1
|
Gerber F, Gupta R, Lejone TI, Tahirsylaj T, Lee T, Sanchez-Samaniego G, Kohler M, Haldemann MI, Raeber F, Chitja M, Mathulise M, Kabi T, Mokaeane M, Maphenchane M, Molulela M, Khomolishoele M, Mota M, Masike S, Bane M, Sematle MP, Makabateng R, Mphunyane M, Phaaroe S, Basler DB, Kindler K, Burkard T, Briel M, Chammartin F, Labhardt ND, Amstutz A. Community-based management of arterial hypertension and cardiovascular risk factors by lay village health workers for people with controlled and uncontrolled blood pressure in rural Lesotho: joint protocol for two cluster-randomized trials within the ComBaCaL cohort study (ComBaCaL aHT Twic 1 and ComBaCaL aHT TwiC 2). Trials 2024; 25:365. [PMID: 38845045 PMCID: PMC11157768 DOI: 10.1186/s13063-024-08226-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 06/03/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Arterial hypertension (aHT) is a major cause for premature morbidity and mortality. Control rates remain poor, especially in low- and middle-income countries. Task-shifting to lay village health workers (VHWs) and the use of digital clinical decision support systems may help to overcome the current aHT care cascade gaps. However, evidence on the effectiveness of comprehensive VHW-led aHT care models, in which VHWs provide antihypertensive drug treatment and manage cardiovascular risk factors is scarce. METHODS Using the trials within the cohort (TwiCs) design, we are assessing the effectiveness of VHW-led aHT and cardiovascular risk management in two 1:1 cluster-randomized trials nested within the Community-Based chronic disease Care Lesotho (ComBaCaL) cohort study (NCT05596773). The ComBaCaL cohort study is maintained by trained VHWs and includes the consenting inhabitants of 103 randomly selected villages in rural Lesotho. After community-based aHT screening, adult, non-pregnant ComBaCaL cohort participants with uncontrolled aHT (blood pressure (BP) ≥ 140/90 mmHg) are enrolled in the aHT TwiC 1 and those with controlled aHT (BP < 140/90 mmHg) in the aHT TwiC 2. In intervention villages, VHWs offer lifestyle counseling, basic guideline-directed antihypertensive, lipid-lowering, and antiplatelet treatment supported by a tablet-based decision support application to eligible participants. In control villages, participants are referred to a health facility for therapeutic management. The primary endpoint for both TwiCs is the proportion of participants with controlled BP levels (< 140/90 mmHg) 12 months after enrolment. We hypothesize that the intervention is superior regarding BP control rates in participants with uncontrolled BP (aHT TwiC 1) and non-inferior in participants with controlled BP at baseline (aHT TwiC 2). DISCUSSION The TwiCs were launched on September 08, 2023. On May 20, 2024, 697 and 750 participants were enrolled in TwiC 1 and TwiC 2. To our knowledge, these TwiCs are the first trials to assess task-shifting of aHT care to VHWs at the community level, including the prescription of basic antihypertensive, lipid-lowering, and antiplatelet medication in Africa. The ComBaCaL cohort and nested TwiCs are operating within the routine VHW program and countries with similar community health worker programs may benefit from the findings. TRIAL REGISTRATION ClinicalTrials.gov NCT05684055. Registered on January 04, 2023.
Collapse
Affiliation(s)
- Felix Gerber
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland.
- University of Basel, Basel, Switzerland.
