Changes in hypertension treatment in the yaroslavl region of Russia: improvements observed between 2 cross-sectional surveys

Prevalence, Awareness, and Control of Arterial Hypertension in a Russian Population. The Ural Eye and Medical Study

Background: Applying the criteria recently published by the American College of Cardiology/American Heart Association for the definition of arterial hypertension, we investigated prevalence and awareness of arterial hypertension in Russia. This new definition differentiates between normal BP [SBP (systolic blood pressure)/DBP (diastolic blood pressure) < 120/80 mmHg], elevated BP (SBP 120–129 mmHg; DBP < 80 mmHg), hypertension stage 1 (SBP 130–139 mmHg or DBP 80–89 mmHg), hypertension stage 2 (SBP ≥ 140 and ≤180 mmHg or DBP ≥ 90 and ≤120 mm Hg) and hypertensive crisis (SBP > 180 mmHg and/or DBP > 120).

Methods: The population-based Ural Eye and Medical Study, performed in an urban and rural region in the Russian republic Bashkortostan, included 5,891 (80.5%) individuals aged 40+ years out of 7,328 eligible individuals. The participants underwent a detailed interview and medical examination. Arterial hypertension was defined using the criteria defined by the American College of Cardiology/American Heart Association.

Results: The prevalence of normal blood pressure (BP), elevated BP, hypertension stage 1, stage 2, and hypertensive crisis was 750/5,891 [12.7%; 95% confidence interval (CI): 4.7, 5.9], 312/5, 891 (5.3%; 95% CI: 4.7, 5.9), 2,187/5,891 (37.1%; 95% CI: 35.9, 38.4), 2,484/5,891 (42.2%; 95% CI: 40.9, 43.4), and 158/5,891 (2.7%; 95% CI: 2.3, 3.1), respectively. The overall prevalence of elevated BP/hypertension was 5,141/5,891 (87.3%; 95% CI: 86.4, 88.1). Awareness of elevated BP/hypertension was 2,289/5,223 (45.4%; 95% CI: 44.0, 47.0). Among 1,055 (20.2%; 95% CI: 19.1, 21.3) individuals under anti-hypertensive treatment, 33 (3.1%) individuals had normal BP values. Higher risk of elevated BP/hypertension was associated with older age [odds ratio (OR): 1.04; 95% CI: 1.03,1.05], male gender (OR: 2.56; 95% CI: 2.10, 3.16), urban region (OR: 1.26; 95% CI: 1.05, 1.51), lower educational level (OR: 0.92; 95% CI: 0.87, 0.97), higher body mass index (OR: 1.15; 95% CI: 1.12, 1.18), higher waist-hip circumference ratio (OR: 6.16; 95% CI: 1.89, 20.0), higher prevalence of sitting or reclining for more than 18 h per week (OR: 1.33; 95% CI: 1.10, 1.61), higher prevalence of alcohol consumption (OR: 1.61; 95% CI: 1.27, 2.05), and higher serum concentrations of triglycerides (OR: 1.22; 95% CI: 1.05, 1.43) and glucose (OR: 1.15; 95% CI: 1.07, 1.24). Using the former definition of hypertension (systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg), the prevalence of hypertension was 3,134/5,891 (53.2%; 95% CI: 51.9, 54.5).

Conclusions: Using the new definition of arterial hypertension, the prevalence of elevated BP/hypertension in a typically mixed Russian population aged 40+ years was high (87.3%), with an awareness rate of 45.4% and treatment rate of 20.2%. The rate of therapeutic control of BP elevation in the individuals under treatment was <5%.

[Tactical approaches to the treatment of arterial hypertension in the European part of the Russian Federation. EPOHA study 2017]

AIM

Analysis of antihypertensive treatment among different groups of patients with arterial hypertension from "EPOCHA" study 2017.

MATERIALS AND METHODS

EPOCHA study is a representative sample of the European part of the Russian Federation was created in 2002 and re-examined in 2017.

RESULTS

34.6% of the effectively treated (ET) patients had one antihypertensive drug and 32,2% of the ineffective treatment (IT) patients, p=0.16. Two-component antihypertensive therapy was 45.9% and 44.9%, respectively, p=0.56. Three antihypertensive drugs had 17.9% of the ET patients and 20.7% of the IT patients, p=0.05. Four antihypertensive drugs had 1.6% of the ET patients and 2.2% of the IT patients. The frequency of use of renin-angiotensin-aldosterone system blockers in the group of ET patients was 85.0%, which was significantly lower than 91.6% in the group of IT patients, р&lt;0.0001.

CONCLUSION

EPOCHA study shows that structure of antihypertensive therapy does not differ between ET and IT patients what is caused lack of medical supervision for patients with hypertension in real clinical practice.

Hypertension knowledge, attitudes, and practices of nurses and physicians in primary care in Ulaanbaatar Mongolia

Increased blood pressure is a leading risk for death globally, and interventions to enhance hypertension control have become a high priority. An important aspect of clinical interventions is understanding the knowledge, attitudes, and practices (KAP) of differing primary healthcare practitioners. We examined KAP surveys from 803 primary care practitioners in Ulaanbaatar, Mongolia (response rate 80%), using a comprehensive KAP survey developed by the World Hypertension League (WHL). The WHL KAP survey uniquely includes an assessment of key World Health Organization recommended interventions to enhance hypertension control. There were few substantive differences between healthcare professional disciplines. Primary care practitioners mostly had a positive attitude toward hypertension management. However, confidence and practice in performing specific tasks to control hypertension were suboptimal. A low proportion indicated they systematically screened adults for hypertension and many were not aware of the need to or were confident in prescribing more than two antihypertensive medications. It was the practice of a high proportion of doctors to not pharmacologically treat most people with hypertension who were at high cardiovascular risk. There was a reluctance by physicians to task share hypertension diagnosis, drug prescribing and assessing cardiovascular risk to nurses. The minority of health care professions use a hypertension management algorithm, and few have patient registries with performance reporting functions. There were few substantive differences based on the age, gender, and years of clinical practice of the practitioners. The study findings support the need for standardized education and training of primary care practitioners in Ulaanbaatar to enhance hypertension control.

