Journal Article > LetterFull Text
Lancet. 2013 March 16; Volume 381 (Issue 9870); 901.; DOI:10.1016/S0140-6736(13)60664-9
Fernandez G, Boulle P
Lancet. 2013 March 16; Volume 381 (Issue 9870); 901.; DOI:10.1016/S0140-6736(13)60664-9
Journal Article > CommentaryFull Text
Lancet Diabetes Endocrinol. 2020 February 1; Volume 8 (Issue 2); DOI:10.1016/S2213-8587(19)30408-5
Kehlenbrink S, Boulle P
Lancet Diabetes Endocrinol. 2020 February 1; Volume 8 (Issue 2); DOI:10.1016/S2213-8587(19)30408-5
Conference Material > Slide Presentation
Ansbro E, Masri S, Prieto-Merino D, Bahous SA, Molfino L, et al.
MSF Scientific Days International 2022. 2022 May 11; DOI:10.57740/mzsh-8t29
Conference Material > Abstract
Oza S, Harris P, Ansbro E, Perel P, Frieden M, et al.
MSF Scientific Days International 2020: Research. 2020 May 20
INTRODUCTION
Globally, hypertension is responsible for approximately half of all heart disease and stroke deaths. Over 75% of these deaths occur in low- and middle-income countries. However globally, hypertension awareness, treatment, and control remain low (39%, 29%, and 10%, respectively). Reasons for poor control are multifactorial, and include patient-specific factors such as poor adherence, often associated with high pill-burden regimens. Health system factors are also important and may include the use of complex algorithms, leading to clinical inertia amongst healthcare workers. Fixed-dose combination (FDC) medications may be one way of reducing pill burden and simplifying clinical algorithms. To understand the use of multiple drug classes in the management of hypertension we analysed antihypertensive prescribing patterns and blood pressure (BP) control in cohorts from MSF treatment programmes in Jordan and Zimbabwe to determine the proportion of patients who may benefit from a FDC (those currently treated with more than two drug classes) and the potential extent of clinical inertia.
METHODS
We used routine, retrospective data from two cohorts of adult patients with hypertension; one from Jordan, a semi-urban clinic managed by doctors (using data from October 2016 to December 2018) and one from Zimbabwe, a rural setting managed by nurses (data from May 2016 to July 2019). We carried out descriptive analyses of prescribing patterns and their relationship with BP control.
Ethics
This study was approved by the ethics committees of Jordan and Zimbabwe and the MSF Ethics Review Board.
RESULTS
We analysed data from 3305 and 3957 hypertensive patients from Jordan and Zimbabwe respectively; with median ages in Jordan 61 (interquartile range, IQR, 53-69) and in Zimbabwe 63 (IQR 53-70); the majority were female (62.7% and 80.4% respectively). Retention and BP control at 12 months were 95% and 77% (Jordan) and 59% and 42.3% (Zimbabwe). The proportion of patients on two, three, or four-five antihypertensive drug classes at baseline were 42%, 19%, 4% in Jordan and 46%, 7%, <1% in Zimbabwe. At 12 months follow-up, proportions were 40%, 28%, 11% in Jordan and 46%, 17%, 1% in Zimbabwe. Proportions with controlled BP at 12 months on two, three, or four-five drug classes were 71%, 64% and 55% in Jordan, and 40%, 27%, 25% in Zimbabwe. No medication change for uncontrolled BP was made at the next visit for 1,843 (79.3%) of 2,325 visits in Jordan, and 4,763 (63.5%) of 7,497 visits in Zimbabwe. This included 545 (28.6%) and 2,549 (53.5%) visits with uncontrolled stage two or three hypertension respectively.
CONCLUSION
Most patients with hypertension required more than two antihypertensive medications, but a significant proportion persisted with uncontrolled BP. No additional class of antihypertensive was given in the majority of visits by patients with uncontrolled BP, suggesting possible clinical inertia by healthcare workers. Despite recent inclusion of FDC’s in MSF guidelines and WHO’s Essential Medicines List, their lack of inclusion in national guidelines, and procurement challenges, have hindered MSF’s implementation of FDC’s. Demonstrating feasibility of FDC use in MSF pilot projects could play an important role in furthering uptake.