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
| | | | - Thabo Ishmael Lejone
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Thesar Tahirsylaj
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Tristan Lee
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Giuliana Sanchez-Samaniego
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Maurus Kohler
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Maria-Inés Haldemann
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabian Raeber
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Dave Brian Basler
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Kevin Kindler
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Business, Economics and Informatics, University of Zurich, Zurich, Switzerland
| | - Thilo Burkard
- Medical Outpatient Department and Hypertension Clinic, ESH Hypertension Centre of Excellence, University Hospital Basel, Basel, Switzerland
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Matthias Briel
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Frédérique Chammartin
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Niklaus Daniel Labhardt
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Alain Amstutz
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Oslo Center for Biostatistics and Epidemiology, Oslo University Hospital, University of Oslo, Oslo, Norway
- Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
2
|
Patil SJ, Bhayani V, Yoshida Y, Bushweller L, Udoh EO, Todorov I, Saper R, Stange KC, Bolen S. Lay advisor interventions for hypertension outcomes: A Systematic Review, Meta-analysis and a RE-AIM evaluation. Front Med (Lausanne) 2024; 11:1305190. [PMID: 38831986 PMCID: PMC11144929 DOI: 10.3389/fmed.2024.1305190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 04/22/2024] [Indexed: 06/05/2024] Open
Abstract
Introduction Lay advisor interventions improve hypertension outcomes; however, the added benefits and relevant factors for their widespread implementation into health systems are unknown. We performed a systematic review to: (1) summarize the benefits of adding lay advisors to interventions on hypertension outcomes, and (2) summarize factors associated with successful implementation in health systems using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Methods We systematically searched several databases, including Ovid MEDLINE, CINAHL, PsycINFO from January 1981 to May 2023. All study designs of interventions delivered solely by lay advisors for adults with hypertension were eligible. If both arms received the lay advisor intervention, the study arm with lower intensity was assigned as the low-intensity intervention. Results We included 41 articles, of which 22 were RCTs, from 7,267 screened citations. Studies predominantly included socially disadvantaged populations. Meta-analysis (9 RCTs; n = 4,220) of eligible lay advisor interventions reporting outcomes showed improved systolic blood pressure (BP) [-3.72 mm Hg (CI -6.1 to -1.3; I2 88%)], and diastolic BP [-1.7 mm Hg (CI -1 to -0.9; I2 7%)] compared to control group. Pooled effect from six RCTs (n = 3,277) comparing high-intensity with low-intensity lay advisor interventions showed improved systolic BP of -3.6 mm Hg (CI -6.7 to -0.5; I2 82.7%) and improved diastolic BP of -2.1 mm Hg (CI -3.7 to -0.4; I2 70.9%) with high-intensity interventions. No significant difference in pooled odds of hypertension control was noted between lay advisor intervention and control groups, or between high-intensity and low-intensity intervention groups. Most studies used multicomponent interventions with no stepped care elements or reporting of efficacious components. Indicators of external validity (adoption, implementation, maintenance) were infrequently reported. Discussion Lay advisor interventions improve hypertension outcomes, with high intensity interventions having a greater impact. Further studies need to identify successful intervention and implementation factors of multicomponent interventions for stepped upscaling within healthcare system settings as well as factors used to help sustain interventions.
Collapse
Affiliation(s)
- Sonal J. Patil
- Center for Health Equity, Engagement, Education, and Research (CHEEER), Department of Family Medicine, The MetroHealth Campus of Case Western Reserve University, Cleveland, OH, United States
| | - Vishwa Bhayani
- Department of Public Health, University of Missouri, Columbia, MO, United States
| | - Yilin Yoshida
- Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, United States
| | - Leila Bushweller
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Eno-Obong Udoh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Irina Todorov
- Department of Wellness and Preventive Medicine, Primary Care Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Robert Saper
- Department of Wellness and Preventive Medicine, Primary Care Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Kurt C. Stange
- Center for Community Health Integration, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Shari Bolen
- Department of Medicine, Center for Health Care Research and Policy, The MetroHealth Campus of Case Western Reserve University, Cleveland, OH, United States
| |
Collapse
|
3
|
Brusca SB, Albert MA. Balancing the scales of adversity: a socioecological approach to reducing the global burden of stroke and cardiovascular disease. Lancet Neurol 2023; 22:1094-1096. [PMID: 37827182 DOI: 10.1016/s1474-4422(23)00386-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Samuel B Brusca
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michelle A Albert
- Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA.
