Countries with Fewer Procedures for Cardiovascular Disease Management Face Greater Premature Mortality from Noncommunicable Diseases

Abstract

Background:

The rate at which low- and middle-income countries (LMICs) are transitioning into high-burden states for noncommunicable diseases (NCDs) is currently posing a global health security threat. Not only cardiovascular disease (CVD) occurs earlier in these countries but also it is likely that individuals do not have access to adequate management procedures. The present study was undertaken to find the effect of availability of procedures for CVD management on premature mortality in NCDs and to juxtapose this with the prevalence of two main risk factors, hypertension and diabetes.

Methods:

The World Health Organization’s Global Health Observatory data were used, which include health-related data on its 194 member states. The correlation matrix was constructed for risk factors, income classification, availability of CVD management procedures, and premature NCD mortality. Multiple linear regression was done to find the association between availability of management procedures, income classification, and premature NCD mortality.

Results:

A negative correlation was observed between premature NCD mortality and income group and between premature NCD mortality and availability of CVD management procedures. Countries possessing fewer procedures for CVD management suffered a greater burden of premature NCD mortality, and this was in the form of a strong linear association. Income class and availability of CVD management procedures both independently affected premature NCD mortality. Each unit increase in income class and number of CVD management procedures reduced the premature NCD mortality by 7.9 and 2.8 units, respectively. The impact of both these factors on premature NCD mortality was statistically significant. Countries with higher prevalence of hypertension were seen to be possessing fewer CVD management procedures. Income groups also demonstrated disparities, with high-income countries bearing less burden of hypertension and having more ubiquitous CVD management resources.

Conclusion:

The present study found that availability of CVD management procedures, such as thrombolysis, coronary bypass/stenting, and acute stroke care and rehabilitation, significantly reduce premature NCD mortality across the world. Countries that face higher burden of premature NCD mortality are not only the ones that are least prepared to manage them but also the ones that bear the greatest prevalence of risk factors like hypertension and diabetes. Making procedures for NCD management available in LMICs must be put on high priority on the global health agenda.

INTRODUCTION

The rate at which low- and middle-income countries (LMICs) are transitioning into high burden states for noncommunicable diseases (NCDs) is currently posing a global health security threat.[1] Cardiovascular diseases (CVDs) contribute maximally to the NCD burden in these countries. Most prominent in NCD-related disparities is the disproportionate prematurity of NCDs in LMICs, where the probability of dying prematurely from these diseases is the highest.[2] 48% of NCD deaths in low- and middle-income countries in 2015 occurred before the age of 70.[3] Recognizing this imminent threat to international development,[1] the reduction in premature NCD morality was enshrined in the Sustainable Development Goals, and the WHO called for ‘25 by 25’, that is, a 25% reduction in the mortality caused by NCDs among individuals between 30 and 70 years of age by 2025.[4]

The primary focus of implementation strategies worldwide to address NCDs lies in health promotion activities. Nonetheless, it is crucial to assess whether relying solely on this approach will be adequate to achieve the 25 by 25 target. While health promotion plays a significant role, it appears doubtful that it can meet this goal in isolation.[5] Therefore, it is crucial to evaluate whether countries possess the necessary resources for secondary prevention and whether sufficient attention is given to tools and procedures to fulfill secondary care needs.

An increase in the life expectancy of persons living in LMICs has been implicated in the rise of CVD prevalence. However, it is becoming increasingly clear that this alone cannot explain the rate at which the NCD crisis has risen, which is much faster than the contemporaneous decline in communicable disease burden.[6] Not only CVD occurs earlier in these countries but also it is likely that individuals do not have access to adequate management procedures. Higher NCD mortality may be due to nonaccessibility of life-saving procedures to a significant proportion of patients with CVD. CVD thus may serve as an indicator to examine association between access to life-saving management strategies and NCD mortality.

These issues reflect the need to investigate the potential relationship between the availability of CVD management procedures and premature mortality within the realm of NCDs. By exploring this association, it may be possible to shed light on the critical role of healthcare infrastructure in shaping the outcomes of individuals afflicted with NCDs, with a specific focus on CVD. Furthermore, a more nuanced understanding can be gained by comparing the association with the prevalence of two major risk factors for CVD, namely, hypertension and diabetes. This may offer critical insights into the intricate interplay between healthcare access, risk factors, and premature mortality in NCDs.

The present study was undertaken to determine whether there is an association between availability of procedures for CVD management and premature mortality in NCDs and to juxtapose this with the prevalence of two main risk factors, hypertension and diabetes.

