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SAPHIR Monthly Webinar

SAPHIR Monthly Webinar.

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SAPHIR Monthly Webinar

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  1. SAPHIR Monthly Webinar Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational studyFarshad Farzadfar, MD, MPH, D.ScNon Communicable Diseases Research CenterEndocrinology and Metabolism Research Institute Tehran University of Medical SciencesJuly 13, 2012

  2. Outline of the presentation • Epidemiology of metabolic risk factors at global, regional, and country levels • Objectives of the study • Methodology and results of phase one of the study • Methodology and results of phase two of the study • Conclusion and take home messages

  3. Global epidemiologic transition Lopez et al. Lancet 2006

  4. Age-standardized cardiovascular mortality trends in selected high-income countries Male Female Vital registration data from WHO

  5. Regional FPG trends North Africa and Middle East North America Male North America North Africa and Middle East Female Danaei et al. Lancet 2011

  6. Male FPG, BMI and SBP trends in Iran between 1980 and 2008 FPG BMI SBP Female Farzadfar et al. Lancet 2011, Finucane et al. Lancet 2011, Danaei et al. Lancet 2011

  7. The effects of risk factors on life expectancy in 2005, by region Male Life expectancy Southeast North-Northeast West Central National Female Life expectancy Southeast North-Northeast West Central National Farzadfar, et al, population Health metrics, 2011

  8. Iran’s health system Annual report of MoH . 2005 , Utilization study. 2005

  9. The objectives of the study • Phase one: • Estimating prevalence, diagnosis and coverage of treatment for diabetes and hypertension by residency area • Estimating the treatment effects of diabetes and hypertension by residency area • Phase two: • Estimating the association of Behvarz density with levels of FPG (which has an integrated and well defined program in PHC) and SBP

  10. Data source and definitions Data source: Non-Communicable diseases surveillance survey (2005) Diabetic definition: Fasting plasma glucose (FPG) ≥ 126 mg/dl or on medication to control blood sugar (either oral anti-hyperglycemic agents or insulin) Hypertensive definition: Blood pressure (SBP/DBP) ≥ 140/90 mmHg or on medication to control blood pressure 11

  11. Estimation of treatment effects • Matching: • All treated individuals were matched to controls based on propensity score of their age, sex, BMI, education and wealth index • Random intercept regression analysis with an instrumental variable: • A proxy for potentially unobserved confounders that could affect the use of treatment but not the distribution of risk factors

  12. Age standardized prevalence of diabetes and hypertension by sex and urban and rural residence Hypertension Age standardized prevalence Urban Rural Country Diabetes Age standardized prevalence Urban Rural Country

  13. Diabetes and hypertension diagnosis in Iran

  14. Coverage of treatments for diabetes and hypertension in Iran by sex and urban and rural residence Hypertension Crude coverage of treatment (percent) Urban Rural Country Diabetes Crude coverage of treatment (percent) Urban Rural Country

  15. Treatment coverage of diabetes and hypertension by wealth quintile Probability of receiving treatment Wealth quintile

  16. Coefficients of regression to estimate the effect of diabetes and hypertension treatment on fasting plasma glucose and systolic blood pressure of treated individuals

  17. The average effect of treatment by area of residency Treatment effects for hypertensive individuals (mmHg) Urban Rural Treatment effects for diabetics (mmol/L) Urban Rural

  18. What could be the reason for the diabetes treatment effect differences between rural and urban areas?

  19. Behvarz

  20. Data sources Risk factor exposure: Non-communicable diseases surveillance survey (2005) Behvarz : Census data (2006) Physician: Outpatient care center mapping (2005) ICU bed Ministry of health database (2005) Other socioeconomic indicators Census data (2006) 21

  21. Methods • Propensity score matching: • Individuals living in districts falling in different Behvarz density quintiles were matched based on age, sex, body mass index (BMI), education, marital status, wealth index, physician density, ICU bed density and employment rate • District level random intercept regression: • Adjust for age, sex, BMI, education, marital status, wealth index, physician density, ICU bed density and employment rate 22

  22. The association between Behvarz and physician densities and district average wealth index

  23. Coefficients of regression to estimate the effect of Behvarz-worker density on fasting plasma glucose and systolic blood pressure in Iran

  24. Average effect of Behvarz-worker density on fasting plasma glucose (A) and systolic blood pressure (B)

  25. Take home messages • Risk factors with large burden but no current program to control • Sub-national level policy making • Primary healthcare as an effective management of chronic conditions such as diabetes • Cost considerations

  26. Acknowledgements Co-authors and colleagues MajidEzzati Thomas Bossert HengamehNamdari SiamakAlikhani HamidrezaJamshidi • Co-authors and colleagues • Christopher Murray • Emmanuela Gakidou • Ghobad Moradi • Alireza Delavari

  27. Thank youcomments/questions?

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