Screening for High Blood Pressure in Adults During Ambulatory Nonprimary Care Visits: Opportunities to Improve Hypertension Recognition

Community-based care models for arterial hypertension management in non-pregnant adults in sub-Saharan Africa: A scoping review protocol

Introduction: Arterial hypertension (aHT) is the most important cardiovascular risk factor (CVRF) in adults living in sub-Saharan Africa (SSA), leading to an excess of cardiovascular disease (CVD) morbidity and mortality. Life-long aHT service delivery models in the region remain mostly anchored to health facilities and are provided by physicians or nurses, thus limiting access to care. Over the past years, decentralized community-based aHT care models have been piloted, aiming to improve access to prevention, diagnosis, and treatment. Although individual studies suggest that community-based care is well-received and potentially efficacious, a synthesized overview of such care models is missing. Hence, the aim of this scoping review is to map out and summarize existing interventions for community-based aHT diagnosis and care in non-pregnant adults in SSA. Additionally, we will describe outcomes in terms of acceptability, blood pressure control, patient engagement in care, and occurrence of aHT caused end-organ damage. Methods and analysis: We will apply the Arksey and O’Malley scoping review methodology and best practice, as outlined by Levac and the Joanna Briggs Institute scoping review guidelines. The research questions have been identified through a literature review and expert consultation. A systematic literature search will be conducted in four databases using a tailored search strategy, including a supplemental search through backward and forward citation. Abstracts and full text screening as well as the extraction of data will be conducted by two independent reviewers. Discrepancies will be resolved by a third reviewer. Information will be presented in both tabular and narrative form. Ethics and dissemination: This scoping review will summarize findings from existing publications, rather than primary data, and as such, does not require ethics review. Findings will be disseminated through stakeholder meetings, conference presentations, websites, and a peer-reviewed publication.

Screening strategies for hypertension

BACKGROUND

Hypertension is a major public health challenge affecting more than one billion people worldwide; it disproportionately affects populations in low- and middle-income countries (LMICs), where health systems are generally weak. The increasing prevalence of hypertension is associated with population growth, ageing, genetic factors, and behavioural risk factors, such as excessive salt and fat consumption, physical inactivity, being overweight and obese, harmful alcohol consumption, and poor management of stress. Over the long term, hypertension leads to risk for cardiovascular events, such as heart disease, stroke, kidney failure, disability, and premature mortality. Cardiovascular events can be preventable when high-risk populations are targeted, for example, through population-wide screening strategies. When available resources are limited, taking a total risk approach whereby several risk factors of hypertension are taken into consideration (e.g. age, gender, lifestyle factors, diabetes, blood cholesterol) can enable more accurate targeting of high-risk groups. Targeting of high-risk groups can help reduce costs in that resources are not spent on the entire population. Early detection in the form of screening for hypertension (and associated risk factors) can help identify high-risk groups, which can result in timely treatment and management of risk factors. Ultimately, early detection can help reduce morbidity and mortality linked to it and can help contain health-related costs, for example, those associated with hospitalisation due to severe illness and poorly managed risk factors and comorbidities.

OBJECTIVES

To assess the effectiveness of different screening strategies for hypertension (mass, targeted, or opportunistic) to reduce morbidity and mortality associated with hypertension.

SEARCH METHODS

An Information Specialist searched the Cochrane Register of Studies (CRS-Web), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American Caribbean Health Sciences Literature (LILACS) Bireme, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) without language, publication year, or publication status restrictions. The searches were conducted from inception until 9 April 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and non-RCTs (NRCTs), that is, controlled before and after (CBA), interrupted time series (ITS), and prospective analytic cohort studies of healthy adolescents, adults, and elderly people participating in mass, targeted, or opportunistic screening of hypertension.

DATA COLLECTION AND ANALYSIS

Screening of all retrieved studies was done in Covidence. A team of reviewers, in pairs, independently assessed titles and abstracts of identified studies and acquired full texts for studies that were potentially eligible. Studies were deemed to be eligible for full-text screening if two review authors agreed, or if consensus was reached through discussion with a third review author. It was planned that at least two review authors would independently extract data from included studies, assess risk of bias using pre-specified Cochrane criteria, and conduct a meta-analysis of sufficiently similar studies or present a narrative synthesis of the results.

MAIN RESULTS

We screened 9335 titles and abstracts. We identified 54 potentially eligible studies for full-text screening. However, no studies met the eligibility criteria.

AUTHORS' CONCLUSIONS

There is an implicit assumption that early detection of hypertension through screening can reduce the burden of morbidity and mortality, but this assumption has not been tested in rigorous research studies. High-quality evidence from RCTs or programmatic evidence from NRCTs on the effectiveness and costs or harms of different screening strategies for hypertension (mass, targeted, or opportunistic) to reduce hypertension-related morbidity and mortality is lacking.

Leveraging the Electronic Health Records for Population Health: A Case Study of Patients With Markedly Elevated Blood Pressure

Background

The digital transformation of medical data provides opportunities to perform digital population health surveillance and identify people inadequately managed in usual care. We leveraged the electronic health records of a large health system to identify patients with markedly elevated blood pressure and characterize their follow‐up care pattern.

Methods and Results

We included 373 861 patients aged 18 to 85 years, who had at least 1 outpatient encounter in the Yale New Haven Health System between January 2013 and December 2017. We described the prevalence and follow‐up pattern of patients with at least 1 systolic blood pressure (SBP) ≥160 mm Hg or diastolic blood pressure (DBP) ≥100 mm Hg and patients with at least 1 SBP ≥180 mm Hg or DBP ≥120 mm Hg. Of 373 861 patients included, 56 909 (15.2%) had at least 1 SBP ≥160 mm Hg or DBP ≥100 mm Hg, and 10 476 (2.8%) had at least 1 SBP ≥180 mm Hg or DBP ≥120 mm Hg. Among patients with SBP ≥160 mm Hg or DBP ≥100 mm Hg, only 28.3% had a follow visit within 1 month (time window of follow‐up recommended by the guideline) and 19.9% subsequently achieved control targets (SBP <130 mm Hg and DBP <80 mm Hg) within 6 months. Follow‐up rate at 1 month and control rate at 6 months for patients with SBP ≥180 mm Hg or DBP ≥120 mm Hg was 31.9% and 17.2%.

Conclusions

Digital population health surveillance with an electronic health record identified a large number of patients with markedly elevated blood pressure and inadequate follow‐up. Many of these patients subsequently failed to achieve control targets.

What is the evidence base for diagnosing hypertension and for subsequent blood pressure treatment targets in the prevention of cardiovascular disease?

Diagnosing and treating hypertension plays an important role in minimising the risk of cardiovascular disease and stroke. Early and accurate diagnosis of hypertension, as well as regular monitoring, is essential to meet treatment targets. In this article, current recommendations for the screening and diagnosis of hypertension are reviewed. The evidence for treatment targets specified in contemporary guidelines is evaluated and recommendations from the USA, Canada, Europe and the UK are compared. Finally, consideration is given as to how diagnosis and management of hypertension might develop in the future.