Task shifting for non-communicable disease management in low and middle income countries--a systematic review.

BACKGROUND: One potential solution to limited healthcare access in low and middle income countries (LMIC) is task-shifting- the training of non-physician healthcare workers (NPHWs) to perform tasks traditionally undertaken by physicians. The aim of this paper is to conduct a systematic review of studies involving task-shifting for the management of non-communicable disease (NCD) in LMIC. METHODS: A search strategy with the following terms "task-shifting", "non-physician healthcare workers", "community healthcare worker", "hypertension", "diabetes", "cardiovascular disease", "mental health", "depression", "chronic obstructive pulmonary disease", "respiratory disease", "cancer" was conducted using Medline via Pubmed and the Cochrane library. Two reviewers independently reviewed the databases and extracted the data. FINDINGS: Our search generated 7176 articles of which 22 were included in the review. Seven studies were randomised controlled trials and 15 were observational studies. Tasks performed by NPHWs included screening for NCDs and providing primary health care. The majority of studies showed improved health outcomes when compared with usual healthcare, including reductions in blood pressure, increased uptake of medications and lower depression scores. Factors such as training of NPHWs, provision of algorithms and protocols for screening, treatment and drug titration were the main enablers of the task-shifting intervention. The main barriers identified were restrictions on prescribing medications and availability of medicines. Only two studies described cost-effective analyses, both of which demonstrated that task-shifting was cost-effective. CONCLUSIONS: Task-shifting from physicians to NPHWs, if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs. Since the majority of study designs reviewed were of inadequate quality, future research methods should include robust evaluations of such strategies.

Low HDL cholesterol and the risk of diabetic nephropathy and retinopathy: results of the ADVANCE study.

OBJECTIVE: Although low HDL cholesterol (HDL-C) is an established risk factor for atherosclerosis, data on HDL-C and the risk of microvascular disease are limited. We tested the association between HDL-C and microvascular disease in a cohort of patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 11,140 patients with type 2 diabetes and at least one additional vascular risk factor were followed a median of 5 years. Cox proportional hazards models were used to assess the association between baseline HDL-C and the development of new or worsening microvascular disease, defined prospectively as a composite of renal and retinal events. RESULTS: The mean baseline HDL-C level was 1.3 mmol/L (SD 0.45 mmol/L [range 0.1-4.0]). During follow-up, 32% of patients developed new or worsening microvascular disease, with 28% experiencing a renal event and 6% a retinal event. Compared with patients in the highest third, those in the lowest third had a 17% higher risk of microvascular disease (adjusted hazard ratio 1.17 [95% CI 1.06-1.28], P = 0.001) after adjustment for potential confounders and regression dilution. This was driven by a 19% higher risk of renal events (1.19 [1.08-1.32], P = 0.0005). There was no association between thirds of HDL-C and retinal events (1.01 [0.82-1.25], P = 0.9). CONCLUSIONS: In patients with type 2 diabetes, HDL-C level is an independent risk factor for the development of microvascular disease affecting the kidney but not the retina.

Women's cardiovascular health in India.

Cardiovascular diseases (CVDs) are the leading cause of death among adult women in many parts of India and a major cause of morbidity. In some parts of the world, gender inequities have been observed in cardiovascular healthcare and cardiovascular outcomes. The authors discuss the data for potential disparities in cardiovascular healthcare for women in India. Data on cardiovascular healthcare provision and CVD outcomes among women in India are generally lacking. The little available data suggest that women in rural areas, younger women and girl children with CVD are less likely to receive appropriate management than men, with this disparity most apparent in those of lower socioeconomic status and education. However, there is a particular lack of information about the prevention and management of atherosclerotic heart disease in women from a range of communities that comprise the extremely diverse population of India.

Cardiovascular risk management in chronic kidney disease in general practice (the AusHEART study).

BACKGROUND: Chronic kidney disease (CKD) is common and increasing in prevalence. Adverse outcomes of CKD can be prevented through early detection and treatment. There is limited data on the awareness of CKD and the quality of care offered to patients with CKD in the primary care setting. The objectives of this study were to assess the prevalence, general practitioner (GP) awareness and extent of current evidence-practice gaps in the management of CKD in Australian primary care. METHODS: The Australian Hypertension and Absolute Risk Study (AusHEART) was a nationally representative, cluster stratified, cross-sectional survey among 322 GPs. Each GP was asked to provide data for 15-20 consecutive patients (age ≥ 55 years) who presented between April and June, 2008. The main outcome measures were CKD prevalence based on proteinuria and decreased estimated glomerular filtration rate. Evidence-practice gaps in management of patients with CKD were identified. RESULTS: Among a total of 4966 patients with kidney function test data, 1845 (37%) had abnormal kidney function. Of the 1312 patients with abnormal kidney function known to the GP at the time of visit, only 235 were correctly identified as having CKD. GPs under-estimated cardiovascular (CV) risks in patients with CKD when compared with the prevailing guidelines at the time of survey and the recent national guidelines, particularly in later stages of CKD. Among CKD patients not prescribed blood pressure-lowering agents or lipid-lowering agents, treatment was indicated as per relevant guidelines in 51 and 46%, respectively. For CKD patients who were already prescribed blood pressure-lowering and lipid-lowering agents, 61 and 50%, respectively, did not meet the treatment targets recommended by the relevant guidelines. CONCLUSIONS: CKD is common, significantly under-recognized and under-treated in primary care. Effort to increase awareness and provide opportunities for improved screening and assessment should improve the management and outcome of these patients at high risk of CV disease.

