As pressure increases on public health systems globally, a potential consequence is that this is transferred to patients in the form of longer waiting times to receive care. In this review, we ...overview what waiting for health care encompasses, its measurement, and the data available in terms of trends and comparability. We also discuss whether waiting time is equally distributed according to socioeconomic status. Finally, we discuss the policy implications and potential approaches to addressing the burden of waiting time. Waiting time for elective surgery and emergency department care is the best described type of waiting time, and it either increases or remains unchanged across multiple developed countries. There are many challenges in drawing direct comparisons internationally, as definitions for these types of waiting times vary. There are less data on waiting time from other settings, but existing data suggest waiting time presents a significant barrier to health care access for a range of health services. There is also evidence that waiting time is unequally distributed to those of lower socioeconomic status, although this may be improving in some countries. Further work to better clarify definitions, identify driving factors, and understand hidden waiting times and identify opportunities for reducing waiting time or better using waiting time could improve health outcomes of our health services.
Hypertension is the most important preventable cause of morbidity and mortality globally, yet there are relatively few data collected using standardized methods.
To examine hypertension prevalence, ...awareness, treatment, and control in participants at baseline in the Prospective Urban Rural Epidemiology (PURE) study.
A cross-sectional study of 153,996 adults (complete data for this analysis on 142,042) aged 35 to 70 years, recruited between January 2003 and December 2009. Participants were from 628 communities in 3 high-income countries (HIC), 10 upper-middle-income and low-middle-income countries (UMIC and LMIC), and 4 low-income countries (LIC).
Hypertension was defined as individuals with self-reported treated hypertension or with an average of 2 blood pressure measurements of at least 140/90 mm Hg using an automated digital device. Awareness was based on self-reports, treatment was based on the regular use of blood pressure-lowering medications, and control was defined as individuals with blood pressure lower than 140/90 mm Hg.
Among the 142,042 participants, 57,840 (40.8%; 95% CI, 40.5%-41.0%) had hypertension and 26,877 (46.5%; 95% CI, 46.1%-46.9%) were aware of the diagnosis. Of those who were aware of the diagnosis, the majority (23,510 87.5%; 95% CI, 87.1%-87.9% of those who were aware) were receiving pharmacological treatments, but only a minority of those receiving treatment were controlled (7634 32.5%; 95% CI, 31.9%-33.1%). Overall, 30.8%, 95% CI, 30.2%-31.4% of treated patients were taking 2 or more types of blood pressure-lowering medications. The percentages aware (49.0% 95% CI, 47.8%-50.3% in HICs, 52.5% 95% CI, 51.8%-53.2% in UMICs, 43.6% 95% CI, 42.9%-44.2% in LMICs, and 40.8% 95% CI, 39.9%-41.8% in LICs) and treated (46.7% 95% CI, 45.5%-47.9% in HICs, 48.3%, 95% CI, 47.6%-49.1% in UMICs, 36.9%, 95% CI, 36.3%-37.6% in LMICs, and 31.7% 95% CI, 30.8%-32.6% in LICs) were lower in LICs compared with all other countries for awareness (P <.001) and treatment (P <.001). Awareness, treatment, and control of hypertension were higher in urban communities compared with rural ones in LICs (urban vs rural, P <.001) and LMICs (urban vs rural, P <.001), but similar for other countries. Low education was associated with lower rates of awareness, treatment, and control in LICs, but not in other countries.
Among a multinational study population, 46.5% of participants with hypertension were aware of the diagnosis, with blood pressure control among 32.5% of those being treated. These findings suggest substantial room for improvement in hypertension diagnosis and treatment.
