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Qalby N, Arsyad DS, Qanitha A, Cramer MJ, Appelman Y, Pabittei DR, Doevendans PA, Mappangara I, Muzakkir AF. In-hospital mortality of patients with acute coronary syndrome (ACS) after implementation of national health insurance (NHI) in Indonesia. BMC Health Serv Res 2024; 24:284. [PMID: 38443913 PMCID: PMC10916244 DOI: 10.1186/s12913-024-10637-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/25/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The National Health Insurance (NHI) was implemented in Indonesia in 2014, and cardiovascular diseases are one of the diseases that have overburdened the healthcare system. However, data concerning the relationship between NHI and cardiovascular healthcare in Indonesia are scarce. We aimed to describe changes in cardiovascular healthcare after the implementation of the NHI while determining whether the implementation of the NHI is related to the in-hospital mortality of patients with acute coronary syndrome (ACS). METHODS This is a retrospective comparative study of two cohorts in which we compared the data of 364 patients with ACS from 2013 to 2014 (Cohort 1), before and early after NHI implementation, with those of 1142 patients with ACS from 2018 to 2020 (Cohort 2), four years after NHI initiation, at a tertiary cardiac center in Makassar, Indonesia. We analyzed the differences between both cohorts using chi-square test and Mann-Whitney U test. To determine the association between NHI and in-hospital mortality, we conducted multivariable logistic regression analysis. RESULTS We observed an increase in NHI users (20.1% to 95.6%, p < 0.001) accompanied by a more than threefold increase in patients with ACS admitted to the hospital in Cohort 2 (from 364 to 1142, p < 0.001). More patients with ACS received invasive treatment in Cohort 2, with both thrombolysis and percutaneous coronary intervention (PCI) rates increasing more than twofold (9.2% to 19.2%; p < 0.001). There was a 50.8% decrease in overall in-hospital mortality between Cohort 1 and Cohort 2 (p < 0.001). CONCLUSIONS This study indicated the potential beneficial effect of universal health coverage (UHC) in improving cardiovascular healthcare by providing more accessible treatment. It can provide evidence to urge the Indonesian government and other low- and middle-income nations dealing with cardiovascular health challenges to adopt and prioritize UHC.
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Affiliation(s)
- Nurul Qalby
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
- Department of Public Health, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia.
| | - Dian S Arsyad
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Epidemiology, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
| | - Andriany Qanitha
- Department of Physiology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Cardiovascular Sciences, Amsterdam UMC Location VUMC, Amsterdam, the Netherlands
| | - Dara R Pabittei
- Department of Physiology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
- Department of Cardiothoracic Surgery, AMC Heart Center, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
- Central Military Hospital, Utrecht, The Netherlands
| | - Idar Mappangara
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Akhtar Fajar Muzakkir
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia.
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Krishnan A, Asadullah M, Kumar R, Amarchand R, Bhatia R, Roy A. Prevalence and determinants of delays in care among premature deaths due to acute cardiac conditions and stroke in residents of a district in India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 15:100222. [PMID: 37614354 PMCID: PMC10442961 DOI: 10.1016/j.lansea.2023.100222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/15/2023] [Accepted: 05/09/2023] [Indexed: 08/25/2023]
Abstract
Background Lack of timely care is a predictor of poor outcomes in acute cardiovascular emergencies including stroke. We assessed the presence of delay in seeking appropriate care among those who died due to cardiac/stroke emergencies in a community in northern India and identified the reasons and determinants of this delay. Methods We conducted a social audit among all civil-registered premature (30-69 years) deaths due to acute cardiac event or stroke in the district. The three-delays model was used to qualitatively classify the delays in care-seeking-deciding to seek care, reaching the appropriate health facility (AHF) and initiating definitive treatment. Based on the estimated time from symptom onset to reaching AHF, we classified patients as early (reached within one hour) or delayed arrivers. We used mixed-effect logistic regression with postal code as a random effect to identify determinants of delayed arrival. Findings Only 10.8% of the deceased reached an AHF within one hour. We noted level-1 delay in 38.4% (60% due to non-recognition of seriousness); level-2 delay in 20% (40% due to going to an inappropriate facility) and level-3 delay in 10.8% (57% due to lack of affordability). Patients with a monthly family income of >270US$ (aOR 0.44; 95% CI 0.21-0.93) were less and those staying farther from AHF (aOR 1.12; 95% CI 1.01-1.25 for each Km) were more likely to have delayed arrival in AHF. Interpretation A small proportion of patients with cardiac and stroke emergencies reach health facility early with delays at multiple levels. Addressing the reasons for delay could prevent these deaths. Funding : Indian Council of Medical Research, New Delhi, India.
