Overcoming Barriers in the Management of Hypertension: The Experience of the Cardiovascular Health Program in Chilean Primary Health Care Centers

Objective. To assess the blood pressure control and cardiovascular risk factors (CVRFs) in a population of hypertensive patients with access to care under a government-financed program, the Cardiovascular Health Program (CHP). Design. A cross-sectional and multicenter study. Setting. 52 primary care centers, metropolitan area of Santiago, Chile. Participants. 1,194 patients were selected by a systematic random sampling from a universe of 316,654 hypertensive patients. Key Measurements. Demographic information, blood pressure (BP) measurements, and CVRF were extracted from medical records of patients followed for a 12-month period. Results. 59.7% of patients reached target BP <140/90 mmHg. More women were captured in the sampling (2.1 : 1), achieving better BP control than men. Diabetic patients (26.4%) had worse BP control than nondiabetics. Antihypertensive medications were used in 91.5%, with multidrug therapy more frequent in patients with higher BP and more difficult control. Conclusions. The success in improving the BP control to values <140/90 mmHg from 45.3% to 59.7% underscores the contribution of this program in the Chilean primary care cardiovascular preventive strategies. However, fewer hypertensive men than women were captured by this program, and it is of concern the underperforming of BP control observed in diabetics

egislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states

Objective To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health. Design Population-based natural experiment. Setting and data sources Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011. Main outcomes Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR). Independent variables Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence

Women's Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: A Natural Experiment in Chile from 1957 to 2007

The aim of this study was to assess the main factors related to maternal mortality reduction in large time series available in Chile in context of the United Nations' Millennium Development Goals (MDGs).Time series of maternal mortality ratio (MMR) from official data (National Institute of Statistics, 1957-2007) along with parallel time series of education years, income per capita, fertility rate (TFR), birth order, clean water, sanitary sewer, and delivery by skilled attendants were analysed using autoregressive models (ARIMA). Historical changes on the mortality trend including the effect of different educational and maternal health policies implemented in 1965, and legislation that prohibited abortion in 1989 were assessed utilizing segmented regression techniques.During the 50-year study period, the MMR decreased from 293.7 to 18.2/100,000 live births, a decrease of 93.8%. Women's education level modulated the effects of TFR, birth order, delivery by skilled attendants, clean water, and sanitary sewer access. In the fully adjusted model, for every additional year of maternal education there was a corresponding decrease in the MMR of 29.3/100,000 live births. A rapid phase of decline between 1965 and 1981 (-13.29/100,000 live births each year) and a slow phase between 1981 and 2007 (-1.59/100,000 live births each year) were identified. After abortion was prohibited, the MMR decreased from 41.3 to 12.7 per 100,000 live births (-69.2%). The slope of the MMR did not appear to be altered by the change in abortion law.Increasing education level appears to favourably impact the downward trend in the MMR, modulating other key factors such as access and utilization of maternal health facilities, changes in women's reproductive behaviour and improvements of the sanitary system. Consequently, different MDGs can act synergistically to improve maternal health. The reduction in the MMR is not related to the legal status of abortion

Consenso salud materna para Chile en el nuevo milenio

Contexto: Chile presenta una tendencia secular hacia una sostenida mejoría en los principales indicadores materno-infantiles. Su situación constituye una experiencia positiva a nivel de la región de Latino-América y el Caribe. Sin embargo, esta tendencia se ha estancado en los últimos diez años lo que produce una situación inestable y preocupante desde el punto de vista de la salud pública materna. Esto motiva una reunión de expertos a nivel nacional e internacional para proponer estrategias para el alto nivel político orientadas a alcanzar los Objetivos 4 y 5 del Milenio. Conclusión: Este documento de consenso sobre mortalidad materna, sugiere un enfrentamiento en dos ejes: primero, enfrentar la nueva realidad epidemiológica desde la etapa pre-concepcional, esto incluye considerar la alta prevalencia de obesidad, hipertensión arterial, diabetes, hiperlipidemias e hipotiroidismo en la población, y por otro lado reforzar la seguridad de la asistencia del embarazo, parto y puerperio en los lugares más alejados y más vulnerables del país. Es necesario focalizar las intervenciones en los grupos de mayor riesgo vital (edades extremas de la vida fértil y portadoras de enfermedades médico-quirúrgicas severas, que se reflejan en el aumento proporcional de las causas indirectas de muerte materna), reforzar las actividades de auditorías de mortalidad/near miss, así como controlar el aumento alarmante de la tasa de partos por cesáreas

