Cambios políticos y educación para todos en América Latina : tendencias del financiamiento en Bolivia y Paraguay

A menudo se han enmarcado los procesos de cambio político -especialmente en el Cono Sur-, como anti-neoliberales. En el sector Educación se produjeron discursos de voluntad de giro de la Agenda Educativa, con una reivindicación del rol del Estado. ¿En qué medida ello se tradujo en la práctica? Asumiendo o incluso yendo más allá de los objetivos de la Educación para Todos, con prioridades contextualizadas a cada país, los gobiernos y Ministerios de Educación se han enfrentado al deseo, la voluntad y la capacidad de emprender caminos propios. En este artículo, revisamos las tendencias del cambio en el financiamiento público, considerando tres dimensiones: el presupuesto en Educación, los acuerdos de crédito y cooperación, y las políticas sociales vinculadas al sector. Comparamos dos casos y periodos recientes -Bolivia (2006-2009) y Paraguay (2008-2011)- y mostramos el efectivo cambio de tendencia, aunque con matices intra e inter casos, considerando no sólo el marco nacional, sino también la perspectiva de cambios en el contexto internacional.The processes of political change have often been framed, particularly in the Southern Cone, as anti-neo-liberal. In the Education sector specifically, there were speeches asking for a drastic change in the Educational Agenda, with claims about the role of the State. To what extent did that translate into practice? Assuming, or even going beyond the goals of Education for All, with contextualized priorities for each country, governments and Education Ministries have faced the desire, the will and the ability to undertake their own paths. In this article, we look into the tendencies of change in public financing, taking into account three dimensions: the Education Budget, cooperation and credit agreements, and social policies linked to the sector. We compare two cases -Bolivia (2006-2009) and Paraguay (2008-2011)- in recent periods, and we show the effective change in tendencies, considering not only the local context but also the perspective of changes in the international context

La agenda educativa pos-neoliberal. Alternativas de cambio en Bolivia y Paraguay /

Esta investigación se proyecta y delinea entre finales de 2011 y principios de 2012, en pleno momento de desarrollo y despliegue de los procesos de cambio político en América del Sur. En ese contexto, empieza a inquietarme el modo en que la educación se estaría transformando o se podría, -y quizá debería- transformar a partir de tales cambios. Desde aquel primer momento los interrogantes surgen en torno a la vinculación entre lo político y lo educativo. ¿Qué implica que gobiernen unos y no otros para lo político y lo público? ¿Qué implica que hayan llegado al gobierno, -no siempre al poder-, grupos sociales y políticos que siempre estuvieron excluidos de la toma de decisiones de política y políticas? ¿Cómo se traducen esos cambios en el sector educativo y más específicamente en la agenda educativa? ¿Qué agenda educativa alternativa es posible? ¿Quiénes y cómo la están construyendo? Siendo el neoliberalismo hegemónico, ¿hay un horizonte pos-neoliberal para la Educación? La hipótesis general establece que los cambios en la Agenda Educativa pos-neoliberal dependen de las características de los cambios en el gobierno del Estado. En relación a ella, las sub-hipótesis destacaban el cambio de actores en Bolivia con la irrupción de los movimientos sociales, la búsqueda de una ruptura epistemológica contra-hegemónica y la consideración de la educación como un elemento clave para consolidar una revolución cultural. En Paraguay, la preeminencia de actores de élite, la tendencia más evolutiva y continuista de la agenda educativa, y la permanencia de estructuras estatales tradicionales que no permiten un planteo de cambio profundo. Se realiza un estudio de casos, comparado entre opuestos, siendo Bolivia el caso paradigmático. Entrevistamos a más de veinticinco actores clave en cada país, miembros del gobierno, la sociedad civil y los organismos de cooperación y crédito. Esto se complementa con la revisión documental. El análisis se realiza mediante el process-tracing, apropiado para este tipo de estudios, en donde la reconstrucción narrativa está orientada al desarrollo de nuevas premisas e hipótesis. En las conclusiones se establecen principalmente las diferencias entre dos agendas pos-neoliberales, cuyo principal elemento en común es la crítica hacia lo neoliberal y el contexto de cambio político regional. Es determinante en cada una de ellas, la estructura histórico-política de la hegemonía en cada país, así como la envergadura de las resistencias previas. En Bolivia se forma una agenda educativa des-colonizadora e innovadora. Y en Paraguay, una agenda educativa modernizadora y renovadora. En el primer caso hay un amplio consenso entre actores sociales y populares, si bien las ideas de los grupos indígenas predominan en el sector tanto desde dentro como desde fuera del Estado. En el segundo caso, el gobierno asume un discurso de protagonismo estatal, pero la agenda sigue siendo definida por élites intelectuales y no por una (inexistente) base popular en educación. En el primer caso se cuestiona la modernidad como paradigma que se inicia con la colonización, y se busca desmontar las estructuras civilizadoras, epistemológicas y políticas. Se imagina un horizonte común basado en distintos recorridos de la memoria, y con proyecciones también hacia distintos tiempos. En el segundo caso, se reafirma el ideal del paradigma moderno, nunca alcanzado en el Estado-Nación paraguayo, y se busca el modo de renovarlo desde un nivel de políticas concretas, muy coyuntural y con proyección a corto plazo. La tesis deja abierto el interrogante acerca de la posibilidad de consolidación de una nueva epistemología des-colonizadora para la educación, la sociedad y el Estado.This research project was outlined between late 2011 and early 2012, precisely during a moment of development and deployment of political change processes in South America. In this context, I am concerned with how education could be transformed or, and perhaps should be transformed, from such changes. From that first moment questions arise about the relationship between politics and education. What does the governing of ones and not others mean for the political and the public? What does it mean when excluded social and political groups, that have always been excluded from policy decisions and policies, are now the government-though not always the power? How do these changes translate into the education sector and more specifically on the educational agenda? What is a possible alternative educational agenda? By whom, and how is it being constructed? Given that neoliberalism is hegemonic, is there a post-neoliberal horizon for Education? The general hypothesis states that changes in the post-neoliberal Agenda Educational depend on the characteristics of changes in the state government. In relation to it, the sub-hypothesis highlights the change of actors in Bolivia with the emergence of social movements, seeking a counter-hegemonic epistemological break and consideration of education as a key element to consolidate a cultural revolution. In Paraguay, the preeminence of elite players, the most evolutionary and continuist trend of the educational agenda, and the permanence of traditional state structures do not allow a proposal of profound change. A comparative case study compared between opposites, Bolivia being the paradigmatic. We interviewed more than twenty key actors in each country: embers of the government, civil society and cooperating agencies and credit. This is complemented by the document review. The analysis was performed using process-tracing, which is appropriate for this type of study, where narrative reconstruction is aimed at developing new premises and assumptions. The conclusions establish differences between two post-neoliberal agendas, whose main element in common is the criticism of neoliberalism the context of political change in the region. In each country the historical and political hegemonic, as well as the size of previous resistance, is determinant. In Bolivia a decolonizing and innovative educational agenda was formed. And in Paraguay, a modernizing and renewing educational agenda. In the first case there is a broad consensus among social and popular actors, although the ideas of indigenous groups predominate both from within and from outside the state. In the second case, the government assumes the discourse of state protagonism, but the agenda is still defined by intellectual elites and not on a (nonexistent) popular education base. In the first case a paradigm of modernity that begins with colonization is questioned, and the civilizing, epistemological and political structures it created are sought to be disassembled. An imagined common horizon based on different routes of memory, and with projections to different times. In the second case, the ideal of the modern Paraguayan state, never reached, is reaffirmed and is renewed from concrete, very cyclical and short-term policies. The thesis leaves open the question about the possibility of consolidating a new de-colonial epistemology for education, society and the state

