood pressure. INTERPRETATION: Task-sharing interventions are effective in reducing blood pressure. Long-term studies are needed to understand their potential impact on cardiovascular outcomes and mortality. FUNDING: Wellcome Trust/DBT India Alliance.

14.
PLoS Med ; 16(5): e1002801, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31050680

RESUMO

BACKGROUND: Evidence on where in the hypertension care process individuals are lost to care, and how this varies among states and population groups in a country as large as India, is essential for the design of targeted interventions and to monitor progress. Yet, to our knowledge, there has not yet been a nationally representative analysis of the proportion of adults who reach each step of the hypertension care process in India. This study aimed to determine (i) the proportion of adults with hypertension who have been screened, are aware of their diagnosis, take antihypertensive treatment, and have achieved control and (ii) the variation of these care indicators among states and sociodemographic groups. METHODS AND FINDINGS: We used data from a nationally representative household survey carried out from 20 January 2015 to 4 December 2016 among individuals aged 15-49 years in all states and union territories (hereafter "states") of the country. The stages of the care process-computed among those with hypertension at the time of the survey-were (i) having ever had one's blood pressure (BP) measured before the survey ("screened"), (ii) having been diagnosed ("aware"), (iii) currently taking BP-lowering medication ("treated"), and (iv) reporting being treated and not having a raised BP ("controlled"). We disaggregated these stages by state, rural-urban residence, sex, age group, body mass index, tobacco consumption, household wealth quintile, education, and marital status. In total, 731,864 participants were included in the analysis. Hypertension prevalence was 18.1% (95% CI 17.8%-18.4%). Among those with hypertension, 76.1% (95% CI 75.3%-76.8%) had ever received a BP measurement, 44.7% (95% CI 43.6%-45.8%) were aware of their diagnosis, 13.3% (95% CI 12.9%-13.8%) were treated, and 7.9% (95% CI 7.6%-8.3%) had achieved control. Male sex, rural location, lower household wealth, and not being married were associated with greater losses at each step of the care process. Between states, control among individuals with hypertension varied from 2.4% (95% CI 1.7%-3.3%) in Nagaland to 21.0% (95% CI 9.8%-39.6%) in Daman and Diu. At 38.0% (95% CI 36.3%-39.0%), 28.8% (95% CI 28.5%-29.2%), 28.4% (95% CI 27.7%-29.0%), and 28.4% (95% CI 27.8%-29.0%), respectively, Puducherry, Tamil Nadu, Sikkim, and Haryana had the highest proportion of all adults (irrespective of hypertension status) in the sampled age range who had hypertension but did not achieve control. The main limitation of this study is that its results cannot be generalized to adults aged 50 years and older-the population group in which hypertension is most common. CONCLUSIONS: Hypertension prevalence in India is high, but the proportion of adults with hypertension who are aware of their diagnosis, are treated, and achieve control is low. Even after adjusting for states' economic development, there is large variation among states in health system performance in the management of hypertension. Improvements in access to hypertension diagnosis and treatment are especially important among men, in rural areas, and in populations with lower household wealth.

15.
Circ Cardiovasc Qual Outcomes ; 12(5): e005251, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31092020

RESUMO

Background Hospital management practices are associated with cardiovascular process of care measures and patient outcomes. However, management practices related to acute cardiac care in India has not been studied. Methods and Results We measured management practices through semistructured, in-person interviews with hospital administrators, physician managers, and nurse managers in Kerala, India between October and November 2017 using the adapted World Management Survey. Trained interviewers independently scored management interview responses (range: 1-5) to capture management practices ranging from performance data tracking to setting targets. We performed univariate regression analyses to assess the relationship between hospital-level factors and management practices. Using Pearson correlation coefficients and mixed-effect logistic regression models, we explored the relationship between management practices and 30-day major adverse cardiovascular events defined as all-cause mortality, reinfarction, stroke, or major bleeding. Ninety managers from 37 hospitals participated. We found suboptimal management practices across 3 management levels (mean [SD]: 2.1 [0.5], 2.0 [0.3], and 1.9 [0.3] for hospital administrators, physician managers, and nurse managers, respectively [ P=0.08]) with lowest scores related to setting organizational targets. Hospitals with existing healthcare quality accreditation, more cardiologists, and private ownership were associated with higher management scores. In our exploratory analysis, higher physician management practice scores related to operation, performance, and target management were correlated with lower 30-day major adverse cardiovascular event. Conclusions Management practices related to acute cardiac care in participating Kerala hospitals were suboptimal but were correlated with clinical outcomes. We identified opportunities to strengthen nonclinical practices to improve patient care.

