Development and validation of a clinical and computerised Decision Support System for Management of Hypertension (DSS-HTN) at a Primary Health Care (PHC) setting

Background: Hypertension remains the top global cause of disease burden. Decision support systems (DSS) could provide an adequate and cost-effective m

Prevalence of vitamin B12 deficiency among individuals with type 2 diabetes mellitus in a South Indian rural community

Background: To estimate the prevalence of vitamin B12 deficiency in a rural south Indian community and to evaluate the association between metformin use and prevalent vitamin B12 deficiency in people with T2DM stratified by oral vitamin B12 supplementation.Methods: Using a cross sectional study design, a random sample of people with T2DM (N=438) was recruited from a rural community. Vitamin B12 deficiency was defined as serum B12 ≤200pg/ml. Data on metformin dose, duration of use, oral vitamin B12 supplementation, and diet were collected. Laboratory measurements included complete blood count, tests for hepatic, renal, and thyroid function, as well as serum vitamin B12 levels and HbA1c.Results: The prevalence of vitamin B12 deficiency in people with T2DM was 11.2% (95% Confidence Interval (CI) 8.2%-14.1%). The odds of vitamin B12 deficiency in patients receiving a metformin dose of 2 grams/day were 4 times higher compared to those receiving ≤1 gram/day, after adjusting for oral B12 supplementation (odds ratio 4.2;95% CI 1.5-11.8). The odds of vitamin B12 deficiency in those taking metformin and receiving oral vitamin B12 supplementation were lower compared to those on metformin and not receiving vitamin B12 supplementation (adjusted odds ratio 0.20; 95% CI 0.06-0.70).Conclusions: Vitamin B12 deficiency affects 1 in 10 people with T2DM, is associated with higher dose metformin use, and oral vitamin B12 supplementation mitigates B12 deficiency in this group

Footprint and imprint: an ecologic time-trend analysis of cardiovascular publications in general and specialty journals.

Studies have demonstrated strong associations between publication source and citations, as well as investigatory analysis of collaboration effects, in general and medical literature, but are limited to specific journals or short duration of time. This study sought to analyze time trends in cardiovascular research publications in leading general and specialty journals and to determine the association between collaboration and citation index. Cardiovascular publications were retrieved from Web of Knowledge by a cardiovascular bibliometric filter, and annual publication volumes in 8 general and specialty journals were compared. Univariable linear regression models were used to determine global and journal-specific trends for overall publication, cardiovascular publication, proportion of cardiovascular publication, collaboration, and citations. Cardiovascular publications increased (1999 to 2008) by 36% and number of sources by 74%. Volume increased in European Heart Journal (beta: 18.4, 95% confidence interval [CI]: 10.6 to 26.3) and decreased in Circulation (beta: -42.9, 95% CI: -79.3 to -6.5), Annals of Internal Medicine (beta: -1.9, 95% CI: -3.5 to -0.3), and Lancet (beta: -11.2, 95% CI: -14.7 to -7.8). Number of contributing countries increased in 3 journals: BMJ (beta: 0.8, 95% CI: 0.2 to 1.5), European Heart Journal (beta: -1.2, 95% CI: 0.8 to 1.7), and New England Journal of Medicine (beta: 1.6, 95% CI: 0.6 to 2.7). Fraction of collaborative publications increased (beta: 1.1 to 2.9) in all but Annals of Internal Medicine. Collaboration was associated with a higher median actual citation index (p < 0.0001). We found increasing trends in collaboration and citation in both general and specialty journals. Contribution by country in selected journals was disproportionate and under-represents total cardiovascular research in low- and middle-income countries

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

Collaborative Quality Improvement Strategy in Secondary Prevention of Cardiovascular Disease in India: Findings from a Multi-Stakeholder, Qualitative Study using Consolidated Framework for Implementation Research (CFIR).

