Know-do gaps for cardiovascular disease care in Cambodia: Evidence on clinician knowledge and delivery of evidence-based prevention actions

Cardiovascular diseases (CVD) are the leading cause of death in Cambodia. However, it is unknown whether clinicians in Cambodia provide evidence-based CVD preventive care actions. We address this important gap and provide one of the first assessments of clinical care for CVD prevention in an LMIC context. We determined the proportion of primary care visits by adult patients that resulted in evidence-based CVD preventive care actions, identified which care actions were most frequently missed, and estimated the know-do gap for each clinical action. We used data on 190 direct clinician-patient observations and 337 clinician responses to patient vignettes from 114 public primary care health facilities. Our main outcomes were the proportion of patient consultations and responses to care vignettes where clinicians measured blood pressure, blood glucose, body mass index, and asked questions regarding alcohol, tobacco, physical activity, and diet. There were very large clinical care shortfalls for all CVD care actions. Just 6.4% (95% CI: 3.0%, 13.0%) of patients had their BMI measured, 8.0% (4.6%, 13.6%) their blood pressure measured at least twice, only 4.7% (1.9%, 11.2%) their blood glucose measured. Less than 21% of patients were asked about their physical activity (11.7% [7.0%, 18.9%]), smoking (18.0% [11.8%, 26.5%]), and alcohol-related behaviors (20.2% [13.7%, 28.9%]). We observed the largest know-do gaps for blood glucose and BMI measurements with smaller but important know-do gaps for the other clinical actions. CVD care did not vary across clinician cadre or by years of experience. We find large CVD care delivery gaps in primary-care facilities across Cambodia. Our results suggest that diabetes is being substantially underdiagnosed and that clinicians are losing CVD prevention potential by not identifying individuals who would benefit from behavioral changes. The large overall and know-do gaps suggest that interventions for improving preventive care need to target both clinical knowledge and the bottlenecks between knowledge and care behavior.

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"We use the standard definition of "clinician" to mean all individuals who provide clinical patient care. In the Health Centres in Cambodia, this includes midwives, nurses, and physicians/medical doctors." 2. There is no mention about the basic demographic and clinical details of the patients who have been observed as part of consultations.
We only collected information on the age and sex of the patients being observed. We made this decision for two main reasons: "Lastly, our study did not investigate whether some types of patients were more likely to receive screening actions compared to others. This is an important question and future research should collect more detailed information on patient characteristics to determine whether certain population groups are being disproportionately overlooked by clinician screening." 3. No details available on how many di erent types of clinical vignettes were used.
We thank the reviewer for catching this omission. We have revised our manuscript (page 8) to be clear that we used one clinical vignette.
4. Further, related to "Adherence to evidence-based prevention guidelines", neither it was not defined by the authors nor it was comprehensive assessment. Like a) whether history of pre-existing diabetes and hypertension and its treatment status was asked by the doctor, nurse or midwife; and presence of any previous episode of CVD are missing.
We thank the reviewer for noting that we do not measure all aspects of CVD preventive care. We have revised the manuscript throughout (including the title and abstract) to remove mention of "adherence to guidelines" and rather be clearer that we are measuring clinical behavior for a set of clinical actions but not necessarily adherence to the entire set of guideline actions. We also now acknowledge this point in the limitations section, but note that since CVD screening actions are not substitutes for one another, omitting one action (such as asking about family history) would not bias our estimate of how frequently the other care actions are being performed (page 15): "While we measure many key aspects of preventive care, our analysis does not examine all actions, including for example an assessment of family history. However, as family history is not a substitute for the other actions, this omission would not bias our assessment of the share of clinicians that are not meeting the other clinical actions." 5. I could not understand and also not agreeing with the authors on comparing the midwifes and nurses with doctors who have di erent knowledge and skill levels and also care responsibilities.
We focused on all those providing clinical care in the health centres, including midwives and nurses. We believe this focus on all clinicians and not just physicians was especially relevant since the majority of care at the health facility level is provided by nurses and midwives, rather than physicians. The nurses and midwives also have similar care responsibilities regarding CVD risk assessments and should be conducting the basic screening actions we examine in the manuscript. However, to the reviewer's concern, we also stratified our results by nurses, midwives, and physicians ( Figure 2). Although we observe small di erences, we do not find evidence that care meaningfully di ers across these groups (page 12): "We did not find strong evidence of di erences in the size of CVD care gaps by clinician cadre (Fig 2). We thank the reviewer for noting this omission in the description of the study sites and have revised our manuscript (pages 5-6) to include this information: "The Health Centres provide a range of basic preventive and curative services including care for infectious and acute conditions (like malaria, respiratory disease, and tuberculosis), family planning and ante and postnatal care, and basic care and screening for chronic non-communicable diseases including screening for hypertension and diabetes. The full range of services that the Health Centres provide is specified in the Cambodian Minimum Package of Activities." 7. What are the brief job responsibilities of midwifes, nurses and doctors, e.g if Midwife or nurse is only responsible for providing counselling service, then of course she will not test the patient for blood sugar; We thank the reviewer for raising this important point. Nurses and midwives are indeed expected to provide the basic CVD screening actions we investigate in our manuscript. We have revised our manuscript in the Setting section (page 6) to include this point and provide more detail on the responsibilities of the di erent types of clinicians: "Clinical care in the Health Centres is provided by nurses, midwives, and medical doctors (physicians), with nurses and midwives providing the majority of care. While some of the care responsibilities are di erentiated by clinician cadre (e.g. midwives focus more heavily on ante and postnatal care while physicians focus more heavily on the outpatient department), there is substantial overlap in the care responsibilities by cadre, and importantly, all three clinician types are expected to provide CVD preventive care that includes screening for hypertension and diabetes and assessing a range of behavioral risk factors." 8. Availability of blood sugar machine, sphygmomanometer, stadiometer and weighing machine.
We thank the reviewer for raising this important question and omission from our initial manuscript. All facilities we visited had a scale and height board and either a manual or electronic sphygmomanometer. Only a minority of facilities had a glucometer and test strips. We found some evidence that having a glucometer and test strips were associated with a greater chance that clinicians measured blood sugar; however, this estimate had a wide confidence interval that overlapped the null and the proportion of visits that received a blood glucose measurement within facilities with this equipment was still low. We have revised our manuscript to include this information (page 13; the results are now presented in the Supporting Information): "An important question is whether the low shares of BMI, blood glucose, and blood pressure measurement is due to clinicians not having access to measurement devices. However, every facility in our study reported having a scale and height board and a sphygmomanometer, making this explanation unlikely for BMI and blood pressure. We did find that only 21% of facilities had access to glucometers and test strips and that clinicians in facilities with these materials were 11 percentage points more likely to measure blood glucose although the 95% confidence interval for this estimate was wide and overlapped the null. Importantly, even among facilities with access to blood glucose measurement devices, just 14% of adult patients had their blood pressure screened, indicating a large remaining gap that is not attributable to equipment availability (Supporting Information)."

