Mapping stages, barriers and facilitators to the implementation of HEARTS in the Americas initiative in 12 countries: A qualitative study

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.

[Exploring facilitators and barriers to implementing expanded nursing roles in MexicoEstudo de facilitadores e barreiras para a implementação de funções ampliadas de enfermagem no México]

Objective

To explore the perceptions of nursing professionals regarding facilitators and barriers to the implementation of expanded nursing functions in a state in central Mexico.

Methods

Qualitative descriptive phenomenological study. During 2022, 18 semi-structured interviews were conducted with three types of informants: a) head nurses at state-level facilities; b) head nurses at local-level facilities; and c) heads of health units and operational nursing staff who have direct contact with patients.

Results

The following facilitators were identified: willingness to adopt the strategy (seen as favorable by managers and acceptable by nursing staff); reorganization of functions (simplification of processes and analysis of the situation of health units); access to training; and characteristics of nursing staff (professionalization, work experience, and favorable attitude). Barriers included: conditions at the first level of care (personnel shortages, too many administrative activities, lack of physical space, materials, supplies, and consumables), resistance to change (professional jealousy of other disciplines and duplication of tasks), staff salaries, lack of training, not trusted with expanded duties, and attitude of patients (resistance to nursing care).

Conclusions

By understanding the perceptions of nursing professionals, we can identify key elements for the successful expansion of nursing functions through expansion of the competencies of operational staff. Reorganization and proper management at different levels of decision-making will be necessary.

Using the RE-AIM framework to evaluate the implementation and effectiveness of a WHO HEARTS-based intervention to integrate the management of hypertension into HIV care in Uganda: a process evaluation

BACKGROUND

World Health Organization (WHO) HEARTS packages are increasingly used to control hypertension. However, their feasibility in persons living with HIV (PLHIV) is unknown. We studied the effectiveness and implementation of a WHO HEARTS intervention to integrate the management of hypertension into HIV care.

METHODS

This was a mixed methods study at Uganda's largest HIV clinic. Components of the adapted WHO HEARTS intervention were lifestyle counseling, free hypertension medications, hypertension treatment protocol, task shifting, and monitoring tools. We determined the effectiveness of the intervention among PLHIV by comparing hypertension and HIV outcomes at baseline and 21 months. The RE-AIM framework was used to evaluate the implementation outcomes of the intervention at 21 months. We conducted four focus group discussions with PLHIV (n = 42), in-depth interviews with PLHIV (n = 9), healthcare providers (n = 15), and Ministry of Health (MoH) policymakers (n = 2).

RESULTS

Reach: Among the 15,953 adult PLHIV in the clinic, of whom 3892 (24%) had been diagnosed with hypertension, 1133(29%) initiated integrated hypertension-HIV treatment compared to 39 (1%) at baseline. Among the enrolled patients, the mean age was 51.5 ± 9.7 years and 679 (62.6%) were female.

EFFECTIVENESS

Among the treated patients, hypertension control improved from 9 to 72% (p < 0.001), mean systolic blood pressure (BP) from 153.2 ± 21.4 to 129.2 ± 15.2 mmHg (p < 0.001), and mean diastolic BP from 98.5 ± 13.5 to 85.1 ± 9.7 mmHg (p < 0.001). Overall, 1087 (95.9%) of patients were retained by month 21. HIV viral suppression remained high, 99.3 to 99.5% (p = 0.694). Patients who received integrated hypertension-HIV care felt healthy and saved more money. Adoption: All 48 (100%) healthcare providers in the clinic were trained and adopted the intervention. Training healthcare providers on WHO HEARTS, task shifting, and synchronizing clinic appointments for hypertension and HIV promoted adoption.

IMPLEMENTATION

WHO HEARTS intervention was feasible and implemented with fidelity. Maintenance: Leveraging HIV program resources and adopting WHO HEARTS protocols into national guidelines will promote sustainability.

CONCLUSIONS

The WHO HEARTS intervention promoted the integration of hypertension management into HIV care in the real-world setting. It was acceptable, feasible, and effective in controlling hypertension and maintaining optimal viral suppression among PLHIV. Integrating this intervention into national guidelines will promote sustainability.