La agenda educativa pos-neoliberal. Alternativas de cambio en Bolivia y Paraguay

Esta investigación se proyecta y delinea entre finales de 2011 y principios de 2012, en pleno momento de desarrollo y despliegue de los procesos de cambio político en América del Sur. En ese contexto, empieza a inquietarme el modo en que la educación se estaría transformando o se podría, -y quizá debería- transformar a partir de tales cambios. Desde aquel primer momento los interrogantes surgen en torno a la vinculación entre lo político y lo educativo. ¿Qué implica que gobiernen unos y no otros para lo político y lo público? ¿Qué implica que hayan llegado al gobierno, -no siempre al poder-, grupos sociales y políticos que siempre estuvieron excluidos de la toma de decisiones de política y políticas? ¿Cómo se traducen esos cambios en el sector educativo y más específicamente en la agenda educativa? ¿Qué agenda educativa alternativa es posible? ¿Quiénes y cómo la están construyendo? Siendo el neoliberalismo hegemónico, ¿hay un horizonte pos-neoliberal para la Educación? La hipótesis general establece que los cambios en la Agenda Educativa pos-neoliberal dependen de las características de los cambios en el gobierno del Estado. En relación a ella, las sub-hipótesis destacaban el cambio de actores en Bolivia con la irrupción de los movimientos sociales, la búsqueda de una ruptura epistemológica contra-hegemónica y la consideración de la educación como un elemento clave para consolidar una revolución cultural. En Paraguay, la preeminencia de actores de élite, la tendencia más evolutiva y continuista de la agenda educativa, y la permanencia de estructuras estatales tradicionales que no permiten un planteo de cambio profundo. Se realiza un estudio de casos, comparado entre opuestos, siendo Bolivia el caso paradigmático. Entrevistamos a más de veinticinco actores clave en cada país, miembros del gobierno, la sociedad civil y los organismos de cooperación y crédito. Esto se complementa con la revisión documental. El análisis se realiza mediante el process-tracing, apropiado para este tipo de estudios, en donde la reconstrucción narrativa está orientada al desarrollo de nuevas premisas e hipótesis. En las conclusiones se establecen principalmente las diferencias entre dos agendas pos-neoliberales, cuyo principal elemento en común es la crítica hacia lo neoliberal y el contexto de cambio político regional. Es determinante en cada una de ellas, la estructura histórico-política de la hegemonía en cada país, así como la envergadura de las resistencias previas. En Bolivia se forma una agenda educativa des-colonizadora e innovadora. Y en Paraguay, una agenda educativa modernizadora y renovadora. En el primer caso hay un amplio consenso entre actores sociales y populares, si bien las ideas de los grupos indígenas predominan en el sector tanto desde dentro como desde fuera del Estado. En el segundo caso, el gobierno asume un discurso de protagonismo estatal, pero la agenda sigue siendo definida por élites intelectuales y no por una (inexistente) base popular en educación. En el primer caso se cuestiona la modernidad como paradigma que se inicia con la colonización, y se busca desmontar las estructuras civilizadoras, epistemológicas y políticas. Se imagina un horizonte común basado en distintos recorridos de la memoria, y con proyecciones también hacia distintos tiempos. En el segundo caso, se reafirma el ideal del paradigma moderno, nunca alcanzado en el Estado-Nación paraguayo, y se busca el modo de renovarlo desde un nivel de políticas concretas, muy coyuntural y con proyección a corto plazo. La tesis deja abierto el interrogante acerca de la posibilidad de consolidación de una nueva epistemología des-colonizadora para la educación, la sociedad y el Estado.This research project was outlined between late 2011 and early 2012, precisely during a moment of development and deployment of political change processes in South America. In this context, I am concerned with how education could be transformed or, and perhaps should be transformed, from such changes. From that first moment questions arise about the relationship between politics and education. What does the governing of ones and not others mean for the political and the public? What does it mean when excluded social and political groups, that have always been excluded from policy decisions and policies, are now the government-though not always the power? How do these changes translate into the education sector and more specifically on the educational agenda? What is a possible alternative educational agenda? By whom, and how is it being constructed? Given that neoliberalism is hegemonic, is there a post-neoliberal horizon for Education? The general hypothesis states that changes in the post-neoliberal Agenda Educational depend on the characteristics of changes in the state government. In relation to it, the sub-hypothesis highlights the change of actors in Bolivia with the emergence of social movements, seeking a counter-hegemonic epistemological break and consideration of education as a key element to consolidate a cultural revolution. In Paraguay, the preeminence of elite players, the most evolutionary and continuist trend of the educational agenda, and the permanence of traditional state structures do not allow a proposal of profound change. A comparative case study compared between opposites, Bolivia being the paradigmatic. We interviewed more than twenty key actors in each country: embers of the government, civil society and cooperating agencies and credit. This is complemented by the document review. The analysis was performed using process-tracing, which is appropriate for this type of study, where narrative reconstruction is aimed at developing new premises and assumptions. The conclusions establish differences between two post-neoliberal agendas, whose main element in common is the criticism of neoliberalism the context of political change in the region. In each country the historical and political hegemonic, as well as the size of previous resistance, is determinant. In Bolivia a decolonizing and innovative educational agenda was formed. And in Paraguay, a modernizing and renewing educational agenda. In the first case there is a broad consensus among social and popular actors, although the ideas of indigenous groups predominate both from within and from outside the state. In the second case, the government assumes the discourse of state protagonism, but the agenda is still defined by intellectual elites and not on a (nonexistent) popular education base. In the first case a paradigm of modernity that begins with colonization is questioned, and the civilizing, epistemological and political structures it created are sought to be disassembled. An imagined common horizon based on different routes of memory, and with projections to different times. In the second case, the ideal of the modern Paraguayan state, never reached, is reaffirmed and is renewed from concrete, very cyclical and short-term policies. The thesis leaves open the question about the possibility of consolidating a new de-colonial epistemology for education, society and the state