Conflicts of Interest
None declared.
Globally, hypertension is responsible for approximately half of all heart disease and stroke deaths. Over 75% of these deaths occur in low- and middle-income countries. However globally, hypertension awareness, treatment, and control remain low (39%, 29%, and 10%, respectively). Reasons for poor control are multifactorial, and include patient-specific factors such as poor adherence, often associated with high pill-burden regimens. Health system factors are also important and may include the use of complex algorithms, leading to clinical inertia amongst healthcare workers. Fixed-dose combination (FDC) medications may be one way of reducing pill burden and simplifying clinical algorithms. To understand the use of multiple drug classes in the management of hypertension we analysed antihypertensive prescribing patterns and blood pressure (BP) control in cohorts from MSF treatment programmes in Jordan and Zimbabwe to determine the proportion of patients who may benefit from a FDC (those currently treated with more than two drug classes) and the potential extent of clinical inertia.
METHODS
We used routine, retrospective data from two cohorts of adult patients with hypertension; one from Jordan, a semi-urban clinic managed by doctors (using data from October 2016 to December 2018) and one from Zimbabwe, a rural setting managed by nurses (data from May 2016 to July 2019). We carried out descriptive analyses of prescribing patterns and their relationship with BP control.
Ethics
This study was approved by the ethics committees of Jordan and Zimbabwe and the MSF Ethics Review Board.
RESULTS
We analysed data from 3305 and 3957 hypertensive patients from Jordan and Zimbabwe respectively; with median ages in Jordan 61 (interquartile range, IQR, 53-69) and in Zimbabwe 63 (IQR 53-70); the majority were female (62.7% and 80.4% respectively). Retention and BP control at 12 months were 95% and 77% (Jordan) and 59% and 42.3% (Zimbabwe). The proportion of patients on two, three, or four-five antihypertensive drug classes at baseline were 42%, 19%, 4% in Jordan and 46%, 7%, <1% in Zimbabwe. At 12 months follow-up, proportions were 40%, 28%, 11% in Jordan and 46%, 17%, 1% in Zimbabwe. Proportions with controlled BP at 12 months on two, three, or four-five drug classes were 71%, 64% and 55% in Jordan, and 40%, 27%, 25% in Zimbabwe. No medication change for uncontrolled BP was made at the next visit for 1,843 (79.3%) of 2,325 visits in Jordan, and 4,763 (63.5%) of 7,497 visits in Zimbabwe. This included 545 (28.6%) and 2,549 (53.5%) visits with uncontrolled stage two or three hypertension respectively.
CONCLUSION
Most patients with hypertension required more than two antihypertensive medications, but a significant proportion persisted with uncontrolled BP. No additional class of antihypertensive was given in the majority of visits by patients with uncontrolled BP, suggesting possible clinical inertia by healthcare workers. Despite recent inclusion of FDC’s in MSF guidelines and WHO’s Essential Medicines List, their lack of inclusion in national guidelines, and procurement challenges, have hindered MSF’s implementation of FDC’s. Demonstrating feasibility of FDC use in MSF pilot projects could play an important role in furthering uptake.
Conflicts of Interest
None declared.
Journal Article > LetterFull Text
Lancet Diabetes Endocrinol. 2022 February 7; Volume S2213-8587 (Issue 22); 00036-5.; DOI:10.1016/S2213-8587(22)00036-5
Kehlenbrink S, Mahboob O, Al-Zubi S, Boulle P, Aebischer-Perone S, et al.
Lancet Diabetes Endocrinol. 2022 February 7; Volume S2213-8587 (Issue 22); 00036-5.; DOI:10.1016/S2213-8587(22)00036-5
Journal Article > CommentaryFull Text
Lancet Diabetes Endocrinol. 2019 August 1; DOI:10.1016/S2213-8587(19)30197-4.
Kehlenbrink S, Jaacks LM, Perone SA, Ansbro É, Ashbourne E, et al.
Lancet Diabetes Endocrinol. 2019 August 1; DOI:10.1016/S2213-8587(19)30197-4.
Journal Article > CommentaryFull Text
Lancet. 2016 September 13; Volume 389 (Issue 10066); DOI:10.1016/S0140-6736(16)31404-0
Slama S, Kim HJ, Roglic G, Boulle P, Hering H, et al.
