Impact of the high-risk and mass strategies on hypertension control and stroke mortality in primary health care

Interventions to improve primary healthcare in rural settings: A scoping review

BACKGROUND

Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations.

OBJECTIVE

Synthesize and categorize studies that examine interventions to improve rural primary care.

ELIGIBILITY CRITERIA

Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison.

SOURCES OF EVIDENCE

Pubmed, CINAHL, Cochrane Library, Embase.

CHARTING METHODS

We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant.

RESULTS

372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017.

CONCLUSIONS

Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Frontiers of Upstream Stroke Prevention and Reduced Stroke Inequity Through Predicting, Preventing, and Managing Hypertension and Atrial Fibrillation: A Call to Action From the Value in Healthcare Initiative's Predict & Prevent Learning Collaborative

Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.

Effect of a community-based intervention for cardiovascular risk factor control on stroke mortality in rural Gadchiroli, India: study protocol for a cluster randomised controlled trial

BACKGROUND

Stroke has emerged as a leading cause of death in rural India. However, well-tested healthcare interventions to reduce stroke mortality in rural under-resourced settings are lacking. The aim of this study is to evaluate the effect of a community-based preventive intervention on stroke mortality in rural Gadchiroli, India.

METHODS

The study is a two-arm, parallel group, cluster randomised controlled trial in which 32 villages will be randomised to the intervention and the enhanced usual care (EUC) arm. In the intervention arm, individuals ≥50 years of age will be screened for hypertension, diabetes and stroke by trained Community Health Workers (CHWs). Screened individuals who are positive will be referred to a mobile outreach clinic which will visit the intervention villages periodically. A physician in the clinic will confirm the diagnosis, provide guideline-based treatment and follow up patients. The CHWs will make home visits once a month to ensure medication compliance and counsel patients to reduce salt consumption and quit tobacco and alcohol. In the EUC arm, households will be provided information on the ill effects of tobacco use and steps to quit it. Individuals from both the arms will have access to the government's national programme for the prevention and control of non-communicable diseases, where treatment for hypertension, diabetes and preventive treatment after stroke is available at the nearest primary health centres (PHCs). The intervention will be implemented for 3.5 years. The primary outcome will be a reduction in stroke mortality in the last 2.5 years of the intervention.

DISCUSSION

This trial will provide important information regarding the feasibility and effect of a community-based preventive intervention package on stroke mortality in a rural under-resourced setting and can inform India's non-communicable diseases prevention and control programme. If successful, such an intervention can be scaled up in the rural regions of India and other countries.

TRIAL REGISTRATION

Clinical Trials Registry of India: CTRI/2015/12/006424. Registered on 8 December 2015.

Stroke Is the Leading Cause of Death in Rural Gadchiroli, India: A Prospective Community-Based Study

BACKGROUND AND PURPOSE

Stroke is an important cause of death and disability worldwide. However, information on stroke deaths in rural India is scarce. To measure the mortality burden of stroke, we conducted a community-based study in a rural area of Gadchiroli, one of the most backward districts of India.

METHODS

We prospectively collected information on all deaths from April 2011 to March 2013 and assigned causes of death using a well-validated verbal autopsy tool in a rural population of 94 154 individuals residing in 86 villages. Two trained physicians independently assigned the cause of death, and the disagreements were resolved by a third physician.

RESULTS

Of 1599 deaths during the study period, 229 (14.3%) deaths were caused by stroke. Stroke was the most frequent cause of death. For those who died because of stroke, the mean age was 67.47±11.8 years and 48.47% were women. Crude stroke mortality rate was 121.6 (95% confidence interval, 106.4-138.4), and age-standardized stroke mortality rate was 191.9 (95% confidence interval, 165.8-221.1) per 100,000 population. Of total stroke deaths, 87.3% stroke deaths occurred at home and 46.3% occurred within the first month from the onset of symptoms.

CONCLUSIONS

Stroke is the leading cause of death and accounted for 1 in 7 deaths in this rural community in Gadchiroli. There was high early mortality, and the mortality rate because of stroke was higher than that reported from previous studies from India. Stroke is emerging as a public health priority in rural India.

Risk Factors of Stroke in Pakistan: A Dedicated Stroke Clinic Experience

Background:

Secondary prevention of cerebrovascular disease through dedicated stroke clinics has been shown to decrease recurrent vascular events in patients. However, there is limited literature describing such stroke clinic experiences from low and middle income countries. This study describes patient characteristics and observations made at the first systematized stroke clinic in Pakistan.

Methods:

Aretrospective audit of medical records of all patients presenting between September 2006 and August 2008 with a cerebrovascular event was conducted. Information about clinical presentation, modifiable risk factors and laboratory and radiological investigations was collected. Burden of disability was assessed using Modified Rankin score. Data was entered and analyzed using SPSS 14.0.

