Multimorbidity and social determinants of health in the US prior to the COVID-19 pandemic and implications for health outcomes: a cross-sectional analysis based on NHANES 2017-2018.

Multimorbidity increases the risk of all-cause mortality, and along with age, is an independent risk factor for severe disease and mortality from COVID-19. Inequities in the social determinants of health contributed to increased mortality from COVID-19 among disadvantaged populations. This study aimed to evaluate the prevalence of multimorbid conditions and associations with the social determinants of health in the US prior to the pandemic.Methods Data from the 2017-18 cycle of NHANES were used to determine the prevalence of 13 chronic conditions, and the prevalence of having 0, 1, or 2 or more of those conditions, among the US adult population aged ≥ 20 years. Multimorbidity was defined as having 2 or more of these conditions. Data were stratified according to demographic, socioeconomic and indicators of health access, and analyses including logistic regression, performed to determine the factors associated with multimorbidity.Results The prevalence of multimorbidity was 58.4% (95% CI 55.2 to 61.7). Multimorbidity was strongly associated with age and was highly prevalent among those aged 20-29 years at 22.2% (95% CI 16.9 to 27.6) and continued to increase with older age. The prevalence of multimorbidity was highest in those defined as Other or multiple races (66.9%), followed in decreasing frequency by rates among non-Hispanic Whites (61.2%), non-Hispanic Blacks (57.4%), Hispanic (52.0%) and Asian (41.3%) groups.Logistic regression showed a statistically significant relationship between multimorbidity and age, as expected. Asian race was associated with a reduced likelihood of 2 or more chronic conditions (OR 0.4; 95% CI 0.35 to 0.57; P < 0.0001). Socioeconomic factors were related to multimorbidity. Being above the poverty level (OR 0.64; 95% CI 0.46 to 0.91, p = 0.013); and a lack of regular access to health care (OR 0.61 (95% CI 0.42 to 0.88, p = 0.008) were both associated with a reduced likelihood of multimorbidity. Furthermore, there was a borderline association between not having health insurance and reduced likelihood of multimorbidity (OR 0.63; 95% CI 0.40 to 1.0; p = 0.053).Conclusions There are high levels of multimorbidity in the US adult population, evident from young adulthood and increasing with age. Cardiometabolic causes of multimorbidity were highly prevalent, especially obesity, hyperlipidemia, hypertension, and diabetes; conditions subsequently found to be associated with severe disease and death from COVID-19. A lack of access to care was paradoxically associated with reduced likelihood of comorbidity, likely linked to underdiagnosis of chronic conditions. Obesity, poverty, and lack of access to healthcare are factors related to multimorbidity and were also relevant to the health impact of the COVID-19 pandemic, that must be addressed through comprehensive social and public policy measures. More research is needed on the etiology and determinants of multimorbidity, on those affected, patterns of co-morbidity, and implications for individual health and impact on health systems and society to promote optimal outcomes. Comprehensive public health policies are needed to tackle multimorbidity and reduce disparities in the social determinants of health, as well as to provide universal access to healthcare.

What is the NCD service capacity and disruptions due to COVID-19? Results from the WHO non-communicable disease country capacity survey in the Americas region.

OBJECTIVE: This article presents the Americas regional results of the WHO non-communicable diseases (NCDs) Country Capacity Survey from 2019 to 2021, on NCD service capacity and disruptions from the COVID-19 pandemic. SETTING: Information on public sector primary care services for NCDs, and related technical inputs from 35 countries in the Americas region are provided. PARTICIPANTS: All Ministry of Health officials managing a national NCD programme, from a WHO Member State in the Americas region, were included throughout this study. Government health officials from countries that are not WHO Member States were excluded. OUTCOME MEASURES: The availability of evidence-based NCD guidelines, essential NCD medicines and basic technologies in primary care, cardiovascular disease risk stratification, cancer screening and palliative care services were measured in 2019, 2020 and 2021. NCD service interruptions, reassignments of NCD staff during the COVID-19 pandemic and mitigation strategies to reduce disruptions for NCD services were measured in 2020 and 2021. RESULTS: More than 50% of countries reported a lack of comprehensive package of NCD guidelines, essential medicines and related service inputs. Extensive disruptions in NCD services resulted from the pandemic, with only 12/35 countries (34%), reporting that outpatient NCD services were functioning normally. Ministry of Health staff were largely redirected to work on the COVID-19 response, either full time or partially, reducing the human resources available for NCD services. Six of 24 countries (25%) reported stock out of essential NCD medicines and/or diagnostics at health facilities which affected service continuity. Mitigation strategies to ensure continuity of care for people with NCDs were deployed in many countries and included triaging patients, telemedicine and teleconsultations, and electronic prescriptions and other novel prescribing practices. CONCLUSIONS: The findings from this regional survey suggest significant and sustained disruptions, affecting all countries regardless of the country's level of investments in healthcare or NCD burden.