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Affiliation(s)
- Anand Krishnan
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Md Asadullah
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Kumar
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ritvik Amarchand
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ambuj Roy
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Ravindra P, Bhat R, Karanth N, Wilson W, Lavanya BN, Umra S, Mahesh S. Patterns and Predictors of Emergency Medical Services Utilisation by Patients Attending the Emergency Medicine Department of a Tertiary Care Hospital in India. J Emerg Trauma Shock 2022; 15:99-104. [PMID: 35910313 PMCID: PMC9336641 DOI: 10.4103/jets.jets_83_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/11/2021] [Accepted: 02/18/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Establishment of strong emergency medical services (EMS) systems plays a pivotal role in reducing morbidity and mortality, especially in low and middle-income countries. We aimed to study the EMS utilization and resources available in the ambulances to deliver prehospital care among patients presenting to the Emergency Medicine Department in a tertiary care hospital in south India. Methods Data regarding prehospital transport practices such as mode of arrival, utilization of EMS, resources available in the ambulance, presenting complaints, triage category, and demographic details were collected and analyzed. Subgroup analysis for time-sensitive complaints was done. Variables were subjected to univariate and multivariate analysis to find the predictors of ambulance usage. Results The study included 3935 patients. The most common time-sensitive complaints were trauma (17%) and chest pain (11.5%). The most preferred mode of transport was the personal vehicle (45.6%). 29.8% of patients arrived in the ambulance. 97.7% of ambulances were not Advanced Cardiac Life Support equipped and 87.1% did not have an accompanying health care provider. 64.5% inter-hospital patient transfers were through ambulance, 83.8% transfers were unaccompanied. Among patients with time-sensitive complaints, EMS utilization was inadequate (46.8% in acute coronary syndrome, 34% in trauma, and 56.5% in early acute ischemic stroke). Conclusion There was underutilization of the EMS services. Majority of the ambulances were not adequately equipped/staffed to deliver prehospital interventions. Policies at national level are required to encourage EMS utilization by the public and urgent measures are needed to improve services provided by them.
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Affiliation(s)
- Prithvishree Ravindra
- Department of Emergency Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Rachana Bhat
- Department of Emergency Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Nisarg Karanth
- Department of Emergency Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - William Wilson
- Department of Emergency Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India,Address for correspondence: Dr. William Wilson, Department of Emergency Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal - 576 104, Karnataka, India. E-mail:
| | - B. N. Lavanya
- Department of Emergency Medical Technology, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Simran Umra
- Department of Emergency Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shweta Mahesh
- Department of Emergency Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Mathew A, Hong Y, Yogasundaram H, Nagendran J, Punnoose E, Ashraf S, Fischer L, Abdullakutty J, Pisharody S, Bainey K, Graham M. Sex and Medium-term Outcomes of ST-Segment Elevation Myocardial Infarction in Kerala, India: A Propensity Score–Matched Analysis. CJC Open 2021; 3:S71-S80. [PMID: 34993436 PMCID: PMC8712709 DOI: 10.1016/j.cjco.2021.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/21/2021] [Indexed: 11/24/2022] Open
Abstract
Background Sex-based differences have been found in outcomes following ST-segment myocardial infarction (STEMI). Studies assessing sex-based differences in STEMI among Indian patients have reported conflicting results. Methods A prospective multicenter registry of consecutive patients with STEMI who presented to percutaneous coronary intervention (PCI)–capable hospitals in the Indian state of Kerala between June 2013 and March 2017 was used to assess 1-year outcomes. The primary endpoint was a composite of major adverse cardiac events (MACE), including death, stroke, nonfatal myocardial infarction, and rehospitalization for heart failure. Outcomes of 2 sex-based propensity score–matched groups were compared. Results We included 3194 patients (19.4% women). Women presenting with STEMI were older, had more traditional cardiovascular risk factors, and were more likely to be classified as living in poverty. After propensity-score matching, women experienced greater incidence of MACE (20.9% vs 14.3%, P < 0.01), primarily driven by increased 1-year mortality (14.3% vs 8.6%, P < 0.01). Women were more likely to experience prehospital delays, compared with men. Although reperfusion rates were similar between the groups, men were more likely than women to undergo reperfusion within the first 12 hours of chest pain onset. Among patients undergoing primary PCI, women were more likely to have delayed PCI than were men (80.2% vs 72.9%, P = 0.03). Procedural characteristics were similar between groups. Conclusions Women in this cohort experienced higher incidence of MACE at 1 year, compared to men, primarily owing to increased mortality. Timeliness of reperfusion appears to be the primary factor impacting differences in outcomes between the 2 groups and may represent an attractive target for quality-improvement initiatives.