Results:

159 patients with a mean age of 57.0 ± 13.9 years were included in this study and 34.6% of all patients were women. 108 patients were diagnosed with ischemic stroke (67.9%) while 34 patients presented with hemorrhagic stroke (21.4%) and 17 patients presented with transient ischemic attacks (10.7%). Hypertension was the most common modifiable risk factor seen in 78.0%, followed by diabetes in 40.3% and dyslipidemia in 31.5%. At presentation to clinic, only 26.0% patients with dyslipidemia and 64.5% patients with hypertension were on appropriate medications.

Conclusion:

A high prevalence of modifiable risk factors such as hypertension in stroke patients was observed and it presents an opportunity for conventional interventions in Pakistan. Systematized clinics for stroke and an algorithmic approach in primary care towards stroke may improve the implementation of evidence based secondary prevention strategies in developing countries.

Hypertension education and adherence in South Africa: a cost-effectiveness analysis of community health workers

Background

To determine whether training community health workers (CHWs) about hypertension in order to improve adherence to medications is a cost-effective intervention among community members in South Africa.

Methods

We used an established Markov model with age-varying probabilities of cardiovascular disease (CVD) events to assess the benefits and costs of using CHW home visits to increase hypertension adherence for individuals with hypertension and aged 25–74 in South Africa. Subjects considered for CHW intervention were those with a previous diagnosis of hypertension and on medications but who had not achieved control of their blood pressure. We report our results in incremental cost-effectiveness ratios (ICERs) in US dollars per disability-adjusted life-year (DALY) averted.

Results

The annual cost of the CHW intervention is about $8 per patient. This would lead to over a 2% reduction in CVD events over a life-time and decrease DALY burden. Due to reductions in non-fatal CVD events, lifetime costs are only $6.56 per patient. The CHW intervention leads to an incremental cost-effectiveness ratio of $320/DALY averted. At an annual cost of $6.50 or if the blood pressure reduction is 5 mmHg or greater per patient the intervention is cost-saving.

Conclusions

Additional training for CHWs on hypertension management could be a cost-effective strategy for CVD in South Africa and a very good purchase according to World Health Organization (WHO) standards. The intervention could also lead to reduced visits at the health centres freeing up more time for new patients or reducing the burden of an overworked staff at many facilities.

The development and validation of the hypertension evaluation of lifestyle and management knowledge scale

Hypertension knowledge is an integral component of the chronic care model. A valid scale to assess hypertension knowledge and self-management skills is needed. The hypertension evaluation of lifestyle and management (HELM) scale was developed as part of a community-based study designed to improve self-management of hypertension. Participants included 404 veterans with hypertension. Literature review and an expert panel were used to identify required skills. Items were generated and pilot tested in the target population. Validity was assessed through comparisons of performance with education, health numeracy, print numeracy, patient activation and self-efficacy, and hypertension control. The HELM knowledge scale had 14 items across 3 domains: general hypertension knowledge, lifestyle and medication management, and measurement and treatment goals. Scores were positively associated with education (0.28, P<.0001), print health literacy (0.21, P<.001), health numeracy (0.17, P<.001), and patient activation (0.12, P=.015) but no association was found with diastolic or systolic blood pressure. The HELM knowledge scores increased following the educational intervention from baseline (mean, 8.7; standard deviation, 2.2) to 12-month follow-up (mean, 9.2, standard deviation, 2.2; P<.001). We conclude that the HELM provides a valid measure of the knowledge required for patients to take an active role in the chronic disease management of hypertension.

Trends in mortality from all causes and cardiovascular disease among hypertensive and nonhypertensive adults in the United States

BACKGROUND

Little is known about trends in the mortality rate among people with hypertension in the United States. The objective of the present study was to examine the change in the all-cause mortality rate among people with and without hypertension in the United States and whether any such changes differed by sex or race.

METHODS AND RESULTS

Data from 10 852 participants aged 25 to 74 years of the National Health and Nutrition Examination Survey (NHANES) I Epidemiological Follow-Up Study (1971 to 1975) and of 12 420 participants of the NHANES III Linked Mortality Study (1988 to 1994) were used. The mean follow-up times were 17.5 and 14.2 years, respectively. In each cohort, the mortality rate was higher among hypertensive adults than nonhypertensive adults, among hypertensive men than hypertensive women, and among hypertensive blacks than hypertensive whites. Among all hypertensive participants, the age-adjusted mortality rate was 18.8 per 1000 person-years for NHANES I and 14.3 for NHANES III (13.3 and 9.1 per 1000 person-years for nonhypertensive participants, respectively). The reduction among hypertensive men (7.7 per 1000 person-years; 95 confidence interval, 5.2 to 10.2) exceeded that among hypertensive women (1.9 per 1000 person-years; 95 confidence interval, [-0.4 to 4.2]) (P<0.001), and the reduction among hypertensive blacks (5.4 per 1000 person-years; 95 confidence interval, [0.6 to 10.1]) exceeded that among hypertensive whites (4.4 per 1000 person-years; 95 confidence interval, [2.2 to 6.5]) (P=0.707).

