Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data
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Date
2020
Journal Title
Journal ISSN
Volume Title
Publisher
PLoS Med
Abstract
Cardiovascular diseases are leading causes of death, globally, and health systems that
deliver quality clinical care are needed to manage an increasing number of people with risk
factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global
health agencies. We aimed to assess whether these indicators are associated with patient
receipt of quality clinical care.
Methods and findings
We did a secondary analysis of cross-sectional, nationally representative, individual-patient
data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in
43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age
52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of
provision of quality clinical care.
Data were extracted from national-level World Health Organization (WHO) Stepwise
Approach to Surveillance (STEPS), or other similar household surveys, conducted between
July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development
(gross domestic product [GDP] per capita or Human Development Index [HDI]); national
capacity for the prevention and control of noncommunicable diseases (‘NCD readiness indicators’ from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health
[both as percentage of current]); and health service readiness (number of physicians,
nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All
models were adjusted for individual-level predictors including age, sex, and education. In an
exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between
indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both
positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence
of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08–3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09–4.69], p = 0.03). Hospital
beds (OR, 1.14 [95% CI 1.02–1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06–
1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11–1.32], p < 0.001) per 1,000 people
were positively associated with being diagnosed and, similarly, with being treated; and the
number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI
1.01–1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development,
health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12–2.59], p = 0.01), HDI (OR, 1.21 [95% CI
1.01–1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09–
1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on
cascades of care and nationwide-level data on facility preparedness. Of the 27 associations
tested between facility preparedness indicators and outcomes, the only association that
was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01–1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood
glucose measurement to diagnose diabetes.
Conclusion
In this study, we observed that indicators of country preparedness to deal with CVDRFs are
poor proxies for quality clinical care received by patients for hypertension and diabetes. The
major implication is that assessments of countries’ preparedness to manage CVDRFs
should not rely on proxies; rather, it should involve direct assessment of quality clinical care.
Description
Keywords
Country preparedness indicators, Clinical care, Cardiovascular disease, Lower- and middle-income countries, Survey data
Citation
: Davies JI, Reddiar SK, Hirschhorn LR, Ebert C, Marcus M-E, Seiglie JA, et al. (2020) Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data. PLoS Med 17(11): e1003268. https://doi.org/10.1371/journal.pmed.1003268