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Affiliation(s)
- Anoop Mathew
- Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada
- Division of Cardiology, Malankara Orthodox Syrian Christian Medical College Hospital, Kolenchery, Kerala, India
- Corresponding author: Dr Anoop Mathew, Division of Cardiology, Department of Medicine, Mazankowski Alberta Heart Institute, 2C2 WMC, 8440 – 112 St, NW, Edmonton, Alberta T6G 2B7, Canada
| | - Yongzhe Hong
- Division of Cardiac Surgery, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Haran Yogasundaram
- Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Eapen Punnoose
- Division of Cardiology, Malankara Orthodox Syrian Christian Medical College Hospital, Kolenchery, Kerala, India
| | - S.M. Ashraf
- Division of Cardiology, Government Medical College Hospital, Pariyaram, Kerala, India
| | - Louie Fischer
- Division of Cardiology, Malankara Orthodox Syrian Christian Medical College Hospital, Kolenchery, Kerala, India
| | | | - Sunil Pisharody
- Division of Cardiology, Elamkulam Manakkal Sankaran Memorial Co-operative Hospital and Research Centre, Perinthalmanna, Kerala, India
| | - Kevin Bainey
- Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michelle Graham
- Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada
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Muraleedharan M, Chandak AO. Emerging challenges in the health systems of Kerala, India: qualitative analysis of literature reviews. JOURNAL OF HEALTH RESEARCH 2021. [DOI: 10.1108/jhr-04-2020-0091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PurposeThe substantial increase in non-communicable diseases (NCDs) is considered a major threat to developing countries. According to various international organizations and researchers, Kerala is reputed to have the best health system in India. However, many economists and health-care experts have discussed the risks embedded in the asymmetrical developmental pattern of the state, considering its high health-care and human development index and low economic growth. This study, a scoping review, aims to explore four major health economic issues related to the Kerala health system.Design/methodology/approachA systematic review of the literature was performed using PRISMA to facilitate selection, sampling and analysis. Qualitative data were collected for thematic content analysis.FindingsChronic diseases in a significant proportion of the population, low compliance with emergency medical systems, high health-care costs and poor health insurance coverage were observed in the Kerala community.Research limitations/implicationsThe present study was undertaken to determine the scope for future research on Kerala's health system. Based on the study findings, a structured health economic survey is being conducted and is scheduled to be completed by 2021. In addition, the scope for future research on Kerala's health system includes: (1) research on pathways to address root causes of NCDs in the state, (2) determine socio-economic and health system factors that shape health-seeking behavior of the Kerala community, (3) evaluation of regional differences in health system performance within the state, (4) causes of high out-of-pocket expenditure within the state.Originality/valueGiven the internationally recognized standard of Kerala's vital statistics and health system, this review paper highlights some of the challenges encountered to elicit future research that contributes to the continuous development of health systems in Kerala.
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Rehman H, Kalra A, Kochar A, Uberoi AS, Bhatt DL, Samad Z, Virani SS. Secondary prevention of cardiovascular diseases in India: Findings from registries and large cohorts. Indian Heart J 2020; 72:337-344. [PMID: 33189191 PMCID: PMC7670271 DOI: 10.1016/j.ihj.2020.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/20/2020] [Accepted: 08/31/2020] [Indexed: 11/30/2022] Open
Abstract
Several registries and quality improvement initiatives have focused on assessing and improving secondary prevention of CVD in India. While the Treatment and Outcomes of Acute Coronary Syndromes in India (CREATE), Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF), and Trivandrum Heart Failure (THF) registries are limited to collecting data, the Tamil Nadu-ST-Segment Elevation Myocardial Infarction (TN-STEMI) program was aimed at examining and improving access to revascularization after an ST-elevation myocardial infarction (STEMI). The Acute Coronary Syndromes: Quality Improvement in Kerala (ACS-QUIK) study recruited hospitals from the Kerala ACS registry to assess a quality improvement kit for patients with ACS while the Practice Innovation and Clinical Excellence India Quality Improvement Program (PIQIP) provides valuable data on outpatient CVD quality of care. Collaborative efforts between health professionals are needed to assess further gaps in knowledge and policy makers to utilize new and existing data to drive policy-making.