La agenda educativa pos-neoliberal. Alternativas de cambio en Bolivia y Paraguay

Esta investigación se proyecta y delinea entre finales de 2011 y principios de 2012, en pleno momento de desarrollo y despliegue de los procesos de cambio político en América del Sur. En ese contexto, empieza a inquietarme el modo en que la educación se estaría transformando o se podría, -y quizá debería- transformar a partir de tales cambios. Desde aquel primer momento los interrogantes surgen en torno a la vinculación entre lo político y lo educativo. ¿Qué implica que gobiernen unos y no otros para lo político y lo público? ¿Qué implica que hayan llegado al gobierno, -no siempre al poder-, grupos sociales y políticos que siempre estuvieron excluidos de la toma de decisiones de política y políticas? ¿Cómo se traducen esos cambios en el sector educativo y más específicamente en la agenda educativa? ¿Qué agenda educativa alternativa es posible? ¿Quiénes y cómo la están construyendo? Siendo el neoliberalismo hegemónico, ¿hay un horizonte pos-neoliberal para la Educación? La hipótesis general establece que los cambios en la Agenda Educativa pos-neoliberal dependen de las características de los cambios en el gobierno del Estado. En relación a ella, las sub-hipótesis destacaban el cambio de actores en Bolivia con la irrupción de los movimientos sociales, la búsqueda de una ruptura epistemológica contra-hegemónica y la consideración de la educación como un elemento clave para consolidar una revolución cultural. En Paraguay, la preeminencia de actores de élite, la tendencia más evolutiva y continuista de la agenda educativa, y la permanencia de estructuras estatales tradicionales que no permiten un planteo de cambio profundo. Se realiza un estudio de casos, comparado entre opuestos, siendo Bolivia el caso paradigmático. Entrevistamos a más de veinticinco actores clave en cada país, miembros del gobierno, la sociedad civil y los organismos de cooperación y crédito. Esto se complementa con la revisión documental. El análisis se realiza mediante el process-tracing, apropiado para este tipo de estudios, en donde la reconstrucción narrativa está orientada al desarrollo de nuevas premisas e hipótesis. En las conclusiones se establecen principalmente las diferencias entre dos agendas pos-neoliberales, cuyo principal elemento en común es la crítica hacia lo neoliberal y el contexto de cambio político regional. Es determinante en cada una de ellas, la estructura histórico-política de la hegemonía en cada país, así como la envergadura de las resistencias previas. En Bolivia se forma una agenda educativa des-colonizadora e innovadora. Y en Paraguay, una agenda educativa modernizadora y renovadora. En el primer caso hay un amplio consenso entre actores sociales y populares, si bien las ideas de los grupos indígenas predominan en el sector tanto desde dentro como desde fuera del Estado. En el segundo caso, el gobierno asume un discurso de protagonismo estatal, pero la agenda sigue siendo definida por élites intelectuales y no por una (inexistente) base popular en educación. En el primer caso se cuestiona la modernidad como paradigma que se inicia con la colonización, y se busca desmontar las estructuras civilizadoras, epistemológicas y políticas. Se imagina un horizonte común basado en distintos recorridos de la memoria, y con proyecciones también hacia distintos tiempos. En el segundo caso, se reafirma el ideal del paradigma moderno, nunca alcanzado en el Estado-Nación paraguayo, y se busca el modo de renovarlo desde un nivel de políticas concretas, muy coyuntural y con proyección a corto plazo. La tesis deja abierto el interrogante acerca de la posibilidad de consolidación de una nueva epistemología des-colonizadora para la educación, la sociedad y el Estado.This research project was outlined between late 2011 and early 2012, precisely during a moment of development and deployment of political change processes in South America. In this context, I am concerned with how education could be transformed or, and perhaps should be transformed, from such changes. From that first moment questions arise about the relationship between politics and education. What does the governing of ones and not others mean for the political and the public? What does it mean when excluded social and political groups, that have always been excluded from policy decisions and policies, are now the government-though not always the power? How do these changes translate into the education sector and more specifically on the educational agenda? What is a possible alternative educational agenda? By whom, and how is it being constructed? Given that neoliberalism is hegemonic, is there a post-neoliberal horizon for Education? The general hypothesis states that changes in the post-neoliberal Agenda Educational depend on the characteristics of changes in the state government. In relation to it, the sub-hypothesis highlights the change of actors in Bolivia with the emergence of social movements, seeking a counter-hegemonic epistemological break and consideration of education as a key element to consolidate a cultural revolution. In Paraguay, the preeminence of elite players, the most evolutionary and continuist trend of the educational agenda, and the permanence of traditional state structures do not allow a proposal of profound change. A comparative case study compared between opposites, Bolivia being the paradigmatic. We interviewed more than twenty key actors in each country: embers of the government, civil society and cooperating agencies and credit. This is complemented by the document review. The analysis was performed using process-tracing, which is appropriate for this type of study, where narrative reconstruction is aimed at developing new premises and assumptions. The conclusions establish differences between two post-neoliberal agendas, whose main element in common is the criticism of neoliberalism the context of political change in the region. In each country the historical and political hegemonic, as well as the size of previous resistance, is determinant. In Bolivia a decolonizing and innovative educational agenda was formed. And in Paraguay, a modernizing and renewing educational agenda. In the first case there is a broad consensus among social and popular actors, although the ideas of indigenous groups predominate both from within and from outside the state. In the second case, the government assumes the discourse of state protagonism, but the agenda is still defined by intellectual elites and not on a (nonexistent) popular education base. In the first case a paradigm of modernity that begins with colonization is questioned, and the civilizing, epistemological and political structures it created are sought to be disassembled. An imagined common horizon based on different routes of memory, and with projections to different times. In the second case, the ideal of the modern Paraguayan state, never reached, is reaffirmed and is renewed from concrete, very cyclical and short-term policies. The thesis leaves open the question about the possibility of consolidating a new de-colonial epistemology for education, society and the state

Policy brief. Políticas públicas y derecho a la educación de los pueblos indígenas en Paraguay. Evaluación de la implementación y alcance de las becas estatales para el acceso a la universidad

I.PRESENTACIÓN Y ANTECEDENTES II.PENSAR EL ESTADO Y LA DEMOCRACIA CON LOS PUEBLOS ORIGINARIOS Estado, Democracia y Pluralismo: la urgencia decolonial Ciudadanía Indígena y Políticas Públicas con enfoque de derechos Pueblos Indígenas y Universidad: la deuda intercultural III.POLÍTICA EDUCATIVA DE ACCESO A LA UNIVERSIDAD: IMPLEMENTACIÓN Y ALCANCE La política pública: el pluralismo en la política de becas para el acceso a la Educación Superior El sector: igualdad, no discriminación y derechos de Pueblos Indígenas en la Política Educativa. El caso de las becas para el acceso a la universidad La población: alcance intercultural y democratizador de las políticas para el acceso a la universidad de los Pueblos Indígenas IV.EL ESTADO ANTE LA EDUCACIÓN SUPERIOR DE LOS PUEBLOS INDÍGENAS EN PARAGUAY V.HACIA LAS POLÍTICAS PÚBLICAS EN EDUCACIÓN SUPERIOR DESDE Y PARA LOS PUEBLOS ORIGINARIOS Legislación y normativa en Educación Superior Expansión territorial de la Universidad e igualdad de oportunidades Becas universitarias y Pueblos Indígenas como población-objetivo Pueblos Indígenas y condiciones educativas en la Universidad Estado y organizaciones indígenas: articulación para las Políticas Públicas VI.BIBLIOGRAFÍA -Acrónimos y siglas -Autora

