The distribution of cardiac diagnostic testing for acute coronary syndrome in the Brazilian healthcare system: A national geospatial evaluation of health access.
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2019-01-10
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BACKGROUND:Little is known about the utilization of cardiac diagnostic testing in Brazil and how such testing is related with local rates of acute coronary syndrome (ACS)-related mortality. METHODS AND RESULTS:Using data from DATASUS, the public national healthcare database, absolute counts of diagnostic tests performed were calculated for each of the 5570 municipalities and mapped. Spatial error regression and geographic weighted regression models were used to describe the geographic variation in the association between ACS mortality, income, and access to diagnostic testing. From 2008 to 2014, a total of 4,653,884 cardiac diagnostic procedures were performed in Brazil, at a total cost of $271 million USD. The overall ACS mortality rate during this time period was 133.8 deaths per 100,000 inhabitants aged 20 to 79. The most commonly utilized test was the stress ECG (3,015,993), followed by catheterization (862,627), scintigraphy (669,969) and stress echocardiography (105,295). The majority of these procedures were conducted in large urban centers in more economically developed regions of the country. Increased access to testing and increased income were not uniformly associated with decreased ACS mortality, and tremendous geographic heterogeneity was observed in the relationship between these variables. CONCLUSIONS:The majority of testing for ACS in Brazil is conducted at referral centers in developed urban settings. Stress ECG is the dominant testing modality in use. Increased access to diagnostic testing was not consistently associated with decreased ACS mortality across the country.
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Hertz, Julian T, Tommy Fu, Joao Ricardo Vissoci, Thiago Augusto Hernandes Rocha, Elias Carvalho, Brendan Flanagan, Luciano de Andrade, Alex T Limkakeng, et al. (2019). The distribution of cardiac diagnostic testing for acute coronary syndrome in the Brazilian healthcare system: A national geospatial evaluation of health access. PloS one, 14(1). p. e0210502. 10.1371/journal.pone.0210502 Retrieved from https://hdl.handle.net/10161/20600.
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Scholars@Duke
Julian T Hertz
Julian Hertz, MD, MSc, is an Associate Professor of Emergency Medicine & Global Health. He graduated summa cum laude from Princeton University and attended medical school at Duke University, where he received the Dean's Merit Scholarship and the Thomas Jefferson Award for leadership. He completed his residency training in emergency medicine at Vanderbilt University Medical Center and his fellowship in Global Health at Duke.
Dr. Hertz's primary interests include global health, implementation science, and undergraduate and graduate medical education. Dr. Hertz's research focuses on using implementation science methods to improve cardiovascular care both locally and globally. His current projects involve developing interventions to improve acute myocardial infarction care in Tanzania, to improve management of hypertension among Tanzanians with HIV, and to improve post-hospital care among patients with multimorbidity in East Africa.
Dr. Hertz has received numerous awards for clinical, educational, and research excellence, including the Duke Emergency Medicine Faculty Teacher of the Year Award, the Duke Emergency Medicine Faculty Clinician of the Year Award, and the Duke Emergency Medicine Faculty Researcher of the Year Award. He has also received the Golden Apple Teaching Award from the Duke medical student body, the Duke Master Clinician/Teacher Award, and the Global Academic Achievement Award from the Society of Academic Emergency Medicine.
Joao Ricardo Nickenig Vissoci
Joao Ricardo Nickenig Vissoci, MSc, PhD is an Assistant Professor of Emergency Medicine, Neurosurgery and Global Health. He is the Chief of the Division of Translational Health Sciences in the Department of Emergency Medicine, co-Director of the Global Emergency Medicine Innovation and Implementation (GEMINI) Research Center and a faculty member of the Research Design and Analysis Core (RDAC) in the Duke Global Health Institute. Dr. Vissoci has a background in social psychology and data science. Dr. Vissoci, a Brazilian native, earned a bachelor’s degree in Psychology from State University of Maringá/Brazil, a Masters in Physical Education, an MBA in Human Resources, and a PhD in Social Psychology. During his PhD, he completed a fellowship in Data Science at Duke University. After graduating his PhD in Social Psychology from the Pontificia Universidade Católica of São Paulo/Brazil, Dr. Vissoci completed a postdoctoral fellowship at the University of Sao Paulo (2015) in Design and Analysis for Mental Health research. He completed a second postdoctoral fellowship at the Duke Global Health Institute in Global Health and Data Science in 2016. Dr. Vissoci held a faculty position and taught Public Health and Health Sciences in Brazil from 2009 to 2015. After completing his fellowship at DGHI, he joined the Duke Department of Emergency Medicine as faculty in 2017. In his last 14 years as faculty (2009-current), he has mentored over 200 trainees at all levels of training from undergraduate, graduate, medical education, postdoctoral to faculty level. He has published over 200 manuscripts and collaborated on over 6 R-level NIH grants, multiple (K and D) NIH training grants, other federal grants UK/Brazil based, and foundational grants.