Cardiovascular risk perception and evidence--practice gaps in Australian general practice (the AusHEART study).

OBJECTIVE: To examine the perception and management of cardiovascular disease (CVD) risk in Australian primary care. DESIGN, SETTING AND PARTICIPANTS: The Australian Hypertension and Absolute Risk Study (AusHEART) was a nationally representative, cluster-stratified, cross-sectional survey of 322 general practitioners. Each GP was asked to collect data on CVD risk factors and their management in 15-20 consecutive patients aged >or= 55 years who presented between April and June 2008, and to estimate each patient's absolute risk of a cardiovascular event in the next 5 years. MAIN OUTCOME MEASURES: Estimated 5-year risk of a cardiovascular event, proportion of patients receiving appropriate treatment. RESULTS: Among 5293 patients, 29% (1548) had established CVD. A further 22% (1145), when categorised according to the 2009 National Vascular Disease Prevention Alliance guideline, to 42% (2211), when categorised according to National Heart Foundation (NHF) 2004 guideline, had a high (>or= 15%) 5-year risk of a cardiovascular event. Of the 1548 patients with established CVD, 50% were prescribed a combination of a blood pressure (BP)-lowering medication, a statin and an antiplatelet agent, and 9% were prescribed a BP-lowering medication and a statin but not an antiplatelet agent. Among high-risk patients without established CVD, categorised using NHF 2004 adjustments, 34% were prescribed a combination of a BP-lowering medication and a statin. GPs estimated 60% of patients with established CVD as having a risk of less than 15%. The GPs' estimates of risk among patients without established CVD agreed with the centrally calculated estimate (according to the NHF 2004 guideline) in 48% of instances (Kappa = 0.21). CONCLUSIONS: These data confirm substantial undertreatment of patients who are at high risk of a cardiovascular event. We recommend that GPs assess absolute risk for older patients and ensure that high-risk patients receive evidence-based pharmacotherapy.

An electronic clinical decision support tool to assist primary care providers in cardiovascular disease risk management: development and mixed methods evaluation.

BACKGROUND: Challenges remain in translating the well-established evidence for management of cardiovascular disease (CVD) risk into clinical practice. Although electronic clinical decision support (CDS) systems are known to improve practitioner performance, their development in Australian primary health care settings is limited. OBJECTIVES: Study aims were to (1) develop a valid CDS tool that assists Australian general practitioners (GPs) in global CVD risk management, and (2) preliminarily evaluate its acceptability to GPs as a point-of-care resource for both general and underserved populations. METHODS: CVD risk estimation (based on Framingham algorithms) and risk-based management advice (using recommendations from six Australian guidelines) were programmed into a software package. Tool validation: Data from 137 patients attending a physician's clinic were analyzed to compare the tool's risk scores with those obtained from an independently programmed algorithm in a separate statistics package. The tool's management advice was compared with a physician's recommendations based on a manual review of the guidelines. Field test: The tool was then tested with 21 GPs from eight general practices and three Aboriginal Medical Services. Customized CDS-based recommendations were generated for 200 routinely attending patients (33% Aboriginal) using information extracted from the health record by a research assistant. GPs reviewed these recommendations during each consultation. Changes in CVD risk factor measurement and management were recorded. In-depth interviews with GPs were conducted. RESULTS: Validation testing: the tool's risk assessment algorithm correlated very highly with the independently programmed version in the separate statistics package (intraclass correlation coefficient 0.999). For management advice, there were only two cases of disagreement between the tool and the physician. Field test: GPs found 77% (153/200) of patient outputs easy to understand and agreed with screening and prescribing recommendations in 72% and 64% of outputs, respectively; 26% of patients had their CVD risk factor history updated; 73% had at least one CVD risk factor measured or tests ordered. For people assessed at high CVD risk (n = 82), 10% and 9%, respectively, had lipid-lowering and BP-lowering medications commenced or dose adjustments made, while 7% newly commenced anti-platelet medications. Three key qualitative findings emerged: (1) GPs found the tool enabled a systematic approach to care; (2) the tool greatly influenced CVD risk communication; (3) successful implementation into routine care would require integration with practice software, minimal data entry, regular revision with updated guidelines, and a self-auditing feature. There were no substantive differences in study findings for Aboriginal Medical Services GPs, and the tool was generally considered appropriate for use with Aboriginal patients. CONCLUSION: A fully-integrated, self-populating, and potentially Internet-based CDS tool could contribute to improved global CVD risk management in Australian primary health care. The findings from this study will inform a large-scale trial intervention.

Cardiovascular disease risk management for Aboriginal and Torres Strait Islander peoples in primary health care settings: findings from the Kanyini Audit.