Avances y desafíos en políticas públicas educativas : análisis de casos en Argentina, Brasil, Colombia y Paraguay

En el año 2013 el Consejo Latinoamericano de Ciencias Sociales organizó el concurso Estudios sobre políticas públicas en América Latina y el Caribe. Democracia, ciudadanía y justicia social con el fin de apoyar el desarrollo de investigaciones que permitan impactar en forma más directa en los ámbitos de intervención social y favorecer el diálogo entre las ciencias sociales y las políticas públicas. En el marco de la misma iniciativa, fue organizado este libro que contiene una selección de artículos elaborados en dicho concurso durante el segundo semestre de 2013. Se espera que los análisis que aquí se presentan dialoguen con los debates y las orientaciones de política en la coyuntura actual, y constituyan aportes para quienes se desempeñan en los ámbitos públicos relacionados con el tema de este libro

The Use of Insecticide-Treated Curtains for Control of Aedes aegypti and Dengue Virus Transmission in “Fraccionamiento” Style Houses in México

Dengue, chikungunya, yellow fever, and Zika viruses transmitted by Aedes aegypti mosquitoes are major public health threats in the tropical and subtropical world. In México, construction of large tracts of “fraccionamientos” high density housing to accommodate population growth and urbanization has provided fertile ground for Ae. aegypti-transmitted viruses. We investigated the utility of pyrethroid-treated window curtains to reduce both the abundance of Ae. aegypti and to prevent dengue virus (DENV) transmission in fraccionamiento housing. Windows and doors of fraccionamiento homes in urban/suburban areas, where Ae. aegypti pyrethroid resistance associated with the Ile1016 knock down resistance (kdr) mutation in the voltage gated sodium channel gene was high, and in rural areas, where kdr resistance was low, were fitted with either insecticide-treated curtains (ITCs) or non-treated curtains (NTCs). The homes were monitored for mosquito abundance and DENV infection. ITCs reduced the indoor abundance of Ae. aegypti and the number of DENV-infected mosquitoes in homes in rural but not in urban/suburban study sites. The presence of non-treated screens also was associated with reduced numbers of mosquitoes in homes. “Super-infested” homes, yielding more than 50 mosquitoes, including DENV-infected mosquitoes, provide a significant public health risk to occupants, visitors, and people in neighboring homes

Global perspective of familial hypercholesterolaemia: a cross-sectional study from the EAS Familial Hypercholesterolaemia Studies Collaboration (FHSC)

