Essential medicines for cardiovascular diseases in India: Rapid appraisal of policies and processes at the subnational level

BACKGROUND The burden of cardiovascular diseases (CVDs) and response to health systems vary widely at the subnational level in India. Our study aimed to assess the variation in state-level access to medicines for CVDs by comparing the essential medicines lists (EMLs) at the national and subnational levels in India and by rapid appraisal of the existing policies and processes of drug procurement. METHODS We assessed the inclusion of six classes of medicines for CVDs in the recent and publicly available national and subnational EMLs from July to September 2018 in the states of Telangana and Madhya Pradesh. We examined the drug procurement and distribution policies and processes using documentary review and five key informant interviews between March and June 2018. RESULTS The WHO’s EML, India’s national EML, and 21 of 28 publicly available (75%) Indian state and Union Territory EMLs included all six classes of essential medicines for CVDs. However, some medicines were not included in the policy packages of essential medicines meant for primary health centres. Both the states used centralized tendering and decentralized distribution as part of the public sector drug procurement process. The requirement was based on the previous year’s consumption. The approximate time between procurement planning and distribution was 7–8 months in both the states. CONCLUSION Substantial variation exists in the selection of drugs for CVDs in EMLs at the subnational level in India. Improving forecasting techniques for requirement of medicines and reducing time lags between forecasting and distribution to health facilities may allow for better access to essential medicines.

Feasibility and effect of community health worker support and home monitoring for blood pressure control in Nigeria: a randomised pilot trial

In a three-arm, randomised, controlled trial among 60 Nigerian adults with hypertension, community health worker support and home blood pressure monitoring led to greater reductions in systolic blood pressure at four weeks compared to the usual care

Facilitators and barriers of heart failure care in Kerala, India: A qualitative analysis of health-care providers and administrators

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.

Association between anthropometry, cardiometabolic risk factors, & early life factors & adult measures of endothelial function: Results from the New Delhi Birth Cohort.

Background & objectives: Abnormal endothelial function represents a preclinical marker of atherosclerosis. This study was conducted to evaluate associations between anthropometry, cardiometabolic risk factors, and early life factors and adult measures of endothelial function in a young urban Indian cohort free of clinical cardiovascular disease. Methods: Absolute changes in brachial artery diameter following cuff inflation and sublingual nitroglycerin (400 μg) were recorded to evaluate endothelium-dependent and -independent measures of endothelial function in 600 participants (362 men; 238 women) from the New Delhi Birth Cohort (2006-2009). Data on anthropometry, cardiometabolic risk factors, medical history, socio-economic position, and lifestyle habits were collected. Height and weight were recorded at birth, two and 11 yr of age. Age- and sex-adjusted linear regression models were developed to evaluate these associations. Results: The mean age of participants was 36±1 yr. Twenty two per cent men and 29 per cent women were obese (BMI > 30 kg/m2). Mean systolic blood pressure (SBP) was 131±14 and 119±13 mmHg, and diabetes prevalence was 12 and 8 per cent for men and women, respectively. Brachial artery diameter was higher for men compared with women both before (3.48±0.37 and 2.95±0.35 cm) and after hyperaemia (3.87±0.37 vs. 3.37±0.35 cm). A similar difference was seen before and after nitroglycerin. Markers of increased adiposity, smoking, SBP, and metabolic syndrome, but not early life anthropometry, were inversely associated with endothelial function after adjustment for age and sex. Interpretation & conclusions: The analysis of the current prospective data from a young urban Indian cohort showed that cardiometabolic risk factors, but not early life anthropometry, were associated with worse endothelial function.

Cardiovascular Research Publications from Latin America between 1999 and 2008. A Bibliometric Study / Publicações de Pesquisas Cardiovasculares da América Latina entre 1999 e 2008. Um Estudo Bibliométrico