BACKGROUND: Cardiovascular disease (CVD) is highly prevalent in India, and little is known about the perception of patients and providers about a package of collaborative quality improvement (C-QIP) strategies consisting of provider-focused electronic health records-decision support system (EHR-DSS), non-physician health workers (NPHW), and patient-facing text messages to enhance the CVD care. OBJECTIVE: To explore the barriers and enablers of the C-QIP strategy from the perspective of providers, health administrators, patients, and care givers in India. METHODS: We conducted a qualitative study using the consolidated framework for implementation research (CFIR) to understand the challenges and facilitators of implementing C-QIP strategy to enhance CVD care in the Indian context. A diverse sample of 38 physicians, 14 non-physician health workers (nurses, pharmacists), 4 health administrators, and 16 patients and their caregivers participated in semi-structured interviews. All interviews were audio-recorded, transcribed, translated, anonymised, and coded using MAXQDA software. We used the framework method and CFIR domains to analyze the qualitative data. RESULTS: Barriers perceived from providers' and health administrators' perspectives in providing quality CVD care were high patient volume, physician burnout, lack of robust communication or referral system, paucity of electronic health records, lack of patient counsellors, polypharmacy, poor patient adherence to medications, and lack of financial incentives. Low health literacy, high cost of treatment, misinformation bias, and difficulty in maintaining lifestyle changes were barriers from patients' perspectives. The CFIR identified key enablers for the implementation of C-QIP such as standardized treatment protocol, reduced medication errors, improved physician-patient relationships, and enhanced patient self-care through trained and supported NPHW. Barriers included: heterogenous healthcare settings, diverse patient groups and comorbidities, associated costs of care and interoperability, confidentiality, and data privacy issues around the use of EHR-DSS. CONCLUSION: Strategies to enhance CVD care must be low-cost, culturally acceptable, and integrated into existing care pathways

NOACs added to WHO’s essential medicines list: recommendations for future policy actions

The introduction of non-vitamin K antagonists oral anticoagulants, a class of medicines which includes dabigatran, apixaban, edoxaban and rivaroxaban, has resulted in improvements in the safety and efficacy of non valvular atrial fibrillation treatment for stroke prevention, with significant reductions in stroke, intracranial haemorrhage, and mortality. For these reasons, a team of World Heart Federation Emerging Leaders led efforts to add non-vitamin K antagonists oral anticoagulants to the World Health Organization’s Model List of Essential Medicines in 2019. Following the inclusion of this class of medicines in the Essential Medicines List, this editorial proposes several recommendations to improve the accessibility, affordability and acceptability of non-vitamin K oral anticoagulants, especially in low- and middle-income settings, in order to successfully manage non-valvular atrial fibrillation and to lower the risk of stroke

Global Health Mentoring Toolkits: A Scoping Review Relevant for Low- and Middle-Income Country Institutions.

Capacity building in low- and middle-income country (LMIC) institutions hinges on the delivery of effective mentorship. This study presents an overview of mentorship toolkits applicable to LMIC institutions identified through a scoping review. A scoping review approach was used to 1) map the extent, range, and nature of mentorship resources and tools available and 2) to identify knowledge gaps in the current literature. To identify toolkits, we collected and analyzed data provided online that met the following criteria: written in English and from organizations and individuals involved in global health mentoring. We searched electronic databases, including PubMed, Web of Science, and Google Scholar, and Google search engine. Once toolkits were identified, we extracted the available tools and mapped them to pre-identified global health competencies. Only three of the 18 identified toolkits were developed specifically for the LMIC context. Most toolkits focused on individual mentor-mentee relationships. Most focused on the domains of communication and professional development. Fewer toolkits focused on ethics, overcoming resource limitations, and fostering institutional change. No toolkits discussed strategies for group mentoring or how to adapt existing tools to a local context. There is a paucity of mentoring resources specifically designed for LMIC settings. We identified several toolkits that focus on aspects of individual mentor-mentee relationships that could be adapted to local contexts. Future work should focus on adaptation and the development of tools to support institutional change and capacity building for mentoring

Acute coronary syndrome quality improvement in Kerala (ACS QUIK): Rationale and design for a cluster-randomized stepped-wedge trial.