The HEARTS partner forum-supporting implementation of HEARTS to treat and control hypertension

Cardiovascular diseases (CVD), principally ischemic heart disease (IHD) and stroke, are the leading causes of death (18. 6 million deaths annually) and disability (393 million disability-adjusted life-years lost annually), worldwide. High blood pressure is the most important preventable risk factor for CVD and deaths, worldwide (10.8 million deaths annually). In 2016, the World Health Organization (WHO) and the United States Centers for Disease Control (CDC) launched the Global Hearts initiative to support governments in their quest to prevent and control CVD. HEARTS is the core technical package of the initiative and takes a public health approach to treating hypertension and other CVD risk factors at the primary health care level. The HEARTS Partner Forum, led by WHO, brings together the following 11 partner organizations: American Heart Association (AHA), Center for Chronic Disease Control (CCDC), International Society of Hypertension (ISH), International Society of Nephrology (ISN), Pan American Health Organization (PAHO), Resolve to Save Lives (RTSL), US CDC, World Hypertension League (WHL), World Heart Federation (WHF) and World Stroke Organization (WSO). The partners support countries in their implementation of the HEARTS technical package in various ways, including providing technical expertise, catalytic funding, capacity building and evidence generation and dissemination. HEARTS has demonstrated the feasibility and acceptability of a public health approach, with more than seven million people already on treatment for hypertension using a simple, algorithmic HEARTS approach. Additionally, HEARTS has demonstrated the feasibility of using hypertension as a pathfinder to universal health coverage and should be a key intervention of all basic benefit packages. The partner forum continues to find ways to expand support and reinvigorate enthusiasm and attention on preventing CVD. Proposed future HEARTS Partner Forum activities are related to more concrete information sharing between partners and among countries, expanded areas of partner synergy, support for implementation, capacity building, and advocacy with country ministries of health, professional societies, academy and civil societies organizations. Advancing toward the shared goals of the HEARTS partners will require a more formal, structured approach to the forum and include goals, targets and published reports. In this way, the HEARTS Partner Forum will mirror successful global partnerships on communicable diseases and assist countries in reducing CVD mortality and achieving global sustainable development goals (SDGs).

Malaysian burden of disease: years of life lost due to premature deaths

BACKGROUND

In Malaysia, the previous mortality burden has been a significant concern, particularly due to the high prevalence of noncommunicable diseases (NCDs) as the leading cause of death. Estimates of mortality are key indicators for monitoring population health and determining priorities in health policies and health planning. The aim of this study was to estimate the disease burden attributed to 113 major diseases and injuries in Malaysia in 2018 using years of life lost (YLL) method.

METHODS

This study included all deaths that occurred in Malaysia in 2018. The YLL was derived by adding the number of deaths from 113 specific diseases and multiplying it by the remaining life expectancy for that age and sex group. Data on life expectancy and mortality were collected from the Department of Statistics Malaysia.

RESULTS

In 2018, there were 3.5 million YLL in Malaysia. Group II (NCDs) caused 72.2% of total YLL. Ischaemic heart disease was the leading cause of premature mortality among Malaysians (17.7%), followed by lower respiratory infections (9.7%), road traffic injuries (8.7%), cerebrovascular disease (stroke) (8.0%), and diabetes mellitus (3.9%).

CONCLUSIONS

NCDs are a significant health concern in Malaysia and are the primary contributor to the overall burden of disease. These results are important in guiding the national health systems on how to design and implement effective interventions for NCDs, as well as how to prioritise and allocate healthcare resources. Key strategies to consider include implementing health promotion campaigns, adopting integrated care models, and implementing policy and regulatory measures. These approaches aim to enhance health outcomes and the managements of NCDs in Malaysia.

[Monitoring and evaluation platform for HEARTS in the Americas: improving population-based hypertension control programs in primary health carePlataforma de monitoramento e avaliação do programa HEARTS nas Américas: melhoria dos programas de controle da hipertensão de base populacional na atenção primária à saúde]

HEARTS in the Americas is the Pan American Health Organization flagship program to accelerate the reduction of the cardiovascular disease (CVD) burden by improving hypertension control and CVD secondary prevention in primary health care. A monitoring and evaluation (M&E) platform is needed for program implementation, benchmarking, and informing policy-makers. This paper describes the conceptual bases of the HEARTS M&E platform including software design principles, contextualization of data collection modules, data structure, reporting, and visualization. The District Health Information Software 2 (DHIS2) web-based platform was chosen to implement aggregate data entry of CVD outcome, process, and structural risk factor indicators. In addition, PowerBI was chosen for data visualization and dashboarding for the analysis of performance and trends above the health care facility level. The development of this new information platform was focused on primary health care facility data entry, timely data reporting, visualizations, and ultimately active use of data to drive decision-making for equitable program implementation and improved quality of care. Additionally, lessons learnt and programmatic considerations were assessed through the experience of the M&E software development. Building political will and support is essential to developing and deploying a flexible platform in multiple countries which is contextually specific to the needs of various stakeholders and levels of the health care system. The HEARTS M&E platform supports program implementation and reveals structural and managerial limitations and care gaps. The HEARTS M&E platform will be central to monitoring and driving further population-level improvements in CVD and other noncommunicable disease-related health.

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

Background

HEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative. It is implemented in 24 countries and over 2,000 primary healthcare facilities. This paper describes the results of a multicomponent, stepwise, quality improvement intervention designed by the HEARTS in the Americas to support advances in hypertension treatment protocols and evolution towards the Clinical Pathway.

