Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries:A multicountry analysis of survey data

BackgroundCardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care.Methods and findingsWe did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p ConclusionIn this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care

Multiple cardiovascular risk factor care in 55 low- and middle-income countries:A cross-sectional analysis of nationally-representative, individual-level data from 280,783 adults

The prevalence of multiple age-related cardiovascular disease (CVD) risk factors is high among individuals living in low- and middle-income countries. We described receipt of healthcare services for and management of hypertension and diabetes among individuals living with these conditions using individual-level data from 55 nationally representative population-based surveys (2009–2019) with measured blood pressure (BP) and diabetes biomarker. We restricted our analysis to non-pregnant individuals aged 40–69 years and defined three mutually exclusive groups (i.e., hypertension only, diabetes only, and both hypertension-diabetes) to compare individuals living with concurrent hypertension and diabetes to individuals with each condition separately. We included 90,086 individuals who lived with hypertension only, 11,975 with diabetes only, and 16,228 with hypertension-diabetes. We estimated the percentage of individuals who were aware of their diagnosis, used pharmacological therapy, or achieved appropriate hypertension and diabetes management. A greater percentage of individuals with hypertension-diabetes were fully diagnosed (64.1% [95% CI: 61.8–66.4]) than those with hypertension only (47.4% [45.3–49.6]) or diabetes only (46.7% [44.1–49.2]). Among the hypertension-diabetes group, pharmacological treatment was higher for individual conditions (38.3% [95% CI: 34.8–41.8] using antihypertensive and 42.3% [95% CI: 39.4–45.2] using glucose-lowering medications) than for both conditions jointly (24.6% [95% CI: 22.1–27.2]).The percentage of individuals achieving appropriate management was highest in the hypertension group (17.6% [16.4–18.8]), followed by diabetes (13.3% [10.7–15.8]) and hypertension-diabetes (6.6% [5.4–7.8]) groups. Although health systems in LMICs are reaching a larger share of individuals living with both hypertension and diabetes than those living with just one of these conditions, only seven percent achieved both BP and blood glucose treatment targets. Implementation of cost-effective population-level interventions that shift clinical care paradigm from disease-specific to comprehensive CVD care are urgently needed for all three groups, especially for those with multiple CVD risk factors

Multiple cardiovascular risk factor care in 55 low- and middle-income countries: A cross-sectional analysis of nationally-representative, individual-level data from 280,783 adults

The prevalence of multiple age-related cardiovascular disease (CVD) risk factors is high among individuals living in low- and middle-income countries. We described receipt of healthcare services for and management of hypertension and diabetes among individuals living with these conditions using individual-level data from 55 nationally representative population-based surveys (2009–2019) with measured blood pressure (BP) and diabetes biomarker. We restricted our analysis to non-pregnant individuals aged 40–69 years and defined three mutually exclusive groups (i.e., hypertension only, diabetes only, and both hypertension-diabetes) to compare individuals living with concurrent hypertension and diabetes to individuals with each condition separately. We included 90,086 individuals who lived with hypertension only, 11,975 with diabetes only, and 16,228 with hypertension-diabetes. We estimated the percentage of individuals who were aware of their diagnosis, used pharmacological therapy, or achieved appropriate hypertension and diabetes management. A greater percentage of individuals with hypertension-diabetes were fully diagnosed (64.1% [95% CI: 61.8–66.4]) than those with hypertension only (47.4% [45.3–49.6]) or diabetes only (46.7% [44.1–49.2]). Among the hypertension-diabetes group, pharmacological treatment was higher for individual conditions (38.3% [95% CI: 34.8–41.8] using antihypertensive and 42.3% [95% CI: 39.4–45.2] using glucose-lowering medications) than for both conditions jointly (24.6% [95% CI: 22.1–27.2]).The percentage of individuals achieving appropriate management was highest in the hypertension group (17.6% [16.4–18.8]), followed by diabetes (13.3% [10.7–15.8]) and hypertension-diabetes (6.6% [5.4–7.8]) groups. Although health systems in LMICs are reaching a larger share of individuals living with both hypertension and diabetes than those living with just one of these conditions, only seven percent achieved both BP and blood glucose treatment targets. Implementation of cost-effective population-level interventions that shift clinical care paradigm from disease-specific to comprehensive CVD care are urgently needed for all three groups, especially for those with multiple CVD risk factors

