Evaluating Glycemic Control in Patients of South Asian Origin With Type 2 Diabetes Using a Digital Therapeutic Platform: Analysis of Real-World Data.

BACKGROUND: Digital therapeutics are evidence-based therapeutic interventions driven by high-quality software programs for the treatment, prevention, or management of a medical disorder or disease. Many studies in the western population have shown the effectiveness of mobile app-based digital therapeutics for improving glycemic control in patients with type 2 diabetes (T2D). However, few studies have assessed similar outcomes in the South Asian population. OBJECTIVE: This study aims to investigate the real-world effectiveness of the Wellthy CARE digital therapeutic for improving glycemic control among the South Asian population of Indian origin. METHODS: We analyzed deidentified data from 102 patients with T2D from India enrolled in a 16-week structured self-management program delivered using the Wellthy CARE mobile app. Patients recorded their meals, weight, physical activity, and blood sugar in the app, and they received lessons on self-care behaviors (healthy eating, being active, monitoring, medication adherence, problem solving, healthy coping, and reducing risks); feedback provided by an artificial intelligence-powered chatbot; and periodic interactions with certified diabetes educators via voice calls and chats. The primary outcome of the program was a change in glycated hemoglobin A1c (HbA1c). Secondary outcomes included the difference between preintervention and postintervention fasting blood glucose (FBG) and postprandial blood glucose (PPBG) levels; changes in BMI and weight at the completion of 16 weeks; and the association between program engagement and the changes in HbA1c, FBG, and PPBG levels. RESULTS: At the end of 16 weeks, the average change in HbA1c was -0.49% (n=102; 95% CI -0.73 to 0.25; P<.001). Of all the patients, 63.7% (65/102) had improved HbA1c levels, with a mean change of -1.16% (n=65; 95% CI -1.40 to -0.92; P<.001). The mean preintervention and postintervention FBG levels were 145 mg/dL (n=51; 95% CI 135-155) and 134 mg/dL (n=51; 95% CI 122-146; P=.02) and PPBG levels were 188 mg/dL (n=51; 95% CI 172-203) and 166 mg/dL (n=51; 95% CI 153-180; P=.03), respectively. The mean changes in BMI and weight were -0.47 kg/m2 (n=59; 95% CI -0.22 to -0.71; P<.001) and -1.32 kg (n=59; 95% CI -0.63 to -2.01; P<.001), respectively. There was a stepwise decrease in HbA1c, FBG, and PPBG levels as the program engagement increased. Patients in the highest tertile of program engagement had a significantly higher reduction in HbA1c (-0.84% vs -0.06%; P=.02), FBG (-21.4 mg/dL vs -0.18 mg/dL; P=.02), and PPBG levels (-22.03 mg/dL vs 2.35 mg/dL; P=.002) than those in the lowest tertile. CONCLUSIONS: The use of the Wellthy CARE digital therapeutic for patients with T2D showed a significant reduction in the levels of HbA1c, FBG, and PPBG after 16 weeks. A higher level of participation showed improved glycemic control, suggesting the potential of the Wellthy CARE platform for better management of the disease.

Availability of Safe Childbirth Supplies in 284 Facilities in Uttar Pradesh, India.

Objectives Vital to implementation of the World Health Organization (WHO) Safe Childbirth Checklist (SCC), designed to improve delivery of 28 essential birth practices (EBPs), is the availability of safe birth supplies: 22 EBPs on the SCC require one or more supplies. Mapping availability of these supplies can determine the scope of shortages and need for supply chain strengthening. Methods A cross-sectional survey on the availability of functional and/or unexpired supplies was assessed in 284 public-sector facilities in 38 districts in Uttar Pradesh, India. The twenty-three supplies were categorized into three non-mutually exclusive groups: maternal (8), newborn (9), and infection control (6). Proportions and mean number of supplies available were calculated; means were compared across facility types using t-tests and across districts using a one-way ANOVA. Log-linear regression was used to evaluate facility characteristics associated with supply availability. Results Across 284 sites, an average of 16.9 (73.5%) of 23 basic childbirth supplies were available: 63.4% of maternal supplies, 79.1% of newborn supplies, and 78.7% of infection control supplies. No facility had all 23 supplies available and only 8.5% had all four medicines assessed. Significant variability was observed by facility type and district. In the linear model, facility type and distance from district hospital were significant predictors of higher supply availability. Conclusions for Practice In Uttar Pradesh, more remote sites, and primary and community health centers, were at higher risk of supply shortages. Supply chain management must be improved for facility-based delivery and quality of care initiatives to reduce maternal and neonatal harm.

Sex differences in utilisation of hospital care in a state-sponsored health insurance programme providing access to free services in South India.