OBJECTIVE: To describe cardiovascular disease (CVD) risk management in Indigenous primary health care. DESIGN, SETTING AND PARTICIPANTS: Review of 1165 randomly selected case records of Indigenous Australian adults, aged >/= 18 years, regularly attending eight health services in diverse settings in New South Wales, Queensland and Central Australia, October 2007 - May 2008. MAIN OUTCOME MEASURE: Adherence to CVD risk screening and management guidelines, especially with respect to overall or absolute CVD risk. RESULTS: More than half the people in the sample (53%) were not adequately screened for CVD risk according to national recommendations. Underscreening was significantly associated with younger age, less frequent attendance, and lower uptake of the Medicare Health Assessment. Of the sample, 9% had established CVD, and 29% of those aged >/= 30 years were classified as high risk according to the 2004 National Heart Foundation of Australia (NHFA) adjusted Framingham equation. Of those with CVD, 40% (95% CI, 30%-50%) were not prescribed a combination of blood pressure (BP) medicines, statins and antiplatelet agents, and 56% (95% CI, 49%-62%) of high-risk individuals without CVD were not prescribed BP medicines and statins. For high-risk individuals not prescribed BP medicines or statins, 74% (95% CI, 64%-84%) and 30% (95% CI, 23%-39%) respectively, did not meet 2004 NHFA criteria for prescribing of these medications, and of those already prescribed BP medicines or statins, 41% (95% CI, 36%-47%) and 59% (95% CI, 52%-66%) did not meet respective guideline targets. CONCLUSIONS: These management gaps are similar to those found in non-Indigenous health care settings, suggesting deficiencies across the health system. Prescribing guidelines which exclude many high-risk individuals contribute to suboptimal management. Guideline reform and improved health service capacity could substantially improve Indigenous vascular health.

Gaps in cardiovascular disease risk management in Australian general practice.

OBJECTIVE: To evaluate the management of cardiovascular disease (CVD) risk in Australian general practice. DESIGN, SETTING AND PARTICIPANTS: National cross-sectional survey of 99 Australian general practitioners participating in the Bettering the Evaluation and Care of Health (BEACH) program. Data on 2618 consecutive adult patients presenting to the participating GPs over a 5-week period from September to October 2006 were analysed. MAIN OUTCOME MEASURES: Proportions of patients screened, treated and reaching targets according to (1) current Australian CVD risk guidelines and (2) overall or absolute CVD risk. RESULTS: Blood pressure (BP) had not been recorded for 13% of the sample. Of 1400 patients not prescribed antihypertensive medication, treatment was indicated for 8%. Of 821 patients already prescribed antihypertensive medication, 59% were achieving target BPs. Data on low-density lipoprotein (LDL) cholesterol levels were not available for 53% of the 2175 patients who should have had lipid screening according to the guidelines. Of 624 patients not prescribed a statin, treatment was indicated for 41%. Of 368 already prescribed a statin, 62% were achieving target LDL cholesterol levels. Sufficient data for calculation of absolute risk had been recorded for 74% of the 1736 patients for whom such calculation was recommended by the guidelines. The remaining 26% either had at least one required variable unmeasured (20%) or missing from the data collection (6%). For those at high absolute CVD risk (without established disease) and those with established CVD, 23% and 53%, respectively, had been prescribed both antihypertensive medication and a statin. CONCLUSIONS: Gaps between guideline recommendations and practice in recording and managing BP were relatively low compared with gaps for lipids. When stratified by absolute risk, patients at high risk of a cardiovascular event were found to be substantially undertreated.

Body mass index is an independent determinant of left atrial size.

BACKGROUND: Obesity is a risk factor for atrial fibrillation (AF) but the mechanisms underlying this association are unclear. We aimed to assess whether body mass index (BMI) is an independent determinant of left atrial size, in subjects in sinus rhythm. METHODS: Subjects were consecutive ambulatory patients aged >/=18 years who underwent outpatient transthoracic echocardiography at a major metropolitan teaching hospital in Sydney, Australia. At the time of examination, age, sex, height and weight were measured. Left atrial (LA) area was measured on ultrasound by planimetry. Left ventricular (LV) function and LV posterior wall thickness were measured by M-mode. RESULTS: Of 4859 consecutive subjects who underwent outpatient echocardiography at our institution over a three-year period, we analysed echocardiographic data from 2534 aged >/=18 years with confirmed sinus rhythm, normal LV contractility and no evidence of significant aortic or mitral valve disease. In these subjects (age 47+/-16.6 years, BMI 27.1+/-6.1, 53% male), BMI was a significant predictor of LA size (p<0.001), independent of the significant influences of LV end-diastolic volume and LV posterior wall thickness. Average LA size was 18.5+/-4.0 cm(2) in those with normal BMI, 20.7+/-4.5 cm(2) in the overweight and 22.3+/-4.1cm(2) in obese subjects (p for trend <0.001). CONCLUSIONS: Obesity is associated with increased left atrial size in subjects undergoing clinically indicated echocardiography, independent of the effects of left ventricular size and posterior wall thickness. This may contribute, at least in part, to the rising incidence of atrial fibrillation in the community.