Implementing standardized performance indicators to improve hypertension control at both the population and healthcare organization levels

The ability to reliably evaluate the impact of interventions and changes in hypertension prevalence and control is critical if the burden of hypertension-related disease is to be reduced. Previously, a World Hypertension League Expert Committee made recommendations to standardize the reporting of population blood pressure surveys. We have added to those recommendations and also provide modified recommendations from a Pan American Health Organization expert meeting for "performance indicators" to be used to evaluate clinical practices. Core indicators for population surveys are recommended to include: (1) mean systolic blood pressure and (2) mean diastolic blood pressure, and the prevalences of: (3) hypertension, (4) awareness of hypertension, (5) drug-treated hypertension, and (6) drug-treated and controlled hypertension. Core indicators for clinical registries are recommended to include: (1) the prevalence of diagnosed hypertension and (2) the ratio of diagnosed hypertension to that expected by population surveys, and the prevalences of: (3) controlled hypertension, (4) lack of blood pressure measurement within a year in people diagnosed with hypertension, and (5) missed visits by people with hypertension. Definitions and additional indicators are provided. Widespread adoption of standardized population and clinical hypertension performance indicators could represent a major step forward in the effort to control hypertension.

Hypertension in Russia: Changes Observed After 4 Years of a Comprehensive Health System Improvement Program in the Yaroslavl Region

Rates of cardiovascular mortality and morbidity in Russia have been among the highest in Europe. A comprehensive health system improvement program targeting better diagnosis and control of hypertension was undertaken in the Yaroslavl Region of Russia. This initiative was a joint program between clinicians, the Department of Health and Pharmacy of the Yaroslavl Region, and Novartis Pharma LLC. From 2011 to 2014, the blood pressure control rate improved substantially (94% relative improvement), the percentage of patients with a systolic blood pressure ≥180 mm Hg decreased (from 10% to 5%), and there was a reduction in stroke incidence rate from 4.6 to 3.7 per 1000 population. During this same period, significant changes were made to the way hypertension was diagnosed and treated across all regional government polyclinics, and the use of antihypertensive therapies increased.

Prevention and control of hypertension: developing a global agenda

PURPOSE OF REVIEW

This review demonstrates the need for enhancing strategic approaches to the prevention and control of hypertension, a global health issue.

RECENT FINDINGS

An epidemic of chronic noncommunicable diseases is threatening national healthcare systems' sustainability and the economy of many countries. Increased blood pressure is the leading risk for premature death and disability and accounts for approximately 10% of healthcare spending. Four of nine recent United Nations' targets for reducing chronic noncommunicable diseases relate directly or indirectly to hypertension. The expanded chronic care model provides a comprehensive framework for developing hypertension prevention and control strategies. The model addresses the roles of healthy public policy, healthy living environments, healthy communities, reorientation of health services delivery toward management of chronic illness, support for improving clinical decisions, enhanced skills of people to prevent and self-manage chronic disease, partnerships of stakeholders and information systems to track the impact of interventions and identify care 'gaps'. The authors advocate that hypertension organizations can lead aspects of hypertension strategy development and implementation.

SUMMARY

Prevention and control of hypertension requires a strategic approach that could have a central role for hypertension experts and the hypertension community.

Simulating the impact of improved cardiovascular risk interventions on clinical and economic outcomes in Russia

OBJECTIVES

Russia faces a high burden of cardiovascular disease. Prevalence of all cardiovascular risk factors, especially hypertension, is high. Elevated blood pressure is generally poorly controlled and medication usage is suboptimal. With a disease-model simulation, we forecast how various treatment programs aimed at increasing blood pressure control would affect cardiovascular outcomes. In addition, we investigated what additional benefit adding lipid control and smoking cessation to blood pressure control would generate in terms of reduced cardiovascular events. Finally, we estimated the direct health care costs saved by treating fewer cardiovascular events.

METHODS

The Archimedes Model, a detailed computer model of human physiology, disease progression, and health care delivery was adapted to the Russian setting. Intervention scenarios of achieving systolic blood pressure control rates (defined as systolic blood pressure <140 mmHg) of 40% and 60% were simulated by modifying adherence rates of an antihypertensive medication combination and compared with current care (23.9% blood pressure control rate). Outcomes of major adverse cardiovascular events; cerebrovascular event (stroke), myocardial infarction, and cardiovascular death over a 10-year time horizon were reported. Direct health care costs of strokes and myocardial infarctions were derived from official Russian statistics and tariff lists.

RESULTS

To achieve systolic blood pressure control rates of 40% and 60%, adherence rates to the antihypertensive treatment program were 29.4% and 65.9%. Cardiovascular death relative risk reductions were 13.2%, and 29.6%, respectively. For the current estimated 43,855,000-person Russian hypertensive population, each control-rate scenario resulted in an absolute reduction of 1.0 million and 2.4 million cardiovascular deaths, and a reduction of 1.2 million and 2.7 million stroke/myocardial infarction diagnoses, respectively. Averted direct costs from current care levels ($7.6 billion [in United States dollars]) were $1.1 billion and $2.6 billion, respectively.