The Lancet Global Health (Mar 2018)
Inequalities in the use of secondary prevention of cardiovascular disease by socioeconomic status: evidence from the PURE observational study
- Adrianna Murphy, PhD,
- Benjamin Palafox, MSc,
- Owen O'Donnell, ProfPhD,
- David Stuckler, ProfPhD,
- Pablo Perel, PhD,
- Khalid F AlHabib, ProfMBBS,
- Alvaro Avezum, ProfPhD,
- Xiulin Bai, BSc,
- Jephat Chifamba, ProfDPhil,
- Clara K Chow, ProfPhD,
- Daniel J Corsi, PhD,
- Gilles R Dagenais, MD,
- Antonio L Dans, MD,
- Rafael Diaz, MD,
- Ayse N Erbakan, MD,
- Noorhassim Ismail, MD,
- Romaina Iqbal, PhD,
- Roya Kelishadi, MD,
- Rasha Khatib, PhD,
- Fernando Lanas, PhD,
- Scott A Lear, ProfPhD,
- Wei Li, ProfPhD,
- Jia Liu, MSc,
- Patricio Lopez-Jaramillo, ProfPhD,
- Viswanathan Mohan, ProfMD,
- Nahed Monsef, PhD,
- Prem K Mony, MD,
- Thandi Puoane, ProfDrPH,
- Sumathy Rangarajan, MSc,
- Annika Rosengren, ProfMD,
- Aletta E Schutte, ProfPhD,
- Mariz Sintaha, MSc,
- Koon K Teo, ProfPhD,
- Andreas Wielgosz, ProfMD,
- Karen Yeates, MD,
- Lu Yin, PhD,
- Khalid Yusoff, ProfMBBS,
- Katarzyna Zatońska, PhD,
- Salim Yusuf, ProfPhD,
- Martin McKee, ProfPhD
Affiliations
- Adrianna Murphy, PhD
- Centre for Global Chronic Conditions, London School of Tropical Medicine, London, UK; Correspondence to: Dr Adrianna Murphy, London School of Hygiene & Tropical Medicine, 15–17 Tavistock Place, London WC1H 9SH, UK
- Benjamin Palafox, MSc
- Centre for Global Chronic Conditions, London School of Tropical Medicine, London, UK
- Owen O'Donnell, ProfPhD
- Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, Netherlands; Faculty of Economics and Business, University of Lausanne, Lausanne, Switzerland
- David Stuckler, ProfPhD
- Department of Policy Analysis and Public Management, Bocconi University, Milan, Italy
- Pablo Perel, PhD
- Centre for Global Chronic Conditions, London School of Tropical Medicine, London, UK
- Khalid F AlHabib, ProfMBBS
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Alvaro Avezum, ProfPhD
- Institute of Cardiology, University of Santo Amaro, Sao Paulo, Brazil
- Xiulin Bai, BSc
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Jephat Chifamba, ProfDPhil
- Department of Physiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
- Clara K Chow, ProfPhD
- The University of Sydney and The George Institute for Global Health, Camperdown, NSW, Australia
- Daniel J Corsi, PhD
- Ottawa Hospital Research Institute, OMNI Research Group, Clinical Epidemiology Program, Ottawa, ON, Canada
- Gilles R Dagenais, MD
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec City, QC, Canada
- Antonio L Dans, MD
- University of the Philippines—Manila, Manila, Philippines
- Rafael Diaz, MD
- Estudios Clínicos Latinoamérica (ECLA) International, Rosario, Santa Fe, Argentina
- Ayse N Erbakan, MD
- Nisa Hastanesi, Fatih, Istanbul, Turkey
- Noorhassim Ismail, MD
- Department of Community Health, UKM Medical Centre, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Romaina Iqbal, PhD
- Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
- Roya Kelishadi, MD
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Chamran Hospital, Isfahan, Iran
- Rasha Khatib, PhD
- Department of Public Health Sciences, Loyola Medical Center, Maywood, IL, USA
- Fernando Lanas, PhD
- Universidad de La Frontera, Temuco, Chile
- Scott A Lear, ProfPhD
- Simon Fraser University, Burnaby, BC, Canada
- Wei Li, ProfPhD
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Jia Liu, MSc
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Patricio Lopez-Jaramillo, ProfPhD
- Fundación Oftalmológica de Santander-FOSCAL—FOSCAL Internacional, Floridablanca, Santander, Colombia
- Viswanathan Mohan, ProfMD
- Madras Diabetes Research Foundation and DrMohan's Diabetes Specialities Centre, Gopalapuram, Chennai, India
- Nahed Monsef, PhD
- Dubai Health Authority, Dubai, United Arab Emirates
- Prem K Mony, MD
- St John's Medical College and Research Insitute, Bangalore, India
- Thandi Puoane, ProfDrPH
- School of Public Health, University of the Western Cape, Cape Town, Western Cape Province, South Africa
- Sumathy Rangarajan, MSc
- Population Health Research Institute, McMaster University, C2-106 DBCVSRI Hamilton General Hospital, Hamilton, ON, Canada
- Annika Rosengren, ProfMD
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital/Östra, Göteborg, Sweden
- Aletta E Schutte, ProfPhD
- South African Medical Research Council Unit for Hypertension and Cardiovascular Disease, Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa
- Mariz Sintaha, MSc
- Independent University, Bangladesh, Dhaka, Bangladesh
- Koon K Teo, ProfPhD
- Population Health Research Institute, McMaster University, C2-106 DBCVSRI Hamilton General Hospital, Hamilton, ON, Canada
- Andreas Wielgosz, ProfMD
- University of Ottawa Department of Medicine, Ottawa, ON, Canada
- Karen Yeates, MD
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Lu Yin, PhD
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Khalid Yusoff, ProfMBBS
- Universiti Teknologi MARA, Selyang Campus, Selayang, Selangor and UCSI University, Cheras, Malaysia
- Katarzyna Zatońska, PhD
- Department of Social Medicine, Medical University, Wrocław, Poland
- Salim Yusuf, ProfPhD
- Population Health Research Institute, McMaster University, C2-106 DBCVSRI Hamilton General Hospital, Hamilton, ON, Canada
- Martin McKee, ProfPhD
- Centre for Global Chronic Conditions, London School of Tropical Medicine, London, UK
- Journal volume & issue
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Vol. 6,
no. 3
pp. e292 – e301
Abstract
Summary: Background: There is little evidence on the use of secondary prevention medicines for cardiovascular disease by socioeconomic groups in countries at different levels of economic development. Methods: We 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. Findings: The 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. Interpretation: Use 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. Funding: Full funding sources listed at the end of the paper (see Acknowledgments).