none724siBackground The European Atherosclerosis Society Familial Hypercholesterolaemia Studies Collaboration (FHSC) global registry provides a platform for the global surveillance of familial hypercholesterolaemia through harmonisation and pooling of multinational data. In this study, we aimed to characterise the adult population with heterozygous familial hypercholesterolaemia and described how it is detected and managed globally.Methods Using FHSC global registry data, we did a cross-sectional assessment of adults (aged 18 years or older) with a clinical or genetic diagnosis of probable or definite heterozygous familial hypercholesterolaemia at the time they were entered into the registries. Data were assessed overall and by WHO regions, sex, and index versus non-index cases.Findings Of the 61 612 individuals in the registry, 42 167 adults (21 999 [53.6%] women) from 56 countries were included in the study. Of these, 31 798 (75.4%) were diagnosed with the Dutch Lipid Clinic Network criteria, and 35 490 (84.2%) were from the WHO region of Europe. Median age of participants at entry in the registry was 46.2 years (IQR 34.3-58.0); median age at diagnosis of familial hypercholesterolaemia was 44.4 years (32.5-56.5), with 40.2% of participants younger than 40 years when diagnosed. Prevalence of cardiovascular risk factors increased progressively with age and varied by WHO region. Prevalence of coronary disease was 17.4% (2.1% for stroke and 5.2% for peripheral artery disease), increasing with concentrations of untreated LDL cholesterol, and was about two times lower in women than in men. Among patients receiving lipid-lowering medications, 16 803 (81.1%) were receiving statins and 3691 (21.2%) were on combination therapy, with greater use of more potent lipid-lowering medication in men than in women. Median LDL cholesterol was 5.43 mmol/L (IQR 4.32-6.72) among patients not taking lipid-lowering medications and 4.23 mmol/L (3.20-5.66) among those taking them. Among patients taking lipid-lowering medications, 2.7% had LDL cholesterol lower than 1.8 mmol/L; the use of combination therapy, particularly with three drugs and with proprotein convertase subtilisin-kexin type 9 inhibitors, was associated with a higher proportion and greater odds of having LDL cholesterol lower than 1.8 mmol/L. Compared with index cases, patients who were non-index cases were younger, with lower LDL cholesterol and lower prevalence of cardiovascular risk factors and cardiovascular diseases (all p<0.001).Interpretation Familial hypercholesterolaemia is diagnosed late. Guideline-recommended LDL cholesterol concentrations are infrequently achieved with single-drug therapy. Cardiovascular risk factors and presence of coronary disease were lower among non-index cases, who were diagnosed earlier. Earlier detection and greater use of combination therapies are required to reduce the global burden of familial hypercholesterolaemia. Copyright (C) 2021 Elsevier Ltd. All rights reserved.mixedVallejo-Vaz, Antonio J.; Stevens, Christophe A.T.; Lyons, Alexander R.M.; Dharmayat, Kanika I.; Freiberger, Tomas; Hovingh, G. Kees; Mata, Pedro; Raal, Frederick J.; Santos, Raul D.; Soran, Handrean; Watts, Gerald F.; Abifadel, Marianne; Aguilar-Salinas, Carlos A.; Alhabib, Khalid F.; Alkhnifsawi, Mutaz; Almahmeed, Wael; Alnouri, Fahad; Alonso, Rodrigo; Al-Rasadi, Khalid; Al-Sarraf, Ahmad; Al-Sayed, Nasreen; Araujo, Francisco; Ashavaid, Tester F.; Banach, Maciej; Béliard, Sophie; Benn, Marianne; Binder, Christoph J.; Bogsrud, Martin P.; Bourbon, Mafalda; Chlebus, Krzysztof; Corral, Pablo; Davletov, Kairat; Descamps, Olivier S.; Durst, Ronen; Ezhov, Marat; Gaita, Dan; Genest, Jacques; Groselj, Urh; Harada-Shiba, Mariko; Holven, Kirsten B.; Kayikcioglu, Meral; Khovidhunkit, Weerapan; Lalic, Katarina; Latkovskis, Gustavs; Laufs, Ulrich; Liberopoulos, Evangelos; Lima-Martinez, Marcos M.; Lin, Jie; Maher, Vincent; Marais, A. David; März, Winfried; Mirrakhimov, Erkin; Miserez, André R.; Mitchenko, Olena; Nawawi, Hapizah; Nordestgaard, Børge G.; Panayiotou, Andrie G.; Paragh, György; Petrulioniene, Zaneta; Pojskic, Belma; Postadzhiyan, Arman; Raslova, Katarina; Reda, Ashraf; Reiner, Željko; Sadiq, Fouzia; Sadoh, Wilson Ehidiamen; Schunkert, Heribert; Shek, Aleksandr B.; Stoll, Mario; Stroes, Erik; Su, Ta-Chen; Subramaniam, Tavintharan; Susekov, Andrey V.; Tilney, Myra; Tomlinson, Brian; Truong, Thanh Huong; Tselepis, Alexandros D.; Tybjærg-Hansen, Anne; Vázquez Cárdenas, Alejandra; Viigimaa, Margus; Wang, Luya; Yamashita, Shizuya; Kastelein, John J.P.; Bruckert, Eric; Vohnout, Branislav; Schreier, Laura; Pang, Jing; Ebenbichler, Christoph; Dieplinger, Hans; Innerhofer, Reinhold; Winhofer-Stöckl, Yvonne; Greber-Platzer, Susanne; Krychtiuk, Konstantin; Speidl, Walter; Toplak, Hermann; Widhalm, Kurt; Stulnig, Thomas; Huber, Kurt; Höllerl, Florian; Rega-Kaun, Gersina; Kleemann, Lucas; Mäser, Martin; Scholl-Bürgi, Sabine; Säly, Christoph; Mayer, Florian J.; Sablon, Gaelle; Tarantino, Eric; Nzeyimana, Charlotte; Pojskic, Lamija; Sisic, Ibrahim; Nalbantic, Azra D.; Jannes, Cinthia E.; Pereira, Alexandre C.; Krieger, Jose E.; Petrov, Ivo; Goudev, Assen; Nikolov, Fedya; Tisheva, Snejana; Yotov, Yoto; Tzvetkov, Ivajlo; Baass, Alexis; Bergeron, Jean; Bernard, Sophie; Brisson, Diane; Brunham, Liam R.; Cermakova, Lubomira; Couture, Patrick; Francis, Gordon A.; Gaudet, Daniel; Hegele, Robert A.; Khoury, Etienne; Mancini, G.B. John; McCrindle, Brian