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Affiliation(s)
- Hasan Rehman
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Ankur Kalra
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA; Section of Cardiovascular Research, Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA
| | - Ajar Kochar
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Angad S Uberoi
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, New York, NY, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Zainab Samad
- Department of Medicine, Section of Cardiology, Aga Khan University, Karachi, Pakistan
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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Jabir A, Mathew A, Zheng Y, Westerhout C, Viswanathan S, Sebastian P, Kumar P, Bangalore S, Bainey KR, Welsh R. Procedural Volume and Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction in Kerala, India: Report of the Cardiological Society of India-Kerala Primary Percutaneous Coronary Intervention Registry. J Am Heart Assoc 2020; 9:e014968. [PMID: 32476563 PMCID: PMC7429028 DOI: 10.1161/jaha.119.014968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background There are limited data to inform policy mandating primary percutaneous coronary intervention (PPCI) volume benchmarks for catheterization laboratories in low‐ and middle‐income countries. Methods and Results This prospective state‐wide registry included ST‐segment–elevation myocardial infarction patients with symptoms of <12 hours, or with ongoing ischemia at 12 to 24 hours, reperfused with PPCI. From June 2013 to March 2016, we recruited 5560 consecutive patients. We categorized hospitals on the basis of annual PPCI volumes into low, medium, and high volume (<100, 100–199, and ≥200 PPCIs per year, respectively). Kaplan‐Meier curves and Cox regression models were used to examine the association between PPCI volume and 1‐year mortality. Among 42 recruiting hospitals, there were 24 (57.2%) low‐volume, 8 (19%) medium‐volume, and 10 (23.8%) high‐volume hospitals. The median (25th–75th percentile) TIMI (Thrombolysis in Myocardial Infarction) ST‐segment–elevation myocardial infarction risk score was 3 (2–5). Cardiac arrest before admission occurred in 4.2%, 2.1%, and 2.9% of cases at low‐, medium‐, and high‐volume hospitals, respectively (P=0.02). Total ischemic time differed significantly among low‐volume (median [25th–75th percentile], 3.5 [2.4–5.5] hours), medium‐volume (median, 3.8 [25th–75th percentile, 2.58–6.05] hours), and high‐volume hospitals (median, 4.16 [25th–75th percentile 2.8–6.3] hours) (P=0.01). Vascular access was radial in 61.5%, 71.3%, and 63.2% of cases at low‐, medium‐, and high‐volume hospitals, respectively (P=0.01). The observed 1‐year mortality rate was 6.5%, 3.4%, and 8.6% at low‐, medium‐ and high‐volume hospitals, respectively (P<0.01), and the difference did not attenuate after multivariate adjustment (low versus medium: hazard ratio [95% CI], 1.80 [1.12–2.90]; high versus medium: hazard ratio [95% CI], 2.53 [1.78–3.58]) (P<0.01). Conclusions Low‐ and middle‐income countries, like India, may have a nonlinear relationship between institutional PPCI volume and outcomes, partly driven by procedural variations and inequalities in access to care.