Integrated approach for noncommunicable disease management in the Americas.

An overview of an integrated approach to improve noncommunicable disease (NCD) management is presented, along with tools on integrating NCD management as part of health system strengthening in the Americas. The study is based on an analysis of Pan American Health Organization/World Health Organization (PAHO/WHO) data and publicly available information on NCD care and capacity, disruptions in NCD services, and guidance on NCD management. Gaps in NCD care are highlighted, in which an estimated 43.0% of men and 28.0% of women with hypertension in Latin America remain undiagnosed; and for those with diabetes, 32.8% in Central and South America are undiagnosed. Yet, only 17/35 countries (49%) in the Americas report having evidence-based national guidelines for NCD management through a primary care approach and only 7/35 countries (20%) report provision of drug therapy, including glycaemic control for eligible persons. To improve NCD management, an integrated approach is needed to coordinate and deliver care across the levels of the health system. This includes increasing primary care capacity and competencies to address multiple chronic conditions, and integration with other complementary programs to avoid missing opportunities for NCD diagnosis and management. An integrated approach to NCD management, and implementation of available tools, should be part of rebuilding health systems after the COVID-19 pandemic.

En este artículo se presenta una visión general de un enfoque integrado para mejorar el manejo de las enfermedades no transmisibles (ENT), así como herramientas para integrar el manejo de las ENT como parte del fortalecimiento de los sistemas de salud en la Región de las Américas. El estudio se basa en un análisis de datos de la Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS/OMS) y en información disponible para el público sobre la atención de las ENT y la capacidad, las interrupciones en los servicios y la orientación sobre el manejo de las ENT. Se destacan las brechas en la atención de estas enfermedades; se estima que 43,0% de los hombres y 28,0% de las mujeres con hipertensión en América Latina siguen sin recibir un diagnóstico, mientras que entre las personas con diabetes, 32,8% en América Central y del Sur no están diagnosticadas. Sin embargo, únicamente 17 de 35 países de la Región (49%) afirman disponer de pautas nacionales basadas en la evidencia para el manejo de las ENT mediante un enfoque de atención primaria, y solo 7 de 35 países (20%) refieren la provisión de farmacoterapia ­por ejemplo, para el control glucémico­ para las personas que reúnen los requisitos. Para mejorar el manejo de las ENT, es necesario un enfoque integrado para coordinar y brindar atención en todos los niveles del sistema de salud. Esto supone el aumento de la capacidad y las competencias de la atención primaria para abordar diversas enfermedades crónicas y su integración con otros programas complementarios y así no perder oportunidades de diagnosticar y gestionar las ENT. Un enfoque integrado para el manejo de las ENT y la aplicación de las herramientas disponibles deben formar parte de la reconstrucción de los sistemas de salud después de la pandemia de COVID-19.

O documento apresenta uma visão geral de uma abordagem integrada para melhorar o manejo de doenças não transmissíveis (DNT), bem com ferramentas para posicionar o manejo das DNT como parte integrante do fortalecimento dos sistemas de saúde nas Américas. O estudo tem como base uma análise dos dados da Organização Pan-Americana da Saúde/Organização Mundial da Saúde (OPAS/OMS) e informações disponíveis publicamente sobre cuidados e capacidade de atendimento a DNT, interrupções nos serviços de DNT e orientações sobre o manejo de DNT. São destacadas as lacunas na atenção às DNT. Estima-se que 43,0% dos homens e 28,0% das mulheres com hipertensão na América Latina permanecem sem diagnóstico, e entre aqueles com diabetes, 32,8% na América Central e do Sul permanecem sem diagnóstico. Apenas 17 de 35 países (49%) nas Américas relatam ter diretrizes nacionais baseadas em evidências para o manejo de DNT na atenção primária e apenas 7 de 35 países (20%) relatam o fornecimento de terapia medicamentosa, incluindo medicamentos para o controle glicêmico para pessoas elegíveis. Para melhorar o manejo das DNT, é necessária uma abordagem integrada para coordenar e prestar cuidados em todos os níveis do sistema de saúde. Isso inclui o aumento da capacidade e da competência da atenção primária para atender pessoas com múltiplas doenças crônicas e a integração com outros programas complementares para evitar a perda de oportunidades para o diagnóstico e o manejo das DNT. Uma abordagem integrada ao manejo das DNT e a implementação das ferramentas disponíveis devem fazer parte da reconstrução dos sistemas de saúde após a pandemia de COVID-19.