Raised blood pressure is the most important risk factor in the global burden of disease.1 Although there is robust evidence to show that lowering blood pressure can substantially reduce ...cardiovascular morbidity and mortality,2 the global burden of hypertension is increasing.3,4 To achieve a reduction in the burden of disease related to hypertension, health systems must ensure that high blood pressure treatment and control rates are achieved. The factors involved range from social determinants (such as rapid and unplanned urbanisation, poverty, illiteracy, the political context, gender and racial discrimination, the human development index, and social development); to factors relating to health care (infrastructure, availability, access, and quality), medical education (the number of physicians, nurses, and paramedical workers), and physicians (competing interests, information overload, and inertia); to patient adherence. In HICs, availability and affordability of medication are less likely to be a barrier to effective control of blood pressure, but better strategies to address physician inertia or medical patient adherence might be needed.
High blood pressure is a leading modifiable cause of premature death and one of WHO's global targets for the prevention of non-communicable diseases. ...these are still estimates based on the best ...available data.6 The disappointing message of this study, however, is that despite much research, health systems, and global policy efforts, progress has been slow in the global control of hypertension.7 There is an urgent need for a transformation and innovative approaches to reduce the burden of hypertension globally. From a medical model point of view, digital transformation such as telemonitoring, home blood pressure monitoring, text message reminders to improve adherence, and other digital health interventions to encourage healthy behaviours, or simpler medical regimens such as initial treatment with a combination therapy—such as a single pill containing ultra-low-dose quadruple combination therapy—should be considered to address barriers to blood pressure control.9–12 Finally the standstill in global prevalence and the global control rates of approximately 20% should serve as an important global wakeup call that cardiovascular disease is going to be a main burden of disease for many years to come, especially if we carry on like this.
Adherence to long-term therapies in chronic disease is poor. Traditional interventions to improve adherence are complex and not widely effective. Mobile telephone text messaging may be a scalable ...means to support medication adherence.
To conduct a meta-analysis of randomized clinical trials to assess the effect of mobile telephone text messaging on medication adherence in chronic disease.
MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, and CINAHL (from database inception to January 15, 2015), as well as reference lists of the articles identified. The data were analyzed in March 2015.
Randomized clinical trials evaluating a mobile telephone text message intervention to promote medication adherence in adults with chronic disease.
Two authors independently extracted information on study characteristics, text message characteristics, and outcome measures as per the predefined protocol.
Odds ratios and pooled data were calculated using random-effects models. Risk of bias and study quality were assessed as per Cochrane guidelines. Disagreement was resolved by consensus.
Sixteen randomized clinical trials were included, with 5 of 16 using personalization, 8 of 16 using 2-way communication, and 8 of 16 using a daily text message frequency. The median intervention duration was 12 weeks, and self-report was the most commonly used method to assess medication adherence. In the pooled analysis of 2742 patients (median age, 39 years and 50.3% 1380 of 2742 female), text messaging significantly improved medication adherence (odds ratio, 2.11; 95% CI, 1.52-2.93; P < .001). The effect was not sensitive to study characteristics (intervention duration or type of disease) or text message characteristics (personalization, 2-way communication, or daily text message frequency). In a sensitivity analysis, our findings remained robust to change in inclusion criteria based on study quality (odds ratio, 1.67; 95% CI, 1.21-2.29; P = .002). There was moderate heterogeneity (I2 = 62%) across clinical trials. After adjustment for publication bias, the point estimate was reduced but remained positive for an intervention effect (odds ratio, 1.68; 95% CI, 1.18-2.39).
Mobile phone text messaging approximately doubles the odds of medication adherence. This increase translates into adherence rates improving from 50% (assuming this baseline rate in patients with chronic disease) to 67.8%, or an absolute increase of 17.8%. While promising, these results should be interpreted with caution given the short duration of trials and reliance on self-reported medication adherence measures. Future studies need to determine the features of text message interventions that improve success, as well as appropriate patient populations, sustained effects, and influences on clinical outcomes.
Many studies have now demonstrated the efficacy of text messaging in positively changing behaviours. We aimed to identify features and factors that explain the effectiveness of a successful text ...messaging program in terms of user engagement, perceived usefulness, behavior change and program delivery preferences.