Methods

The quality improvement intervention comprised: 1) the use of the appraisal checklist to evaluate the current hypertension treatment protocols, 2) a peer-to-peer review and consensus process to resolve discrepancies, 3) a proposal of a clinical pathway to be considered by the countries, and 4) a process of review, adopt/adapt, consensus and approval of the clinical pathway by the national HEARTS protocol committee. A year later, 16 participants countries (10 and 6 from each cohort, respectively) were included in a second evaluation using the HEARTS appraisal checklist. We used the median and interquartile scores range and the percentages of the maximum possible total score for each domain as a performance measure to compare the results pre and post-intervention.

Results

Among the eleven protocols from the ten countries in the first cohort, the baseline assessment achieved a median overall score of 22 points (ICR 18 -23.5; 65% yield). After the intervention, the overall score reached a median of 31.5 (ICR 28.5 -31.5; 93% yield). The second cohort of countries developed seven new clinical pathways with a median score of 31.5 (ICR 31.5 -32.5; 93% yield). The intervention was effective in three domains: 1. implementation (clinical follow-up intervals, frequency of drug refills, routine repeat blood pressure measurement when the first reading is off-target, and a straightforward course of action). 2. treatment (grouping all medications in a single daily intake and using a combination of two antihypertensive medications for all patients in the first treatment step upon the initial diagnosis of hypertension) and 3. management of cardiovascular risk (lower BP thresholds and targets based on CVD risk level, and the use of aspirin and statins in high-risk patients).

Conclusion

This study confirms that this intervention was feasible, acceptable, and instrumental in achieving progress in all countries and all three domains of improvement: implementation, blood pressure treatment, and cardiovascular risk management. It also highlights the challenges that prevent a more rapid expansion of HEARTS in the Americas and confirms that the main barriers are in the organization of health services: drug titration by non-physician health workers, the lack of long-acting antihypertensive medications, lack of availability of fixed-doses combination in a single pill and cannot use high-intensity statins in patients with established cardiovascular diseases. Adopting and implementing the HEARTS Clinical Pathway can improve the efficiency and effectiveness of hypertension and cardiovascular disease risk management programs.

Noncommunicable diseases in the Americas: a review of the Pan American Health Organization's 25-year program of work

This article describes progress in tackling noncommunicable diseases (NCDs) in the Americas since the Pan American Health Organization (PAHO) started its NCD program 25 years ago. Changes in the epidemiology of NCDs, NCD policies, health service capacity, and surveillance are discussed. PAHO's NCD program is guided by regional plans of action on specific NCDs and risk factors, as well as a comprehensive NCD plan. Its work involves implementing evidence-based World Health Organization technical packages on NCDs and their risk factors with the aim of achieving the Sustainable Development Goal target of a one third reduction in premature mortality caused by NCDs by 2030. Important advances have been made in the past 25 years in implementation of: policies on NCD risk factors; interventions to improve NCD diagnosis and treatment; and NCD surveillance. Premature mortality from NCDs decreased by 1.7% a year between 2000 and 2011 and 0.77% a year between 2011 and 2019. However, policies on risk factor prevention and health promotion need to be strengthened to ensure more countries are on track to achieving the NCD-related health goals of the Sustainable Development Goals by 2030. Actions are recommended for governments to raise the priority of NCDs by: making NCDs a core pillar of primary care services, using revenues from health taxes to invest more in NCD prevention and control; and implementing policies, laws, and regulations to reduce the demand for and availability of tobacco, alcohol, and ultra-processed food products.

Diseño de implementación del módulo de hábitos y estilos de vida saludables de HEARTS en el primer nivel de atención en México

El número de personas con enfermedades cardiovasculares constituye uno de los principales problemas de salud pública. La Secretaría de Salud de México, junto con la representación local de la Organización Panamericana de la Salud, suman esfuerzos para la implementación de “HEARTS: paquete técnico para el manejo de las enfermedades cardiovasculares en atención primaria de la salud”. El objetivo del presente artículo es describir el diseño de la implementación del módulo “Hábitos y estilos de vida saludables: asesoramiento para los pacientes”, el cual forma parte del paquete técnico de HEARTS. Para ello se conformó un grupo interdisciplinario e interinstitucional en el que se discutió el objetivo de la implementación, los temas a abordar en cada intervención breve, así como su seguimiento y monitoreo. En conclusión, trabajar con el grupo asesor de diversas disciplinas del área de la salud contribuyó a contar con una visión amplia para el abordaje de la persona, así como con el diseño de la implementación del módulo. Se espera alcanzar una comunicación activa entre paciente y profesional de salud, contribuyendo a generar intervenciones que generen pacientes informados y activos en el cuidado de su salud, así como equipos de salud como mayores herramientas que les posibiliten obtener mejores resultados en salud.

