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

Murphy A 1 , Palafox B 2 , O'Donnell O 3 , Stuckler D 4 , Perel P 2 , AlHabib KF 5 Show all authors , Avezum A 6 , Bai X 7 , Chifamba J 8 , Chow CK 9 , Corsi DJ 10 , Dagenais GR 11 , Dans AL 12 , Diaz R 13 , Erbakan AN 14 , Ismail N 15 , Iqbal R 16 , Kelishadi R 17 , Khatib R 18 , Lanas F 19 , Lear SA 20 , Li W 7 , Liu J 7 , Lopez-Jaramillo P 21 , Mohan V 22 , Monsef N 23 , Mony PK 24 , Puoane T 25 , Rangarajan S 26 , Rosengren A 27 , Schutte AE 28 , Sintaha M 29 , Teo KK 26 , Wielgosz A 30 , Yeates K 31 , Yin L 7 , Yusoff K 32 , Zatońska K 33 , Yusuf S 26 , McKee M 2

Affiliations 

  • 1 Centre for Global Chronic Conditions, London School of Tropical Medicine, London, UK. Electronic address: adrianna.murphy@lshtm.ac.uk
  • 2 Centre for Global Chronic Conditions, London School of Tropical Medicine, London, UK
  • 3 Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, Netherlands; Faculty of Economics and Business, University of Lausanne, Lausanne, Switzerland
  • 4 Department of Policy Analysis and Public Management, Bocconi University, Milan, Italy
  • 5 Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  • 6 Institute of Cardiology, University of Santo Amaro, Sao Paulo, Brazil
  • 7 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
  • 8 Department of Physiology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
  • 9 The University of Sydney and The George Institute for Global Health, Camperdown, NSW, Australia
  • 10 Ottawa Hospital Research Institute, OMNI Research Group, Clinical Epidemiology Program, Ottawa, ON, Canada
  • 11 Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec City, QC, Canada
  • 12 University of the Philippines-Manila, Manila, Philippines
  • 13 Estudios Clínicos Latinoamérica (ECLA) International, Rosario, Santa Fe, Argentina
  • 14 Nisa Hastanesi, Fatih, Istanbul, Turkey
  • 15 Department of Community Health, UKM Medical Centre, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
  • 16 Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
  • 17 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Chamran Hospital, Isfahan, Iran
  • 18 Department of Public Health Sciences, Loyola Medical Center, Maywood, IL, USA
  • 19 Universidad de La Frontera, Temuco, Chile
  • 20 Simon Fraser University, Burnaby, BC, Canada
  • 21 Fundación Oftalmológica de Santander-FOSCAL-FOSCAL Internacional, Floridablanca, Santander, Colombia
  • 22 Madras Diabetes Research Foundation and DrMohan's Diabetes Specialities Centre, Gopalapuram, Chennai, India
  • 23 Dubai Health Authority, Dubai, United Arab Emirates
  • 24 St John's Medical College and Research Insitute, Bangalore, India
  • 25 School of Public Health, University of the Western Cape, Cape Town, Western Cape Province, South Africa
  • 26 Population Health Research Institute, McMaster University, C2-106 DBCVSRI Hamilton General Hospital, Hamilton, ON, Canada
  • 27 Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, and Sahlgrenska University Hospital/Östra, Göteborg, Sweden
  • 28 South African Medical Research Council Unit for Hypertension and Cardiovascular Disease, Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa
  • 29 Independent University, Bangladesh, Dhaka, Bangladesh
  • 30 University of Ottawa Department of Medicine, Ottawa, ON, Canada
  • 31 Department of Medicine, Queen's University, Kingston, ON, Canada
  • 32 Universiti Teknologi MARA, Selyang Campus, Selayang, Selangor and UCSI University, Cheras, Malaysia
  • 33 Department of Social Medicine, Medical University, Wrocław, Poland
Lancet Glob Health, 2018 Mar;6(3):e292-e301.
PMID: 29433667 DOI: 10.1016/S2214-109X(18)30031-7

Abstract

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).

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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