BACKGROUND: Universal healthcare coverage provides healthcare and financial protection to all citizens and might help to facilitate gender equity in care. We assessed the utilisation of hospital care services among women and men in a large underprivileged population with access to free hospital care in India. METHODS: The Rajiv Aarogyasri Community Health Insurance Scheme, a state-sponsored scheme, provided access to free hospital care for poor households across undivided Andhra Pradesh. Claims data for hospitalisations between 2008 and 2012 were analysed to determine the number of individuals, hospitalisations, bed-days and hospital expenditure for sex-specific and sex-neutral conditions, by sex, disease category and age group. RESULTS: A total of 961 442 individuals (43% women), 1 223 723 hospitalisations (48% women), 7.7 million bed-days (47% women) and hospital expenditure of US$579.3 million (42% women) were recorded. Sex-specific conditions accounted for 27% of hospitalisations, 12% of bed-days and 15% of costs for women, compared with 5%, 4% and 4% in men. Women had a lower share of hospitalisations (42%), bed-days (45%) and costs (39%) for sex-neutral conditions than men. These findings were observed across 14 of 18 disease categories and across all age groups, but especially for older and younger women. INTERPRETATION: In this large underprivileged population in India with access to free hospital care, utilisation of hospital care differed for women and men. For sex-neutral conditions, women accessed a smaller proportion of care than men, suggesting that coverage of hospital care alone is not sufficient to guarantee gender equity in access to healthcare.

Major surgery in south India: a retrospective audit of hospital claim data from a large community health insurance programme.

BACKGROUND: Information about use of major surgery in India is scarce. This study aims to bridge this gap by auditing hospital claims from the Rajiv Aarogyasri Community Health Insurance Scheme (RACHIS) that provides access to free tertiary care for major surgery through state-funded insurance to 68 million beneficiaries with limited household incomes-81% of population in states of Telangana and Andhra Pradesh (combined Human Development Index 0·485). Beneficiary households receive an annual coverage of INR 200 000 (US$3333) for admissions to any empanelled public or private hospital. METHODS: Publicly available deidentified hospital claim data for all surgical procedures conducted between mid-2008 and mid-2012 were compiled across all 23 districts in Telangana and Andhra Pradesh. FINDINGS: 677 332 surgical admissions (80% at private hospitals) were recorded at a mean annual rate of 259 per 100 000 beneficiaries (95% CI 235-283), excluding cataract and caesarean sections as these were not covered under the insurance programme. Men accounted for 56% of admissions. Injury was the most common cause for surgical admission (185 733; 27%) with surgical correction of long bone fractures being the most common procedure (144 997; 20%) identified in the audit. Diseases of digestive (110 922; 16%), genitourinary (82 505; 12%), and musculoskeletal system (70 053; 10%) were other leading causes for surgical admissions. Most hospital bed-days were used for injuries (584 days per 100 000 person years; 31%), digestive diseases (314 days; 17%), and musculoskeletal system (207 days; 11%), costing 19% (INR 4·4 billion), 13% (3·03 billion), and 11% (2·5 billion) of claims, respectively. Cardiovascular surgeries (53 023; 8%) alone accounted for 21% (INR 4·9 billion) of cost. Annual per capita cost of surgical claims was US$1·49 (95% CI 1·32-1·65). INTERPRETATION: Our findings are limited to a population socioeconomically representative of India and other countries with low-income and middle-income. Despite near universal access for major surgery, use continues to remain low, at levels expected in countries with per capita health expenditure below US$100, and lower than a tenth of rates estimated at spending (US$400-1000) comparable with financial access provided. Hence, strategies beyond traditional financing for care are required to improve use of surgery in LMICs. FUNDING: The George Institute for Global Health.

Use of major surgery in south India: A retrospective audit of hospital claim data from a large, community health insurance program.

BACKGROUND: Information on the use of major surgery in India is scarce. In this study we aimed to bridge this gap by auditing hospital claims from Rajiv Aarogyasri Community Health Insurance Scheme, which provides access to free hospital care through state-funded insurance to 68 million beneficiaries, an estimated 81% of population in the states of Telangana and Andhra Pradesh. METHODS: Publicly available deidentified hospital claim data for all surgery procedures conducted between mid-2008 and mid-2012 were compiled across all 23 districts in Telangana and Andhra Pradesh. RESULTS: A total of 677,332 operative admissions (80% at private hospitals) were recorded at an annual rate of 259 per 100,000 beneficiaries, with male subjects accounting for 56% of admissions. Injury was the most common cause for operative admission (27%) with operative correction of long bone fractures being the most common procedure (20%) identified in the audit. Diseases of the digestive (16%), genitourinary (12%), and musculoskeletal (10%) systems were other leading causes for operative admissions. Most hospital bed-days were used by admissions for injuries (31%) and diseases of the digestive (17%) and musculoskeletal system (11%) costing 19%, 13%, and 11% of reimbursement. Operations on the circulatory system (8%) accounted for 21% of reimbursements. Annual per capita cost of operative claims was US$1.48. CONCLUSION: The use of surgery by an insured population in India continued to be low despite access to financing comparable with greater spending countries, highlighting need for strategies, beyond traditional health financing, that prioritize improvement in access, delivery, and use of operative care.

Heart failure care in low- and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs. METHODS AND FINDINGS: Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%-64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%-41%) with beta-blockers, and 32% (95% CI: 25%-39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%-7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%-10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified. CONCLUSIONS: The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors' Summary.