W.; Paquette, Martine; Ruel, Isabelle; Cuevas, Ada; Asenjo, Sylvia; Wang, Xumin; Meng, Kang; Song, Xiantao; Yong, Qiang; Jiang, Tao; Liu, Ziyou; Duan, Yanyu; Hong, Jing; Ye, Pucong; Chen, Yan; Qi, Jianguang; Liu, Zesen; Li, Yuntao; Zhang, Chaoyi; Peng, Jie; Yang, Ya; Yu, Wei; Wang, Qian; Yuan, Hui; Cheng, Shitong; Jiang, Long; Chong, Mei; Jiao, Jian; Wu, Yue; Wen, Wenhui; Xu, Liyuan; Zhang, Ruiying; Qu, Yichen; He, Jianxun; Fan, Xuesong; Wang, Zhenjia; Chow, Elaine; Pećin, Ivan; Perica, Dražen; Symeonides, Phivos; Vrablik, Michal; Ceska, Richard; Soska, Vladimir; Tichy, Lukas; Adamkova, Vera; Franekova, Jana; Cifkova, Renata; Kraml, Pavel; Vonaskova, Katerina; Cepova, Jana; Dusejovska, Magdalena; Pavlickova, Lenka; Blaha, Vladimir; Rosolova, Hana; Nussbaumerova, Barbora; Cibulka, Roman; Vaverkova, Helena; Cibickova, Lubica; Krejsova, Zdenka; Rehouskova, Katerina; Malina, Pavel; Budikova, Milena; Palanova, Vaclava; Solcova, Lucie; Lubasova, Alena; Podzimkova, Helena; Bujdak, Juraj; Vesely, Jiri; Jordanova, Marta; Salek, Tomas; Urbanek, Robin; Zemek, Stanislav; Lacko, Jan; Halamkova, Hana; Machacova, Sona; Mala, Sarka; Cubova, Eva; Valoskova, Katerina; Burda, Lukas; Bendary, Ahmed; Daoud, Ihab; Emil, Sameh; Elbahry, Atef; Rafla, Samir; Sanad, Osama; Kazamel, Ghada; Ashraf, Mohamed; Sobhy, Mohamed; El-Hadidy, Amro; Shafy, Mohamed A.; Kamal, Saif; Bendary, Mohamed; Talviste, Grete; Angoulvant, Denis; Boccara, Franck; Cariou, Bertrand; Carreau, Valérie; Carrie, Alain; Charrieres, Sybil; Cottin, Yves; Di-Fillipo, Mathilde; Ducluzeau, Pierre H.; Dulong, Sonia; Durlach, Vincent; Farnier, Michel; Ferrari, Emile; Ferrieres, Dorota; Ferrieres, Jean; Gallo, Antonio; hankard, Regis; Inamo, Jocelyne; Lemale, Julie; Moulin, Philippe; Paillard, François; Peretti, Noel; Perrin, Agnès; Pradignac, Alain; Rabes, Jean P.; Rigalleau, Vincent; Sultan, Ariane; Schiele, François; Tounian, Patrick; Valero, René; Verges, Bruno; Yelnik, Cécile; Ziegler, Olivier; Haack, Ira A.; Schmidt, Nina; Dressel, Alexander; Klein, Isabel; Christmann, Jutta; Sonntag, Antonia; Stumpp, Christine; Boger, Diana; Biedermann, Dana; Usme, Monica M.N.; Beil, F. Ulrich; Klose, Gerald; König, Christel; Gouni-Berthold, Ioanna; Otte, Britta; Böll, Gereon; Kirschbaum, Anja; Merke, Jürgen; Scholl, Johannes; Segiet, Thomas; Gebauer, Marco; Predica, Florentina; Mayer, Manfred; Leistikow, Frank; Füllgraf-Horst, Sabine; Müller, Cornelius; Schüler, Melanie; Wiener, Judith; Hein, Konrad; Baumgartner, Peter; Kopf, Stefan; Busch, Reinhold; Schömig, Michael; Matthias, Stephan; Allendorf-Ostwald, Nicole; Fink, Bruno; Böhm, Dieter; Jäkel, Alexander; Koschker, Ann-Cathrin; Schweizer, Rüdiger; Vogt, Anja; Parhofer, Klaus; König, Wolfgang; Reinhard, Wibke; Bäßler, Andrea; Stadelmann, Alexander; Schrader, Volker; Katzmann, Julius; Tarr, Adrienne; Steinhagen-Thiessen, Elisabeth; Kassner, Ursula; Paulsen, Gerret; Homberger, Jürgen; Zemmrich, Claudia; Seeger, Wolfgang; Biolik, Kathrin; Deiss, Dorothee; Richter, Corinna; Pantchechnikova, Elina; Dorn, Elena; Schatz, Ulrike; Julius, Ulrich; Spens, Antje; Wiesner, Tobias; Scholl, Michael; Rizos, Christos V.; Sakkas, Nikolaos; Elisaf, Moses; Skoumas, Ioannis; Tziomalos, Konstantinos; Rallidis, Loukianos; Kotsis, Vasileios; Doumas, Michalis; Athyros, Vasileios; Skalidis, Emmanouil; Kolovou, Genovefa; Garoufi, Anastasia; Bilianou, Eleni; Koutagiar, Iosif; Agapakis, Dimitrios; Kiouri, Estela; Antza, Christina; Katsiki, Niki; Zacharis, Evangelos; Attilakos, Achilleas; Sfikas, George; Koumaras, Charalambos; Anagnostis, Panagiotis; Anastasiou, Georgia; Liamis, George; Koutsogianni, Amalia-Despoina; Karányi, Zsolt; Harangi, Mariann; Bajnok, László; Audikovszky, Mária; Márk, László; Benczúr, Béla; Reiber, István; Nagy, Gergely; Nagy, András; Reddy, Lakshmi L.; Shah, Swarup A.V.; Ponde, Chandrashekhar K.; Dalal, Jamshed J.; Sawhney, Jitendra P.S.; Verma, Ishwar C.; Altaey, Mays; Al-Jumaily, Khalid; Rasul, Dilshad; Abdalsahib, Ali F.; Jabbar, Amer A.; Al-ageedi, Mohanad; Agar, Ruth; Cohen, Hofit; Ellis, Avishay; Gavishv, Dov; Harats, Dror; Henkin, Yaacov; Knobler, Hila; Leavit, Leah; Leitersdorf, Eran; Rubinstein, Ardon; Schurr, Daniel; Shpitzen, Shoshi; Szalat, Auryan; Casula, Manuela; Zampoleri, Veronica; Gazzotti, Marta; Olmastroni, Elena; Sarzani, Riccardo; Ferri, Claudio; Repetti, Elena; Sabbà, Carlo; Bossi, Antonio Carlo; Borghi, Claudio; Muntoni, Sandro; Cipollone, Francesco; Purrello, Francesco; Pujia, Arturo; Passaro, Angelina; Marcucci, Rossella; Pecchioli, Valerio; Pisciotta, Livia; Mandraffino, Giuseppe; Pellegatta, Fabio; Mombelli, Giuliana; Branchi, Adriana; Fiorenza, Anna Maria; Pederiva, Cristina; Werba, Josè Pablo; Parati, Gianfranco; Carubbi, Francesca; Iughetti, Lorenzo; Iannuzzi, Arcangelo; Iannuzzo, Gabriella; Calabrò, Paolo; Averna, Maurizio; Biasucci, Giacomo; Zambon, Sabina; Roscini, Anna Rita; Trenti, Chiara; Arca, Marcello; Federici, Massimo; Del Ben, Maria; Bartuli, Andrea; Giaccari, Andrea; Pipolo, Antonio; Citroni, Nadia; Guardamagna, Ornella; Bonomo, Katia; Benso, Andrea; Biolo, Gianni; Maroni, Lorenzo; Lupi, Alessandro; Bonanni, Luca; Zenti, Maria Grazia; Matsuki, Kota; Hori, Mika; Ogura, Masatsune; Masuda, Daisaku; Kobayashi, Takuya; Nagahama, Kumiko; Al-Jarallah, Mohammed; Radovic, Mirjana; Lunegova, Olga; Bektasheva, Erkayim; Khodzhiboboev, Elyor; Erglis, Andrejs; Gilis, Dainus; Nesterovics, Georgijs; Saripo, Vita; Meiere, Ruta; Upena-RozeMicena, Arta; Terauda, Elizabete; Jambart, Selim; Khoury, Petra