Faculty Bibliography

The coronavirus disease 2019 (COVID-19) pandemic has disrupted health systems worldwide, gravely threatening continuity of care for non-communicable diseases (NCDs), particularly in low-resource settings. We describe our efforts to maintain the continuity of care for patients with NCDs in rural western Kenya during the COVID-19 pandemic, using a five-component approach: 1) Protect: protect staff and patients; 2) Preserve: ensure medication availability and clinical services; 3) Promote: conduct health education and screenings for NCDs and COVID-19; 4) Process: collect process indicators and implement iterative quality improvement; and 5) Plan: plan for the future and ensure financial risk protection in the face of a potentially overwhelming health and economic catastrophe. As the pandemic continues to evolve, we must continue to pursue new avenues for improvement and expansion. We anticipate continuing to learn from the evolving local context and our global partners as we proceed with our efforts.

Introduction/UNASSIGNED:An epidemic of non-communicable diseases (NCDs) in India is fueling a growing demand for primary care and hospitalization services. Difficulties in coordinating inpatient and outpatient care create significant barriers to providing high-quality medical care. In this paper, we describe patient experiences, perceptions, and expectations of doctor-patient relationships in a secondary-level private hospital in Karnataka, India. Methods/UNASSIGNED:We conducted a cross-sectional, mixed-method needs assessment with surveys and in-depth interviews at Dr. TMA Pai Hospital (TMAPH), a secondary-level, private sector hospital in Karnataka, India. Inclusion criteria included all adults over 18 years old hospitalized at TMAPH in the past year. Patients were consecutively recruited from August 2019-October 2019 and asked to rate aspects of their relationship with their primary care provider (PCP). Descriptive statistics and multivariable logistic regression were used to analyze predictors of the doctor-patient relationship. Patients were interviewed regarding their perceptions of care coordination and doctor-patient relationships. General Thematic Analysis was utilized to analyze qualitative data and develop themes. Quantitative and qualitative findings were then merged to interpret the various dimensions of doctor-patient relationships. Results/UNASSIGNED:= 0.04). The following themes were developed from patient interviews: (1) patients trusted and respected their PCP believing they were receiving high quality care; and (2) despite perceived fragmentation in care, patients spoke favorably of their relationships with their doctors. Conclusions/UNASSIGNED:Among a sample of recently hospitalized patients, those with a PCP reported more positive doctor-patient relationships, though rates of dissatisfaction with doctors were still high. Further research and strategies are required to optimize continuity of care and doctor-patient relationships across the entire continuum of outpatient and inpatient care.

Background/UNASSIGNED:Social media advertising by fast food companies continues to increase globally, and exposure to food advertising contributes to poor diet and negative health outcomes (eg, cardiovascular disease). McDonald's-the largest fast food company in the world-operates in 101 countries, but little is known about their marketing techniques in various regions. The objective of this study was to compare the social media advertising practices of McDonald's-the largest fast food company in the world-in 15 high-income, upper-middle-income and lower-middle-income countries. Methods/UNASSIGNED:We randomly selected official McDonald's Instagram accounts for 15 high-income, upper-middle-income and lower-middle-income countries. We captured all the screenshots that McDonald's posted on those Instagram accounts from September to December 2019. We quantified the number of followers, 'likes', 'comments' and video views associated with each account in April 2020. We used content analysis to examine differences in the marketing techniques. Results/UNASSIGNED:The 15 accounts collectively maintained 10 million followers and generated 3.9 million 'likes', 164 816 comments and 38.2 million video views. We identified 849 posts. The three lower-middle-income countries had more posts (n=324; M, SD=108.0, 38.2 posts) than the five upper-middle-income countries (n=227; M, SD=45.4, 37.5 posts) and seven high-income countries (n=298; M, SD=42.6, 28.2 posts). Approximately 12% of the posts in high-income countries included child-targeted themes compared with 22% in lower-middle-income countries. Fourteen per cent of the posts in high-income countries included price promotions and free giveaways compared with 40% in lower-middle-income countries. Conclusions/UNASSIGNED:Social media advertising has enabled McDonald's to reach millions of consumers in lower-middle-income and upper-middle-income countries with disproportionately greater child-targeted ads and price promotions in lower-middle-income countries. Such reach is concerning because of the increased risk of diet-related illnesses, including cardiovascular disease, in these regions.

