Faculty Bibliography

CONTEXT/BACKGROUND:Cardiovascular disease (CVD) is the leading cause of death globally and a significant health burden in Kenya. Despite improved outcomes in CVD, palliative care has limited implementation for CVD in low- and middle-income countries. This may be partly due to providers' perceptions of palliative care and end-of-life decision-making for CVD patients. OBJECTIVES/OBJECTIVE:Our goal was to explore providers' perceptions of palliative care for CVD in Western Kenya in order to inform its implementation. METHODS:We conducted eight focus group discussions as well as five key informant interviews. These were conducted by moderators using structured question guides. Qualitative analysis was performed using the constant comparative method. A coding scheme was developed and agreed upon by consensus by two investigators, each of whom then independently coded each transcript. Relationships between codes were formulated and codes were grouped into distinct themes. New codes were iteratively added with successive focus group or interview until thematic saturation was reached. RESULTS:Four major themes emerged to explain the complexities of integrating of palliative care for CVD patients in Kenya: (1) stigma of discussing death and dying, (2) mismatch between patient and clinician perceptions of disease severity, (3) the effects of poverty on care, and (4) challenges in training and practice environments. All clinicians expressed a need for integrating palliative care for patients with CVD. CONCLUSIONS:These results suggest attainable interventions supported by local providers can help improve CVD care and quality of life for patients living with advanced heart disease in low-resource settings worldwide.

Cardiovascular diseases (CVD) are the world's leading cause of death. High blood pressure (BP) is the leading global risk factor for all-cause preventable morbidity and mortality. Globally, only about 14% of patients achieve BP control to systolic BP <140 mm Hg and diastolic BP <90 mm Hg. Most patients (>60%) require two or more drugs to achieve BP control, yet poor adherence to therapy is a major barrier to achieving this control. Fixed-dose combinations (FDCs) of BP-lowering drugs are one means to improve BP control through greater adherence and efficacy, with favorable safety and cost profiles. The authors present a review of the supporting data from a successful application to the World Health Organization (WHO) for the inclusion of FDCs of two BP-lowering drugs on the 21st WHO Essential Medicines List. The authors discuss the efficacy and safety of FDCs of two BP-lowering drugs for the management of hypertension in adults, relevant hypertension guideline recommendations, and the estimated cost of such therapies.

OBJECTIVES/OBJECTIVE:There is growing recognition around the importance of multimorbidity in low-income and middle-income country (LMIC) settings, and specifically the need for pragmatic intervention studies to reduce the risk of developing multimorbidity, and of mitigating the complications and progression of multimorbidity in LMICs. One of many challenges in completing such research has been the selection of appropriate outcomes measures. A 2018 Delphi exercise to develop a core-outcome set for multimorbidity research did not specifically address the challenges of multimorbidity in LMICs where the global burden is greatest, patterns of disease often differ and health systems are frequently fragmented. We, therefore, aimed to summarise and critically review outcome measures suitable for studies investigating mitigation of multimorbidity in LMIC settings. SETTING/METHODS:LMIC. PARTICIPANTS/METHODS:People with multimorbidity. OUTCOME MEASURES/METHODS:Identification of all outcome measures. RESULTS:We present a critical review of outcome measures across eight domains: mortality, quality of life, function, health economics, healthcare access and utilisation, treatment burden, measures of 'Healthy Living' and self-efficacy and social functioning. CONCLUSIONS:Studies in multimorbidity are necessarily diverse and thus different outcome measures will be appropriate for different study designs. Presenting the diversity of outcome measures across domains should provide a useful summary for researchers, encourage the use of multiple domains in multimorbidity research, and provoke debate and progress in the field.

An amendment to this paper has been published and can be accessed via the original article.