| |
Collapse
|
4
|
Abrahams-Gessel S, Beratarrechea A, Irazola V, Gulayin P, Gutierrez L, Mahoney M, Gaziano T. Managing high cardiovascular disease risk among adults in Argentina using a multicomponent strategy linking key aspects of care: A two-arm cluster-randomized clinical trial (PRIMECare) protocol. Contemp Clin Trials 2023; 134:107357. [PMID: 37852532 PMCID: PMC10842453 DOI: 10.1016/j.cct.2023.107357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/28/2023] [Accepted: 10/15/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) imposes a significant burden on the Argentinian population. Management of its leading risk factors can significantly reduce the CVD burden in high-resource settings, but there is insufficient evidence for effective implementation of evidence-based interventions in lower-resource settings like Argentina. METHODS In this two-arm cluster-randomized trial we seek to compare the effective implementation, of a multicomponent intervention, versus usual care, to improve the management of high CVD risk across the care continuum in three provinces of Argentina. The multicomponent intervention strategy links five primary components of the CVD care continuum to improve its management: (1) a data management system linking a digital mHealth (mobile health) screening tool used by community health workers (CHWs), (2) an electronic appointment scheduler that is integrated with the primary care center electronic appointment system, (3) point of care testing for lipid profiles, (4) a clinical decision support (CDS) system for medication initiation, and (5) a text message (SMS) reminder system to improve treatment adherence and life-style changes. The primary outcome is the mean change in Framingham laboratory-based, 10-year absolute CVD risk score between the study arms from baseline to twelve months after enrollment. CONCLUSIONS This protocol describes the development of a multicomponent intervention to implement effective management of CVD, developed with partners at the National and provincial Departments of Health in Argentina, with the goal of understanding its effective implementation in a primary health care system strengthened by universal health coverage, provision of free health care services, and provision of free medication.
Collapse
Affiliation(s)
| | | | - Vilma Irazola
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Pablo Gulayin
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Laura Gutierrez
- Instituto de Efectividad Clinica y Sanitaria (IECS), Buenos Aires, Argentina
| | - Margaret Mahoney
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas Gaziano
- Harvard TH Chan School of Public Health, Boston, MA, USA; Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| |
Collapse
|
5
|
Tolley A, Hassan R, Sanghera R, Grewal K, Kong R, Sodhi B, Basu S. Interventions to promote medication adherence for chronic diseases in India: a systematic review. Front Public Health 2023; 11:1194919. [PMID: 37397765 PMCID: PMC10311913 DOI: 10.3389/fpubh.2023.1194919] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/02/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Cost-effective interventions that improve medication adherence are urgently needed to address the epidemic of non-communicable diseases (NCDs) in India. However, in low- and middle-income countries like India, there is a lack of analysis evaluating the effectiveness of adherence improving strategies. We conducted the first systematic review evaluating interventions aimed at improving medication adherence for chronic diseases in India. Methods A systematic search on MEDLINE, Web of Science, Scopus, and Google Scholar was conducted. Based on a PRISMA-compliant, pre-defined methodology, randomized control trials were included which: involved subjects with NCDs; were located in India; used any intervention with the aim of improving medication adherence; and measured adherence as a primary or secondary outcome. Results The search strategy yielded 1,552 unique articles of which 22 met inclusion criteria. Interventions assessed by these studies included education-based interventions (n = 12), combinations of education-based interventions with regular follow up (n = 4), and technology-based interventions (n = 2). Non-communicable diseases evaluated commonly were respiratory disease (n = 3), type 2 diabetes (n = 6), cardiovascular disease (n = 8) and depression (n = 2). Conclusions Although the vast majority of primary studies supporting the conclusions were of mixed methodological quality, patient education by CHWs and pharmacists represent promising interventions to improve medication adherence, with further benefits from regular follow-up. There is need for systematic evaluation of these interventions with high quality RCTs and their implementation as part of wider health policy. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022345636, identifier: CRD42022345636.
Collapse
Affiliation(s)
| | | | | | | | - Ruige Kong
- University of Cambridge, Cambridge, United Kingdom
| | - Baani Sodhi
- Indian Institute of Public Health-Delhi, Gurugram, India
| | - Saurav Basu
- Indian Institute of Public Health-Delhi, Gurugram, India
| |
Collapse
|
6
|
Abstract
We stand at a critical juncture in the delivery of health care for hypertension. Blood pressure control rates have stagnated, and traditional health care is failing. Fortunately, hypertension is exceptionally well-suited to remote management, and innovative digital solutions are proliferating. Early strategies arose with the spread of digital medicine, long before the COVID-19 pandemic forced lasting changes to the way medicine is practiced. Highlighting one contemporary example, this review explores salient features of remote management hypertensive programs, including: an automated algorithm to guide clinical decisions, home (as opposed to office) blood pressure measurements, an interdisciplinary care team, and robust information technology and analytics. Dozens of emerging hypertension management solutions are contributing to a highly fragmented and competitive landscape. Beyond viability, profit and scalability are critical. We explore the challenges impeding large-scale acceptance of these programs and conclude with a hopeful look to the future when remote hypertension care will have dramatic impact on global cardiovascular health.
