CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Rohina Joshi, MBBS, MPH, PhD*,
Stephen Jan, MEc, PhD,
Yangfeng Wu, MD, PhD and
Stephen MacMahon, DSc, PhD
* The George Institute for International Health, University of Sydney, Cardiovascular Division, P.O. Box M201, Missenden Road, Sydney NSW 2050, Australia (Email: rjoshi{at}george.org.au).
We thank Drs. Aslam and Waheed for their comments on our recent paper (1). They raise an important issue regarding the role of nonphysician health care workers in the identification of individuals at high risk of cardiovascular disease, such as those with a history of myocardial infarction or ischemic stroke, and their management in the community with low-cost drugs such as aspirin. We agree that nonphysician health care workers (NPHWs) should be able to prescribe aspirin for secondary prevention, but we also believe that they should be able to prescribe other low-cost, low-risk, high-benefit treatments both for secondary prevention (e.g., blood pressure- and lipid-lowering drugs) and for cardiovascular symptom management (e.g., nitrates, beta-blockers) (2). Low-dose combination therapy for secondary prevention will lower the risk of cardiovascular death by up to one half, with few adverse effects (3). This strategy, which is recommended by the World Health Organization, would be more acceptable to many patients and NPHWs if combination treatment were provided in a single tablet (i.e., a "polypill") (4). If the components of such a pill were entirely generic, the cost could be as little as $10 per person per year. We believe the development of such low-cost options is an essential strategy for improving patient access to (and compliance with) evidence-based preventive care in resource-poor settings. The development of support tools to guide care provided by NPHWs is therefore a priority. Ideally, this would comprise a purpose-built electronic decision support tool incorporating simple algorithms for risk assessment, treatment, and follow-up.
For such a model of care to succeed, there would need to be systemic changes in the health care infrastructure of most low- and middle-income countries. Currently, NPHWs do not have the authority to prescribe medicines in many countries. A first step is therefore providing the appropriate authority to prescribe a limited number of drugs. However, because health care systems and the capacity of NPHWs may vary significantly among different low- and middle-income countries, each setting will need to develop its own process for implementation. Any such model of care should be augmented by training of NPHWs in a system of referrals to hospitals for specialist care for those in need. Given that there will be a continuing shortage of physicians in most countries for the foreseeable future, NPHWs have an important contribution to make. Investment is urgently required to ensure that these health care professionals are appropriately trained and equipped to provide essential primary heath care for cardiovascular and other serious chronic diseases.
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1. Joshi R, Jan S, Wu Y, MacMahon S. Global inequalities in cardiovascular health care J Am Coll Cardiol 2008;52:1817-1825.[Abstract/Free Full Text]2. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80% BMJ 2003;326:1419-1423.[Abstract/Free Full Text] 3. Gaziano TA, Opie LH, Weinstein MC. Cardiovascular disease prevention with a multidrug regimen in the developing world: a cost-effectiveness analysis Lancet 2006;368:679-686.[CrossRef][Web of Science][Medline] 4. World Health Organization. Secondary prevention of noncommunicable diseases in low and middle income countries through community-based and health service interventions. Geneva: World Health Organization—Wellcome Trust meeting report, August 1–3, 2001.
Related Article
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Aspirin for the Masses
- Fawad Aslam and Abdul Waheed
J. Am. Coll. Cardiol. 2009 54: 91.
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