Impact of common cardio-metabolic risk factors on fatal and non-fatal cardiovascular disease in Latin America and the Caribbean: an individual-level pooled analysis of 31 cohort studies

Background: Estimates of the burden of cardio-metabolic risk factors in Latin America and the Caribbean (LAC) rely on relative risks (RRs) from non-LAC countries. Whether these RRs apply to LAC remains un- known. Methods: We pooled LAC cohorts. We estimated RRs per unit of exposure to body mass index (BMI), systolic blood pressure (SBP), fasting plasma glucose (FPG), total cholesterol (TC) and non-HDL cholesterol on fatal (31 cohorts, n = 168,287) and non-fatal (13 cohorts, n = 27,554) cardiovascular diseases, adjusting for regression dilution bias. We used these RRs and national data on mean risk factor levels to estimate the number of cardiovascular deaths attributable to non-optimal levels of each risk factor. Results: Our RRs for SBP, FPG and TC were like those observed in cohorts conducted in high-income countries; however, for BMI, our RRs were consistently smaller in people below 75 years of age. Across risk factors, we observed smaller RRs among older ages. Non-optimal SBP was responsible for the largest number of attributable cardiovascular deaths ranging from 38 per 10 0,0 0 0 women and 54 men in Peru, to 261 (Dominica, women) and 282 (Guyana, men). For non-HDL cholesterol, the lowest attributable rate was for women in Peru (21) and men in Guatemala (25), and the largest in men (158) and women (142) from Guyana. Interpretation: RRs for BMI from studies conducted in high-income countries may overestimate disease burden metrics in LAC; conversely, RRs for SBP, FPG and TC from LAC cohorts are similar to those esti- mated from cohorts in high-income countries

Influence of psychosocial factors on adherence to antihypertensive drug therapy. Results from a Cardiovascular Health Program cohort followed in the Metropolitan Region of Santiago, Chile Influencia de factores psicosociales en la adherencia al tratamient

© 2014, Sociedad Medica de Santiago. All rights reserved.Background: Inadequate blood pressure control in hypertensive patients remains a persistent health problem in Chile and worldwide. Poor adherence to antihypertensive drug therapy is one of the frequently cited factors. Objectives: To determine the influence of psychosocial factors in the adherence to drug therapy in hypertensive patients followed through a Cardiovascular Health Program (CHP) that provides free access to primary care centers located in the Metropolitan Region of Santiago, Chile. Methods: Cross sectional study. A randomized sample of 513 hypertensive patients (30 to 68 years) was obtained from a universe of 1.484 patients. Adherence to treatment was determined by the Morisky-Green-Levine test. Demographic, socioeconomic and average values of blood pressure were recorded. Validated questionnaires were utilized to assess the patient-physician relationship, awareness of being hypertensive, patient perception of socia

Overcoming Barriers in the Management of Hypertension: The Experience of the Cardiovascular Health Program in Chilean Primary Health Care Centers

Objective. To assess the blood pressure control and cardiovascular risk factors (CVRFs) in a population of hypertensive patients with access to care under a government-financed program, the Cardiovascular Health Program (CHP). Design. A cross-sectional and multicenter study. Setting. 52 primary care centers, metropolitan area of Santiago, Chile. Participants. 1,194 patients were selected by a systematic random sampling from a universe of 316,654 hypertensive patients. Key Measurements. Demographic information, blood pressure (BP) measurements, and CVRF were extracted from medical records of patients followed for a 12-month period. Results. 59.7% of patients reached target BP &lt; 140/90 mmHg. More women were captured in the sampling (2.1 : 1), achieving better BP control than men. Diabetic patients (26.4%) had worse BP control than nondiabetics. Antihypertensive medications were used in 91.5%, with multidrug therapy more frequent in patients with higher BP and more difficult control. Conclusions. The success in improving the BP control to values &lt;140/90 mmHg from 45.3% to 59.7% underscores the contribution of this program in the Chilean primary care cardiovascular preventive strategies. However, fewer hypertensive men than women were captured by this program, and it is of concern the underperforming of BP control observed in diabetics