E.; Elbitar, Sandy; Ayoub, Carine; Ghaleb, Youmna; Aliosaitiene, Urte; Kutkiene, Sandra; Kasim, Noor A.M.; Nor, Noor S.M.; Ramli, Anis S.; Razak, Suraya A.; Al-Khateeb, Alyaa; Kadir, Siti H.S.A.; Muid, Suhaila A.; Rahman, Thuhairah A.; Kasim, Sazzli S.; Radzi, Ahmad B.M.; Ibrahim, Khairul S.; Razali, Salmi; Ismail, Zaliha; Ghani, Rohana A.; Hafidz, Muhammad I.A.; Chua, Ang L.; Rosli, Marshima M.; Annamalai, Muthukkaruppan; Teh, Lay K.; Razali, Rafezah; Chua, Yung A.; Rosman, Azhari; Sanusi, Abdul R.; Murad, Nor A.A.; Jamal, A. Rahman A.; Nazli, Sukma A.; Razman, Aimi Z.; Rosman, Norhidayah; Rahmat, Radzi; Hamzan, Nur S.; Azzopardi, C.; Mehta, Roopa; Martagon, Alexandro J.; Ramirez, Gabriela A.G.; Villa, Neftali E.A.; Vazquez, Arsenio V.; Elias-Lopez, Daniel; Retana, Gustavo G.; Rodriguez, Betsabel; Macías, Jose J.C.; Zazueta, Alejandro R.; Alvarado, Rocio M.; Portano, Julieta D.M.; Lopez, Humberto A.; Sauque-Reyna, Leobardo; Herrera, Laura G.G.; Mendia, Luis E.S.; Aguilar, Humberto Garcia; Cooremans, Elizabeth R.; Aparicio, Berenice P.; Zubieta, Victoria M.; Gonzalez, Perla A.C.; Ferreira-Hermosillo, Aldo; Portilla, Nacu C.; Dominguez, Guadalupe J.; Garcia, Alinna Y.R.; Cazares, Hector E.A.; Gonzalez, Jesus R.; Valencia, Carla V.M.; Padilla, Francisco G.; Prado, Ramon M.; De los Rios Ibarra, Manuel O.; Villicaña, Ruy D.A.; Rivera, Karina J.A.; Carrera, Ricardo A.; Alvarez, Jose A.; Martinez, Jose C.A.; de los Reyes Barrera Bustillo, Manuel; Vargas, Gonzalo C.; Chacon, Roberto C.; Andrade, Mario H.F.; Ortega, Ashanty F.; Alcala, Hector G.; de Leon, Laura E.G.; Guzman, Berenice G.; Garcia, Jose J.G.; Cuellar, Juan C.G.; Cruz, Jose R.G.; Garcia, Anell Hernandez; Almada, Jesus R.H.; Herrera, Ursulo J.; Sobrevilla, Fabiola L.; Rodriguez, Eduardo M.; Sibaja, Cristina M.; Rodriguez, Alma B.M.; Oyervides, Jose C.M.; Vazquez, Daniel I.P.; Rodriguez, Eduardo A.R.; Osorio, Ma L.R.; Saucedo, Juan R.; Tamayo, Margarita T.; Talavera, Luis A.V.; Arroyo, Luis E.V.; Carrillo, Eloy A.Z.; Isara, Alphonsus; Obaseki, Darlington E.; Al-Waili, Khalid; Al-Zadjali, Fahad; Al-Zakwani, Ibrahim; Al-Kindi, Mohammed; Al-Mukhaini, Suad; Al-Barwani, Hamida; Rana, Asim; Shah, Lahore S.U.; Starostecka, Ewa; Konopka, Agnieszka; Lewek, Joanna; Bartłomiejczyk, Marcin; Gąsior, Mariusz; Dyrbuś, Krzysztof; Jóźwiak, Jacek; Gruchała, Marcin; Pajkowski, Marcin; Romanowska-Kocejko, Marzena; Żarczyńska-Buchowiecka, Marta; Chmara, Magdalena; Wasąg, Bartosz; Parczewska, Aleksandra; Gilis-Malinowska, Natasza; Borowiec-Wolna, Justyna; Stróżyk, Aneta; Woś, Marlena; Michalska-Grzonkowska, Aleksandra; Medeiros, Ana M.; Alves, Ana C.; Silva, Francisco; Lobarinhas, Goreti; Palma, Isabel; de Moura, Jose P.; Rico, Miguel T.; Rato, Quitéria; Pais, Patrícia; Correia, Susana; Moldovan, Oana; Virtuoso, Maria J.; Salgado, Jose M.; Colaço, Ines; Dumitrescu, Andreea; Lengher, Calin; Mosteoru, Svetlana; Meshkov, Alexey; Ershova, Alexandra; Rozkova, Tatiana; Korneva, Victoria; Yu, Kuznetsova T.; Zafiraki, Vitaliy; Voevoda, Mikhail; Gurevich, Victor; Duplyakov, Dmitry; Ragino, Yulia; Safarova, Maya; Shaposhnik, Igor; Alkaf, Fahmi; Khudari, Alia; Rwaili, Nawal; Al-Allaf, Faisal; Alghamdi, Mohammad; Batais, Mohammed A.; Almigbal, Turky H.; Kinsara, Abdulhalim; AlQudaimi, Ashraf H.A.; Awan, Zuhier; Elamin, Omer A.; Altaradi, Hani; Rajkovic, Natasa; Popovic, Ljiljana; Singh, Sandra; Stosic, Ljubica; Rasulic, Iva; Lalic, Nebojsa M.; Lam, Carolyn; Le, Tan J.; Siang, Eric L.T.; Dissanayake, Sanjaya; I-Shing, Justin T.; Shyong, Tai E.; Jin, Terrance C.S.; Balinth, Karin; Buganova, Ingrid; Fabryova, Lubomira; Kadurova, Michaela; Klabnik, Alexander; Kozárová, Miriam; Sirotiakova, Jana; Battelino, Tadej; Kovac, Jernej; Mlinaric, Matej; Sustar, Ursa; Podkrajsek, Katarina T.; Fras, Zlatko; Jug, Borut; Cevc, Matija; Pilcher, Gillian J.; Blom, D.J.; Wolmarans, K.H.; Brice, B.C.; Muñiz-Grijalvo, Ovidio; Díaz-Díaz, Jose L.; de Isla, Leopoldo P.; Fuentes, Francisco; Badimon, Lina; Martin, François; Lux, Angela; Chang, Nien-Tzu; Ganokroj, Poranee; Akbulut, Mehmet; Alici, Gökhan; Bayram, Fahri; Can, Levent H.; Celik, Ahmet; Ceyhan, Ceyhun; Coskun, Fatma Y.; Demir, Mesut; Demircan, Sabri; Dogan, Volkan; Durakoglugil, Emre; Dural, Ibrahim E.; Gedikli, Omer; Hacioglu, Aysa; Ildizli, Muge; Kilic, Salih; Kirilmaz, Bahadir; Kutlu, Merih; Oguz, Aytekin; Ozdogan, Oner; Onrat, Ersel; Ozer, Savas; Sabuncu, Tevfik; Sahin, Tayfun; Sivri, Fatih; Sonmez, Alper; Temizhan, Ahmet; Topcu, Selim; Tuncez, Abdullah; Vural, Mirac; Yenercag, Mustafa; Yesilbursa, Dilek; Yigit, Zerrin; Yildirim, Aytul B.; Yildirir, Aylin; Yilmaz, Mehmet B.; Atallah, Bassam; Traina, Mahmoud; Sabbour, Hani; Hay, Dana A.; Luqman, Neama; Elfatih, Abubaker; Abdulrasheed, Arshad; Kwok, See; Oca, Nicolas D.; Reyes, Ximena; Alieva, Rano B.; Kurbanov, Ravshanbek D.; Hoshimov, Shavkat U.; Nizamov, Ulugbek I.; Ziyaeva, Adolat V.; Abdullaeva, Guzal J.; Do, Doan L.; Nguyen, Mai N.T.; Kim, Ngoc T.; Le, Thanh T.; Le, Hong A.; Tokgozoglu, Lale; Catapano, Alberico L.; Ray, Kausik K.Vallejo-Vaz, Antonio J.; Stevens, Christophe A. T.; Lyons, Alexander R. M.; Dharmayat, Kanika I.; Freiberger, Tomas; Hovingh, G. Kees; Mata, Pedro; Raal, Frederick J.; Santos, Raul D.; Soran, Handrean; Watts, Gerald F.; Abifadel, Marianne; Aguilar-Salinas, Carlos A.; Alhabib, Khalid F.; Alkhnifsawi, Mutaz; Almahmeed, Wael; Alnouri, Fahad; Alonso, Rodrigo; Al-Rasadi, Khalid; Al-Sarraf, Ahmad; Al-Sayed, Nasreen; Araujo, Francisco; Ashavaid, Tester