PURPOSE OF REVIEW/OBJECTIVE:This review summarizes the most recent and innovative implementation strategies for hypertension control in low- and middle-income countries (LMICs). RECENT FINDINGS/RESULTS:Implementation strategies from Latin America, Africa, and Asia were organized across three levels: community, health system, and policy/population. Multicomponent interventions involving task-shifting strategies, with or without mobile health tools, had the most supporting evidence, with policy or population-level interventions having the least, focused only on salt reduction with mixed results. More research is needed to better understand how context affects intervention implementation. There is an emerging evidence base for implementation strategies for hypertension control and CVD risk reduction in LMICs at the community and health system levels, but further research is needed to determine the most effective policy and population-level strategies. How to best account for local context in adapting and implementing these evidence-based interventions in LMICs still remains largely unknown. Accelerating the translation of this implementation research into policy and practice is imperative to improve health and save lives globally.

BACKGROUND:Non-communicable disease (NCD) care in Sub-Saharan Africa is challenging due to barriers including poverty and insufficient health system resources. Local culture and context can impact the success of interventions and should be integrated early in intervention design. Human-centered design (HCD) is a methodology that can be used to engage stakeholders in intervention design and evaluation to tailor-make interventions to meet their specific needs. METHODS:We created a Design Team of health professionals, patients, microfinance officers, community health workers, and village leaders. Over 6 weeks, the Design Team utilized a four-step approach of synthesis, idea generation, prototyping, and creation to develop an integrated microfinance-group medical visit model for NCD. We tested the intervention with a 6-month pilot and conducted a feasibility evaluation using focus group discussions with pilot participants and community members. RESULTS:Using human-centered design methodology, we designed a model for NCD delivery that consisted of microfinance coupled with monthly group medical visits led by a community health educator and a rural clinician. Benefits of the intervention included medication availability, financial resources, peer support, and reduced caregiver burden. Critical concerns elicited through iterative feedback informed subsequent modifications that resulted in an intervention model tailored to the local context. CONCLUSIONS:Contextualized interventions are important in settings with multiple barriers to care. We demonstrate the use of HCD to guide the development and evaluation of an innovative care delivery model for NCDs in rural Kenya. HCD can be used as a framework to engage local stakeholders to optimize intervention design and implementation. This approach can facilitate the development of contextually relevant interventions in other low-resource settings. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov, NCT02501746, registration date: July 17, 2015.

Overdose of stimulant drugs has been associated with increased risk of adverse cardiovascular events (ACVE), some of which may be ascribed to endothelial dysfunction. The aims of this study were to evaluate biomarkers of endothelial dysfunction in emergency department (ED) patients with acute cocaine overdose and to assess the association between in-hospital ACVE in ED patients with any acute drug overdose. This was a prospective consecutive cohort study over 9 months (2015-2016) at two urban, tertiary-care hospital EDs. Consecutive adults (≥18 years) presenting with suspected acute drug overdose were eligible and separated into three groups: cocaine (n = 47), other drugs (n = 128), and controls (n = 11). Data were obtained from medical records and linked to waste serum specimens, sent as part of routine clinical care, for biomarker analysis. Serum specimens were collected and analyzed using enzyme-linked immunosorbent assay kit for three biomarkers of endothelial dysfunction: (a) endothelin-1 (ET-1), (b) regulated upon activation normal T cell expressed and secreted (RANTES), and (c) soluble intercellular adhesion molecule-1 (siCAM-1). Mean siCAM was elevated for cocaine compared with controls and other drugs (p < .01); however, mean RANTES and ET-1 levels were not significantly different for any drug exposure groups. Receiver operating characteristics curve analysis for prediction of in-hospital ACVE revealed excellent performance of siCAM-1 (area under curve, 0.86; p < .001) but lack of predictive utility for either RANTES or ET-1. These results suggest that serum siCAM-1 is a viable biomarker for acute cocaine overdose and that endothelial dysfunction may be an important surrogate for adverse cardiovascular events following any drug overdose.