Lancet. 2016 September 13; Volume 389 (Issue 10066); DOI:10.1016/S0140-6736(16)31404-0
Journal Article > ResearchFull Text
Confl Health. 2019 August 9; Volume 13 (Issue 1); DOI:10.1186/s13031-019-0217-x
Boulle P, Sibourd Baudry A, Ansbro É, Prieto Merino D, Saleh N, et al.
Confl Health. 2019 August 9; Volume 13 (Issue 1); DOI:10.1186/s13031-019-0217-x
We included 514 patients with ASCVD in the cross-sectional study, performed in 2017. Most (61.9%) were male and mean age was 60.4 years (95% CI, 59.6-61.3). Over half (58.8%) underwent revascularization and 26.1% had known cerebrovascular disease. ASCVD risk factors included 51.8% with diabetes and 72.2% with hypertension. While prescription (75.7 to 98.2%) and self-reported adherence rates (78.4 to 93.9%) for individual ASCVD secondary prevention drugs (ACE-inhibitor, statin and antiplatelet) were high, the use of all three was low at 41.3% (CI95%: 37.0-45.6). The 5-year retrospective cohort study (ending April 2017) identified 1286 patients with ASCVD and 16,618 related consultations (comprising 24% of all NCD consultations). Over one third (39.7%) of patients were lost to follow-up, with lower risk among men.
Journal Article > ResearchFull Text
BMJ Open. 2023 January 25; Volume 13 (Issue 1); e063668.; DOI:10.1136/bmjopen-2022-063668
Ansbro É, Masri S, Prieto-Merino D, Willis R, Aoun Bahous S, et al.
BMJ Open. 2023 January 25; Volume 13 (Issue 1); e063668.; DOI:10.1136/bmjopen-2022-063668
OBJECTIVES
This pre–post implementation study evaluated the introduction of fixed dose combination (FDC) medications for atherosclerotic cardiovascular disease (ASCVD) secondary prevention into routine care in a humanitarian setting.
SETTING
Two Médecins sans Frontières (MSF) primary care clinics serving Syrian refugee and host populations in north Lebanon.
PARTICIPANTS
Consenting patients ≥18 years with existing ASCVD requiring secondary prevention medication were eligible for study enrolment. Those with FDC contraindication(s) or planning to move were excluded. Of 521 enrolled patients, 460 (88.3%) were retained at 6 months, and 418 (80.2%) switched to FDC. Of these, 84% remained on FDC (n=351), 8.1% (n=34) discontinued and 7.9% (n=33) were lost to follow-up by month 12.
INTERVENTIONS
Eligible patients, enrolled February–May 2019, were switched to Trinomia FDC (atorvastatin 20 mg, aspirin 100 mg, ramipril 2.5/5/10 mg) after 6 months’ usual care. During the study, the COVID-19 pandemic, an economic crisis and clinic closures occurred.
OUTCOME MEASURES
Descriptive and regression analyses compared key outcomes at 6 and 12 months: medication adherence, non-high density lipoprotein cholesterol (non-HDL-C) and systolic blood pressure (SBP) control. We performed per-protocol, intention-to-treat and secondary analyses of non-switchers.
RESULTS
Among 385 switchers remaining at 12 months, total adherence improved 23%, from 63% (95% CI 58 to 68) at month 6, to 86% (95% CI 82 to 90) at month 12; mean non-HDL-C levels dropped 0.28 mmol/L (95% CI −0.38 to −0.18; p<0.0001), from 2.39 (95% CI 2.26 to 2.51) to 2.11 mmol/L (95% CI 2.00 to 2.22); mean SBP dropped 2.89 mm Hg (95% CI −4.49 to −1.28; p=0.0005) from 132.7 (95% CI 130.8 to 134.6) to 129.7 mm Hg (95% CI 127.9 to 131.5). Non-switchers had smaller improvements in adherence and clinical outcomes.
CONCLUSION
Implementing an ASCVD secondary prevention FDC improved adherence and CVD risk factors in MSF clinics in Lebanon, with potential for wider implementation by humanitarian actors and host health systems.