Ischemic heart disease is the leading cause of death in India, and there are likely more myocardial infarctions in India than in any other country in the world. We have previously reported heterogeneous care for patients with myocardial infarction in Kerala, a state in southern India, including both gaps in optimal care and inappropriate care. Based on that prior work, limitations from previous nonrandomized quality improvement studies and promising gains in process of care measures demonstrated from previous randomized trials, we and the Cardiological Society of India-Kerala chapter sought to develop, implement, and evaluate a quality improvement intervention to improve process of care measures and clinical outcomes for these patients. In this article, we report the rationale and study design for the ACS QUIK cluster-randomized stepped-wedge clinical trial (NCT02256657) in which we aim to enroll 15,750 participants with acute coronary syndromes across 63 hospitals. To date, most participants are men (76%) and have ST-segment elevation myocardial infarction (63%). The primary outcome is 30-day major adverse cardiovascular events defined as death, recurrent infarction, stroke, or major bleeding. Our secondary outcomes include health-related quality of life and individual- and household-level costs. We also describe the principal features and limitations of the stepped-wedge study design, which may be important for other investigators or sponsors considering cluster-randomized stepped-wedge trials

Global Health Research Mentoring Competencies for Individuals and Institutions in Low- and Middle-Income Countries.

Mentoring is beneficial to mentors, mentees, and their institutions, especially in low- and middle-income countries (LMICs), that are faced with complex disease burdens, skills shortages, and resource constraints. Mentoring in global health research can be enhanced by defining key competencies, to enable the skill set required for effective mentoring, determine training needs for local research mentors, and facilitate institutional capacity building to support mentors. The latter includes advocating for resources, institutional development of mentoring guidelines, and financial and administrative support for mentoring. Nine core global health research mentoring competencies were identified: maintaining effective communication; aligning expectations with reasonable goals and objectives; assessing and providing skills and knowledge for success; addressing diversity; fostering independence; promoting professional development; promoting professional integrity and ethical conduct; overcoming resource limitations; and fostering institutional change. The competencies described in this article will assist mentors to sharpen their cognitive skills, acquire or generate new knowledge, and enhance professional and personal growth and job satisfaction. Similarly, the proposed competencies will enhance the knowledge and skills of mentees, who can continue and extend the work of their mentors, and advance knowledge for the benefit of the health of populations in LMICs

Effectiveness and cost-effectiveness of a Yoga-based Cardiac Rehabilitation (Yoga-CaRe) program following acute myocardial infarction: study rationale and design of a multi-centre randomized controlled trial

© 2019 Background: Cardiac rehabilitation (CR) is a standard treatment for secondary prevention of acute myocardial infarction (AMI) in high income countries (HICs), but it is inaccessible to most patients in India due to high costs and skills required for multidisciplinary CR teams. We developed a low-cost and scalable CR program based on culturally-acceptable practice of yoga (Yoga-CaRe). In this paper, we report the rationale and design for evaluation of its effectiveness and cost-effectiveness. Methods: This is a multi-center, single-blind, two-arm parallel-group randomized controlled trial across 22 cardiac care hospitals in India. Four thousand patients aged 18–80 years with AMI will be recruited and randomized 1:1 to receive Yoga-CaRe program (13 sessions supervised by an instructor and encouragement to self-practice daily) or enhanced standard care (3 sessions of health education) delivered over a period of three months. Participants will be followed 3-monthly till the end of the trial. The co-primary outcomes are a) time to occurrence of first cardiovascular event (composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke and emergency cardiovascular hospitalization), and b) quality of life (Euro-QoL-5L) at 12 weeks. Secondary outcomes include need for revascularization procedures, return to pre-infarct activities, tobacco cessation, medication adherence, and cost-effectiveness of the intervention. Conclusion: This trial will alone contribute >20% participants to existing meta-analyses of randomized trials of CR worldwide. If Yoga-CaRe is found to be effective, it has the potential to save millions of lives and transform care of AMI patients in India and other low and middle income country settings