METHODS

Data

The World Health Organization’s (WHO’s) Global Health Observatory (GHO) data were used, which includes health-related data on its 194 member states. Popularly known as the gateway of WHO to population health data, it provides most recent data on a wide range of health indicators, including NCDs, infectious diseases, maternal and child nutrition, reproductive health, and health care utilization. Data on premature NCD deaths in the GHO were derived from the WHO Global Health Estimates (GHE) 2015[7] and those for availability of management procedures from NCD Country Capacity Survey (NCD CCS) 2017.[8]

NCD premature mortality was calculated as the deaths due to NCDs among people aged below 70 years as a percentage of NCD deaths among all ages.

Availability of management procedures for CVD was considered for the following three procedures, which was classified into ‘yes’ and ‘no’ as per the information provided in the NCD CCS:

1. General availability of coronary bypass or stenting in the public health system

2. General availability of thrombolytic therapy in the public health system

3. Provision for care of acute stroke and rehabilitation in more than 50% of public sector health facilities.

Data on prevalence of hypertension and diabetes were also used for all member states, for which data were extracted from the WHO GHE. For classification by income, the World Bank Atlas Method was used.[9] Low-income economies are defined as those with a GNI per capita of $1025 or less in 2018; lower middle-income economies are those with a GNI per capita between $1026 and $3995; upper middle-income economies are those with a GNI per capita between $3996 and $12,375; high-income economies are those with a GNI per capita of $12,376 or more.

Analysis

Data for 194 countries were extracted. The analysis was carried out in two stages.

Linear regression and correlation matrix

First, a bivariate simple regression was used to examine linear association between potential predictors and NCD mortality. The correlation matrix was constructed for risk factors, income classification, availability of CVD management procedures, and premature NCD mortality, and correlation was examined for magnitude, direction, and statistical significance.

Multiple linear regression

Second, multiple linear regression was done to find the effect of availability of management procedures and income classification on premature NCD mortality and to assist in identifying the strength and direction of the associations, providing valuable insights into the extent to which changes in these predictors are associated with changes in premature NCD mortality.

Scatter plot and regression line

A scatter plot was generated to visually depict the distribution of data points for the variables under consideration, allowing for a qualitative assessment of the relationships, highlighting any discernible patterns or trends. A regression line was constructed to model the relationship between the predictor variables and the response variable (premature NCD mortality) as a mathematical representation of the linear relationship, with a constant and beta coefficient.

By employing these visualization techniques alongside the multiple linear regression analysis, we aimed to enhance the interpretability of our findings. This comprehensive approach enables a more nuanced understanding of how the availability of management procedures and income classification collectively contribute to the observed patterns in premature NCD mortality.

Analyses were done using the software IBM SPSS Statistics version 23.

RESULTS

Data on availability of procedures for CVD management were available for 194 countries. Data on prevalence of risk factors (hypertension and diabetes) and premature NCD mortality were obtained for 190 and 183 countries, respectively.

Out of 190 countries included, 57 (30%) were in the high-income category and 56 (29.5%) in the upper-middle-income category. Forty-six countries (24.2%) constituted the lower-middle-income category, and the least frequent group was low income (31 countries, 16.3%).

The percentage of premature NCD deaths ranged from a minimum of 16% to a maximum of 76%, with a median of 47%. Availability of CVD management procedures as assessed in the NCD country capacity surveys varied across countries. Seventy-nine (40.7%) countries were assessed as having availability of all three procedures for which data were extracted, while 32 (16.5%) were assessed as having two of the procedures available. Fifty (25.3%) of countries were assessed as having none of the CVD management procedures available [Table 1].

Table 1.

Data distribution for dependent and independent variables

	n (%) n=190
Income categories
High income	57 (30)
Low income	31 (16.3)
Lower middle income	46 (24.2)
Upper middle income	56 (29.5)
Premature NCD deaths
Mean	45.73
Standard deviation	47
Median	15.068
Minimum	16
Maximum	76
	n (%) n=194
Procedures for CVD management available
0	50 (25.8)
1	33 (17.0)
2	32 (16.5)
3	79 (40.7)

Correlation of premature NCD mortality with availability of NCD management procedures and income group

A strong negative correlation was observed between premature NCD mortality and income group (reduction in premature NCD mortality with change in income group from low to high). The Spearman’s correlation coefficient for these two factors was -0.725, which was statistically significant.

A moderately strong negative correlation was also observed between premature NCD mortality and availability of CVD management procedures (reduction in premature NCD mortality with increased availability of CVD management procedures). The Spearman’s correlation coefficient for these two factors was -0.606, which was statistically significant.