Integrated approach for noncommunicable disease management in the Americas Un enfoque integrado para el manejo de las enfermedades no transmisibles en la Región de las Américas Uma abordagem integrada para o manejo das doenças não transmissíveis nas Américas

An overview of an integrated approach to improve noncommunicable disease (NCD) management is presented, along with tools on integrating NCD management as part of health system strengthening in the Americas. The study is based on an analysis of Pan American Health Organization/World Health Organization (PAHO/WHO) data and publicly available information on NCD care and capacity, disruptions in NCD services, and guidance on NCD management. Gaps in NCD care are highlighted, in which an estimated 43.0% of men and 28.0% of women with hypertension in Latin America remain undiagnosed;and for those with diabetes, 32.8% in Central and South America are undiagnosed. Yet, only 17/35 countries (49%) in the Americas report having evidence-based national guidelines for NCD management through a primary care approach and only 7/35 countries (20%) report provision of drug therapy, including glycaemic control for eligible persons. To improve NCD management, an integrated approach is needed to coordinate and deliver care across the levels of the health system. This includes increasing primary care capacity and competencies to address multiple chronic conditions, and integration with other complementary programs to avoid missing opportunities for NCD diagnosis and management. An integrated approach to NCD management, and implementation of available tools, should be part of rebuilding health systems after the COVID-19 pandemic.

Prioritizing noncommunicable diseases in the Americas region in the era of COVID-19 Priorizar las enfermedades no transmisibles en la Región de las Américas en la era de la COVID-19 Priorização de doenças não transmissíveis na Região das Américas na era da COVID-19

This article describes the situation of noncommunicable diseases (NCDs) in the Americas, implementation of NCD interventions according to key progress indicators, the impact of COVID-19 on NCD services, and ways to reprioritize NCDs following COVID-19. Information was retrieved from institutional data and through a supplementary scoping review of published articles related to NCDs and COVID-19 in the Americas published April 2020–November 2021. While NCDs account for 80.7% of all deaths in the Americas, implementation of a key set of NCD interventions has been limited, with only three countries reporting implementation of 12 or more of the 19 NCD indicators. By mid-May 2022, the Americas had reported about 29.9% of all COVID-19 cases in the world (154 million of 515 million) and 43.5% all COVID-19 deaths (2.7 million of 6.2 million). This pandemic has hampered progress on NCDs and significantly disrupted services for people who require ongoing care. Adaptive strategies, such as telehealth and mobile pharmacies, have been used to mitigate service disruptions. However, NCD prevention and management must be an integral part of recovering from the COVID-19 pandemic. This will require scaled up efforts to establish/re-establish and enforce policies on NCD risk factors, especially for tobacco control and obesity prevention, as well as greater investment in primary care and expansion of telemedicine and digital health solutions for continuous care for people with NCDs. Lastly, limited data are available on the impact of COVID-19 on NCDs, and hence NCD data and surveillance need to be strengthened.

Prioritizing noncommunicable diseases in the Americas region in the era of COVID-19.

This article describes the situation of noncommunicable diseases (NCDs) in the Americas, implementation of NCD interventions according to key progress indicators, the impact of COVID-19 on NCD services, and ways to reprioritize NCDs following COVID-19. Information was retrieved from institutional data and through a supplementary scoping review of published articles related to NCDs and COVID-19 in the Americas published April 2020-November 2021. While NCDs account for 80.7% of all deaths in the Americas, implementation of a key set of NCD interventions has been limited, with only three countries reporting implementation of 12 or more of the 19 NCD indicators. By mid-May 2022, the Americas had reported about 29.9% of all COVID-19 cases in the world (154 million of 515 million) and 43.5% all COVID-19 deaths (2.7 million of 6.2 million). This pandemic has hampered progress on NCDs and significantly disrupted services for people who require ongoing care. Adaptive strategies, such as telehealth and mobile pharmacies, have been used to mitigate service disruptions. However, NCD prevention and management must be an integral part of recovering from the COVID-19 pandemic. This will require scaled up efforts to establish/re-establish and enforce policies on NCD risk factors, especially for tobacco control and obesity prevention, as well as greater investment in primary care and expansion of telemedicine and digital health solutions for continuous care for people with NCDs. Lastly, limited data are available on the impact of COVID-19 on NCDs, and hence NCD data and surveillance need to be strengthened.

