Inequalities in the use of secondary prevention of cardiovascular disease by socioeconomic status: evidence from the PURE observational study

Abstract

SummaryBackgroundThere is little evidence on the use of secondary prevention medicines for cardiovascular disease by socioeconomic groups in countries at different levels of economic development.MethodsWe assessed use of antiplatelet, cholesterol, and blood-pressure-lowering drugs in 8492 individuals with self-reported cardiovascular disease from 21 countries enrolled in the Prospective Urban Rural Epidemiology (PURE) study. Defining one or more drugs as a minimal level of secondary prevention, wealth-related inequality was measured using the Wagstaff concentration index, scaled from −1 (pro-poor) to 1 (pro-rich), standardised by age and sex. Correlations between inequalities and national health-related indicators were estimated.FindingsThe proportion of patients with cardiovascular disease on three medications ranged from 0% in South Africa (95% CI 0–1·7), Tanzania (0–3·6), and Zimbabwe (0–5·1), to 49·3% in Canada (44·4–54·3). Proportions receiving at least one drug varied from 2·0% (95% CI 0·5–6·9) in Tanzania to 91·4% (86·6–94·6) in Sweden. There was significant (p<0·05) pro-rich inequality in Saudi Arabia, China, Colombia, India, Pakistan, and Zimbabwe. Pro-poor distributions were observed in Sweden, Brazil, Chile, Poland, and the occupied Palestinian territory. The strongest predictors of inequality were public expenditure on health and overall use of secondary prevention medicines.InterpretationUse of medication for secondary prevention of cardiovascular disease is alarmingly low. In many countries with the lowest use, pro-rich inequality is greatest. Policies associated with an equal or pro-poor distribution include free medications and community health programmes to support adherence to medications.FundingFull funding sources listed at the end of the paper (see Acknowledgments).

Disease characteristics and treatment of patients with diabetes mellitus attending government health services in Indonesia, Peru, Romania and South Africa

“…Also, people living with DM in tropical countries may be at higher risk for infectious diseases . Cardiovascular complications, the leading cause of mortality and morbidity among patients with type 2 DM , may also be more common among people living with DM in LMICs , due to higher rates of smoking, and less access to cardiovascular risk assessment and management . Assessment of diabetes disease characteristics, cardiovascular risk profile and medical management of people living with DM has been undertaken in some country‐specific studies and compared across LMIC countries in Asia and sub‐Saharan Africa .…”

Cardiovascular Risk Management Must Always Consider Social Determinants of Health: Past Lessons, Data, Proposals and Challenges

“…Motivation, collaboration, resolve, and persistence by all stakeholders are essential [41]. These assets transcend the boundaries of the health sector, and require the conscious and unconditional support of all facilities, particularly governmental agencies and non-governmental organizations [2,3,7,8,22,26,24,31,34,37].…”

“…Making matters worse, the deficiency in access is frequently accompanied by lack of programs that promote adherence to those medications. Unless significant changes are made in leveling both equity and SES soon, World Health Organization (WHO) targets of 50% use of essential medicines by 2025 will not be reached [30,31].…”

Heart failure around the world

“…Patients from higher‐income countries had lower rates of protocol completion, higher rates of adverse events, and similar mortality rates compared to lower‐ and middle‐income countries . The importance of socioeconomic status on access to medication, lifestyle, treatment quality and clinical outcomes is also apparent beyond HF, and was shown to be relevant in the treatment of stroke and secondary prevention of cardiovascular events in populations at risk . For example, patients from low‐income countries are more likely to be smokers, which might be an important opportunity for intervention .…”