More than twenty percent of all cardiovascular disease (CVD) deaths are caused by air pollution - more than three million deaths every year - and these numbers will continue to rise unless the global community takes action. Nine out of ten people worldwide breathe polluted air, which disproportionately affects those living in low-resource settings. The World Heart Federation (WHF) is committed to reducing the impact of air pollution on people's health and has made this a priority area of its global advocacy efforts. In pursuit of this goal, WHF has formed an Air Pollution Expert Group to inform action on air pollution for CVD health and recommend changes to public health policy. This policy paper lays out the health impacts of air pollution, examines its position on the global policy agenda, demonstrates its relevance to the cardiovascular community, and proposes actionable policy measures to mitigate this deadly risk factor to health. The paper considers the important roles to be played by the Members of WHF, including scientific societies and the physicians that constitute them, heart health foundations, and patient advocacy groups. The paper concludes with a detailed table of recommendations for the various sub-target groups at the global, national, local, and patient level.

BACKGROUND:Non-communicable diseases (NCDs) are the leading cause of mortality in the world, and innovative approaches to NCD care delivery are being actively developed and evaluated. Combining the group-based experience of microfinance and group medical visits is a novel approach to NCD care delivery. However, the contextual factors, facilitators, and barriers impacting wide-scale implementation of these approaches within a low- and middle-income country setting are not well known. METHODS:Two types of qualitative group discussion were conducted: 1) mabaraza (singular, baraza), a traditional East African community gathering used to discuss and exchange information in large group settings; and 2) focus group discussions (FGDs) among rural clinicians, community health workers, microfinance group members, and patients with NCDs. Trained research staff members led the discussions using structured question guides. Content analysis was performed with NVivo using deductive and inductive codes that were then grouped into themes. RESULTS:We conducted 5 mabaraza and 16 FGDs. A total of 205 individuals (113 men and 92 women) participated in the mabaraza, while 162 individuals (57 men and 105 women) participated in the FGDs. In the context of poverty and previous experiences with the health system, participants described challenges to NCD care across three themes: 1) stigma of chronic disease, 2) earned skepticism of the health system, and 3) socio-economic fragility. However, they also outlined windows of opportunity and facilitators of group medical visits and microfinance to address those challenges. DISCUSSION/CONCLUSIONS:Our qualitative study revealed actionable factors that could impact the success of implementation of group medical visits and microfinance initiatives for NCD care. While several challenges were highlighted, participants also described opportunities to address and mitigate the impact of these factors. We anticipate that our approach and analysis provides new insights and methodological techniques that will be relevant to other low-resource settings worldwide.

Background/UNASSIGNED:Elevated blood pressure is the leading cause of death worldwide; however, treatment and control rates remain very low. An expanding literature supports the strategy of task redistribution of hypertension care to nurses. Objective/UNASSIGNED:We aimed to evaluate the effect of a nurse-based hypertension management program in Kenya. Methods/UNASSIGNED:We conducted a retrospective data analysis of patients with hypertension who initiated nurse-based hypertension management care between January 1, 2011, and October 31, 2013. The primary outcome measure was change in systolic blood pressure (SBP) over one year, analyzed using piecewise linear mixed-effect models with a cut point at 3 months. The primary comparison of interest was care provided by nurses versus clinical officers. Secondary outcomes were change in diastolic blood pressure (DBP) over one year, and blood pressure control analyzed using a zero-inflated Poisson model. Results/UNASSIGNED:The cohort consisted of 1051 adult patients (mean age 61 years; 65% women). SBP decreased significantly from baseline to three months (nurse-managed patients: slope -4.95 mmHg/month; clinical officer-managed patients: slope -5.28), with no significant difference between groups. DBP also significantly decreased from baseline to three months with no difference between provider groups. Retention in care at 12 months was 42%. Conclusions/UNASSIGNED:Nurse-managed hypertension care can significantly improve blood pressure. However, retention in care remains a challenge. If these results are reproduced in prospective trial settings with improvements in retention in care, this could be an effective strategy for hypertension care worldwide.