F.; Banach, Maciej; Béliard, Sophie; Benn, Marianne; Binder, Christoph J.; Bogsrud, Martin P.; Bourbon, Mafalda; Chlebus, Krzysztof; Corral, Pablo; Davletov, Kairat; Descamps, Olivier S.; Durst, Ronen; Ezhov, Marat; Gaita, Dan; Genest, Jacques; Groselj, Urh; Harada-Shiba, Mariko; Holven, Kirsten B.; Kayikcioglu, Meral; Khovidhunkit, Weerapan; Lalic, Katarina; Latkovskis, Gustavs; Laufs, Ulrich; Liberopoulos, Evangelos; Lima-Martinez, Marcos M.; Lin, Jie; Maher, Vincent; Marais, A. David; März, Winfried; Mirrakhimov, Erkin; Miserez, André R.; Mitchenko, Olena; Nawawi, Hapizah; Nordestgaard, Børge G.; Panayiotou, Andrie G.; Paragh, György; Petrulioniene, Zaneta; Pojskic, Belma; Postadzhiyan, Arman; Raslova, Katarina; Reda, Ashraf; Reiner, Željko; Sadiq, Fouzia; Sadoh, Wilson Ehidiamen; Schunkert, Heribert; Shek, Aleksandr B.; Stoll, Mario; Stroes, Erik; Su, Ta-Chen; Subramaniam, Tavintharan; Susekov, Andrey V.; Tilney, Myra; Tomlinson, Brian; Truong, Thanh Huong; Tselepis, Alexandros D.; Tybjærg-Hansen, Anne; Vázquez Cárdenas, Alejandra; Viigimaa, Margus; Wang, Luya; Yamashita, Shizuya; Kastelein, John J. P.; Bruckert, Eric; Vohnout, Branislav; Schreier, Laura; Pang, Jing; Ebenbichler, Christoph; Dieplinger, Hans; Innerhofer, Reinhold; Winhofer-Stöckl, Yvonne; Greber-Platzer, Susanne; Krychtiuk, Konstantin; Speidl, Walter; Toplak, Hermann; Widhalm, Kurt; Stulnig, Thomas; Huber, Kurt; Höllerl, Florian; Rega-Kaun, Gersina; Kleemann, Lucas; Mäser, Martin; Scholl-Bürgi, Sabine; Säly, Christoph; Mayer, Florian J.; Sablon, Gaelle; Tarantino, Eric; Nzeyimana, Charlotte; Pojskic, Lamija; Sisic, Ibrahim; Nalbantic, Azra D.; Jannes, Cinthia E.; Pereira, Alexandre C.; Krieger, Jose E.; Petrov, Ivo; Goudev, Assen; Nikolov, Fedya; Tisheva, Snejana; Yotov, Yoto; Tzvetkov, Ivajlo; Baass, Alexis; Bergeron, Jean; Bernard, Sophie; Brisson, Diane; Brunham, Liam R.; Cermakova, Lubomira; Couture, Patrick; Francis, Gordon A.; Gaudet, Daniel; Hegele, Robert A.; Khoury, Etienne; Mancini, G. B. John; Mccrindle, Brian W.; Paquette, Martine; Ruel, Isabelle; Cuevas, Ada; Asenjo, Sylvia; Wang, Xumin; Meng, Kang; Song, Xiantao; Yong, Qiang; Jiang, Tao; Liu, Ziyou; Duan, Yanyu; Hong, Jing; Ye, Pucong; Chen, Yan; Qi, Jianguang; Liu, Zesen; Li, Yuntao; Zhang, Chaoyi; Peng, Jie; Yang, Ya; Yu, Wei; Wang, Qian; Yuan, Hui; Cheng, Shitong; Jiang, Long; Chong, Mei; Jiao, Jian; Wu, Yue; Wen, Wenhui; Xu, Liyuan; Zhang, Ruiying; Qu, Yichen; He, Jianxun; Fan, Xuesong; Wang, Zhenjia; Chow, Elaine; Pećin, Ivan; Perica, Dražen; Symeonides, Phivos; Vrablik, Michal; Ceska, Richard; Soska, Vladimir; Tichy, Lukas; Adamkova, Vera; Franekova, Jana; Cifkova, Renata; Kraml, Pavel; Vonaskova, Katerina; Cepova, Jana; Dusejovska, Magdalena; Pavlickova, Lenka; Blaha, Vladimir; Rosolova, Hana; Nussbaumerova, Barbora; Cibulka, Roman; Vaverkova, Helena; Cibickova, Lubica; Krejsova, Zdenka; Rehouskova, Katerina; Malina, Pavel; Budikova, Milena; Palanova, Vaclava; Solcova, Lucie; Lubasova, Alena; Podzimkova, Helena; Bujdak, Juraj; Vesely, Jiri; Jordanova, Marta; Salek, Tomas; Urbanek, Robin; Zemek, Stanislav; Lacko, Jan; Halamkova, Hana; Machacova, Sona; Mala, Sarka; Cubova, Eva; Valoskova, Katerina; Burda, Lukas; Bendary, Ahmed; Daoud, Ihab; Emil, Sameh; Elbahry, Atef; Rafla, Samir; Sanad, Osama; Kazamel, Ghada; Ashraf, Mohamed; Sobhy, Mohamed; El-Hadidy, Amro; Shafy, Mohamed A.; Kamal, Saif; Bendary, Mohamed; Talviste, Grete; Angoulvant, Denis; Boccara, Franck; Cariou, Bertrand; Carreau, Valérie; Carrie, Alain; Charrieres, Sybil; Cottin, Yves; Di-Fillipo, Mathilde; Ducluzeau, Pierre H.; Dulong, Sonia; Durlach, Vincent; Farnier, Michel; Ferrari, Emile; Ferrieres, Dorota; Ferrieres, Jean; Gallo, Antonio; Hankard, Regis; Inamo, Jocelyne; Lemale, Julie; Moulin, Philippe; Paillard, François; Peretti, Noel; Perrin, Agnès; Pradignac, Alain; Rabes, Jean P.; Rigalleau, Vincent; Sultan, Ariane; Schiele, François; Tounian, Patrick; Valero, René; Verges, Bruno; Yelnik, Cécile; Ziegler, Olivier; Haack, Ira A.; Schmidt, Nina; Dressel, Alexander; Klein, Isabel; Christmann, Jutta; Sonntag, Antonia; Stumpp, Christine; Boger, Diana; Biedermann, Dana; Usme, Monica M. N.; Beil, F. Ulrich; Klose, Gerald; König, Christel; Gouni-Berthold, Ioanna; Otte, Britta; Böll, Gereon; Kirschbaum, Anja; Merke, Jürgen; Scholl, Johannes; Segiet, Thomas; Gebauer, Marco; Predica, Florentina; Mayer, Manfred; Leistikow, Frank; Füllgraf-Horst, Sabine; Müller, Cornelius; Schüler, Melanie; Wiener, Judith; Hein, Konrad; Baumgartner, Peter; Kopf, Stefan; Busch, Reinhold; Schömig, Michael; Matthias, Stephan; Allendorf-Ostwald, Nicole; Fink, Bruno; Böhm, Dieter; Jäkel, Alexander; Koschker, Ann-Cathrin; Schweizer, Rüdiger; Vogt, Anja; Parhofer, Klaus; König, Wolfgang; Reinhard, Wibke; Bäßler, Andrea; Stadelmann, Alexander; Schrader, Volker; Katzmann, Julius; Tarr, Adrienne; Steinhagen-Thiessen, Elisabeth; Kassner, Ursula; Paulsen, Gerret; Homberger, Jürgen; Zemmrich, Claudia; Seeger, Wolfgang; Biolik, Kathrin; Deiss, Dorothee; Richter, Corinna; Pantchechnikova, Elina; Dorn, Elena; Schatz, Ulrike; Julius, Ulrich; Spens, Antje; Wiesner, Tobias; Scholl, Michael; Rizos, Christos V.; Sakkas, Nikolaos; Elisaf, Moses; Skoumas, Ioannis; Tziomalos, Konstantinos; Rallidis, Loukianos; Kotsis, Vasileios; Doumas, Michalis; Athyros, Vasileios; Skalidis, Emmanouil; Kolovou, Genovefa; Garoufi, Anastasi

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research