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Affiliation(s)
| | - Anoop Mathew
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada.,Division of Cardiology Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
| | - Yinggan Zheng
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada
| | - Cynthia Westerhout
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada
| | - Sunitha Viswanathan
- Division of Cardiology Government Medical College Hospital Thiruvanathapuram Kerala India
| | - Placid Sebastian
- Division of Cardiology Pariyaram Medical College Hospital Kannur Kerala India
| | - Prasanna Kumar
- Jubilee Medical College Hospital and Research Centre Thrissur Kerala India
| | | | - Kevin R Bainey
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada.,Division of Cardiology Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
| | - Robert Welsh
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada.,Division of Cardiology Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
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Tongpeth J, Du H, Barry T, Clark RA. Effectiveness of an Avatar application for teaching heart attack recognition and response: A pragmatic randomized control trial. J Adv Nurs 2019; 76:297-311. [DOI: 10.1111/jan.14210] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/22/2019] [Accepted: 08/30/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Jintana Tongpeth
- Prachomklao College of Nursing Praboromrajchanok Institute Ministry of Public Health Muang Phetchaburi Thailand
| | - Huiyun Du
- College of Nursing & Health Sciences Flinders University Adelaide SA Australia
| | - Tracey Barry
- College of Nursing & Health Sciences Flinders University Adelaide SA Australia
| | - Robyn A. Clark
- College of Nursing & Health Sciences Flinders University Adelaide SA Australia
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9
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Prabhakaran D, Singh K, Roth GA, Banerjee A, Pagidipati NJ, Huffman MD. Cardiovascular Diseases in India Compared With the United States. J Am Coll Cardiol 2019; 72:79-95. [PMID: 29957235 DOI: 10.1016/j.jacc.2018.04.042] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/11/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023]
Abstract
This review describes trends in the burden of cardiovascular diseases (CVDs) and risk factors in India compared with the United States; provides potential explanations for these differences; and describes strategies to improve cardiovascular health behaviors, systems, and policies in India. The prevalence of CVD in India has risen over the past 2 decades due to population growth, aging, and a stable age-adjusted CVD mortality rate. Over the same time period, the United States has experienced an overall decline in age-adjusted CVD mortality, although the trend has begun to plateau. These improvements in CVD mortality in the United States are largely due to favorable population-level risk factor trends, specifically with regard to tobacco use, cholesterol, and blood pressure, although improvements in secondary prevention and acute care have also contributed. To realize similar gains in reducing premature death and disability from CVD, India needs to implement population-level policies while strengthening and integrating its local, regional, and national health systems. Achieving universal health coverage that includes financial risk protection should remain a goal to help all Indians realize their right to health.
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Affiliation(s)
- Dorairaj Prabhakaran
- Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, India; London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Kavita Singh
- Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, India
| | - Gregory A Roth
- Institute for Health Metrics and Evaluation and the Division of Cardiology at the University of Washington School of Medicine, Seattle, Washington
| | - Amitava Banerjee
- Farr Institute of Health Informatics, University College London, London, United Kingdom
| | - Neha J Pagidipati
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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10
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Agarwal A, Davies D, Goenka S, Prabhakaran D, Huffman MD, Mohanan PP. Facilitators and barriers of heart failure care in Kerala, India: A qualitative analysis of health-care providers and administrators. Indian Heart J 2019; 71:235-241. [PMID: 31543196 PMCID: PMC6796633 DOI: 10.1016/j.ihj.2019.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/13/2019] [Accepted: 04/26/2019] [Indexed: 12/30/2022] Open
Abstract
Objective Heart failure is a leading cause of death worldwide and in India, yet the qualitative data regarding heart failure care are limited. To fill this gap, we studied the facilitators and barriers of heart failure care in Kerala, India. Methods and results During January 2018, we conducted a qualitative study using in-depth, semi-structured interviews with 21 health-care providers and quality administrators from 8 hospitals in Kerala to understand the context, facilitators, and barriers of heart failure care. We developed a theoretical framework using iteratively developed codes from these data to identify 6 key themes of heart failure care in Kerala: (1) need for comprehensive patient and family education on heart failure; (2) gaps between guideline-directed clinical care for heart failure and clinical practice; (3) national hospital accreditation contributing to a culture of systematically improving quality and safety of in-hospital care; (4) limited system-level attention toward improving heart failure care compared with other cardiovascular conditions; (5) application of existing personnel and technology to improve heart failure care; and (6) longitudinal and recurrent costs as barriers for optimal heart failure care. Conclusions Key themes emerged regarding heart failure care in Kerala in the context of a health system that is increasingly emphasizing health-care quality and safety. Targeted in-hospital quality improvement interventions for heart failure should account for these themes to improve cardiovascular outcomes in the region.