BACKGROUND:People living with HIV are diagnosed with age-related chronic health conditions, including cardiovascular disease, at higher than expected rates. Medical management of these chronic health conditions frequently occur in HIV specialty clinics by providers trained in general internal medicine, family medicine, or infectious disease. In recent years, changes in the healthcare financing for people living with HIV in the U.S. has been dynamic due to changes in the Affordable Care Act. There is little evidence examining how healthcare financing characteristics shape primary and secondary cardiovascular disease prevention among people living with HIV. Our objective was to examine the perspectives of people living with HIV and their healthcare providers on how healthcare financing influences cardiovascular disease prevention. METHODS:As part of the EXTRA-CVD study, we conducted in-depth, semi-structured interviews with 51 people living with HIV and 34 multidisciplinary healthcare providers and at three U.S. HIV clinics in Ohio and North Carolina from October 2018 to March 2019. Thematic analysis using Template Analysis techniques was used to examine healthcare financing barriers and enablers of cardiovascular disease prevention in people living with HIV. RESULTS:Three themes emerged across sites and disciplines (1): healthcare payers substantially shape preventative cardiovascular care in HIV clinics (2); physician compensation tied to relative value units disincentivizes cardiovascular disease prevention efforts by HIV providers; and (3) grant-based services enable tailored cardiovascular disease prevention, but sustainability is limited by sponsor priorities. CONCLUSIONS:With HIV now a chronic disease, there is a growing need for HIV-specific cardiovascular disease prevention; however, healthcare financing complicates effective delivery of this preventative care. It is important to understand the effects of evolving payer models on patient and healthcare provider behavior. Additional systematic investigation of these models will help HIV specialty clinics implement cardiovascular disease prevention within a dynamic reimbursement landscape. TRIAL REGISTRATION/BACKGROUND:Clinical Trial Registration Number: NCT03643705 .

Availability of medicines for treatment of cardiovascular disease (CVD) is low in low-income and middle-income countries (LMIC). Supply chain models to improve the availability of quality CVD medicines in LMIC communities are urgently required. Our team established contextualised revolving fund pharmacies (RFPs) in rural western Kenya, whereby an initial stock of essential medicines was obtained through donations or purchase and then sold at a small mark-up price sufficient to replenish drug stock and ensure sustainability. In response to different contexts and levels of the public health system in Kenya (eg, primary versus tertiary), we developed and implemented three contextualised models of RFPs over the past decade, creating a network of 72 RFPs across western Kenya, that supplied 22 categories of CVD medicines and increased availability of essential CVD medications from <30% to 90% or higher. In one representative year, we were able to successfully supply 5 793 981 units of CVD and diabetes medicines to patients in western Kenya. The estimated programme running cost was US$6.5-25 per patient, serving as a useful benchmark for public governments to invest in medication supply chain systems in LMICs going forward. One important lesson that we have learnt from implementing three different RFP models over the past 10 years has been that each model has its own advantages and disadvantages, and we must continue to stay nimble and modify as needed to determine the optimal supply chain model while ensuring consistent access to essential CVD medications for patients living in these settings.

: As coronavirus disease 2019 (Covid-19) restrictions upend the community bonds that have enabled African communities to thrive in the face of numerous challenges, it is vital that the gains made in community-based healthcare are preserved by adapting our approaches. Instead of reversing the many gains made through locally driven development partnerships with international funding agencies for other viral diseases like HIV, we must use this opportunity to adapt the many lessons learned to address the burden of Covid-19. Programs like the Academic Model Providing Access to Healthcare are currently leveraging widely available technologies in Africa to prevent patients from experiencing significant interruptions in care as the healthcare system adjusts to the challenges presented by Covid-19. These approaches are designed to preserve social contact while incorporating physical distancing. The gains and successes made through approaches like group-based medical care must not only continue but can help expand upon the extraordinary success of programs like President's Emergency Plan for AIDS Relief.