To tackle diabetes, science and health systems must take into account social context

An increasing amount of publications are recognizing that a person's risk of diabetes and diabetes outcomes are influenced largely by social determinants of health. This renewed understanding of disease should influence health provision and diabetes research, but will it

Racial Differences in Neonatal Hypoglycemia among Very Early Preterm Births

Objective: To determine whether the prevalence of neonatal hypoglycemia differs by race/ethnicity. Study Design A retrospective cohort study using prospectively collected data from 515 neonates born very preterm (<32 weeks) to normoglycemic women and admitted to the neonatal intensive care unit (NICU) at a major tertiary hospital in Boston, MA between 2008 and 2012. Results: A total of 61%, 12%, 7%, 7%, and 13% were White, Black, Hispanic, Asian, and Other, respectively. Among the 66% spontaneous preterm births, 63% of the black neonates experienced hypoglycemia (blood glucose level<40 mg/dL), while only 22–30% of the other racial/ethnic neonates did so (Black v. White RR 2.15; 95% CI: 1.54–3.00). After adjusting for maternal education, maternal age, multiple gestations, delivery type, gestational age, birth weight and neonates’ sex, this association remained significant (adjusted Black v. White RR: 1.61, 95% CI: 1.13–2.29). An increased risk of infant hypoglycemia was not seen in infants of other racial/ethnic groups, nor in any racial/ethnic group with a medically-indicated preterm birth. Conclusions: Black neonates delivered for spontaneous (but not medical) indications at <32 weeks had a higher risk of hypoglycemia, which could provide critical information about mechanisms of preterm birth and adverse postnatal outcomes in this high-risk group

Visceral Adiposity and Severe COVID-19 Disease: Application of an Artificial Intelligence Algorithm to Improve Clinical Risk Prediction

Background: Obesity has been linked to severe clinical outcomes among people who are hospitalized with coronavirus disease 2019 (COVID-19). We tested the hypothesis that visceral adipose tissue (VAT) is associated with severe outcomes in patients hospitalized with COVID-19, independent of body mass index (BMI). Methods: We analyzed data from the Massachusetts General Hospital COVID-19 Data Registry, which included patients admitted with polymerase chain reaction–confirmed severe acute respiratory syndrome coronavirus 2 infection from March 11 to May 4, 2020. We used a validated, fully automated artificial intelligence (AI) algorithm to quantify VAT from computed tomography (CT) scans during or before the hospital admission. VAT quantification took an average of 2 ± 0.5 seconds per patient. We dichotomized VAT as high and low at a threshold of ≥100 cm² and used Kaplan-Meier curves and Cox proportional hazards regression to assess the relationship between VAT and death or intubation over 28 days, adjusting for age, sex, race, BMI, and diabetes status. Results: A total of 378 participants had CT imaging. Kaplan-Meier curves showed that participants with high VAT had a greater risk of the outcome compared with those with low VAT (P < .005), especially in those with BMI <30 kg/m2 (P < .005). In multivariable models, the adjusted hazard ratio (aHR) for high vs low VAT was unchanged (aHR, 1.97; 95% CI, 1.24–3.09), whereas BMI was no longer significant (aHR for obese vs normal BMI, 1.14; 95% CI, 0.71–1.82). Conclusions: High VAT is associated with a greater risk of severe disease or death in COVID-19 and can offer more precise information to risk-stratify individuals beyond BMI. AI offers a promising approach to routinely ascertain VAT and improve clinical risk prediction in COVID-19.National Institute of Diabetes and Digestive and Kidney Diseases (Grants T32DK007028 and R01DK085070)National Heart, Lung, and Blood Institute (Grant R01HL132786)National Institute of Allergy and Infectious Diseases (Grants R01AG062393 and K24AI141036)National Institute of General Medical Sciences (Grant R01GM127862

Socio-demographic inequalities and excess non-COVID-19 mortality during the COVID-19 pandemic: a data-driven analysis of 1 069 174 death certificates in Mexico.