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Affiliation(s)
- Anubha Agarwal
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Divin Davies
- WestFort Hi-Tech Hospital Ltd, Thrissur, Kerala, India
| | - Shifalika Goenka
- Centre for Chronic Disease Control, New Delhi, Delhi, India; Public Health Foundation of India, Gurugram, Haryana, India
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, Delhi, India; Public Health Foundation of India, Gurugram, Haryana, India
| | - Mark D Huffman
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; The George Institute for Global Health, Sydney, Australia
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11
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Singh K, Devarajan R, Mohanan PP, Baldridge AS, Kondal D, Victorson DE, Karmali KN, Zhao L, Lloyd-Jones DM, Prabhakaran D, Goenka S, Huffman MD. Implementation and acceptability of a heart attack quality improvement intervention in India: a mixed methods analysis of the ACS QUIK trial. Implement Sci 2019; 14:12. [PMID: 30728053 PMCID: PMC6364470 DOI: 10.1186/s13012-019-0857-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 01/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ACS QUIK trial showed that a multicomponent quality improvement toolkit intervention resulted in improvements in processes of care for patients with acute myocardial infarction in Kerala but did not improve clinical outcomes in the context of background improvements in care. We describe the development of the ACS QUIK intervention and evaluate its implementation, acceptability, and sustainability. METHODS We performed a mixed methods process evaluation alongside a cluster randomized, stepped-wedge trial in Kerala, India. The ACS QUIK intervention aimed to reduce the rate of major adverse cardiovascular events at 30 days compared with usual care across 63 hospitals (n = 21,374 patients). The ACS QUIK toolkit intervention, consisting of audit and feedback report, admission and discharge checklists, patient education materials, and guidelines for the development of code and rapid response teams, was developed based on formative qualitative research in Kerala and from systematic reviews. After four or more months of the center's participation in the toolkit intervention phase of the trial, an online survey and physician interviews were administered. Physician interviews focused on evaluating the implementation and acceptability of the toolkit intervention. A framework analysis of transcripts incorporated context and intervening mechanisms. RESULTS Among 63 participating hospitals, 22 physicians (35%) completed online surveys. Of these, 17 (77%) respondents reported that their hospital had a cardiovascular quality improvement team, 18 (82%) respondents reported having read an audit report, admission checklist, or discharge checklist, and 19 (86%) respondents reported using patient education materials. Among the 28 interviewees (44%), facilitators of toolkit intervention implementation were physicians' support and leadership, hospital administrators' support, ease-of-use of checklists and patient education materials, and availability of training opportunities for staff. Barriers that influenced the implementation or acceptability of the toolkit intervention for physicians included time and staff constraints, Internet access, patient volume, and inadequate understanding of the quality improvement toolkit intervention. CONCLUSIONS Implementation and acceptability of the ACS QUIK toolkit intervention were enhanced by hospital-level management support, physician and team support, and usefulness of checklists and patient education materials. Wider and longer-term use of the toolkit intervention and its expansion to potentially other cardiovascular conditions or other locations where the quality of care is not as high as in the ACS QUIK trial may be useful for improving acute cardiovascular care in Kerala and beyond. TRIAL REGISTRATION NCT02256657.
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Affiliation(s)
- Kavita Singh
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - Padinhare P Mohanan
- Westfort Hi-Tech Hospital, Ltd, Thrissur, India
- Cardiological Society of India - Kerala Chapter, Kerala, India
| | - Abigail S Baldridge
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - David E Victorson
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Kunal N Karmali
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Lihui Zhao
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Donald M Lloyd-Jones
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
- London School of Hygiene and Tropical Medicine, London, UK
| | - Shifalika Goenka
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
- Indian Institute of Public Health-Delhi, New Delhi, India
| | - Mark D Huffman
- Department of Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA.
