HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings

Comparing scale up of status quo hypertension care against dual combination therapy as separate pills or single pill combinations: an economic evaluation in 24 low- and middle-income countries

Background

International hypertension treatment guidelines recommend initiating pharmacological treatment with combination therapy and using fixed dose single pill combinations (SPCs) to improve adherence. However, few countries have adopted combination therapy as a form of first-line treatment and SPC uptake in low- and middle-income countries is low due in part to cost and availability. Evidence on costs and cost-effectiveness is needed as health authorities consider incorporating new recommendations into national clinical practice guidelines.

Methods

Over a 30-year time horizon, we used an Excel-based Markov cohort state-transition model to assess the financial costs (screening, treatment, program, and supply chain costs) and socio-economic outcomes (health outcomes, value of lives saved, productivity losses averted) of three antihypertensive treatment scenarios. A baseline scenario scaled treatment among adults age 30 plus while assuming continuation of the widespread practice of initiating treatment with monotherapy. Scenarios one and two scaled treatment while initiating patients on two antihypertensive medications, either as separate pills or as a SPC. Analysis inputs are informed by country-specific data, meta-analyses of the blood-pressure lowering of antihypertensive medications, and own-studies of medication costs. We compared costs, cost-effectiveness, and net-benefits across scenarios, and assessed uncertainty in a one-way sensitivity analysis.

Findings

Using dual combination therapy (with or without SPCs) as first-line treatment would increase costs relative to current practices that largely use monotherapy. Required additional annual resources averaged as much as 3.6, 0.9, and 0.2 percent of government health expenditures in the analysis' low-, lower-middle, and upper-middle income countries. However, across 24 countries, over the next 30 years, combination therapy with separate pills could save 430,000 more lives and combination therapy with SPCs could save 564,000 more lives compared to baseline treatment practices. Administration of two or more medications using SPCs generated higher net benefits in most countries (16/24) compared to the baseline scenario.

Interpretation

First line treatment employing SPCs is likely to generate higher net benefits compared to status quo treatment practices in countries with relatively higher incomes. To improve population health, national health systems would benefit from reducing structural and other barriers to the use of combination therapy and SPCs.

Funding

This journal article was supported by TEPHINET cooperative agreement number 1NU2HGH000044-01-0 funded by the US Centers for Disease Control and Prevention.

Standardized treatment protocols for hypertension: global availability, characteristics, and alignment with the hypertension guideline recommendations

BACKGROUND

Hypertension control is suboptimal globally. Implementing evidence-based, simple, standardized treatment protocols (STPs) has been instrumental in effectively and efficiently improving treatment and control of hypertension. We aimed to identify, characterize, and critically appraise hypertension STPs.

METHODS

We defined STP as a series of steps for the pharmacological treatment of primary hypertension, with information on target population, BP threshold for treatment initiation, target BP, specific drugs/classes/doses, and follow-up frequency. STPs for adult patients were identified from the websites of relevant health organizations, Google search, and through expert consultations (until July 2023). STPs for secondary, gestational, or malignant hypertension or those that were templates/samples were excluded. Included STPs were critically appraised using HEARTS in the Americas Checklist for hypertension management in primary care and compared with the 2021 WHO hypertension management guideline recommendations.

RESULTS

Fifty STPs were identified. All STPs had a stepwise treatment approach, involved guideline-recommended first-line drugs, and 98% consisted of at least four steps. Majority (54%) recommended monotherapy with calcium channel blockers as first-line treatment. Only 44% STPs recommended treatment initiation with combination therapy, and 16% recommended single-pill combinations. Most (62%) had dose-intensification as the second step. Most (74%) STPs did not provide complete dosing information. Only one STP mentioned a target time for achieving BP control. On average, STPs scored a performance of 68% on the HEARTS Checklist.

CONCLUSION

Several STPs are available globally; however, most of them have enormous scope for improvement through interventions aimed at alignment with the latest evidence-based guidelines and multistakeholder engagement.

HEARTS in the Americas: Targeting Health System Change to Improve Population Hypertension Control

PURPOSE OF REVIEW

HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation.

RECENT FINDINGS

Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation. Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.

[HEARTS in the Americas: targeting health system change to improve population hypertension controlHEARTS nas Américas: impulsionar mudanças no sistema de saúde para melhorar o controle da hipertensão arterial na população]

Purpose of review

HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation.

Recent findings

Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation.

Summary

Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.

The Rationale for Using Fixed-Dose Combination Therapy in the Management of Hypertension in Colombia: A Narrative Review

Hypertension is a major risk factor for cardiovascular disease and the leading cause of death in Colombia. While the rate of hypertension awareness in Colombia is generally high, rates of treatment initiation, adherence, and blood pressure (BP) control are suboptimal. Major international hypertension guidelines recommend starting treatment with a combination of antihypertensive agents, and the use of a single-pill combination (SPC) to maximize adherence. In contrast, Colombian hypertension guidelines recommend starting treatment with diuretic monotherapy in most patients, and only initiating combination therapy in those with BP > 160/100 mmHg. Therefore, the aim of the current narrative review is to examine the rationale for using SPCs to treat hypertension in Colombia, in the context of the major issues for BP control there. There is evidence of widespread therapeutic inertia in hypertension management, particularly in primary care, in Colombia. Moreover, combination therapy, angiotensin-converting enzyme inhibitors, and long-acting calcium channel blockers, which are internationally recommended as first-line drug therapies, are underutilized there. Adherence to antihypertensive therapy is low in Colombia and may be enhanced by use of SPCs as well as better patient education and follow-up. While there are promising national initiatives to improve BP management, more needs to be done by individual physicians. Antihypertensive SPCs are available on the national essential medicines list and may help to overcome some of the problems with suboptimal adherence, therapeutic inertia, and low rates of BP control that contribute to the high cardiovascular death rate in Colombia.