[HEARTS in the Americas: innovations for improving hypertension and cardiovascular disease risk management in primary careHEARTS nas Américas: inovações para melhorar a gestão do risco de hipertensão e de doenças cardiovasculares na atenção primária]

Global Hearts is the flagship initiative of the World Health Organization to reduce the burden of cardiovascular diseases, the leading cause of death and disability worldwide. HEARTS in the Americas Initiative is the regional adaptation that envisions HEARTS as the model for cardiovascular disease risk management, including hypertension and diabetes, in primary health care in the Americas by 2025. This initiative is entering its sixth year of implementation and now includes 22 countries and 1 380 primary health care centers. The objectives of this report are three-fold. First, it describes the emergence and the main elements of HEARTS in the Americas. Secondly, it summarizes the main innovations developed to catalyze and sustain implementation of the initiative. These innovations include: a) introduction of hypertension control drivers; b) development of a comprehensive and practical clinical pathway; c) development of a strategy to improve the accuracy of blood pressure measurement; d) creation of a monitoring and evaluation platform; and e) development of a standardized set of training and education resources. Thirdly, this report discusses future priorities of the initiative. The goal of implementing these innovative and pragmatic solutions is to create a more effective health system and shift the focus of cardiovascular and hypertension programs from the highly specialized care level to primary health care. In addition, HEARTS in the Americas can serve as a model for more comprehensive, effective, and sustainable noncommunicable disease prevention and treatment practices.

La Iniciativa HEARTS en Cuba: experiencias tras 5 años de implementación

Con el propósito de describir los cambios en el control de la hipertensión arterial desde 2016 a 2021 y la relación de los progresos con la madurez de implementación de la Iniciativa HEARTS en el primer nivel de atención de Cuba, se diseñó un estudio prospectivo de implementación que promovió la medición correcta de la presión arterial con esfigmomanómetros automáticos validados, la atención basada en riesgo, la introducción de protocolos de tratamiento antihipertensivo estandarizado, la prevención secundaria y el trabajo en equipo. Se fomentó además la educación a pacientes, la búsqueda activa de casos y las actividades comunitarias. Los datos se obtuvieron de los registros de implementación y fueron analizados con el programa estadístico SPSS versión 21, se reportan las medidas de resultados y sus intervalos de confianza del 95%. Se evaluaron los indicadores poblacionales: cobertura de registro, control entre tratados, control poblacional, así como el índice de madurez de procesos de HEARTS en Las Américas. Comparativamente, entre los años 2016 y 2021 aumentaron los centros participantes, desde un centro de demostración hasta 22 policlínicos en 6 provincias y 7 municipios. Se evidenció un incremento significativo en los valores absolutos del total de población atendida, el número de hipertensos registrados, de pacientes controlados entre los tratados e hipertensos controlados entre todos los adultos, aunque con variaciones anuales en los porcentajes de cobertura, control entre tratados y control poblacional. Los mayores progresos ocurrieron en los centros con equipos de salud de alto desempeño. Cinco años después de la implementación de la Iniciativa HEARTS en Cuba se transita hacia la institucionalización de la metodología.

[Synthesis of evidence and recommendations: guidelines for the pharmacological treatment of arterial hypertension in adultsSíntese de evidências e recomendações: diretrizes para o tratamento farmacológico da hipertensão arterial em adultos]

Introduction

Arterial hypertension (high blood pressure) is one of the most prevalent chronic noncommunicable diseases. It is a cause of cardiovascular disease and is the leading attributable cause of death in the Region of the Americas.

Objectives

Synthesize the recommendations developed by the World Health Organization (WHO) to improve the quality of care and health outcomes of adults with high blood pressure, and address aspects of implementing these recommendations.

Methods

A synthesis was conducted of the recommendations contained in the WHO Guideline for the pharmacological treatment of hypertension in adults. In addition, a systematic search for studies carried out in the Region of the Americas was conducted in PubMed, Lilacs, Health Systems Evidence, Epistemonikos, and gray literature in order to identify barriers, facilitators, and implementation strategies.

Results

Ten recommendations were made for adults with high blood pressure. Implementation barriers, facilitators, and strategies were identified, and indicators were created for assessing treatment adherence and outcomes.

Conclusions

The formulated recommendations aim to provide guidance on how to approach the pharmacological treatment of hypertension in adults, except pregnant women, as well as considerations for implementation of the recommendations in Latin America and the Caribbean.