Review, replication, and re-analysis of a recent study on the impact of abortion law on maternal mortality in Mexico – Maintaining rigor and research integrity

This report provides a review, replication, and re-analysis of an study by Darney et al (Contraception. 2017;95(1):105-111) on the association between maternal mortality ratio (MMR, number of maternal deaths per 100,000 live births) and abortion legislation in Mexico City compared with 31 other states. In their study, Darney et al disputed evidence from our study (Koch et al, BMJ Open 2015;5(2):e006013), which found a null association between abortion laws and MMR, and reported their own conclusion of a negative association between abortion availability and MMR. After replicating their dataset and statistical analysis, we found that the beta coefficient (effect size) for abortion legislation was apparently misinterpreted by Darney et al to support the conclusion that legislation allowing abortion on request in Mexico City was associated with a 22.49-unit decrease in MMR. In fact, their analysis showed the opposite result: after multivariable adjustments, Mexico City was associated with a 22.49-unit increase in MMR compared with the 31 states with restricted access to abortion. Moreover, Darney et al did not report the initial time-adjusted effect size, where the 95% CI supports the hypothesis of null association (beta = 4.17; 95%CI -7.19 to 15.54; p=0.470). In our re-analysis of their data, estimates were highly unstable in multiple regression models, and the initial effect size (4.17) for the association between abortion legislation and the MMR was inflated up to 5-fold (22.49) as a result of a ‘tipping effect’ on coefficients and multicollinearity among covariates. In conclusion, our reanalysis of Darney et al’s study provides evidence of serious methodological flaws, faulty statistical analysis and misinterpretation of regression coefficients, ultimately resulting in an invalid conclusion

Fundamental discrepancies in abortion estimates and abortion-related mortality: A reevaluation of recent studies in Mexico with special reference to the International Classification of Diseases

In countries where induced abortion is legally restricted, as in most of Latin America, evaluation of statistics related to induced abortions and abortion-related mortality is challenging. The present article reexamines recent reports estimating the number of induced abortions and abortion-related mortality in Mexico, with special reference to the International Classification of Diseases (ICD). We found significant overestimations of abortion figures in the Federal District of Mexico (up to 10-fold), where elective abortion has been legal since 2007. Significant overestimation of maternal and abortion-related mortality during the last 20 years in the entire Mexican country (up to 35%) was also found. Such overestimations are most likely due to the use of incomplete in-hospital records as well as subjective opinion surveys regarding induced abortion figures, and due to the consideration of causes of death that are unrelated to induced abortion, including flawed denominators of live bir

Overestimation of abortion in Colombia and other Latin American countries Sobrestimación del aborto inducido en Colombia y otros países latinoamericanos

Recently, the Guttmacher Institute estimated a number of 400,400 clandestine abortions for Colombia. Because of the strong implications that such brief could have in different areas of interest, a full revision of the methodology of estimation was performed. The methodology used by the Guttmacher Institute was as follows: first, the authors estimated the losses from spontaneous and induced abortions from the opinion of 289 subjects who work in an equal number of Colombian health institutions through the opinion survey entitled "Health Facilities Survey". Subsequently, an expansive multiplier (x3, x4, x5, etc.) was applied to the numbers obtained by this survey that also emerges from a subjective opinion of another 102 respondents of the "Health Professional Survey" selected by convenience. There is no objective data based on real vital events, the whole estimate is based on imagining/ numbers underlying mere opinions. Even as public opinion survey, the sampling technique introduced se