His research interests focus on leveraging data through analytics and technology to bridge the gap in access and equity in care in low resource settings, translating evidence into practice or policy impact. He uses data science and mixed-methods research to design and implement innovative data-driven solutions to address health care gaps.
Brendan James Flanagan
I graduated from UMass Medical School in 2015 and came down to Duke to complete my Emergency Medicine residency. I served as Chief Resident in my last year of residency and graduated from the program in 2018. I stayed on as an Assistant Professor with the Duke Emergency Department where I continue to to practice and teach. My primary academic interests are education and wellness in medicine with a focus on reforming medical education culture to produce healthier, happier and more resilient clinicians. I teach multiple courses for the Duke School of Medicine and serve as an instructor and mentor to current residents.
Alexander Tan Limkakeng
Dr. Alexander T. Limkakeng, Jr., MD, MHSc, FACEP is a Professor of Emergency Medicine, Vice Chair of Clinical Research, Director of the Acute Care Research Team, and Director of the Resident Research Fellowship for the Department of Emergency Medicine in the Duke University School of Medicine in Durham, North Carolina.
Dr. Limkakeng has served as chair of the American College of Emergency Physicians (ACEP) Research Committee, and been the Course Director of the ACEP Research Forum from 2016-2018, the largest emergency medical research platform in the nation. He is also the Assistant Director of ACEP’s Emergency Medicine Basic Research Skills course. He was elected to the Nominating Committee of the Society of Academic Emergency Medicine.
As a researcher, Dr. Limkakeng has led multiple clinical trials and interdepartmental sponsored projects and is author on over 100 peer-reviewed manuscripts. These include studies in emergency conditions such as COVID-19, traumatic brain injury, hypertension, heart failure, thrombosis, stroke, envenomations, and septic shock. His research has been funded by grants and contracts totaling over $9 million dollars. He has lectured internationally on acute coronary syndrome, responsible conduct of research, design of clinical trials, and precision medicine in emergency care. He has led Duke’s involvement in NIH-funded research networks and in industry-funded work that led to FDA approval for multiple high-sensitivity cardiac troponin assays and point-of-care COVID-19 diagnostic tests. He has servesd as Co-PI for the Duke U24 Hub in the NIH Early Phase Pain Investigation Clinical Network (EPPIC-Net) (1U24NS114416) and now serves as a co-PI on the Duke U24 Hub award (1U24NS129498) in the NIH Strategies to Innovate Emergency Care Clinical Trials (SIREN) Network and in the NIH NINDS Strokenet network (1U24NS135250)
His personal research interest is finding new ways to diagnose acute coronary syndrome. In particular, he is interested in novel biomarkers and precision medicine approaches to this problem. The common element throughout this work is a focus on time-sensitive health conditions.
Catherine Ann Staton
Catherine Staton MD MSc
Dr. Staton is a Professor in Emergency Medicine (EM), Neurosurgery & Global Health with tenure at Duke University. She is the Director of the GEMINI (Global EM Innovation & Implementation) Research Center and the EM Vice Chair of Research Strategy & Faculty Development. Her research integrates innovative implementation methods into health systems globally to improve access to acute care. In 2012, with an injury registry at Kilimanjaro Christian Medical Center, Tanzania Dr. Staton demonstrated 30% of injury patients had at risk alcohol use, providing preliminary data for a K01/Career Development Award. Her K01 award adapted a brief alcohol intervention to the KCMC ED and Swahili. This intervention has been proven to reduce 26 binge drinking events per year compared to usual care, and the team is now planning for regional implementation. Dr. Staton and her mentor and collaborator Dr. Mmbaga are co-PD of the “The TReCK Program: Trauma Research Capacity Building in Kilimanjaro” to train 12 masters and doctoral learners to conduct innovative implementation and data science projects to improve care for injury patients. Currently, Dr. Staton and GEMINI partners with over a dozen faculty from over 6 low- and middle-income countries to conduct research, has mentored over 150 learners from undergraduate to post-doctoral levels from high, middle and low- income settings and has over 160 manuscripts.
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