Improving cardiovascular health with the patient-centered, integrated primary care HEARTS model in Trinidad and Tobago

This article describes the introduction of the Pan American Health Organization's HEARTS in the Americas program in Trinidad and Tobago and the successful experiences and challenges encountered in introducing and scaling it up as a strategy for strengthening the health system's response to cardiovascular diseases. Evidence about implementation of the HEARTS program in the World Health Organization's Region of the Americas was reviewed to identify the progress made, barriers, success factors and lessons learned. In 2019, the Ministry of Health commenced implementation of the program in 5 (4.9%) of the 102 primary health care centers, and by the end of 2021, it had been scaled up to 46 (45.0%) centers. The HEARTS program ensures that patients' cardiovascular health is managed in a comprehensive way through providing counseling about a healthy lifestyle, using evidence-based treatment protocols, ensuring access to essential medicines and technologies, and using a risk-based team approach, a monitoring and evaluation system and also a team-based approach to care delivery. The barriers encountered during implementation included the fragmentation of the existing health care system, the paternalistic role assumed by health care professionals, the resistance of some health care workers to change and a lack of team-based approaches to providing care. Successful implementation of the program was enabled through ensuring high-level political commitment, establishing the national HEARTS Oversight Committee, ensuring stakeholder involvement throughout all phases and implementing standardized approaches to care. When implemented in the context of existing primary health care settings, the HEARTS program provides an exceptionally well integrated and comprehensive model of care that embodies the principles of universal health care while ensuring the health of both populations and individuals. Thus, it enables and promotes a strengthened primary health care system and services that are responsive and resilient.

Civil society’s role in improving hypertension control in Latin America

Despite effort in Latin America to implement the HEARTS initiative, hypertension control is still inadequate. There are many advances in the medical and technical arena, but little to promote political and systemic change. The vibrant civil society that has advanced policy change in tobacco control, food policy, and other public health initiatives can make a crucial contribution to prioritize hypertension control in the political agenda, ensure sustainable funding, promote the procurement of affordable and effective medications, and expand community demand for action. The recommended first step for civil society’s involvement is to analyze the political landscape to design an advocacy plan. The political landscape includes a legal analysis, policy mapping, stakeholders mapping, identifying obstacles, mapping community strategies, and risk assessment. The second step is to define policy goals and an advocacy strategy. Based on experience, there would be two main policy goals: to increase political will to make hypertension a top priority, securing necessary resources; and strengthen community awareness and social demand for action. The third step is to develop and implement the advocacy plan with the tools familiar to civil society, including building a case for support, advocacy towards decision makers, media advocacy, coalition building, countering the opposition, and civil society monitoring and accountability. To jumpstart this approach, there should be incentives for civil society and a transition for transferring competencies to a new arena. The results would be more sustainable and scalable hypertension control, better health outcomes, and advances toward the 2030 Sustainable Development Goals and universal health coverage.

Impacto de la Iniciativa HEARTS en una institución de salud de segundo nivel en Colombia

RESUMEN

Objetivo.

Identificar el impacto de la iniciativa HEARTS en los pacientes con hipertensión arterial atendidos en un hospital colombiano.

Métodos.

Estudio cuasiexperimental, retrospectivo entre 2017 y 2019 con pacientes hipertensos mayores de 18 años, incluidos en la estrategia HEARTS, atendidos en el Hospital Santa Mónica del municipio de Dosquebradas, departamento de Risaralda. La unidad de análisis fue la historia clínica. Se evaluaron las metas de presión arterial (definido en la Iniciativa HEARTS como un paciente con presión arterial sistólica <140 mmHg y <90 mmHg en la presión diastólica) al momento del ingreso al programa HEARTS y un año después. Se incluyeron variables sociodemográficas, farmacológicas, clínicas, metas de presión arterial y cumplimiento de la iniciativa. Se realizaron análisis descriptivos y se aplicó regresión logística binaria (p <0.05).

Resultados.

Se analizaron 372 pacientes de los cuales 262 eran mujeres (70,4%). La edad media fue de 66,3 ± 12,2 años. En la primera consulta de control se reportaron 285 pacientes (76,6%) que presentaron cifras de tensión arterial en metas, en la segunda consulta este logro fue alcanzado por el 84,1% de los pacientes (n=313 diferencia media: 7,5%, IC95%: 1,8 a 13,1; p=0,005). Después de la implementación de la Iniciativa HEARTS el 77,4% en los pacientes (n=288) continuaron con el manejo inicial. Cumplir las recomendaciones HEARTS aumenta la probabilidad de estar en las metas (p=0,033; OR= 2,688; IC= 1,081 - 6,684).

Conclusiones.

La implementación de la Iniciativa HEARTS impactó favorablemente las cifras de tensión arterial en pacientes con hipertensión, con beneficios adicionales en variables que disminuyen el riesgo cardiovascular.