CONCLUSIONS

The mortality rate decreased among hypertensive adults, but the mortality gap between adults with and without hypertension remained relatively constant. Efforts are needed to accelerate the decrease in the mortality rate among hypertensive adults.

Development of complex interventions in stroke care: a systematic review

BACKGROUND AND PURPOSE

Stroke care is complex, requiring input from professionals, patients and carers. Identifying and developing appropriate intervention components to meet these complex needs is difficult. The Medical Research Council (MRC) Framework for developing and evaluating 'complex' (nonpharmacological) interventions aims to improve intervention development. This study uses the Framework to review complex interventions in stroke care.

METHODS

Systematic review with multiple search strategies (electronic databases, recent journals, gray literature) was used. The MRC Framework was used to guide the search strategy and assess study quality. 'Complex interventions' were defined as educational/psychosocial interventions to change knowledge, beliefs or behaviors.

RESULTS

Sixty-seven studies were included: 39 randomized controlled trials (RCT) and 28 other designs. Complex interventions targeted healthcare professionals (17), and patients, carers and the general population (21 targeting primary or secondary prevention; 30 targeting adjustment and recovery after stroke). Compared with recovery studies, primary and secondary prevention studies were significantly less likely to have been evaluated in RCTs. Interventions evaluated in RCTs were significantly less likely to influence primary outcomes (26%) compared with other designs (44%). Theoretical grounding to support intervention choice was reported in 40 studies but only 14 were theoretically 'well developed'; 21 RCTs listed multiple primary outcome measures, with 10 listing 5 or more. Of these only 3 reported considering statistical power before recruitment and none was sufficiently powered.

CONCLUSIONS

Few complex interventions in stroke care have been adequately developed or evaluated. This may explain failures to demonstrate efficacy. In future, greater attention is needed to theoretical development and methodological quality.

Trends in the prevalence, awareness, treatment and control of hypertension: the WHO MONICA Project

OBJECTIVE

To describe the secular changes in the prevalence, awareness, treatment and control of hypertension.

DESIGN

Two independent cross-sectional population surveys using standardized methods conducted between the early 1980s and mid-1990s.

SETTING

Twenty-four geographically defined populations of the WHO MONICA Project.

PARTICIPANTS

Randomly selected men and women aged 35-64 years. The total number of participants was 69 907.

MAIN OUTCOME MEASURES

Two definitions of hypertension were used: 160/95 mmHg or above and 140/90 mmHg or above for systolic or diastolic blood pressure. Subjects on antihypertensive drug treatment were considered to be hypertensive regardless of their blood pressure. Treated subjects whose measured blood pressure level was less than 160/95 or 140/90 mmHg according to the two definitions, respectively, were considered to be adequately treated.

RESULTS

The age-adjusted prevalence of hypertension decreased in most and increased in only a few populations. For both definitions of hypertension, the proportion of hypertensive subjects who were aware of their condition increased in three-quarters of the male populations and in two-thirds of the female populations. Furthermore, the proportion of hypertensive individuals on antihypertensive drug treatment increased in three-quarters of the populations. In the final survey, hypertension tended to be better treated and controlled in women than in men. Nevertheless, a large proportion of patients receiving antihypertensive drug therapy still had inadequately controlled blood pressure levels.

CONCLUSION

Although awareness and treatment of hypertension according to the data obtained during the late 1980s to the mid-1990s increased in several populations, the effectiveness of antihypertensive treatment showed the continuing need for improvements.

Multimodality stroke prevention

BACKGROUND

Prevention harbors the greatest potential for reducing the societal burden from stroke. As evidence accumulates on the multifactorial pathogenesis of vascular disease and the impact of novel combination therapies targeted at reducing recurrent vascular events, a new paradigm is emerging, which is that of multimodality vascular prevention. Knowledge of the evidence behind this strategy and the effective means for implementing it could be useful to the practicing neurologist taking care of stroke patients.

REVIEW SUMMARY

Our review presents the evidence behind the broadening therapeutic options for recurrent vascular event prevention in ischemic stroke patients whose underlying stroke pathophysiologic mechanism is either presumed to be due to atherosclerosis or who have prior evidence of systemic atherosclerosis. We elaborate on conventional and novel vascular risk factors, as well as risk factor prediction models. Therapies discussed include antithrombotics, statins, antihypertensives, surgical/endovascular treatments, and lifestyle modification. Basis for evidence (or the lack thereof), national guideline recommendations, areas of controversy, and avenues of future focus for these treatments are also discussed in this paper. Furthermore, the knowledge-treatment gap as it pertains to optimal vascular risk-factor control and appropriate initiation and maintenance of evidence-based preventive therapies is explored, and an effective hospital-based intervention involving the in-hospital initiation of these treatments prior to discharge, that may help bridge this gap, is detailed.

CONCLUSIONS

Neurologists should be aware that a timely, systematic, evidence-based multimodal preventive approach to atherothrombotic disease in stroke patients that transcends the continuum of care across points of service will likely increase treatment rates and improve clinical outcomes.