Stakeholder-informed strategies addressing cardiovascular disease (CVD) burden among people living with HIV (PWH) are needed within healthcare settings. This study provides an assessment of how human-centered design (HCD) guided the adaptation of a nurse-led intervention to reduce CVD risk among PWH. Using a HCD approach, research staff guided two multidisciplinary "design teams" in Ohio and North Carolina, with each having five HCD meetings. We conducted acceptability and feasibility testing. Six core recommendations were produced by two design teams of key stakeholders and further developed after the acceptability and feasibility testing to produce a final list of 14 actionable areas of adaptation. Acceptability and feasibility testing revealed areas for adaptation, e.g. patient preferences for communication and the benefit of additional staff to support patient follow-up. In conclusion, along with acceptability and feasibility testing, HCD led to the production of 14 key recommendations to enhance the effectiveness and scalability of an integrated HIV/CVD intervention.

BACKGROUND:The current trends of unhealthy lifestyle behaviors in underserved communities are disturbing. Thus, effective health promotion strategies constitute an unmet need. OBJECTIVE:To assess the impact of two different lifestyle interventions on parents/caregivers of children attending preschools in a socioeconomically disadvantaged community. METHODS:The FAMILIA study is a cluster-randomized trial involving 15 Head Start preschools in Harlem, New York. Schools, and their children's parents/caregivers, were randomized to receive either an "individual-focused" or "peer-to-peer based" lifestyle intervention program for 12 months or control. The primary outcome was the change from baseline to 12 months in a composite health score related to Blood pressure, Exercise, Weight, Alimentation and Tobacco (Fuster-BEWAT Score, FBS), ranging from 0 to 15 (ideal health=15). To assess the sustainability of the intervention, we evaluated the change of FBS at 24 months. Main pre-specified secondary outcomes included changes in FBS subcomponents and the impact of the knowledge of presence of atherosclerosis as assessed by bilateral carotid/femoral vascular ultrasound. Mixed-effects models were used to test for intervention effects. RESULTS:We enrolled 635 parents/caregivers with a mean age of 38±11 years, 83% female, 57% Hispanic/Latino and 31% African American, and a baseline FBS of 9.3±2.4 points. The mean within-group change in FBS from baseline to 12 months was ∼0.20 points in all groups, with no overall between-group differences. However, high-adherence participants to the intervention exhibited a greater change in FBS than their low-adherence counterparts: 0.30 points (95% CI: 0.03 to 0.57; p-value = 0.025) vs. 0.00 points (95% CI: -0.43 to 0.43; p-value = 1.0), respectively. Furthermore, the knowledge by the participant of the presence of atherosclerosis significantly boosted the intervention effects. Similar results were sustained at 24 months. CONCLUSIONS:Although we did not observe overall significant differences between intervention and control groups, the FAMILIA trial highlights that high adherence rates to lifestyle interventions may improve health outcomes. It also suggests a potential contributory role of the presentation of atherosclerosis pictures, providing helpful information to improve future lifestyle interventions in adults.

Non-communicable disease (NCD) prevention efforts have traditionally targeted high-risk and high-burden populations. We propose an alteration in prevention efforts to also include emphasis and focus on low-risk populations, predominantly younger individuals and low-prevalence populations. We refer to this approach as "proactive prevention." This emphasis is based on the priority to put in place policies, programs, and infrastructure that can disrupt the epidemiological transition to develop NCDs among these groups, thereby averting future NCD crises. Proactive prevention strategies can be classified, and their implementation prioritized, based on a 2-dimensional assessment: impact and feasibility. Thus, potential interventions can be categorized into a 2-by-2 matrix: high impact/high feasibility, high impact/low feasibility, low impact/high feasibility, and low impact/low feasibility. We propose that high impact/high feasibility interventions are ready to be implemented (act), while high impact/low feasibility interventions require efforts to foster buy-in first. Low impact/high feasibility interventions need to be changed to improve their impact while low impact/low feasibility might be best re-designed in the context of limited resources. Using this framework, policy makers, public health experts, and other stakeholders can more effectively prioritize and leverage limited resources in an effort to slow or prevent the evolving global NCD crisis.