Health system’s readiness to provide cardiovascular, diabetes and chronic respiratory disease related services in Nepal: analysis using 2015 health facility survey

BACKGROUND: The burgeoning rise of non-communicable diseases (NCDs) is posing serious challenges in resource constrained health facilities of Nepal. The main objective of this study was to assess the readiness of health facilities for cardiovascular diseases (CVDs), diabetes and chronic respiratory diseases (CRDs) services in Nepal. METHODS: This study utilized data from the Nepal Health Facility Survey 2015. General readiness of 940 health facilities along with disease specific readiness for CVDs, diabetes, and CRDs were assessed using the Service Availability and Readiness Assessment manual of the World Health Organization. Health facilities were categorized into public and private facilities. RESULTS: Out of a total of 940 health facilities assessed, private facilities showed higher availability of items of general service readiness except for standard precautions for infection prevention, compared to public facilities. The multivariable adjusted regression coefficients for CVDs (β = 2.87, 95%CI: 2.42-3.39), diabetes (β =3.02, 95%CI: 2.03-4.49), and CRDs (β = 15.95, 95%CI: 4.61-55.13) at private facilities were higher than the public facilities. Health facilities located in the hills had a higher readiness index for CVDs (β = 1.99, 95%CI: 1.02-1.39). Service readiness for CVDs (β = 1.13, 95%CI: 1.04-1.23) and diabetes (β = 1.78, 95%CI: 1.23-2.59) were higher in the urban municipalities than in rural municipalities. Finally, disease-related services readiness index was sub-optimal with some degree of variation at the province level in Nepal. Compared to province 1, province 2 (β = 0.83, 95%CI: 0.73-0.95) had lower, and province 4 (β =1.24, 95%CI: 1.07-1.43) and province 5 (β =1.17, 95%CI: 1.02-1.34) had higher readiness index for CVDs. CONCLUSION: This study found sub-optimal readiness of services related to three NCDs at the public facilities in Nepal. Compared to public facilities, private facilities showed higher readiness scores for CVDs, diabetes, and CRDs. There is an urgent need for policy reform to improve the health services for NCDs, particularly in public facilities

Myocardial Injury, Obesity, and the Obesity Paradox

To examine whether pre-heart failure (HF) myocardial injury explains the differential mortality after HF across weight categories

Lipoprotein associated phospholipase A2 activity, apolipoprotein C3 loss-of-function variants and cardiovascular disease: The Atherosclerosis Risk In Communities Study

Lipoprotein-associated phospholipase A2 (LpPLA2) activity was associated with higher CHD risk in a meta-analysis, which was partly dependent on circulating lipid levels. Apolipoprotein C3 loss-of-function (ApoC3 LOF) mutations were related with reduced postprandial lipemia and CHD risk. However, the association of LpPLA2 activity with ApoC3 LOF is not known

High-Sensitivity Troponin T and Cardiovascular Events in Systolic Blood Pressure CategoriesNovelty and Significance: Atherosclerosis Risk in Communities Study

Based on observational studies there is a linear increase in cardiovascular risk with higher systolic blood pressure, yet clinical trials have not shown benefit across all systolic blood pressure categories. We assessed if troponin-T measured using high-sensitivity assay was associated with cardiovascular disease within systolic blood pressure categories in 11191 Atherosclerosis Risk in Communities study participants. Rested sitting systolic blood pressure by 10-mmHg increments and troponin categories were identified. Incident heart failure hospitalization, coronary heart disease and stroke were ascertained over a median of 12 years after excluding individuals with corresponding disease. Approximately 53% of each type of cardiovascular event occurred in individuals with systolic blood pressure<140 mmHg and troponin-T≥3ng/L. Higher troponin-T was associated with increasing cardiovascular events across most systolic blood pressure categories. The association was strongest for heart failure and least strong for stroke. There was no similar association of systolic blood pressure with cardiovascular events across troponin-T categories. Individuals with troponin-T≥3ng/L and systolic blood pressure<140mmHg had higher cardiovascular risk compared to those with troponin-T<3ng/L and systolic blood pressure 140-159 mmHg

The promise of proprotein convertase subtilisin/kexin 9 inhibitors for the treatment of familial hypercholesterolemia

Familial hypercholesterolemia comprises a constellation of genetic disorders resulting in very high cholesterol levels since childhood. If untreated, it is associated with accelerated atherosclerosis and premature cardiovascular disease. It has been shown that if aggressive cholesterol lowering is achieved in familial hypercholesterolemia, the incidence of cardiovascular disease can be lowered. However, currently approved pharmacological therapies are not able to lower cholesterol to optimal levels in a large number of these patients. Proprotein convertase subtilisin/kexin 9 inhibitors are a new class of cholesterol-lowering medications that can significantly reduce cholesterol levels in these patients especially those with at least some functioning low-density lipoprotein receptors. In this article, we will briefly review familial hypercholesterolemia and the role of proprotein convertase subtilisin/kexin 9 inhibitors in this condition