Mixed methods qualitative design combining four data sources; (i) analytic data extracted directly from the software system, (ii) participant survey, (iii) focus groups to identify barriers and enablers to implementation and mechanisms of effect and (iv) recruitment screening logs and text message responses to examine engagement. This evaluation was conducted within the TEXT ME trial-a parallel design, single-blind randomized controlled trial (RCT) of 710 patients with coronary heart disease (CHD). Qualitative data were interpreted using inductive thematic analysis.
307/352 (87% response rate) of recruited patients with CHD completed the program evaluation survey at six months and 25 participated in a focus group. Factors increasing engagement included (i) ability to save and share messages, (ii) having the support of providers and family, (iii) a feeling of support through participation in the program, (iv) the program being initiated close to the time of a cardiovascular event, (v) personalization of the messages, (vi) opportunity for initial face-to-face contact with a provider and (vii) that program and content was perceived to be from a credible source. Clear themes relating to program delivery were that diet and physical activity messages were most valued, four messages per week was ideal and most participants felt program duration should be provided for at least for six months or longer.
This study provides context and insight into the factors influencing consumer engagement with a text message program aimed at improving health-related behavior. The study suggests program components that may enhance potential success but will require integration at the development stage to optimize up-scaling.
Australia and New Zealand Clinical Trials Registry, ACTRN12611000161921.
Mobile health is the use of mobile technology in developing healthcare, with the aim of reminding and motivating patients to adopt a healthy lifestyle. We conducted a systematic review assessing the ...effectiveness of text-messaging interventions on HbA1c in patients with Type 2 diabetes mellitus (T2DM).
Two authors independently searched MEDLINE, Embase, CINAHL, Cochrane Register of Randomized Control Trials and PsychInfo. The review included randomized control trials with at least 4 weeks follow up, evaluating the effect of text messaging on HbA1c, in patients with T2DM. Trials involving participants with Type 1 diabetes mellitus, pre-diabetes or gestational diabetes, or other forms of telemedicine were excluded. Studies employing bi-directional messaging were excluded.
208 papers were identified as meeting inclusion criteria and their abstracts reviewed. Of these, we examined the full text article of forty-four studies. Eleven randomized controlled trials were included in the final review, with a total of 1710 participants. One study focused on medication adherence only, while the remaining had educational and motivational messages. Five studies showed a significant improvement in HbA1c with the intervention. The remaining studies demonstrated a trend to improvement in HbA1c. Our meta-analysis on 9 of the 11 studies found an overall reduction in HbA1c of 0.38% (−0.53; −0.23, p-value <0.001).
Lifestyle-focused text messaging is a low cost initiative aimed at motivating patients with T2DM to adhere to a healthy lifestyle. We demonstrate that lifestyle focused text messaging is effective, with a significant improvement in HbA1c in the meta-analysis.
Cardiovascular Disease in the Developing World Celermajer, David S., MBBS, PhD; Chow, Clara K., MBBS, PhD; Marijon, Eloi, MD ...
Journal of the American College of Cardiology,
10/2012, Letnik:
60, Številka:
14
Journal Article
Recenzirano
Odprti dostop
Over the past decade or more, the prevalence of traditional risk factors for atherosclerotic cardiovascular diseases has been increasing in the major populous countries of the developing world, ...including China and India, with consequent increases in the rates of coronary and cerebrovascular events. Indeed, by 2020, cardiovascular diseases are predicted to be the major causes of morbidity and mortality in most developing nations around the world. Techniques for the early detection of arterial damage have provided important insights into disease patterns and pathogenesis and especially the effects of progressive urbanization on cardiovascular risk in these populations. Furthermore, certain other diseases affecting the cardiovascular system remain prevalent and important causes of cardiovascular morbidity and mortality in developing countries, including the cardiac effects of rheumatic heart disease and the vascular effects of malaria. Imaging and functional studies of early cardiovascular changes in those disease processes have also recently been published by various groups, allowing consideration of screening and early treatment opportunities. In this report, the authors review the prevalences and patterns of major cardiovascular diseases in the developing world, as well as potential opportunities provided by early disease detection.