Association between premature NCD mortality and availability of NCD management procedures

Figure 1 depicts the association between premature NCD mortality and availability of NCD management procedures, marked by income group. Countries possessing fewer procedures for CVD management suffered a greater burden of premature NCD mortality, and this was in the form of a strong linear association. High-income countries were seen to aggregate toward the lower right corner of the plot, facing the lowest burden of premature NCD deaths and possessing the highest number of management procedures. The opposite was seen to be true for low-income and lower-middle-income countries, which are facing the highest proportion of premature NCD deaths with the most scarce availability of management procedures.

Figure 1.

Association between availability of procedures for CVD management^$ and premature NCD deaths*. *Deaths due to NCDs among people aged below 70 years as a percentage of NCD deaths among all ages. $ Availability of management procedures for CVD were considered for the following three procedures: General availability of coronary bypass or stenting in the public health system, general availability of thrombolytic therapy in the public health system, provision for care of acute stroke, and rehabilitation in more than 50% of public sector health facilities

Effect of income class and availability of CVD management procedures on premature NCD mortality

Multiple linear regression [Table 2] revealed that income class and availability of CVD management procedures both independently affected premature NCD mortality. Each unit increase in income class and number of CVD management procedures reduced the premature NCD mortality by 7.9 and 2.8 points, respectively. The impact of both these factors on premature NCD mortality was statistically significant.

Table 2.

Effect of income class and availability of CVD management procedures on premature NCD deaths

Model	Unstandardized Coefficients		Sig.
	B	Std. error
Constant	64.135	1.471	<0.001
Income classification	-7.991	0.953	<0.001
Procedures for CVD management available	-2.788	0.811	0.001

Dependent variable: Premature NCD deaths

Association of hypertension/diabetes prevalence with availability of procedures for CVD management

Countries with higher prevalence of hypertension were seen to be possessing fewer CVD management procedures. Income groups also demonstrated disparities, with high-income countries bearing less burden of hypertension and having more ubiquitous CVD management resources [Figure 2].

Figure 2.

Association between prevalence of hypertension and availability of CVD management procedures

A similar linear association was also observed between diabetes prevalence and availability of procedures for CVD management; however, this association was not as strong as with hypertension [Figure 3].

Figure 3.

Association between prevalence of diabetes and availability of CVD management procedures

DISCUSSION

The present study found that availability of CVD management procedures, such as thrombolysis, coronary bypass/stenting, and acute stroke care and rehabilitation, significantly reduces premature NCD mortality across the world. Independent significant correlations also exist between income groups and premature NCD mortality, and risk factors and availability of NCD management procedures. Countries that face higher burden of premature NCD mortality are not only the ones that are least prepared to manage them but also the ones that bear the greatest prevalence of risk factors like hypertension and diabetes.

These findings arouse our deepest concerns about the access to treatment for thousands of patients of CVD in LMICs. It is clear that LMICs around the world are not equipped enough to deal with the current burden of NCDs or its imminent exponential growth. The health systems in these countries may not have been able to adapt to the rapid epidemiological transition in terms of technical and resource-related factors.

Premature mortality from NCDs has serious implications at the individual and macro levels.[10] At the household level, premature death and disability result in catastrophic health expenditures and stress. For a nation, this results in major loss to an economically productive group of individuals. Some nations may have to face severe loss of productivity. The WHO projects the cumulative economic losses due to NCDs in LMICs to be 7 trillion USD during 2011–2025, which outweighs the annual 11.2 billion USD cost of implementing high-impact interventions to reduce the NCD burden.[10]

In the age of globalization, this puts all countries at risk of instability. NCDs exacerbate economic inequities within societies and pose an impediment to achieving SDG 1, SDG 2, SDG 4, SDG 5, and SDG 10. Productivity gains from preventing and managing NCDs will contribute to SDG 8. SDG 11 and SDG 12 offer clear opportunities to reduce the NCD burden and to create sustainable and healthy cities.[11]

This study challenges proponents clinging to the convenient theory that primary prevention, being a ‘best buy’ strategy for NCD control, is enough. It may help to build a compelling argument to invest in resources for management of CVDs. LMICs must increase spending for health. So far as public policy is concerned, health resources have been low on the priority list of a lot of these countries. Moreover, many challenges exist in being able to generate domestic funds and to use them efficiently for health care. Low-income countries, where a large proportion of individuals work in the informal sector, face a challenge in collecting taxes and insurance premiums. Health administrators in these counties are often also handicapped with the limited technical capacity to convince the finance authorities that spending on health care resources will not result in macroeconomic problems. Hence, for improving procurement efficiency and to adequately maintain the supply chain, domestic resources will not be sufficient.[12]

