Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys

<h4>Background</h4> As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care a...

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Autores principales:	Maja E. Marcus, Cara Ebert, Pascal Geldsetzer, Michaela Theilmann, Brice Wilfried Bicaba, Glennis Andall-Brereton, Pascal Bovet, Farshad Farzadfar, Mongal Singh Gurung, Corine Houehanou, Mohammad-Reza Malekpour, Joao S. Martins, Sahar Saeedi Moghaddam, Esmaeil Mohammadi, Bolormaa Norov, Sarah Quesnel-Crooks, Roy Wong-McClure, Justine I. Davies, Mark A. Hlatky, Rifat Atun, Till W. Bärnighausen, Lindsay M. Jaacks, Jennifer Manne-Goehler, Sebastian Vollmer
Formato:	article
Lenguaje:	EN
Publicado:	Public Library of Science (PLoS) 2021
Materias:	Medicine R
Acceso en línea:	https://doaj.org/article/8b14b816c7ee49f486425b06460660ff
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id	oai:doaj.org-article:8b14b816c7ee49f486425b06460660ff
record_format	dspace
institution	DOAJ
collection	DOAJ
language	EN
topic	Medicine R
spellingShingle	Medicine R Maja E. Marcus Cara Ebert Pascal Geldsetzer Michaela Theilmann Brice Wilfried Bicaba Glennis Andall-Brereton Pascal Bovet Farshad Farzadfar Mongal Singh Gurung Corine Houehanou Mohammad-Reza Malekpour Joao S. Martins Sahar Saeedi Moghaddam Esmaeil Mohammadi Bolormaa Norov Sarah Quesnel-Crooks Roy Wong-McClure Justine I. Davies Mark A. Hlatky Rifat Atun Till W. Bärnighausen Lindsay M. Jaacks Jennifer Manne-Goehler Sebastian Vollmer Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys
description	<h4>Background</h4> As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs. <h4>Methods and findings</h4> We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings. <h4>Conclusions</h4> Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs—calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD. Maja Marcus and colleagues use nationally-representative surveys conducted between 2009 and 2018 to investigate the unmet need for hypercholesterolemia care in 35 low- and middle-income countries. Author summary <h4>Why was this study done?</h4> The prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs). Evidence on how well health systems address this rising hypercholesterolemia burden is limited. Nationally representative studies analyzing care at the individual level across a larger number of LMICs are largely missing. <h4>What did the researchers do and find?</h4> We analyzed access to hypercholesterolemia care using pooled data from 35 nationally representative, individual-level surveys from LMICs. We found a prevalence of high total cholesterol (TC) of 7.1% (95% CI: 6.8% to 7.4%) and a high low-density lipoprotein cholesterol (LDL-C) prevalence of 7.5% (95% CI: 7.1% to 7.9%) in this set of countries. Using a cascade of care approach, we found that 43% (95% CI: 40% to 45%) of individuals with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. Using modified Poisson regression models, we found that access to care was significantly associated with a range of sociodemographic characteristics, such as high education and old age, as well as with the presentation of other cardiovascular disease (CVD) risk factors, such as comorbid diabetes or hypertension and a high body mass index. <h4>What do these findings mean?</h4> We found large unmet need for hypercholesterolemia care in this sample of LMICs. This calls for greater policy and research attention toward this CVD risk factor. High-performing countries, such as Sri Lanka, Costa Rica, Iran, and Morocco, may highlight policy opportunities for improved prevention of CVD. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings.
format	article
author	Maja E. Marcus Cara Ebert Pascal Geldsetzer Michaela Theilmann Brice Wilfried Bicaba Glennis Andall-Brereton Pascal Bovet Farshad Farzadfar Mongal Singh Gurung Corine Houehanou Mohammad-Reza Malekpour Joao S. Martins Sahar Saeedi Moghaddam Esmaeil Mohammadi Bolormaa Norov Sarah Quesnel-Crooks Roy Wong-McClure Justine I. Davies Mark A. Hlatky Rifat Atun Till W. Bärnighausen Lindsay M. Jaacks Jennifer Manne-Goehler Sebastian Vollmer
