Viewpoint

Reinventing primary health care: the need for systems integration

One of the key aspects to enhance the suitability for surgery in elective arthroplasty is the optimization of hemoglobin concentration. In this randomized controlled trial, we investigated the efficacy of an oral iron supplement and its impact on blood management practices.

A total of 60 older adults undergoing elective hip or knee surgery were randomized to follow a month and a half of supplementation with a water-soluble powder containing iron and vitamins. We monitored iron homeostasis and the use of blood resources.

The trial was completed by 58 subjects. We observed a significant inter-group change in hemoglobin and its mean corpuscular concentration (P < 0.05), vitamin B6, B9 (P < 0.001), and B12 (P < 0.05). Albeit not statistically significant, fewer patients in the intervention group had hemoglobin over the threshold for blood unit request before (11 vs. 14) or transfusion evaluation after surgery (1 vs. 6), or actually received a blood transfusion (1 vs. 3). The extent of preoperative iron deficiency and hematocrit were predictive for postoperative blood units (AUC = 0.9).

Iron homeostasis improved in the intervention group, while the changes in the control group were consistent with the depletion of iron reserves. The iron-based formulation enriched with vitamins was safe but showed a slight impact on blood management practices. The potential of optimizing patient blood management encourages the planning of large-scale studies, possibly combining a diet therapy to promote the consumption of foods rich in iron long before the operation.

L’optimisation de la concentration d’hémoglobine est l’un des aspects clés pour améliorer la santé physique avant une chirurgie de la hanche ou du genou. Dans cet essai contrôlé randomisé, nous avons étudié l’efficacité d’un supplément de fer par voie orale et son impact sur les pratiques de gestion du sang.

Un total de 60 personnes âgées subissant une chirurgie élective de la hanche ou du genou ont été randomisées pour recevoir 45 jours de supplémentation avec une poudre hydrosoluble contenant du fer et des vitamines. Nous avons surveillé l’homéostasie du fer et l’utilisation des ressources sanguines.

L’étude a été complété par 58 sujets. Nous avons observé entre les groupes une variation significative de l’hémoglobine et de sa concentration corpusculaire moyenne (p < 0,05), des vitamines B6, B9 (p < 0,001) et B12 (p < 0,05). Bien que non statistiquement significatif, moins de patients dans le groupe d’intervention avaient des valeurs d’hémoglobine supérieures au seuil nécessitant des unités de sang avant la chirurgie (11 c. 14) ou des transfusions postopératoires (1 c. 6), ou ont été effectivement transfusés (1 c. 3). L’étendue de la carence en fer et l’hématocrite préopératoire étaient prédictifs pour les unités de sang postopératoires (AUC = 0,9).

L’homéostasie du fer s’est améliorée dans le groupe d’intervention, tandis que les changements dans le groupe témoin étaient compatibles avec l’épuisement des réserves de fer. La formulation de fer enrichie en vitamines s’est avérée sûre mais a eu peu d’impact sur les pratiques de gestion du sang. Le potentiel de pouvoir optimiser la santé physique des patients orthopédiques avec une supplémentation en fer par voie orale nécessite la planification d’études à plus grande échelle, combinant éventuellement une thérapie diététique pour favoriser la consommation d’aliments riches en fer bien avant l’opération.

Foreign health aid forms a substantial portion of health spending in many low- and middle-income countries (LMICs). It can be either vertical (funds earmarked for specific diseases) or horizontal (funds used for broad health sector strengthening). Historically, most health aid has been disbursed vertically toward key infectious diseases, with minimal allocations to noncommunicable diseases (NCDs). High NCD burden in LMICs underscores a need for increased assistance toward NCD objectives, but evidence on the outcomes of health aid for NCDs is sparse. We obtained annual data on cause-specific deaths and disability-adjusted life years (DALYs) for four leading NCDs across 116 countries, 2000–2016, and evaluated the relationship between these indicators and vertical and horizontal health aid using country fixed-effects models with 1-to-5-year lagged effects. After adjusting for fixed and time-variant country heterogeneity, vertical assistance for NCDs was significantly associated with subsequent reductions in NCD morbidity and mortality, particularly for persons under age 70 and for cardiovascular and chronic respiratory diseases. An additional dollar in per-capita NCD vertical assistance corresponded to reductions in the average annual NCD burden of 7,459 DALYs/281 deaths after one year, 7,728 DALYs/319 deaths after two years, and 8,957 DALYs/346 deaths after three years. The findings suggest that vertical assistance for NCD programs may be an appropriate mechanism for addressing short-term NCD needs in LMICs, where it may help to fill health sector gaps in NCD care, but longer-term evaluation is needed for assessing the role of horizontal assistance.