92 Chapter 4 was not significantly different between coverage groups, except for ACE-inhibitor use that was higher in uninsured participants. Most participants with CHD were taking at least one of the recommended medicines, and there were no significant differences in the proportion of insured and uninsured subjects taking at least one and at least two medications. Barriers to receive necessary medical care were reported by almost one fifth of the participants, and they were reported significantly more often by participants with public coverage. Discussion of main findings Study population characteristics We find that 57.7% of participants was insured only by the public sector. This proportion was lower in Argentina (54.9% in Marcos Paz and 31.0% in Bariloche) and Uruguay (54.8%), and higher in Chile (75.3%). This is in line with other studies, that report that 36.0% to 50% of the population in Argentina and Uruguay, and 70.0% of the Chilean population have exclusive public coverage (14–19,22). Medication use The use of the various cardioprotective medication classes was suboptimal (28.3% for antiplatelets, 51.9% for antihypertensives, and 24.4% for lipid-lowering drugs), considering that long-term use of these medications is recommended in patients with established CHD. The estimates of medication use observed in our study are in line with the PURE Study (7), that reports slightly higher use of beta-blockers and ACE-inhibitors and similar use of statins in people with CHD residing in urban areas. The remarkably low use of statins found in our study may be explained by factors such as low prescription rates, limited access, or difficulties with adherence. The Epi-Cor study conducted in 54 centres in Argentina showed an overall increase in statin prescription after an acute coronary syndrome in the period 2005-2014, but with lower prescription rates in the years 2009 to 2012 (30), which could be reflected in our data. Despite the lower prescription rates in this period, a survey conducted in 2015 in Argentina showed that 86.0% of the participating clinicians would indicate high-dose statins for secondary prevention of CHD (31). The South American and global trends show an increase of statin use in the period 2008-2020 (32,33), due to changes in clinical guidelines that included lower thresholds to prescribe statins and lower cholesterol target levels, among other factors (32,34). Almost all participants in our study were taking at least one drug (95.4%) and more than half were taking at least two drugs (59.3%), which are higher estimates than reported in participants with CHD in urban and rural areas in Argentina and Chile by Avezum et al (7). They also report that medication use is higher in urban areas, and this may why in the CESCAS Study, conducted in urban areas only, finds higher estimates of medication use. Medication use by insurance coverage The most important finding of our study is that there were no significant differences by coverage status in the use of most medication classes and in the use of at least one and
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