author_facet	Maja E. Marcus Cara Ebert Pascal Geldsetzer Michaela Theilmann Brice Wilfried Bicaba Glennis Andall-Brereton Pascal Bovet Farshad Farzadfar Mongal Singh Gurung Corine Houehanou Mohammad-Reza Malekpour Joao S. Martins Sahar Saeedi Moghaddam Esmaeil Mohammadi Bolormaa Norov Sarah Quesnel-Crooks Roy Wong-McClure Justine I. Davies Mark A. Hlatky Rifat Atun Till W. Bärnighausen Lindsay M. Jaacks Jennifer Manne-Goehler Sebastian Vollmer
author_sort	Maja E. Marcus
title	Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys
title_short	Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys
title_full	Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys
title_fullStr	Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys
title_full_unstemmed	Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys
title_sort	unmet need for hypercholesterolemia care in 35 low- and middle-income countries: a cross-sectional study of nationally representative surveys
publisher	Public Library of Science (PLoS)
publishDate	2021
url	https://doaj.org/article/8b14b816c7ee49f486425b06460660ff
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spelling	oai:doaj.org-article:8b14b816c7ee49f486425b06460660ff2021-11-18T05:40:40ZUnmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys1549-12771549-1676https://doaj.org/article/8b14b816c7ee49f486425b06460660ff2021-10-01T00:00:00Zhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8575312/?tool=EBIhttps://doaj.org/toc/1549-1277https://doaj.org/toc/1549-1676<h4>Background</h4> As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs. <h4>Methods and findings</h4> We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings. <h4>Conclusions</h4> Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs—calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD. Maja Marcus and colleagues use nationally-representative surveys conducted between 2009 and 2018 to investigate the unmet need for hypercholesterolemia care in 35 low- and middle-income countries. Author summary <h4>Why was this study done?</h4> The prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs). Evidence on how well health systems address this rising hypercholesterolemia burden is limited. Nationally representative studies analyzing care at the individual level across a larger number of LMICs are largely missing. <h4>What did the researchers do and find?</h4> We analyzed access to hypercholesterolemia care using pooled data from 35 nationally representative, individual-level surveys from LMICs. We found a prevalence of high total cholesterol (TC) of 7.1% (95% CI: 6.8% to 7.4%) and a high low-density lipoprotein cholesterol (LDL-C) prevalence of 7.5% (95% CI: 7.1% to 7.9%) in this set of countries. Using a cascade of care approach, we found that 43% (95% CI: 40% to 45%) of individuals with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. Using modified Poisson regression models, we found that access to care was significantly associated with a range of sociodemographic characteristics, such as high education and old age, as well as with the presentation of other cardiovascular disease (CVD) risk factors, such as comorbid diabetes or hypertension and a high body mass index. <h4>What do these findings mean?</h4> We found large unmet need for hypercholesterolemia care in this sample of LMICs. This calls for greater policy and research attention toward this CVD risk factor. High-performing countries, such as Sri Lanka, Costa Rica, Iran, and Morocco, may highlight policy opportunities for improved prevention of CVD. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings.Maja E. MarcusCara EbertPascal GeldsetzerMichaela TheilmannBrice Wilfried BicabaGlennis Andall-BreretonPascal BovetFarshad FarzadfarMongal Singh GurungCorine HouehanouMohammad-Reza MalekpourJoao S. MartinsSahar Saeedi MoghaddamEsmaeil MohammadiBolormaa NorovSarah Quesnel-CrooksRoy Wong-McClureJustine I. DaviesMark A. HlatkyRifat AtunTill W. BärnighausenLindsay M. JaacksJennifer Manne-GoehlerSebastian VollmerPublic Library of Science (PLoS)articleMedicineRENPLoS Medicine, Vol 18, Iss 10 (2021)

Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys

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