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      Facilitators and barriers of heart failure care in Kerala, India: A qualitative analysis of health-care providers and administrators

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          Abstract

          Objective

          Heart failure is a leading cause of death worldwide and in India, yet the qualitative data regarding heart failure care are limited. To fill this gap, we studied the facilitators and barriers of heart failure care in Kerala, India.

          Methods and results

          During January 2018, we conducted a qualitative study using in-depth, semi-structured interviews with 21 health-care providers and quality administrators from 8 hospitals in Kerala to understand the context, facilitators, and barriers of heart failure care. We developed a theoretical framework using iteratively developed codes from these data to identify 6 key themes of heart failure care in Kerala: (1) need for comprehensive patient and family education on heart failure; (2) gaps between guideline-directed clinical care for heart failure and clinical practice; (3) national hospital accreditation contributing to a culture of systematically improving quality and safety of in-hospital care; (4) limited system-level attention toward improving heart failure care compared with other cardiovascular conditions; (5) application of existing personnel and technology to improve heart failure care; and (6) longitudinal and recurrent costs as barriers for optimal heart failure care.

          Conclusions

          Key themes emerged regarding heart failure care in Kerala in the context of a health system that is increasingly emphasizing health-care quality and safety. Targeted in-hospital quality improvement interventions for heart failure should account for these themes to improve cardiovascular outcomes in the region.

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          Most cited references18

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          Qualitative and mixed methods provide unique contributions to outcomes research.

          Leslie A Curry, Ingrid Nembhard, Elizabeth H Bradley (2009)
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            Cardiovascular disease in the developing world and its cost-effective management.

            Thomas A Gaziano (2005)
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              Baseline assessment of WHO’s target for both availability and affordability of essential medicines to treat non-communicable diseases

              Margaret Ewen, Marjolein Zweekhorst, Barbara Regeer … (2017)
              Background WHO has set a voluntary target of 80% availability of affordable essential medicines, including generics, to treat major non-communicable diseases (NCDs), in the public and private sectors of countries by 2025. We undertook a secondary analysis of data from 30 surveys in low- and middle-income countries, conducted from 2008–2015 using the World Health Organization (WHO)/Health Action International (HAI) medicine availability and price survey methodology, to establish a baseline for this target. Methods Data for 49 medicines (lowest priced generics and originator brands) to treat cardiovascular diseases (CVD), diabetes, chronic obstructive pulmonary diseases (COPD) and central nervous system (CNS) conditions were analysed to determine their availability in healthcare facilities and pharmacies, their affordability for those on low incomes (based on median patient prices of each medicine), and the percentage of medicines that were both available and affordable. Affordability was expressed as the number of days’ wages of the lowest-paid unskilled government worker needed to purchase 30 days’ supply using standard treatment regimens. Paying more than 1 days’ wages was considered unaffordable. Findings In low-income countries, 15.2% and 18.9% of lowest-priced generics met WHO’s target in the public and private sectors, respectively, and 2.6% and 5.2% of originator brands. In lower-middle income countries, 23.8% and 23.2% of lowest priced generics, and 0.8% and 1.4% of originator brands, met the target in the public and private sectors, respectively. In upper-middle income countries, the situation was better for generics but still suboptimal as 36.0% and 39.4% met the target in public and private sectors, respectively. For originator brands in upper-middle income countries, none reached the target in the public sector and 13.7% in the private sector. Across the therapeutic groups for lowest priced generics, CVD medicines in low-income countries (11.9%), and CNS medicines in lower-middle (10.2%) and upper-middle income countries (33.3%), were least available and affordable in the public sector. In the private sector for lowest priced generics, CNS medicines were least available and affordable in all three country income groups (11.4%, 5.8% and 29.3% in low-, lower-middle and upper-middle income countries respectively). Interpretation This data, which can act as a baseline for the WHO target, shows low availability and/or poor affordability is resulting in few essential NCD medicines meeting the target in low- and middle-income countries. In the era of Sustainable Development Goals, and as countries work to achieve Universal Health Coverage, increased commitments are needed by governments to improve the situation through the development of evidence-informed, nationally-contextualised interventions, with regular monitoring of NCD medicine availability, patient prices and affordability.
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                Author and article information

                Contributors
                Anubha Agarwal
                Journal
                Journal ID (nlm-ta): Indian Heart J
                Journal ID (iso-abbrev): Indian Heart J
                Title: Indian Heart Journal
                Publisher: Elsevier
                ISSN (Print): 0019-4832
                ISSN (Electronic): 2213-3763
                Publication date (Print): May-Jun 2019
                Publication date (Electronic): 08 May 2019
                Volume: 71
                Issue: 3
                Pages: 235-241
                Affiliations
                [a ]Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
                [b ]WestFort Hi-Tech Hospital Ltd, Thrissur, Kerala, India
                [c ]Centre for Chronic Disease Control, New Delhi, Delhi, India
                [d ]Public Health Foundation of India, Gurugram, Haryana, India
                [e ]Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
                [f ]The George Institute for Global Health, Sydney, Australia
                Author notes
                [∗ ] Corresponding author. Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611 USA. anubha.agarwal@ 123456northwestern.edu
                Article
                Publisher ID: S0019-4832(19)30040-9
                DOI: 10.1016/j.ihj.2019.04.009
                PMC ID: 6796633
                PubMed ID: 31543196
                SO-VID: 019552ec-43dc-4bed-9ba0-0a07781a5980
                Copyright © © 2019 Cardiological Society of India. Published by Elsevier B.V.
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 24 January 2019
                Date accepted : 26 April 2019
                Categories
                Subject: Original Article

                Keywords: heart failure,india,kerala,qualitative
                Data availability:
                Keywords: heart failure, india, kerala, qualitative

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