Global Variation in the Prevalence of Elevated Cholesterol in Outpatients with Established Vascular Disease or 3 Cardiovascular Risk Factors According to National Indices of Economic Development and Health System Performance Running title: Venkitachalam et al.; Elevated cholesterol and national indices

Abstract: Background - Elevated serum cholesterol accounts for a considerable proportion of cardiovascular disease worldwide. An understanding of the relationship between country-level economic and health system factors and elevated cholesterol may provide insight for prioritization of cardiovascular prevention programs. Methods and Results - Using hierarchical models, we examined the relationship between elevated total cholesterol (>200 mg/dL) in 53,570 outpatients from 36 countries, and tertiles of several country-level indices: (1) gross national income (GNI), (2) total expenditure on health as % gross domestic product, (3) government expenditure on health as % of total expenditure on health, (4) out-of-pocket expenditures as % of private expenditure on health, and the World Health Organization (WHO) indices of (5) Health System Achievement (HAI) and (6) Performance/Efficiency . Overall, 38% of outpatients had total cholesterol>200 mg/dL (>5.18 mmol/L), and 9.3% of the total variability in elevated cholesterol was at the country level; this proportion was higher for patients with (12.1%) vs. without (7.4%) history of hyperlipidemia. Among patients with history of hyperlipidemia, countries in the highest tertile of GNI or WHO HAI had lower odds of elevated cholesterol than lower tertiles (p<0.001, for both). Countries in the highest tertile of out-of-pocket health expenditures had higher odds of elevated cholesterol than those in the lowest tertile (p<0.001). No significant associations were found for patients without history of hyperlipidemia.