Background: Cardiovascular research publications seem to be increasing in Latin America overall. Objective: To analyze trends in cardiovascular publications and their citations from countries in Latin America between 1999 and 2008, and to compare them with those from the rest of the countries. Methods: We retrieved references of cardiovascular publications between 1999 and 2008 and their five-year post-publication citations from the Web of Knowledge database. For countries in Latin America, we calculated the total number of publications and their citation indices (total citations divided by number of publications) by year. We analyzed trends on publications and citation indices over time using Poisson regression models. The analysis was repeated for Latin America as a region, and compared with that for the rest of the countries grouped according to economic development. Results: Brazil (n = 6,132) had the highest number of publications in1999-2008, followed by Argentina (n = 1,686), Mexico (n = 1,368) and Chile (n = 874). Most countries showed an increase in publications over time, leaded by Guatemala (36.5% annually [95%CI: 16.7%-59.7%]), Colombia (22.1% [16.3%-28.2%]), Costa Rica (18.1% [8.1%-28.9%]) and Brazil (17.9% [16.9%-19.1%]). However, trends on citation indices varied widely (from -33.8% to 28.4%). From 1999 to 2008, cardiovascular publications of Latin America increased by 12.9% (12.1%-13.5%) annually. However, the citation indices of Latin America increased 1.5% (1.3%-1.7%) annually, a lower increase than those of all other country groups analyzed. Conclusions: Although the number of cardiovascular publications of Latin America increased from 1999 to 2008, trends on citation indices suggest they may have had a relatively low impact on the research field, stressing the importance of considering quality and dissemination on local research policies. .

Fundamento: As publicações sobre pesquisa cardiovascular parecem estar crescendo na América Latina em geral. Objetivo: Analisar as tendências nas publicações cardiovasculares e suas citações de países na América Latina entre 1999 e 2008, e compará-las àquelas dos demais países. Métodos: Recuperamos, a partir da base de dados Web of Knowledge, as referências de publicações cardiovasculares entre 1999 e 2008 e as suas citações cinco anos após publicação. Para os países da América Latina, calculamos o número total de publicações e seus índices de citação (número total de citações dividido pelo número de publicações) por ano. Analisamos as tendências das publicações e dos índices de citação ao longo do tempo usando modelos de regressão de Poisson. A análise foi repetida para a América Latina como região e comparada àquela para os demais países agrupados de acordo com o desenvolvimento econômico. Resultados: O Brasil (n = 6.132) apresentou o mais alto número de publicações no período 1999-2008, seguindo-se Argentina (n = 1.686), México (n = 1.368) e Chile (n = 874). A maioria dos países apresentou elevação do número de publicações ao longo do tempo, principalmente Guatemala (36,5% anual [IC 95%: 16,7%-59,7%]), Colômbia (22,1% [16,3%-28,2%]), Costa Rica (18,1% [8,1%-28,9%]) e Brasil (17,9% [16,9%-19,1%]). No entanto, as tendências dos índices de citação variaram muito, de -33,8% a 28,4%. De 1999 a 2008, as publicações cardiovasculares na América Latina aumentaram em 12,9% (12,1%-13,5%) por ano. Entretanto, os índices de citação da América Latina aumentaram 1,5% (1,3%-1,7%) por ano, um aumento menor do que aqueles dos demais grupos de países analisados. Conclusões: Embora o número de publicações cardiovasculares da América Latina tenha aumentado de 1999 a 2008, tendências nos índices de citação sugerem que elas possam ter tido um impacto relativamente baixo na área de pesquisa, reforçando a importância de se considerar a qualidade e a disseminação ...

Heart failure: Epidemiology and prevention in India.

Reliable estimates of heart failure are lacking in India because of the absence of a surveillance programme to track incidence, prevalence, outcomes and key causes of heart failure. Nevertheless, we propose that the incidence and prevalence rates of heart failure are rising due to population, epidemiological and health transitions. Based on disease-specific estimates of prevalence and incidence rates of heart failure, we conservatively estimate the prevalence of heart failure in India due to coronary heart disease, hypertension, obesity, diabetes and rheumatic heart disease to range from 1.3 to 4.6 million, with an annual incidence of 491 600–1.8 million. The double burden of rising cardiovascular risk factors and persistent ‘pretransition’ diseases such as rheumatic heart disease, limited healthcare infrastructure and social disparities contribute to these estimates. Staging of heart failure, introduced in 2005, provides a framework to target preventive strategies in patients at risk for heart failure (stage A), with structural disease alone (B), with heart failure symptoms (C) and with end-stage disease (D). Policy-level interventions, such as regulations to limit salt and tobacco consumption, are effective for primordial prevention and would have a wider impact on prevention of heart failure. Clinical preventive interventions and clinical quality improvement interventions, such as treatment of hypertension, atherosclerotic disease, diabetes and acute decompensated heart failure are effective for primary, secondary and even tertiary prevention.