16.
JAMA Netw Open ; 2(5): e193831, 2019 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-31099866

RESUMO

Importance: Ischemic heart disease is the leading cause of death in India, and treatment can be costly. Objective: To evaluate individual- and household-level costs and impoverishing effects of acute myocardial infarction among patients in Kerala, India. Design, Setting, and Participants: This investigation was a prespecified substudy of the Acute Coronary Syndrome Quality Improvement in Kerala study, a stepped-wedge, cluster randomized clinical trial conducted between November 2014 and November 2016 across 63 hospitals in Kerala, India. In this cross-sectional substudy, individual- and household-level cost data were collected 30 days after hospital discharge from a sample of 2114 respondents from November 2014 to July 2016. Data were analyzed from July through October 2018 and in March 2019. Exposures: Health insurance status. Main Outcomes and Measures: The primary outcomes were detailed direct and indirect cost data associated with acute myocardial infarction and respondent ability to pay as well as catastrophic health spending and distress financing. Catastrophic health spending was defined as 40% or more of household expenditures minus food costs spent on health, and distress financing was defined as borrowing money or selling assets to cover health costs. Hierarchical regression models were used to evaluate the association between health insurance and measures of financial risk. Costs were converted from Indian rupees to international dollars (represented herein as "$"). Results: Among 2114 respondents, the mean (SD) age was 62.3 (12.7) years, 1521 (71.9%) were men, 1144 (54.1%) presented with an ST-segment elevation myocardial infarction, and 1600 (75.7%) had no health insurance. The median (interquartile range) expenditure among respondents was $480.4 ($112.5-$1733.0) per acute myocardial infarction encounter, largely driven by in-hospital expenditures. There was greater than 15-fold variability between the 25th and 75th percentiles. Individuals with or without health insurance had similar monthly incomes and annual household expenditures, yet individuals without health insurance had approximately $400 higher out-of-pocket cardiovascular health care costs (median [interquartile range] total cardiovascular expenditures among uninsured, $560.3 [$134.1-$1733.6] vs insured, $161.4 [$23.2-$1726.9]; P < .001). Individuals without health insurance also had a 24% higher risk of catastrophic health spending (adjusted risk ratio, 1.24; 95% CI, 1.07-1.43) and 3-fold higher risk of distress financing (adjusted risk ratio; 3.05; 95% CI, 1.45-6.44). Conclusions and Relevance: The results of this study indicate that acute myocardial infarction carries substantial financial risk for patients in Kerala. Expansion of health insurance may be an important strategy for financial risk protection to disrupt the poverty cycle associated with cardiovascular diseases in India.

17.
BMJ Open ; 9(5): e027841, 2019 May 19.
Artigo em Inglês | MEDLINE | ID: mdl-31110103

RESUMO

INTRODUCTION: India has high prevalence of hypertension but low awareness, treatment and control rate. A cluster randomised trial entitled 'm-Power Heart Project' is being implemented to test the effectiveness of a nurse care coordinator (NCC) led complex intervention to address uncontrolled hypertension in the community health centres (CHCs). The trial's process evaluation will assess the fidelity and quality of implementation, clarify the causal mechanisms and identify the contextual factors associated with variation in the outcomes. The trial will use a theory-based mixed-methods process evaluation, guided by the Consolidated Framework for Implementation Research. METHODS AND ANALYSIS: The process evaluation will be conducted in the CHCs of Visakhapatnam (southern India). The key stakeholders involved in the intervention development and implementation will be included as participants. In-depth interviews will be conducted with intervention developers, doctors, NCCs and health department officials and focus groups with patients and their caregivers. NCC training will be evaluated using Kirkpatrick's model for training evaluation. Key process evaluation indicators (number of patients recruited and retained; concordance between the treatment plans generated by the electronic decision support system and treatment prescribed by the doctor and so on) will be assessed. Fidelity will be assessed using Borrelli et al's framework. Qualitative data will be analysed using the template analysis technique. Quantitative data will be summarised as medians (IQR), means (SD) and proportions as appropriate. Mixed-methods analysis will be conducted to assess if the variation in the mean reduction of systolic blood pressure between the intervention CHCs is influenced by patient satisfaction, training outcome, attitude of doctors, patients and NCCs about the intervention, process indicators etc. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the ethics committees at Public Health Foundation of India and Deakin University. Findings will be disseminated via peer-reviewed publications, national and international conference presentations. TRIAL REGISTRATION NUMBER: NCT03164317; Pre-results.