Monitoring and evaluation platform for HEARTS in the Americas: improving population-based hypertension control programs in primary health care

ABSTRACT

HEARTS in the Americas is the Pan American Health Organization flagship program to accelerate the reduction of the cardiovascular disease (CVD) burden by improving hypertension control and CVD secondary prevention in primary health care. A monitoring and evaluation (M&E) platform is needed for program implementation, benchmarking, and informing policy-makers. This paper describes the conceptual bases of the HEARTS M&E platform including software design principles, contextualization of data collection modules, data structure, reporting, and visualization. The District Health Information Software 2 (DHIS2) web-based platform was chosen to implement aggregate data entry of CVD outcome, process, and structural risk factor indicators. In addition, PowerBI was chosen for data visualization and dashboarding for the analysis of performance and trends above the health care facility level. The development of this new information platform was focused on primary health care facility data entry, timely data reporting, visualizations, and ultimately active use of data to drive decision-making for equitable program implementation and improved quality of care. Additionally, lessons learnt and programmatic considerations were assessed through the experience of the M&E software development. Building political will and support is essential to developing and deploying a flexible platform in multiple countries which is contextually specific to the needs of various stakeholders and levels of the health care system. The HEARTS M&E platform supports program implementation and reveals structural and managerial limitations and care gaps. The HEARTS M&E platform will be central to monitoring and driving further population-level improvements in CVD and other noncommunicable disease-related health.

Resultados preliminares de la Iniciativa HEARTS en México: facilitadores y barreras de los sistemas de información

Objetivo.

Comparar la diferencia en la cobertura y proporción de pacientes controlados con hipertensión arterial sistémica entre diciembre de 2020 y diciembre de 2021 en los establecimientos de salud con implementación de la Iniciativa HEARTS, y explorar los facilitadores y las barreras relacionados con los sistemas de información en México.

Métodos.

Estudio observacional ecológico descriptivo. Se compararon los resultados de los establecimientos de salud que han iniciado la implementación de la Iniciativa HEARTS (n=29) en Chiapas y Sonora, respecto a las variables de cobertura de atención y control de la hipertensión, en 4 periodos (semestres) del 2020 al 2021.

Resultados.

Existe mayor número de mujeres en tratamiento y en control respecto de los hombres en los diferentes grupos de edad. Se identificaron algunas barreras (p. ej.multiplicidad de sistemas, falta de interoperabilidad, conectividad limitada a internet en los establecimientos de salud) y facilitadores (p. ej.acceso libre a la información, disponibilidad de datos desde años previos, generación de estimaciones y proyecciones) en los sistemas de información.

Conclusiones.

El 55% de los establecimientos bajo implementación (16 establecimientos) mejoraron la proporción de pacientes controlados en el periodo analizado. Es importante monitorear indicadores a nivel de procesos, lo cual debe ir acompañado de una redistribución de las funciones de los equipos de salud y asegurar el abastecimiento de medicamentos para potenciar la efectividad de la estrategia. Se sugiere fortalecer la implementación con los impulsores clave para el control de la hipertensión.

Improving cardiovascular health in primary care in Saint Lucia through the HEARTS Initiative

ABSTRACT

Objective.

To improve blood pressure control and hypertension registry coverage at six demonstration sites in St Lucia.

Methods.

From January 2020 to December 2021, St Lucia’s Ministry of Health, with support of the Pan American Health Organization, implemented the HEARTS Technical Package in six primary health care facilities with six-monthly monitoring of blood pressure control and hypertension registry coverage. The modules included healthy-lifestyle counselling, evidence-based treatment protocols, access to essential medicines and technology, risk-based cardiovascular management, team-based care and systems for monitoring.

Results.

Levels of blood pressure control at 6, 12, 18 and 24-months after the intervention were 37.1%, 28.9%, 33.9% and 36.5% respectively. Hypertension registry coverage increased by 17.8% (1 434 to 1 689) for patients accessing service. Implementing the monitoring for action initiative 12 to 15 months after the start of the intervention resulted in policy and operational changes, improved documentation, and provided accurate and reliable data.

Conclusions.

The HEARTS initiative unearthed basic infrastructural challenges in blood pressure control. The essential elements for success were (1) buy in at all levels of the health sector; (2) addressing policy and operational changes; (3) accurate documentation and required analysis; (4) standardization of equipment and procedures and (5) regular monitoring and evaluation. Capacity building underpinned all changes.

Hypertension Treatment in Nigeria (HTN) Program: rationale and design for a type 2 hybrid, effectiveness, and implementation interrupted time series trial

Background

Hypertension is the most common cardiovascular disease in Nigeria and contributes to a large non-communicable disease burden. Our aim was to implement and evaluate a large-scale hypertension treatment and control program, adapted from the Kaiser Permanent Northern California and World Health Organization HEARTS models, within public primary healthcare centers in the Federal Capital Territory, Nigeria.