The overall and DM/HTN/CVD patient load, the % of acute and non-acute visits
We have revised the manuscript in the methods section to now provide information on the overall patient caseloads in the selected facilities. Specifically, we included (page 7): "The median number of patients seen in the facilities per month was 773, ranging from a minimum of 114 to a maximum of 2820 patients." 10. Availability of any national or local guidelines on prevention and control of CVDs, its implementation and training status; We have revised the manuscript in the Setting section to detail the national guidelines, providing citations to the actual guideline documents (pages 6-7): "The Government of Cambodia established evidence-based care guidelines for cardiovascular disease prevention (in the form of guidelines for nutrition, physical activity, hypertension, and diabetes care) as part of the first National Plan for Prevention and Control of Non-Communicable Diseases 2007-2010. These guidelines were updated for the second, 2013-2020, and third, 2018-2077 plans." We have also noted in the Setting and Discussion section that there have been no assessments of the training status on these guidelines.

In the Setting section (page 7):
Unfortunately, there is no definitive evidence on how thoroughly clinicians in Health Centres were trained on these guidelines; this is an important point we return to when contextualizing our findings in the Discussion section.

In the Discussion section (pages 13-14):
Our results implicate several areas where clinical knowledge improvements are needed. While the care actions we study are all outlined in the o cial Cambodian care guidelines, there is limited evidence on whether clinicians practicing in health facilities are aware of and have been trained on these guideline actions. Therefore, measuring what share of clinicians have been trained on guideline actions and subsequently, improving clinician training are likely an important first step for improving clinical care in the country.
11. What was the flow of observed patients in the study health centre. Whether all patients goes through everyone or meets only certain people. It is also not clear whether the same patient consultation was observed in all three places and counted as one or three?
We have revised the manuscript in the Setting section (page 6) to describe the flow of patients: "Patients that arrive at the Health Centres are first directed to a reception area, after which they are directed to either an outpatient department for general medicine (primary care) or to a maternal child health/delivery department. After their consultation, patients are then directed to the station for wound dressing (if needed following minor surgeries) and pharmacy. If no additional care is required at that time the patient is then sent home; otherwise, the patient is admitted and referred to a public Referral Hospital." We observed distinct patients in each facility (e.g. it was not just the case that the same patient met a nurse, midwife, and physician and was thus counted as three observations). We have revised the manuscript in the Methods section to make this clearer (page 8): "We observed a unique set of patients in each facility (e.g. it was not the case that the same patient met a nurse, midwife, and physician and was counted as three observations)." 12. Whether the care is Paid or unpaid or free for patient?
We have revised our manuscript in the Setting section to now include the following information (page 6): "Care in the Health Centres is free for poorer families through Cambodia's Health Equity Fund; families that are not eligible for the Health Equity Fund have to pay for their care based on a pre-specified fee schedule." 13. Unfortunately, the authors are also made discussion points on information which is not part of their results. Like Line number 191-192 of page 11, "First, they suggest that individuals with diabetes are being overlooked and left undiagnosed by the public primary care system in Cambodia.". In the current manuscript, other than testing for blood sugar, the study did not explore anything at all to bring this point for discussion.
We have revised this sentence to now say: "Due to the low rates of blood sugar measurement, it is likely that many individuals with diabetes are not being detected." We believe this conclusion is justified and would like to respectfully disagree with the reviewer's statement that "the study did not explore at all to bring this point for discussion" since blood sugar measurement is the key necessary condition for diabetes diagnosis.
14. Similarly, without testing any educational intervention, the authors are discussing its e ectiveness.
We thank the reviewer for raising this concern. As part of the discussion section, we discussed whether educational interventions alone will be able to close the gaps we observe, citing several prior studies: