Rationale and design of a cluster randomized trial of a multifaceted intervention in people with hypertension: The Heart Outcomes Prevention and Evaluation 4 (HOPE-4) Study

Managing hypertension in rural Gambia and Kenya: Protocol for a qualitative study exploring the experiences of patients, health care workers, and decision-makers

Background

Hypertension is the single leading risk factor for premature death in Sub-Saharan Africa (SSA). Prevalence is high, but awareness, treatment, and control are low. Community-centred interventions show promise for effective hypertension management, but embedding such interventions sustainably requires a good understanding of the wider context within which they are being introduced. This study aims to conduct a systematic health system assessment exploring the micro (patients/carers), meso (health care workers and facilities), and macro (broader system) contexts in rural Gambia and Kenya.

Methods

This study will utilise various qualitative approaches. We will conduct (i) focus group discussions with people living with hypertensive to map a 'typical' patient journey through health systems, and (ii) in-depth interviews with patients and family carers, health care workers, decision-makers, and NCD partners to explore their experiences of managing hypertension and assess the capacity and readiness of the health systems to strengthen hypertension management. We will also review national guidelines and policy documents to map the organisation of services and guidance on hypertension management. We will use thematic analysis to analyse data, guided by the cumulative complexity model, and theories of organisational readiness and dissemination of innovations.

Expected findings

This study will describe the current context for the management of hypertension from the perspective of those involved in seeking (patients), delivering (health care workers) and overseeing (decision-makers) health services in rural Gambia and Kenya. It will juxtapose what should be happening according to health system guidance and what is happening in practice, drawing on the experiences of study participants. It will outline the various barriers to and facilitators of hypertension management, as perceived by patients, providers, and decision-makers, and the conditions that would need to be in place for effective and sustainable implementation of a community-centred intervention to improve the management of hypertension in rural settings.

Role of Health Care Professionals in the Success of Blood Pressure Control Interventions in Patients With Hypertension: A Meta-Analysis

BACKGROUND

Globally, only 13.8% of patients with hypertension have their blood pressure (BP) controlled. Trials testing interventions to overcome barriers to BP control have produced mixed results. Type of health care professional delivering the intervention may play an important role in intervention success. The goal of this meta-analysis is to determine which health care professionals are most effective at delivering BP reduction interventions.

METHODS

We searched Medline and Embase (until December 2023) for randomized controlled trials of interventions targeting barriers to hypertension control reporting who led intervention delivery. One hundred articles worldwide with 116 comparisons and 90 474 participants with hypertension were included. Trials were grouped by health care professional, and the effects of the intervention on systolic and diastolic BP were combined using random effects models and generalized estimating equations.

RESULTS

Pharmacist-led interventions , community health worker-led interventions, and health educator-led interventions resulted in the greatest systolic BP reductions of -7.3 (95% CI, -9.1 to -5.6), -7.1 (95% CI, -10.8 to -3.4), and -5.2 (95% CI, -7.8 to -2.6) mm Hg, respectively. Interventions led by multiple health care professionals, nurses, and physicians also resulted in significant systolic BP reductions of -4.2 (95% CI, -6.1 to -2.4), -3.0 (95% CI, -4.2 to -1.9), and -2.4 (95% CI, -3.4 to -1.5) mm Hg, respectively. Similarly, the greatest diastolic BP reductions were -3.9 (95% CI, -5.2 to -2.5) mm Hg for pharmacist-led and -3.7 (95% CI, -6.6 to -0.8) mm Hg for community health worker-led interventions. In pairwise comparisons, pharmacist were significantly more effective than multiple health care professionals, nurses, and physicians at delivering interventions.

CONCLUSIONS

Pharmacists and community health workers are most effective at leading BP intervention implementation and should be prioritized in future hypertension control efforts.

Relationship Between Social Support and Clinical Outcomes: An Evaluation of Participant-Nominated Treatment Supporters in the HOPE 4 Intervention

BACKGROUND

The HOPE 4 trial (Heart Outcomes Prevention and Evaluation 4) investigated the effectiveness of a comprehensive, collaborative model of care, implemented in Colombia and Malaysia, which aimed to reduce cardiovascular disease risk in individuals with hypertension. One component of this intervention was the nomination of a treatment supporter, where participants could select a family member or friend to assist them with their care. The purpose of this study was to investigate the impact of these individuals on participant outcomes, as well as the relationship dynamics between participants and their treatment supporter.

METHODS

Participants in the HOPE 4 intervention group with baseline and 12 months of follow-up were included for analysis. They were divided into Every Visit (n=339) and

RESULTS

Groups were majority female (53% versus 62%) with a mean age of 63 and 66 years. Country of origin differed between groups (22% versus 86%; Colombia). A 15.5% ([95% CI, 6.2%-24.8%] P=0.004) greater increase in statin medication use was reported in the Every Visit group at 12 months compared with the

CONCLUSIONS

Long-term support from a nominated treatment supporter was associated with improved adherence, risk factor management, and medication use among individuals with hypertension.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01826019.

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Key Words

• cardiovascular diseases
• hypertension
• medical adherence
• risk factors
• social support

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MESH Headings

• Humans
• Female
• Middle Aged
• Aged
• Hypertension/diagnosis
• Hypertension/drug therapy
• Hypertension/epidemiology
• Blood Pressure
• Medication Adherence
• Risk Factors
• Social Support

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Affiliation(s)

Anastasia Drakos Faculty of Medicine, University of Ottawa, ON, Canada (A.D.) Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)
Tara McCready Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)
Patricio Lopez-Jaramillo Research Institute, Fundación Oftalmológica de Santander, Floridablanca, Colombia (P.L.-J.) Masira Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.)
Shofiqul Islam Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)
Martin McKee Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom (M.M.)
Salim Yusuf Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.) Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, ON, Canada (S.Y.)
J D Schwalm Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)

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[Prevalence, knowledge and control of arterial hypertension in vulnerable neighborhoods of Argentina: A Cross-sectional Study]

INTRODUCTION

Hypertension (HTN) represents the primary individual risk factor, contributing significantly to the global burden of cardiovascular diseases (CVD). In our country, epidemiological research has highlighted substantial variations in the prevalence of these risk factors across different populations. However, there is a lack of epidemiological studies assessing exclusive cardiovascular risk factors within vulnerable neighborhoods characterized by extremely limited economic resources, sociocultural challenges, and inadequate healthcare access.

METHODS

A multicenter cross-sectional observational study was conducted among individuals residing in economically deprived and marginalized communities, including informal settlements and underprivileged neighborhoods. Simple random sampling of households was employed. Blood pressure measurements, anthropometric assessments, and epidemiological, economic, and sociocultural questionnaires were administered. Results encompass prevalence rates, awareness levels, and blood pressure control across diverse regions. Logistic regression was utilized to identify independent variables influencing primary outcomes.

RESULTS

A total of 989 participants were analyzed. The overall prevalence of hypertension was 48.2%. About 82% had a body mass index (BMI) >25. Approximately 45.3% had less than 6 years of formal education. Independent association was established between education levels below 6 years and higher hypertension prevalence. Among hypertensive individuals, 44% were unaware of their condition, with only 17.2% achieving control, correlated with having health insurance and a higher educational background. Merely 24% were receiving combined therapy.

CONCLUSION

The prevalence of hypertension within vulnerable neighborhoods is alarmingly high, surpassing rates in other social strata. Knowledge, treatment, and control levels of hypertension are suboptimal, comparable to other populations. Inadequate use of combination therapy was observed. This study underscores the urgent need for targeted interventions addressing cardiovascular risk factors in poor areas to mitigate the burden of CVD.

Hipertensión arterial y riesgo cardiovascular

Introducción: la hipertensión arterial es una de las principales enfermedades a nivel mundial y constituye una importante causa de morbilidad y mortalidad para países de bajos y medianos ingresos. Objetivo: determinar la importancia epidemiológica de la hipertensión arterial como factor de riesgo cardiovascular en diferentes estudios realizados a nivel mundial, en Latinoamérica y Colombia. Metodología: se realizó una búsqueda de la literatura científica en las bases de datos de PudMed/Medline, Scielo, LILACS, así como también en revistas médicas y textos publicados por el Ministerio de Salud y Protección Social de Colombia. Discusión y conclusiones: más de 90% de los pacientes hipertensos padecen la forma primaria de la enfermedad, la cual está asociada con un aumento de la resistencia vascular periférica. Las características socioeconómicas de los países y el nivel educativo individual se relacionan con la prevalencia y el manejo adecuado de esta patología. El aumento en la prevalencia de las enfermedades crónicas, sumado a eventos históricos de importancia, fueron determinantes para el desarrollo de estudios epidemiológicos mundiales como el Framingham Heart Study. En América Latina y en Colombia se han realizado diferentes estudios que permiten establecer datos relacionados con la hipertensión arterial, demostrando cifras alarmantes en cuanto al conocimiento, tratamiento y control de esta condición, por lo cual, surge la necesidad de establecer programas para la detección de pacientes hipertensos con el fin de generar estrategias que disminuyan de manera significativa las enfermedades cardiovasculares.

Barriers and Facilitators in Access to Diabetes, Hypertension, and Dyslipidemia Medicines: A Scoping Review

Objective: Identify barriers and facilitators in access to medicines for diabetes, hypertension, and dyslipidemia, considering patient, health provider, and health system perspectives.

Methods: Scoping review based on Joanna Briggs methodology. The search considered PubMed, Cochrane Library, CINAHL, Academic Search Ultimate, Web of Science, SciELO Citation Index, and grey literature. Two researchers conducted screening and eligibility phases. Data were thematically analyzed.

Results: The review included 219 documents. Diabetes was the most studied condition; most of the evidence comes from patients and the United States. Affordability and availability of medicines were the most reported dimension and specific barrier respectively, both cross-cutting concerns. Among high- and middle-income countries, identified barriers were cost of medicines, accompaniment by professionals, long distances to facilities, and cultural aspects; cost of transportation emerges in low-income settings. Facilitators reported were financial accessibility, trained health workers, medicines closer to communities, and patients’ education.

Conclusion: Barriers and facilitators are determined by socioeconomic and cultural conditions, highlighting the role of health systems in regulatory and policy context (assuring financial coverage and free medicines); providers’ role bringing medicines closer; and patients’ health education and disease management.

Exploring New Models for Cardiovascular Risk Reduction: The Heart Outcomes Prevention and Evaluation 4 (HOPE 4) Canada Pilot Study

Background

There is a gap between evidence and practice in the management of cardiovascular (CV) risk. Previous research indicated benefits from community-based, multi-faceted interventions to screen, diagnose, and manage CV risk in people with hypertension.

Methods

The Heart Outcomes Prevention and Evaluation 4 Canada pilot study (HOPE 4) was a quasi-experimental pre-post interventional study, involving one community each in Hamilton, Ontario and Surrey, British Columbia, Canada. Individuals aged ≥50 years with newly diagnosed or poorly controlled hypertension were included. The intervention was comprised of: (i) simplified diagnostic/treatment algorithms implemented by community health workers (firefighters in British Columbia and community health workers in Ontario) guided by decision support and counselling software; (ii) recommendations for evidence-based CV medications and lifestyle modifications; and (iii) support from family/friends to promote healthy behaviours. The intervention was developed as part of the international Heart Outcomes Prevention and Evaluation 4 Canada pilot study trial and adapted to the Canadian context. The primary outcome was the change in Framingham Risk Score 10-year CV disease risk estimate between baseline and 6 months.

Results

Between 2016 and 2017, a total of 193 participants were screened, with 37 enrolled in Surrey, and 19 in Hamilton. Mean age was 69 years (standard deviation 11), with 54% female, 27% diabetic, and 73% with a history of hypertension. An 82% follow-up level had been obtained at 6 months. Compared to baseline, there were significant improvements in the Framingham Risk Score 10-year risk estimate (30.6% vs 24.7%, P < 0.01), and systolic blood pressure (153.1 vs 136.7 mm Hg, P < 0.01). No significant changes in lipids or healthy behaviours were noted.

Conclusions

A comprehensive approach to health care delivery, using a community-based intervention with community health workers, supported by mobile-health technologies, has the potential to significantly reduce cardiovascular risk, but further evaluation is warranted.

Clinical Decision Support for the Diagnosis and Management of Adult and Pediatric Hypertension

PURPOSE OF REVIEW

To review literature from 2016 to 2019 on clinical decision support (CDS) for diagnosis and management of hypertension in children and adults.

RECENT FINDINGS

Ten studies described hypertension CDS systems. Novel advances included the integration of patient-collected blood pressure data, automated information retrieval and management support, and use of CDS in low-resource/developing-world settings and in pediatrics. Findings suggest that CDS increases hypertension detection/control, yet many children and adults with hypertension remain undetected or undercontrolled. CDS challenges included poor usability (from lack of health record integration, excessive data entry requests, and wireless connectivity challenges) and lack of clinician trust in blood pressure measures. Hypertension CDS has improved but not closed gaps in the detection and control of hypertension in children and adults. The studies reviewed indicate that the usability of CDS and the system where CDS is deployed (e.g., commitment to high-quality blood pressure measurement/infrastructure) may impact CDS's ability to increase hypertension detection and control.

Challenges in management and prevention of ischemic heart disease in low socioeconomic status people in LLMICs

BACKGROUND

Cardiovascular diseases, principally ischemic heart disease (IHD), are the most important cause of death and disability in the majority of low- and lower-middle-income countries (LLMICs). In these countries, IHD mortality rates are significantly greater in individuals of a low socioeconomic status (SES).

MAIN TEXT

Three important focus areas for decreasing IHD mortality among those of low SES in LLMICs are (1) acute coronary care; (2) cardiac rehabilitation and secondary prevention; and (3) primary prevention. Greater mortality in low SES patients with acute coronary syndrome is due to lack of awareness of symptoms in patients and primary care physicians, delay in reaching healthcare facilities, non-availability of thrombolysis and coronary revascularization, and the non-affordability of expensive medicines (statins, dual anti-platelets, renin-angiotensin system blockers). Facilities for rapid diagnosis and accessible and affordable long-term care at secondary and tertiary care hospitals for IHD care are needed. A strong focus on the social determinants of health (low education, poverty, working and living conditions), greater healthcare financing, and efficient primary care is required. The quality of primary prevention needs to be improved with initiatives to eliminate tobacco and trans-fats and to reduce the consumption of alcohol, refined carbohydrates, and salt along with the promotion of healthy foods and physical activity. Efficient primary care with a focus on management of blood pressure, lipids and diabetes is needed. Task sharing with community health workers, electronic decision support systems, and use of fixed-dose combinations of blood pressure-lowering drugs and statins can substantially reduce risk factors and potentially lead to large reductions in IHD. Finally, training of physicians, nurses, and health workers in IHD prevention should be strengthened.

CONCLUSION

The management and prevention of IHD in individuals with a low SES in LLMICs are poor. Greater availability, access, and affordability for acute coronary syndrome management and secondary prevention are important. Primary prevention should focus on tackling the social determinants of health as well as policy and individual interventions for risk factor control, supported by task sharing and use of technology.

A community-based comprehensive intervention to reduce cardiovascular risk in hypertension (HOPE 4): a cluster-randomised controlled trial

BACKGROUND

Hypertension is the leading cause of cardiovascular disease globally. Despite proven benefits, hypertension control is poor. We hypothesised that a comprehensive approach to lowering blood pressure and other risk factors, informed by detailed analysis of local barriers, would be superior to usual care in individuals with poorly controlled or newly diagnosed hypertension. We tested whether a model of care involving non-physician health workers (NPHWs), primary care physicians, family, and the provision of effective medications, could substantially reduce cardiovascular disease risk.

METHODS

HOPE 4 was an open, community-based, cluster-randomised controlled trial involving 1371 individuals with new or poorly controlled hypertension from 30 communities (defined as townships) in Colombia and Malaysia. 16 communities were randomly assigned to control (usual care, n=727), and 14 (n=644) to the intervention. After community screening, the intervention included treatment of cardiovascular disease risk factors by NPHWs using tablet computer-based simplified management algorithms and counselling programmes; free antihypertensive and statin medications recommended by NPHWs but supervised by physicians; and support from a family member or friend (treatment supporter) to improve adherence to medications and healthy behaviours. The primary outcome was the change in Framingham Risk Score 10-year cardiovascular disease risk estimate at 12 months between intervention and control participants. The HOPE 4 trial is registered at ClinicalTrials.gov, NCT01826019.

FINDINGS

All communities completed 12-month follow-up (data on 97% of living participants, n=1299). The reduction in Framingham Risk Score for 10-year cardiovascular disease risk was -6·40% (95% CI 8·00 to -4·80) in the control group and -11·17% (-12·88 to -9·47) in the intervention group, with a difference of change of -4·78% (95% CI -7·11 to -2·44, p<0·0001). There was an absolute 11·45 mm Hg (95% CI -14·94 to -7·97) greater reduction in systolic blood pressure, and a 0·41 mmol/L (95% CI -0·60 to -0·23) reduction in LDL with the intervention group (both p<0·0001). Change in blood pressure control status (<140 mm Hg) was 69% in the intervention group versus 30% in the control group (p<0·0001). There were no safety concerns with the intervention.

INTERPRETATION

A comprehensive model of care led by NPHWs, involving primary care physicians and family that was informed by local context, substantially improved blood pressure control and cardiovascular disease risk. This strategy is effective, pragmatic, and has the potential to substantially reduce cardiovascular disease compared with current strategies that are typically physician based.

FUNDING

Canadian Institutes of Health Research; Grand Challenges Canada; Ontario SPOR Support Unit and the Ontario Ministry of Health and Long-Term Care; Boehringer Ingelheim; Department of Management of Non-Communicable Diseases, WHO; and Population Health Research Institute. VIDEO ABSTRACT.

Personalized Medicine and the Treatment of Hypertension

PURPOSE OF REVIEW

The purpose of this review is to discuss the implications of personalized medicine for the treatment of hypertension, including resistant hypertension.

RECENT FINDINGS

We suggest a framework for the personalized treatment of hypertension based on the concept of a trade-off between simplicity and personalization. This framework is based on treatment strategies classified as low, medium, or high information burden personalization approaches. The extent to which a higher information burden is justified depends on the clinical scenario, particularly the ease with which the blood pressure can be controlled. A one-size-fits-many treatment strategy for hypertension is efficacious for most people; however, a more personalized approach could be useful in patients with subtypes of hypertension that do not respond as expected to treatment. Clinicians seeing patients with unusual hypertension phenotypes should be familiar with emerging trends in personalized treatment of hypertension.