BACKGROUND: In 2020, Mexico experienced one of the highest rates of excess mortality globally. However, the extent of non-COVID deaths on excess mortality, its regional distribution and the association between socio-demographic inequalities have not been characterized. METHODS: We conducted a retrospective municipal and individual-level study using 1 069 174 death certificates to analyse COVID-19 and non-COVID-19 deaths classified by ICD-10 codes. Excess mortality was estimated as the increase in cause-specific mortality in 2020 compared with the average of 2015-2019, disaggregated by primary cause of death, death setting (in-hospital and out-of-hospital) and geographical location. Correlates of individual and municipal non-COVID-19 mortality were assessed using mixed effects logistic regression and negative binomial regression models, respectively. RESULTS: We identified a 51% higher mortality rate (276.11 deaths per 100 000 inhabitants) compared with the 2015-2019 average period, largely attributable to COVID-19. Non-COVID-19 causes comprised one-fifth of excess deaths, with acute myocardial infarction and type 2 diabetes as the two leading non-COVID-19 causes of excess mortality. COVID-19 deaths occurred primarily in-hospital, whereas excess non-COVID-19 deaths occurred in out-of-hospital settings. Municipal-level predictors of non-COVID-19 excess mortality included levels of social security coverage, higher rates of COVID-19 hospitalization and social marginalization. At the individual level, lower educational attainment, blue-collar employment and lack of medical care assistance prior to death were associated with non-COVID-19 deaths. CONCLUSION: Non-COVID-19 causes of death, largely chronic cardiometabolic conditions, comprised up to one-fifth of excess deaths in Mexico during 2020. Non-COVID-19 excess deaths occurred disproportionately out-of-hospital and were associated with both individual- and municipal-level socio-demographic inequalities

Facility reported readiness to provide services.

Cardiovascular disease risk factors (CVDRF), in particular diabetes and hypertension, are chronic conditions which carry a substantial disease burden in Low- and Middle-Income Countries. Unlike HIV, they were neglected in the Millenium Development Goals along with the health services required to manage them. To inform the level of health service readiness that could be achieved with increased attention, we compared readiness for CVDRF with that for HIV. Using data from national Service Provision Assessments, we describe facility-reported readiness to provide services for CVDRF and HIV, and derive a facility readiness score of observed essential components to manage them. We compared HIV vs CVDRF coverage scores by country, rural or urban location, and facility type, and by whether or not facilities reported readiness to provide care. We assessed the factors associated with coverage scores for CVDRF and HIV in a multivariable analysis. In our results, we include 7522 facilities in 8 countries; 86% of all facilities reported readiness to provide services for CVDRF, ranging from 77–98% in individual countries. For HIV, 30% reported of facilities readiness to provide services, ranging from 3–63%. Median derived facility readiness score for CVDRF was 0.28 (IQR 0.16–0.50), and for HIV was 0.43 (0.32–0.60). Among facilities which reported readiness, this rose to 0.34 (IQR 0.18–0.52) for CVD and 0.68 (0.56–0.76) for HIV. Derived readiness scores were generally significantly lower for CVDRF than for HIV, except in private facilities. In multivariable analysis, odds of a higher readiness score in both CVDRF or HIV care were higher in urban vs rural and secondary vs primary care; facilities with higher CVDRF scores were significantly associated with higher HIV scores. Derived readiness scores for HIV are higher than for CVDRF, and coverage for CVDRF is significantly higher in facilities with higher HIV readiness scores. This suggests possible benefits from leveraging HIV services to provide care for CVDRF, but poor coverage in rural and primary care facilities threatens Sustainable Development Goal 3.8 to provide high quality universal healthcare for all.</div

Heatmap showing median derived readiness scores in facilities reporting readiness for that score.

CVDRF–Cardiovascular Disease Risk Factors; DRC–Democratic Republic of Congo. Scores reported for all and each individual country by level of facility, funding, and geographical location, restricting facilities to those which reported readiness for HIV or CVDRF (see S6 Appendix for data in table form). Colorbar to the right of the figure represents median readiness score.</p