This pre–post implementation study evaluated the introduction of fixed dose combination (FDC) medications for atherosclerotic cardiovascular disease (ASCVD) secondary prevention into routine care in a humanitarian setting.
SETTING
Two Médecins sans Frontières (MSF) primary care clinics serving Syrian refugee and host populations in north Lebanon.
PARTICIPANTS
Consenting patients ≥18 years with existing ASCVD requiring secondary prevention medication were eligible for study enrolment. Those with FDC contraindication(s) or planning to move were excluded. Of 521 enrolled patients, 460 (88.3%) were retained at 6 months, and 418 (80.2%) switched to FDC. Of these, 84% remained on FDC (n=351), 8.1% (n=34) discontinued and 7.9% (n=33) were lost to follow-up by month 12.
INTERVENTIONS
Eligible patients, enrolled February–May 2019, were switched to Trinomia FDC (atorvastatin 20 mg, aspirin 100 mg, ramipril 2.5/5/10 mg) after 6 months’ usual care. During the study, the COVID-19 pandemic, an economic crisis and clinic closures occurred.
OUTCOME MEASURES
Descriptive and regression analyses compared key outcomes at 6 and 12 months: medication adherence, non-high density lipoprotein cholesterol (non-HDL-C) and systolic blood pressure (SBP) control. We performed per-protocol, intention-to-treat and secondary analyses of non-switchers.
RESULTS
Among 385 switchers remaining at 12 months, total adherence improved 23%, from 63% (95% CI 58 to 68) at month 6, to 86% (95% CI 82 to 90) at month 12; mean non-HDL-C levels dropped 0.28 mmol/L (95% CI −0.38 to −0.18; p<0.0001), from 2.39 (95% CI 2.26 to 2.51) to 2.11 mmol/L (95% CI 2.00 to 2.22); mean SBP dropped 2.89 mm Hg (95% CI −4.49 to −1.28; p=0.0005) from 132.7 (95% CI 130.8 to 134.6) to 129.7 mm Hg (95% CI 127.9 to 131.5). Non-switchers had smaller improvements in adherence and clinical outcomes.
CONCLUSION
Implementing an ASCVD secondary prevention FDC improved adherence and CVD risk factors in MSF clinics in Lebanon, with potential for wider implementation by humanitarian actors and host health systems.
Journal Article > ReviewFull Text
Confl Health. 2021 February 25; Volume 15 (Issue 1); DOI:10.1186/s13031-021-00345-w
Bausch FJ, Beran D, Hering H, Boulle P, Chappuis F, et al.
Confl Health. 2021 February 25; Volume 15 (Issue 1); DOI:10.1186/s13031-021-00345-w
Non-communicable diseases (NCD) represent an increasing global challenge with the majority of mortality occurring in low- and middle-income countries (LMICs). Concurrently, many humanitarian crises occur in these countries and the number of displaced persons, either refugees or internally displaced, has reached the highest level in history. Until recently NCDs in humanitarian contexts were a neglected issue, but this is changing. Humanitarian actors are now increasingly integrating NCD care in their activities and recognizing the need to harmonize and enhance NCD management in humanitarian crises. However, there is a lack of a standardized response during operations as well as a lack of evidence-based NCD management guidelines in humanitarian settings. An informal working group on NCDs in humanitarian settings, formed by members of the World Health Organization, Médecins Sans Frontières, the International Committee of the Red Cross, the International Federation of the Red Cross and others, and led by the United Nations High Commissioner for Refugees, teamed up with the University of Geneva and Geneva University Hospitals to develop operational considerations for NCDs in humanitarian settings. This paper presents these considerations, aiming at ensuring appropriate planning, management and care for NCD-affected persons during the different stages of humanitarian emergencies. Key components include access to treatment, continuity of care including referral pathways, therapeutic patient education/patient self-management, community engagement and health promotion. In order to implement these components, a standardized approach will support a consistent response, and should be based on an ethical foundation to ensure that the "do no harm" principle is upheld. Advocacy supported by evidence is important to generate visibility and resource allocation for NCDs. Only a collaborative approach of all actors involved in NCD management will allow the spectrum of needs and continuum of care for persons affected by NCDs to be properly addressed in humanitarian programmes.