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Bahiru E, Temu T, Mwanga J, Ndede K, Vusha S, Gitura B, Farquhar C, Bukachi F, Huffman MD. Facilitators, context of and barriers to acute coronary syndrome care at Kenyatta National Hospital, Nairobi, Kenya: a qualitative analysis. Cardiovasc J Afr 2018; 29:177-182. [PMID: 29750227 PMCID: PMC6107733 DOI: 10.5830/cvja-2018-013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 02/15/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The prevalence of ischaemic heart disease and its acute manifestation, acute coronary syndrome (ACS), is growing throughout sub-Saharan Africa, including Kenya. To address this increasing problem, we sought to understand the facilitators, context of and barriers to ACS care at Kenyatta National Hospital, with the aim of improving the quality of care of ACS. METHODS We conducted in-depth interviews with healthcare providers involved in the management of ACS patients from January to February 2017 at Kenyatta National Hospital in Nairobi, Kenya. We selected an initial sample of key participants for interviewing and used a snowballing technique to identify additional participants until we achieved saturation. After transcription of audio recordings of the interviews, two authors conducted data coding and analysis using a framework approach. RESULTS We conducted 16 interviews with healthcare providers. Major themes included the need to improve the diagnostic and therapeutic capabilities of the hospital, including increasing the number of ECG machines and access to thrombolytics. Participants highlighted an overall wide availability of other guideline-directed medical therapies, including antiplatelets, beta-blockers, statins, anticoagulants and ACE inhibitors. All participants also stated the need for and openness to accepting future interventions for improvement of quality of care, including checklists and audits to improve ACS care at Kenyatta National Hospital. CONCLUSION Major barriers to ACS care at Kenyatta National Hospital include inadequate diagnostic and therapeutic capabilities, lack of hospital-wide ACS guidelines, undertraining of healthcare providers and delayed presentation of patients seeking care. We also identified potential targets, including checklists and audits for future improvements in quality of care from the perspective of healthcare providers.
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Affiliation(s)
- Ehete Bahiru
- Northern Pacific Global Health Research Fellowship Training Consortium, University of Washington, Seattle, WA; and Division of Cardiology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, USA.
| | - Tecla Temu
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Julia Mwanga
- Department of Medicine, University of Nairobi, Nairobi, Kenya
| | - Kevin Ndede
- Department of Medicine, University of Nairobi, Nairobi, Kenya
| | - Sophie Vusha
- Organization International Centre for Reproductive Health Kenya (ICRHK), Kenya
| | - Bernard Gitura
- Division of Cardiology, Department of Medicine, Kenyatta National Hospital, Nairobi, Kenya
| | - Carey Farquhar
- Departments of Global Health, Epidemiology and Medicine, University of Washington, Seattle, WA, USA
| | - Frederick Bukachi
- Department of Medical Physiology, University of Nairobi, Nairobi, Kenya
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
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13
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A J, Mathew A, Viswanathan S, S M A, Sebastian P, C K P, A GK, Pisharody S, Mathew R, Jeyasheelan L. The design and rationale of the primary angioplasty registry of Kerala. Indian Heart J 2017; 69:777-783. [PMID: 29174258 PMCID: PMC5717295 DOI: 10.1016/j.ihj.2017.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 04/21/2017] [Accepted: 05/28/2017] [Indexed: 11/17/2022] Open
Abstract
Background ST-elevation myocardial infarction (STEMI) continues to be a major cause of cardiovascular mortality in Kerala, India. Timely primary percutaneous coronary intervention (PCI) is the recommended reperfusion strategy for STEMI. There is limited data on the safety, effectiveness, equity and efficiency of regional primary PCI services in India. Methods/Design The primary angioplasty registry of Kerala is a clinician-initiated prospective state-wide longitudinal hospital-based registry of patients undergoing primary PCI for STEMI. The registry aims to document the efficacy and safety of the real world use of primary PCI in Indian patients presenting with STEMI, in order to achieve regional adoption of global standard performance indicators. In addition, the registry would analyze procedural variations in the performance of primary PCI and assess its impact on relevant patient centered outcomes. We plan to enroll 6000 STEMI patients, undergoing primary PCI, across 48 hospitals. These patients would be followed up for a minimum of 1 year. Conclusions The primary angioplasty registry of Kerala would help analyze the quality and outcomes of primary PCI services in Kerala, thereby yielding insights that can help limit unacceptable procedural variations in the performance of primary PCI. Identifying deviations from guideline based therapies can form the basis of quality improvement programs, which in turn will enable hospitals to achieve better patient outcomes.
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Affiliation(s)
- Jabir A
- Lisie Hospital, Kochi, Kerala, India.
| | - Anoop Mathew
- MOSC Medical College, Kolencherry, Kerala, India.
| | | | - Ashraf S M
- Sahakarana Medical College, Pariyaram, Kannur, Kerala, India.
| | | | | | - George Koshy A
- Government Medical College, Thiruvanathapuram, Kerala, India.
| | | | | | - L Jeyasheelan
- Christian Medical College, Vellore, Tamilnadu, India.
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