Summary Background Although most cardiovascular disease occurs in low-income and middle-income countries, little is known about the use of effective secondary prevention medications in these ...communities. We aimed to assess use of proven effective secondary preventive drugs (antiplatelet drugs, β blockers, angiotensin-converting-enzyme ACE inhibitors or angiotensin-receptor blockers ARBs, and statins) in individuals with a history of coronary heart disease or stroke. Methods In the Prospective Urban Rural Epidemiological (PURE) study, we recruited individuals aged 35–70 years from rural and urban communities in countries at various stages of economic development. We assessed rates of previous cardiovascular disease (coronary heart disease or stroke) and use of proven effective secondary preventive drugs and blood-pressure-lowering drugs with standardised questionnaires, which were completed by telephone interviews, household visits, or on patient's presentation to clinics. We report estimates of drug use at national, community, and individual levels. Findings We enrolled 153 996 adults from 628 urban and rural communities in countries with incomes classified as high (three countries), upper-middle (seven), lower-middle (three), or low (four) between January, 2003, and December, 2009. 5650 participants had a self-reported coronary heart disease event (median 5·0 years previously IQR 2·0–10·0) and 2292 had stroke (4·0 years previously 2·0–8·0). Overall, few individuals with cardiovascular disease took antiplatelet drugs (25·3%), β blockers (17·4%), ACE inhibitors or ARBs (19·5%), or statins (14·6%). Use was highest in high-income countries (antiplatelet drugs 62·0%, β blockers 40·0%, ACE inhibitors or ARBs 49·8%, and statins 66·5%), lowest in low-income countries (8·8%, 9·7%, 5·2%, and 3·3%, respectively), and decreased in line with reduction of country economic status (ptrend <0·0001 for every drug type). Fewest patients received no drugs in high-income countries (11·2%), compared with 45·1% in upper middle-income countries, 69·3% in lower middle-income countries, and 80·2% in low-income countries. Drug use was higher in urban than rural areas (antiplatelet drugs 28·7% urban vs 21·3% rural, β blockers 23·5% vs 15·6%, ACE inhibitors or ARBs 22·8% vs 15·5%, and statins 19·9% vs 11·6%; all p<0·0001), with greatest variation in poorest countries (pinteraction <0·0001 for urban vs rural differences by country economic status). Country-level factors (eg, economic status) affected rates of drug use more than did individual-level factors (eg, age, sex, education, smoking status, body-mass index, and hypertension and diabetes statuses). Interpretation Because use of secondary prevention medications is low worldwide—especially in low-income countries and rural areas—systematic approaches are needed to improve the long-term use of basic, inexpensive, and effective drugs. Funding Full funding sources listed at end of paper (see Acknowledgments).
Polypills can contain multiple pharmaceutical agents targeting the cardiovascular system. The use of polypills in the secondary prevention of cardiovascular disease (CVD) has received broad support; ...however, the use of polypills in the primary prevention of CVD is more controversial. This controversy stems from an inherent resistance to the medicalization of primary prevention, and the lower CVD event rate in this population means that smaller absolute benefits are derived. Indeed, drug-related adverse effects, such as from aspirin, might even outweigh the benefits. The role of fixed-dose combination (FDC) therapy for blood pressure (BP) lowering in combatting the widespread undertreatment of high BP - the leading modifiable risk factor contributing to the global burden of CVD - has gained momentum. Increasing evidence suggests that FDC pills containing multiple low doses of BP-lowering drugs produce more effective BP lowering than the use of fewer separate BP-lowering drugs at higher doses, without an increase in adverse effects. Trials of FDC pills comprising three half-dose or four quarter-dose BP-lowering drugs have shown substantial efficacy. In this Review, we summarize the current evidence on low-dose BP-lowering FDC pills and the justification for this approach in the context of polypills in the primary prevention of CVD.
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