En este artículo se describe la situación de las enfermedades no transmisibles (ENT) en la Región de las Américas, la ejecución de intervenciones contra las ENT según los indicadores clave de progreso, el efecto de la COVID-19 en los servicios contra las ENT y las formas de priorizar nuevamente las ENT tras la COVID-19. Se obtuvo información de datos institucionales y mediante una revisión exploratoria complementaria de artículos relacionados con las ENT y la COVID-19 en la Región publicados entre abril del 2020 y noviembre del 2021. Si bien las ENT representan 80,7 % de todas las muertes en la Región, la ejecución de un conjunto clave de intervenciones contra las ENT ha sido limitada, y solo tres países han notificado la ejecución de 12 o más indicadores de los 19 indicadores relativos a las ENT. A mediados de mayo del 2022, la Región había notificado alrededor de 29,9 % de todos los casos de COVID-19 en el mundo (154 millones de 515 millones) y 43,5 % del total de muertes por COVID-19 (2,7 millones de 6,2 millones). Esta pandemia ha obstaculizado el progreso contra las ENT y ha causado interrupciones significativas en los servicios para las personas que requieren atención continua. Para mitigar las interrupciones en los servicios se han empleado estrategias de adaptación, como la telemedicina y las farmacias móviles. Sin embargo, la prevención y el manejo de las ENT deben constituir una parte integral de la recuperación de la pandemia de COVID-19. Esto requerirá mayores esfuerzos de establecimiento, restablecimiento y cumplimiento de políticas sobre los factores de riesgo de las ENT, especialmente el control del tabaco y la prevención de la obesidad; así como una mayor inversión en atención primaria y la expansión de la telemedicina y las iniciativas de salud digital para la atención continua de las personas con ENT. Por último, se dispone de datos limitados sobre el impacto de la COVID-19 en las ENT y, por lo tanto, es necesario reforzar la recopilación de datos y la vigilancia de las ENT.

Este artigo descreve a situação das doenças não transmissíveis (DNTs) nas Américas, a implementação de intervenções para DNTs de acordo com indicadores de progresso importantes, o impacto da COVID-19 nos serviços de DNT e formas de priorizar novamente as DNTs após a COVID-19. As informações foram obtidas a partir de dados institucionais e uma revisão de escopo complementar de artigos relacionados a DNTs e COVID-19 nas Américas, publicados entre abril de 2020 e novembro de 2021. Embora as DNTs representem 80,7% de todas as mortes nas Américas, a implementação de um conjunto essencial de intervenções para DNTs tem sido limitada. Apenas três países relataram a implementação de 12 ou mais dos 19 indicadores de DNT. Até meados de maio de 2022, as Américas haviam registrado 29,9% de todos os casos de COVID-19 no mundo (154 milhões de 515 milhões) e 43,5% de todas as mortes por COVID-19 (2,7 milhões de 6,2 milhões). Essa pandemia atrapalhou o avanço com relação às DNTs e prejudicou significativamente a prestação de serviços para pessoas que necessitam de cuidados contínuos. Estratégias adaptativas, como telessaúde e farmácias móveis, foram utilizadas para mitigar as interrupções dos serviços. Porém, a prevenção e o manejo das DNTs devem ser parte integrante da recuperação da pandemia de COVID-19. Isso vai exigir mais esforços para estabelecer/restabelecer e fiscalizar políticas voltadas para fatores de risco para DNTs, principalmente controle do tabagismo e prevenção da obesidade, além de maior investimento na atenção primária e na expansão da telemedicina e de soluções digitais em saúde para cuidados continuados de pessoas com DNTs. Por fim, os dados disponíveis sobre o impacto da COVID-19 nas DNTs são limitados; portanto, é preciso fortalecer os dados e a vigilância de DNTs.