Global partnerships and aid from external donors may constitute an important step to help LMICs out of this crisis. The increased burden of NCDs on low-income countries that have inadequate health systems might increase global inequality and instability. However, this seemingly has not compelled governments and donor agencies for global partnerships to combat NCDs. NCDs receive only 2% of donor assistance, while 36% is allocated to human immunodeficiency virus (HIV), tuberculosis, and malaria.[13] Communicable disease control has seen global cooperation and investment, perhaps due to the fear of contagion. But it is time that these agencies realize that foreign investment in control of NCDs is a global public good and is in their self-interest as well.

Strengths and limitations

The present study is, to the best of our knowledge, the first to reflect on the findings of the National Country Capacity Survey 2017 in terms of how they correspond to risk factor prevalence and mortality burden. Using secondary data from these large country-wide comprehensive and globally representative datasets enhances the generalizability of the study findings to diverse populations and regions. Also implicit in this data is the use of internationally recognized and standardized measures. This strengthens the validity and comparability of the study’s results across different countries and income groups.

There are some limitations in the present study. Although the WHO’s GHO data are a reliable source for comparable data from all countries, they are mostly reliant on the quality of the estimates provided by individual countries. Cause-specific mortality is often difficult to obtain correctly from state-specific data. The estimates provided are national averages and do not take into account possible inequalities within member states. Since this study is based on cross-sectional data, this limits the ability to establish causality or temporal relationships. Longitudinal data could provide a more dynamic understanding of the changes in NCD mortality rates and associated factors over time. Moreover, the study may not have accounted for all possible confounding variables that could influence the observed relationships. Unmeasured factors, such as healthcare infrastructure, cultural differences, or political stability, could impact the outcomes but have been included in the analysis.

The trend of reduction in premature CVD mortality in different regions has been studied in previous literature. Kontis et al.[5] concluded from their analyses that the no WHO region would be able to meet the ‘25 by 25’ premature mortality target if current mortality trends continue. They also reported that interventions targeting CVD are required in Africa in order to meet this target.

Authors of the PURE study have reported that age- and sex-standardized cardiovascular mortality is more than threefold higher in individuals of low SES (socioeconomic status) in LMICs as compared to HICs (high-income countries).[14]

It is documented in previous studies that the mortality from acute coronary syndrome in LMICs is almost twice that in HICs and is significantly greater in rural persons of low SES. Gupta et al. have attributed this difference to delays in reaching healthcare facilities, nonavailability of thrombolysis and coronary revascularization, and poor affordability for medicines. They postulate that facilities for cardiac rehabilitation and adherence to long-term secondary prevention therapies are suboptimal due to poor availability, access, affordability, and physician knowledge.[15]

The possibility of achieving the SDG target of reducing, by one third, the premature mortality from NCDs by 2030 may also be different for high-income and low- and middle-income countries. Cao et al. estimated the feasibility of reducing mortality to the targeted level on the basis of historical mortality trends from 2000 to 2015. They concluded that this may be feasible in high-income and upper-middle-income countries but remains challenging in countries with lower income levels.[16] This may be attributed to inadequate access to low-cost primary care, early detection, and treatment to effectively prevent and treat NCDs.[17]

The findings of the present study are corroborated by Bollyky et al.,[13] who projected that the LMICs faced the greatest surge in burden of NCDs and feature the lowest in their health system capacity index. Health spending also differed across income groups in their analysis. Low-income countries were projected to increase their health care spending the least in the period 2015–2040.

Morgan et al.[18] have emphasized the importance of a strengthened health system for NCDs. They report that whereas prevention is an essential part of the management of NCDs and even though it may be cost-effective, it will take several decades for prevention measures, such as smoking cessation, to have any impact.

Cameron et al.[19] found a discrepancy in the availability of medicines for chronic diseases in developing nations. In their study, LMICs were found to have more availability of drugs for acute conditions. It was 33.9% and 12.9% more in low- and lower-middle-income countries, respectively, in the public sector than medicines for chronic conditions.

Countries that grapple with the highest burden of risk factors and the highest premature mortality from NCDs are in need of upgradation of management procedures. Making procedures for NCD management available in LMICs must be put on high priority on the global health agenda.

Statement of ethics

The present study is a secondary data analysis of WHO and UNICEF data. The authors have no ethical conflicts to disclose.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.