Methods

A type 2 hybrid, interrupted time series design was used to generate novel information on large-scale implementation and effectiveness of a multi-level hypertension control program within 60 primary healthcare centers in the Federal Capital Territory, Nigeria. During the formative phase, baseline qualitative assessments were held with patients, health workers, and administrators to inform implementation package adaptation. The package includes a hypertension patient registry with empanelment, performance and quality reporting, simplified treatment guideline emphasizing fixed-dose combination therapy, reliable access to quality essential medicines and technology, team-based care, and health coaching and home blood pressure monitoring. Strategies to implement and adapt the package were identified based on barriers and facilitators mapped in the formative phase, previous implementation experience, mid-term qualitative evaluation, and ongoing stakeholder and site feedback. The control phase included 11 months of sequential registration of hypertensive patients at participating primary healthcare centers, followed by implementation of the remainder of the package components and evaluation over 37 subsequent, consecutive months of the intervention phase.

The formative phase was completed between April 2019 and August 2019, followed by initiation of the control phase in January 2020. The control phase included 11 months (January 2020 to November 2020) of sequential registration and empanelment of hypertensive patients at participating primary healthcare centers. After completion of the control phase in November 2020, the intervention phase commenced in December 2020 and will be completed in December 2023.

Discussion

This trial will provide robust evidence for implementation and effectiveness of a multi-level implementation package more broadly throughout the Federal Capital Territory, which may inform hypertension systems of care throughout Nigeria and in other low- and middle-income countries. Implementation outcome results will be important to understand what system-, site-, personnel-, and patient-level factors are necessary for successful implementation of this intervention.

Trial registration

ClinicalTrials.gov NCT04158154. The trial was prospectively registered on November 8, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00328-9.

HEARTS in the Americas: innovations for improving hypertension and cardiovascular disease risk management in primary care

Global Hearts is the flagship initiative of the World Health Organization to reduce the burden of cardiovascular diseases, the leading cause of death and disability worldwide. HEARTS in the Americas Initiative is the regional adaptation that envisions HEARTS as the model for cardiovascular disease risk management, including hypertension and diabetes, in primary health care in the Americas by 2025. This initiative is entering its sixth year of implementation and now includes 22 countries and 1 380 primary health care centers. The objectives of this report are three-fold. First, it describes the emergence and the main elements of HEARTS in the Americas. Secondly, it summarizes the main innovations developed to catalyze and sustain implementation of the initiative. These innovations include: a) introduction of hypertension control drivers; b) development of a comprehensive and practical clinical pathway; c) development of a strategy to improve the accuracy of blood pressure measurement; d) creation of a monitoring and evaluation platform; and e) development of a standardized set of training and education resources. Thirdly, this report discusses future priorities of the initiative. The goal of implementing these innovative and pragmatic solutions is to create a more effective health system and shift the focus of cardiovascular and hypertension programs from the highly specialized care level to primary health care. In addition, HEARTS in the Americas can serve as a model for more comprehensive, effective, and sustainable noncommunicable disease prevention and treatment practices.

[Drivers and scorecards to improve hypertension control in primary care practice: Recommendations from the HEARTS in the Americas Innovation GroupFactores impulsores y métodos de puntuación para mejorar el control de la hipertensión en la práctica clínica de la atención primaria: recomendaciones del grupo de innovación de HEARTS en las Américas]

Background

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the Americas, and hypertension is the most significant modifiable risk factor. However, hypertension control rates remain low, and CVD mortality is stagnant or rising after decades of continuing reduction. In 2016, the World Health Organization (WHO) launched the HEARTS technical package to improve hypertension control. The Pan American Health Organization (PAHO) designed the HEARTS in the Americas Initiative to improve CVD risk management, emphasizing hypertension control, to date implemented in 21 countries.

Methods

To advance implementation, an interdisciplinary group of practitioners was engaged to select the key evidence-based drivers of hypertension control and to design a comprehensive scorecard to monitor their implementation at primary care health facilities (PHC). The group studied high-performing health systems that achieve high hypertension control through quality improvement programs focusing on specific process measures, with regular feedback to providers at health facilities.

Findings

The final selected eight drivers were categorized into five main domains: (1) diagnosis (blood pressure measurement accuracy and CVD risk evaluation); (2) treatment (standardized treatment protocol and treatment intensification); (3) continuity of care and follow-up; (4) delivery system (team-based care, medication refill), and (5) system for performance evaluation. The drivers and recommendations were then translated into process measures, resulting in two interconnected scorecards integrated into the HEARTS in the Americas monitoring and evaluation system.

Interpretation

Focus on these key hypertension drivers and resulting scorecards, will guide the quality improvement process to achieve population control goals at the participating health centers in HEARTS implementing countries.