Collapse
Affiliation(s)
- Simin Gharib Lee
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Naomi D.L. Fisher
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| |
Collapse
|
7
|
Brook RD, Levy PD, Brook AJ, Opara IN. Community Health Workers as Key Allies in the Global Battle Against Hypertension: Current Roles and Future Possibilities. Circ Cardiovasc Qual Outcomes 2023; 16:e009900. [PMID: 36815465 PMCID: PMC11200125 DOI: 10.1161/circoutcomes.123.009900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- Robert D Brook
- Division of Cardiovascular Diseases, Department of Internal Medicine (R.D.B.), Wayne Health Physician Group, Wayne State University, Detroit MI
| | - Phillip D Levy
- Department of Emergency Medicine and Integrative Biosciences Center (P.D.L.), Wayne Health Physician Group, Wayne State University, Detroit MI
| | | | - Ijeoma N Opara
- Departments of Internal Medicine and Pediatrics (I.O.), Wayne Health Physician Group, Wayne State University, Detroit MI
| |
Collapse
|
8
|
Meng T, Wang P, Xie X, Li T, Kong L, Xu Y, Cao K, Gao Y, He Q, Lai X. Efficacy and safety of Songling Xuemaikang capsule for essential hypertension: A systematic review and meta-analysis of randomized controlled trials. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2022; 107:154459. [PMID: 36183476 DOI: 10.1016/j.phymed.2022.154459] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/28/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Hypertension is one of the most significant public health challenges worldwide. An increasing number of patients prefer to incorporate traditional Chinese medicine into their hypertensive care. The Songling Xuemaikang capsule (SXC), a Chinese herbal formula, is widely used in China for essential hypertension. PURPOSE To assess the efficacy and safety of SXC for essential hypertension. STUDY DESIGN Systematic review and meta-analysis of randomized controlled trials (RCTs). METHODS We conducted a systematic literature search of seven databases to identify randomized controlled trials of SXC for hypertension. The outcome measures included blood pressure parameters and patient-reported outcomes. Potential heterogeneity between the studies was resolved by subgroup and sensitivity analyses. The quality of the results was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. RESULTS A total of 34 trials with 4306 patients were included. The results showed that SXC plus antihypertensive drugs produced a greater effect on reducing systolic blood pressure (SBP) (MD: -7.54 mmHg; 95% CI: -8.92, -6.17; p < 0.00001), diastolic blood pressure (DBP) (MD: -6.42 mmHg; 95% CI: -7.54, -5.29; p < 0.00001), 24-hour SBP (MD: -6.88 mmHg; 95% CI: -8.36, -5.39; p < 0.00001), and 24-hour DBP (MD: -4.31 mmHg; 95% CI: -6.55, -2.07; p = 0.0002) and improving hypertensive symptoms (SMD: -1.09; 95% CI: -1.34, -0.84; p < 0.00001) than antihypertensive drugs alone. SXC monotherapy was less effective than antihypertensive drugs for 24-hour SBP reduction (MD: 2.07 mmHg; 95% CI: 0.19, 3.96; p = 0.03). No significant difference was observed in the incidence of adverse events between the SXC and control groups. CONCLUSION SXC is beneficial for essential hypertension; it can lower BP, improve hypertensive symptoms and is well tolerated.
Collapse
Affiliation(s)
- Tiantian Meng
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, China; Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100032, China
| | - Peng Wang
- Department of Traditional Chinese Medicine, Beijing Jiangong Hospital, Beijing, 100032, China
| | - Xiaolong Xie
- Department of Acupuncture, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, China
| | - Tingting Li
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, 100010, China
| | - Lingbo Kong
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, 100010, China
| | - Yingzhi Xu
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, 100010, China
| | - Kegang Cao
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, 100010, China
| | - Ying Gao
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, 100010, China
| | - Qingyong He
- Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100032, China.
| | - Xinxing Lai
- Department of Neurology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing, 100010, China.
| |
Collapse
|