Cholesterol guidelines: More similar than different

A clinician has a large number of guidelines to follow. Searching the words cardiovascular and guideline on the website, www.guideline.gov yielded 502 cardiovascular guidelines, 40 alone in 2015. 1 [National Guideline Clearinghouse: Agency for Healthcare Research and 19 Quality (n.d.)] Similarly, searching the words cholesterol and guideline yielded 107 results, 6 alone in 2015. This information overload can decrease providers\u27 self-efficacy in using guidelines, particularly if they have inconsistent messages. Moreover, a busy provider can easily be lost if the emphasis is on highlighting differences rather than similarities on the same topic. There are several guidelines for management of blood cholesterol and lipids. Despite being more similar than different, their similarities have not received as much attention as the differences between them. Unfortunately, there are still major gaps in current clinical practice even across these common themes. In this review, we will provide a brief overview of various cholesterol/lipid guidelines followed by a discussion of the differences but more importantly, similarities between them

CLINICIANS’ SELF-REPORTED EFFICACY IN CARDIOVASCULAR PREVENTION PRACTICE IN THE SOUTHEASTERN UNITED STATES

Therapeutic Area: Preventive Cardiology Best Practices Background: Cardiovascular disease disproportionately affects the Southeastern US. Cardiovascular preventive care is offered by various specialties with differences in training and perspectives. Therefore, there is potential heterogeneity in self-efficacy when delivering cardiovascular preventive care. We assessed clinicians’ self-reported efficacy regarding cardiovascular prevention practice in the Southeast US. Methods: We emailed a 21-item questionnaire four times between November 10, 2021, and January 3, 2022, to 956 clinicians (physicians, nurse practitioners, physician assistants, and pharmacists) from internal medicine, family medicine, endocrinology, and cardiology specialties in the Southeast US. We assessed clinicians’ self-efficacy using Likert scales. Participants rated self-efficacy as completely confident, fairly confident, somewhat confident, slightly confident, and not confident. We combined completely confident and fairly confident responses together and compared categorical responses from primary care providers (PCPs) (internal and family medicine) with specialists (endocrinology and cardiology) using Chi-Square test. Results: 264 clinicians from 19 institutions completed the survey (median age 39 years, 55% women). Specialists comprised 46% (9% endocrinology, 91% cardiology) and PCPs 54% (62% internal medicine, 38% family medicine). PCPs expressed lower self-efficacy compared to specialists in interpreting and managing results of coronary artery calcium testing (24% vs. 69%), high-sensitivity C-reactive protein (20% vs. 46%), lipoprotein(a) (17% vs. 40%), familial hypercholesterolemia (45% vs 72%), and in prescribing ezetimibe (64% vs. 88%), proprotein convertase subtilisin/kexin type 9 inhibitors (18% vs. 70%), and icosapent ethyl (18% vs. 46%) (Figure). Conversely, PCPs expressed greater self-efficacy compared with specialists in prescribing metformin (96% vs. 64%), sodium-glucose cotransporter-2 inhibitors (82% vs. 59%), and glucagon-like peptide-1 receptor agonists (86% vs. 40%) (P-value for all comparisons ≤0.0001). Both PCPs and specialists expressed lower self-efficacy in prescribing bempedoic acid (10%, 18%, P = 0.11) and higher self-efficacy in prescribing aspirin for primary prevention (75% vs 86%, P = 0.07). Conclusion: Our results highlight the heterogeneity in clinicians’ self-reported efficacy in CVD prevention practice in the Southeast United States. Further research should explore effective strategies to enhance clinicians’ self-efficacy

Cardio-metabolic disease risk factors among South Asian labour migrants to the Middle East: a scoping review and policy analysis

This paper aims to explore the burgeoning burden of cardiovascular and metabolic disease (CMD) risk factors among South Asian labor migrants to the Middle East. We conducted a qualitative synthesis of literature using PubMed/Medline and grey literature searches, supplemented by a policy review of policies from the South Asian countries. We found a high burden of cardio-metabolic risk factors among the migrants as well as among the populations in the home and the host countries. For example, two studies reported the prevalence of diabetes mellitus (DM) ranging between 9 and 17% among South Asian migrants. Overweight and obesity were highly prevalent amongst South Asian male migrants; prevalence ranged from 30 to 66% (overweight) and 17-80% (obesity) respectively. The home country population had a significant CMD risk factor burden. Nearly 14 to 40% have three or more risk factors: such as hypertension (17 to 37%), diabetes (3 to 7%), overweight (18 to 41%), and obesity (2 to 15%). The host country also exhibited similar burden of risk factors: hypertension (13 to 38%), diabetes (8 to 17%), overweight (33 to 77%) and obesity (35 to 41%). Only Nepal, Bangladesh and Sri Lanka have some provisions related to screening of CMDs before labor migration. Further, analysis of policy papers showed that none of the reviewed documents had requirements for screening of any specific CMDs, but chronic diseases were used generically, failing to specify specific screening target. Given the high burden of risk factors, migrants' health should become an urgent priority. The lack of specific focus on screening during different stages of labor migration should receive attention. The International Labour Organization and the International Office for Migration, through their country coordination teams should engage local stakeholders to create policies and plans to address this concern. Similarly, there is a need for the host country to become an equal partner in these efforts, as migrant's better cardiometabolic health is in the benefit of both host and home countries