[Drivers and scorecards to improve hypertension control in primary care practice: Recommendations from the HEARTS in the Americas Innovation GroupFatores impulsionadores e scorecards para melhorar o controle da hipertensão arterial na atenção primária: recomendações do Grupo de Inovação da Iniciativa HEARTS nas Américas]

Background

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the Americas, and hypertension is the most significant modifiable risk factor. However, hypertension control rates remain low, and CVD mortality is stagnant or rising after decades of continuing reduction. In 2016, the World Health Organization (WHO) launched the HEARTS technical package to improve hypertension control. The Pan American Health Organization (PAHO) designed the HEARTS in the Americas Initiative to improve CVD risk management, emphasizing hypertension control, to date implemented in 21 countries.

Methods

To advance implementation, an interdisciplinary group of practitioners was engaged to select the key evidence-based drivers of hypertension control and to design a comprehensive scorecard to monitor their implementation at primary care health facilities (PHC). The group studied high-performing health systems that achieve high hypertension control through quality improvement programs focusing on specific process measures, with regular feedback to providers at health facilities.

Findings

The final selected eight drivers were categorized into five main domains: (1) diagnosis (blood pressure measurement accuracy and CVD risk evaluation); (2) treatment (standardized treatment protocol and treatment intensification); (3) continuity of care and follow-up; (4) delivery system (team-based care, medication refill), and (5) system for performance evaluation. The drivers and recommendations were then translated into process measures, resulting in two interconnected scorecards integrated into the HEARTS in the Americas monitoring and evaluation system.

Interpretation

Focus on these key hypertension drivers and resulting scorecards, will guide the quality improvement process to achieve population control goals at the participating health centers in HEARTS implementing countries.

Drivers and scorecards to improve hypertension control in primary care practice: Recommendations from the HEARTS in the Americas Innovation Group

Background

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the Americas, and hypertension is the most significant modifiable risk factor. However, hypertension control rates remain low, and CVD mortality is stagnant or rising after decades of continuing reduction. In 2016, the World Health Organization (WHO) launched the HEARTS technical package to improve hypertension control. The Pan American Health Organization (PAHO) designed the HEARTS in the Americas Initiative to improve CVD risk management, emphasizing hypertension control, to date implemented in 21 countries.

Methods

To advance implementation, an interdisciplinary group of practitioners was engaged to select the key evidence-based drivers of hypertension control and to design a comprehensive scorecard to monitor their implementation at primary care health facilities (PHC). The group studied high-performing health systems that achieve high hypertension control through quality improvement programs focusing on specific process measures, with regular feedback to providers at health facilities.

Findings

The final selected eight drivers were categorized into five main domains: (1) diagnosis (blood pressure measurement accuracy and CVD risk evaluation); (2) treatment (standardized treatment protocol and treatment intensification); (3) continuity of care and follow-up; (4) delivery system (team-based care, medication refill), and (5) system for performance evaluation. The drivers and recommendations were then translated into process measures, resulting in two interconnected scorecards integrated into the HEARTS in the Americas monitoring and evaluation system.

Interpretation

Focus on these key hypertension drivers and resulting scorecards, will guide the quality improvement process to achieve population control goals at the participating health centers in HEARTS implementing countries.

Funding

No funding to declare.

World Heart Federation Roadmap for Hypertension - A 2021 Update

The World Heart Federation (WHF) Roadmap series covers a large range of cardiovascular conditions. These Roadmaps identify potential roadblocks and their solutions to improve the prevention, detection and management of cardiovascular diseases and provide a generic global framework available for local adaptation. A first Roadmap on raised blood pressure was published in 2015. Since then, advances in hypertension have included the publication of new clinical guidelines (AHA/ACC; ESC; ESH/ISH); the launch of the WHO Global HEARTS Initiative in 2016 and the associated Resolve to Save Lives (RTSL) initiative in 2017; the inclusion of single-pill combinations on the WHO Essential Medicines' list as well as various advances in technology, in particular telemedicine and mobile health. Given the substantial benefit accrued from effective interventions in the management of hypertension and their potential for scalability in low and middle-income countries (LMICs), the WHF has now revisited and updated the 'Roadmap for raised BP' as 'Roadmap for hypertension' by incorporating new developments in science and policy. Even though cost-effective lifestyle and medical interventions to prevent and manage hypertension exist, uptake is still low, particularly in resource-poor areas. This Roadmap examined the roadblocks pertaining to both the demand side (demographic and socio-economic factors, knowledge and beliefs, social relations, norms, and traditions) and the supply side (health systems resources and processes) along the patient pathway to propose a range of possible solutions to overcoming them. Those include the development of population-wide prevention and control programmes; the implementation of opportunistic screening and of out-of-office blood pressure measurements; the strengthening of primary care and a greater focus on task sharing and team-based care; the delivery of people-centred care and stronger patient and carer education; and the facilitation of adherence to treatment. All of the above are dependent upon the availability and effective distribution of good quality, evidence-based, inexpensive BP-lowering agents.