18.
J Hum Hypertens ; 33(8): 594-601, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30979950

RESUMO

Often a single blood pressure (BP) measurement is used to diagnose and manage hypertension in busy clinics. However, repeated BP measurements have been shown to be more representative of the true BP status of the individual. Improper measurement of office BP can lead to inaccurate classification, overestimation of a patient's true BP, unnecessary treatment, and misinterpretation of the true prevalence of hypertension. There is no consensus among major guidelines on the number of recommended measurements at a single visit or the method of arriving at final clinic BP reading. The participants of the National Family Health Survey (NFHS-4), a nationwide survey conducted in India from 2015 to 2016, were used for the analysis. The prevalence and median difference in systolic blood pressure (SBP) and diastolic blood pressure (DBP) for single as well as combinations of two or more readings were calculated. Cross-tabulation was used to assess classification of individuals based on first BP reading compared with the mean of two or more BP measurements. There was a 63% higher prevalence of hypertension when only the first reading was considered for diagnosis in comparison to the mean of the second and third readings. A decrease of 3.6 mmHg and 2.4 mm Hg in mean SBP and DBP, respectively, was observed when the mean of the second and third readings was compared to the first reading. In those who are identified to have grade 1 or higher categories of hypertension, we recommend three BP measurements, with the mean of the second and third measurements being the clinic BP.

19.
Prev Chronic Dis ; 16: E49, 2019 04 18.
Artigo em Inglês | MEDLINE | ID: mdl-31002636

RESUMO

PURPOSE AND OBJECTIVES: Low- and middle-income countries (LMICs) have a large burden of noncommunicable diseases and confront leadership capacity challenges and gaps in implementation of proven interventions. To address these issues, we designed the Public Health Leadership and Implementation Academy (PH-LEADER) for noncommunicable diseases. The objective of this program evaluation was to assess the quality and effectiveness of PH-LEADER. INTERVENTION APPROACH: PH-LEADER was directed at midcareer public health professionals, researchers, and government public health workers from LMICs who were involved in prevention and control of noncommunicable diseases. The 1-year program focused on building implementation research and leadership capacity to address noncommunicable diseases and included 3 complementary components: a 2-month online preparation period, a 2-week summer course in the United States, and a 9-month, in-country, mentored project. EVALUATION METHODS: Four trainee groups participated from 2013 through 2016. We collected demographic information on all trainees and monitored project and program outputs. Among the 2015 and 2016 trainees, we assessed program satisfaction and pre-post program changes in leadership practices and the perceived competence of trainees for performing implementation research. RESULTS: Ninety professionals (mean age 38.8 years; 57% male) from 12 countries were trained over 4 years. Of these trainees, 50% were from India and 29% from Mexico. Trainees developed 53 projects and 9 publications. Among 2015 and 2016 trainees who completed evaluation surveys (n = 46 of 55), we saw pre-post training improvements in the frequency with which they acted as role models (Cohen's d = 0.62, P <.001), inspired a shared vision (d = 0.43, P =.005), challenged current processes (d = 0.60, P <.001), enabled others to act (d = 0.51, P =.001), and encouraged others by recognizing or celebrating their contributions and accomplishments (d = 0.49, P =.002). Through short on-site evaluation forms (scale of 1-10), trainees rated summer course sessions as useful (mean, 7.5; SD = 0.2), with very good content (mean, 8.5; SD = 0.6) and delivered by very good professors (mean, 8.6; SD = 0.6), though they highlighted areas for improvement. IMPLICATIONS FOR PUBLIC HEALTH: The PH-LEADER program is a promising strategy to build implementation research and leadership capacity to address noncommunicable diseases in LMICs.

20.
Can J Cardiol ; 35(4): 430-437, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30935633

RESUMO

BACKGROUND: The effect of sex on self-reported frailty in acute coronary syndromes (ACS) is unclear. We examined the prevalence of self-reported frailty and its association with all-cause death among men and women. METHODS: Elderly (≥ 65 years) male (n = 2691) and female (n = 2305) patients with ACS enrolled in the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial were screened using the Fried Frailty Index. Sex differences in prevalence of frailty symptoms and categories (not frail; prefrail [1 to 2 symptoms]; and frail [≥ 3 symptoms]) and their prognostic importance were examined. RESULTS: Women were older and had higher rates of comorbidities than men. A total of 739 (27.5%) men and 645 (28%) women reported ≥ 1 frailty symptom. Prevalence of frailty increased with age among men but not women. During a median follow-up of 17.3 months, 353 (13.1%) men and 266 (11.5%) women died. After adjusting for age, prefrail men had a 35% increased risk (hazard ratio [HR] 1.35; 95% confidence interval [CI], 1.07-1.71), and frail men had an 80% increased risk (HR 1.80; 95% CI, 1.22-2.67) of death relative to not-frail men. The age-adjusted HR for death in prefrail women was 1.40 (95% CI, 1.07-1.84), and 1.55 (95% CI, 0.96-2.49) in frail women relative to not-frail women. Self-reported slow walk time and decreased physical activity appeared to provide the most prognostic information. CONCLUSION: Self-reported frailty was similar among men and women with ACS. Frailty increased with age only among men, in whom it added more prognostic information. Patient-reported frailty may identify elderly patients with ACS, particularly men, at high-risk of mortality.

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