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Wellmann IA, Ayala LF, Rodríguez JJ, Guetterman TC, Irazola V, Palacios E, Huffman MD, Rohloff P, Heisler M, Ramírez-Zea M, Flood D. Implementing integrated hypertension and diabetes management using the World Health Organization's HEARTS model: protocol for a pilot study in the Guatemalan national primary care system. Implement Sci Commun 2024; 5:7. [PMID: 38195600 PMCID: PMC10775666 DOI: 10.1186/s43058-023-00539-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/07/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND The HEARTS technical package was developed by the World Health Organization to address the implementation gap in cardiovascular disease prevention in low- and middle-income countries. Guatemala is a middle-income country that is currently implementing HEARTS. National authorities in Guatemala are interested in exploring how hypertension and diabetes management can be integrated in HEARTS implementation. The objective of this study is to conduct a feasibility and acceptability pilot trial of integrated hypertension and diabetes management based on HEARTS in the publicly funded primary care system in Guatemala. METHODS A single-arm pilot trial for 6 months will be carried out in 11 Ministry of Health primary care facilities starting in September 2023. A planned sample of 100 adult patients diagnosed with diabetes (n = 45), hypertension (n = 45), or both (n = 10) will be enrolled. The intervention will consist of HEARTS-aligned components: Training health workers on healthy-lifestyle counseling and evidence-based treatment protocols, strengthening access to medications and diagnostics, training on risk-based cardiovascular disease management, team-based care and task sharing, and systems monitoring and feedback, including implementation of a facility-based electronic monitoring tool at the individual level. Co-primary outcomes of feasibility and acceptability will be assessed using an explanatory sequential mixed-methods design. Secondary outcomes include clinical effectiveness (treatment with medication, glycemic control, and blood pressure control), key implementation outcomes (adoption, fidelity, usability, and sustainability), and patient-reported outcome measures (diabetes distress, disability, and treatment burden). Using an implementation mapping approach, a Technical Advisory Committee will develop implementation strategies for subsequent scale-up planning. DISCUSSION This trial will produce evidence on implementing HEARTS-aligned hypertension and diabetes care in the MOH primary care system in Guatemala. Results also will inform future HEARTS projects in Guatemala and other low- and middle-income countries. TRIAL REGISTRATION ClinicalTrials.gov ID NCT06080451. The trial was prospectively registered on October 12, 2023.
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Affiliation(s)
- Irmgardt Alicia Wellmann
- Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Luis Fernando Ayala
- Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - José Javier Rodríguez
- Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | | | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Eduardo Palacios
- National Program for the Prevention of Chronic Non-Communicable Diseases and Cancer, Ministry of Health, Guatemala City, Guatemala
| | - Mark D Huffman
- Department of Medicine and Global Health Center, Washington University in St. Louis, St. Louis, MO, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Peter Rohloff
- Center for Indigenous Health Research, Wuqu' Kawoq, Tecpán, Guatemala
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Michele Heisler
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Manuel Ramírez-Zea
- Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - David Flood
- Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala.
- Center for Indigenous Health Research, Wuqu' Kawoq, Tecpán, Guatemala.
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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Kishindo M, Kamano J, Mwangi A, Andale T, Mwaura GW, Limo O, Too K, Mugo R, Maree E, Aruasa W. Are outpatient costs for hypertension and diabetes care affordable? Evidence from Western Kenya. Afr J Prim Health Care Fam Med 2023; 15:e1-e9. [PMID: 37916717 PMCID: PMC10546227 DOI: 10.4102/phcfm.v15i1.3889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Diabetes and hypertension pose a significant socio-economic burden in developing countries such as Kenya, where financial risk-protection mechanisms remain inadequate. This proves to be a great barrier towards achieving universal health care in such settings unless mechanisms are put in place to ensure greater access and affordability to non-communicable disease (NCD) management services. AIM This article aims to examine outpatient management services costs for patients with diabetes and hypertension attending public primary healthcare facilities. SETTING The study was conducted in Busia and Trans-Nzoia counties in Western Kenya in facilities supported by the PIC4C project, between August 2020 and December 2020. METHODS This cross-sectional survey included 719 adult participants. Structured interviewer-administered questionnaires were used to collect information on healthcare-seeking behaviour and associated costs. The annual direct and indirect costs borne by patients were computed by disease type and level of healthcare facility visited. RESULTS Patients with both diabetes and hypertension incurred higher annual costs (KES 13 149) compared to those with either diabetes (KES 8408) or hypertension (KES 7458). Patients attending dispensaries and other public healthcare facilities incurred less direct costs compared to those who visited private clinics. Furthermore, a higher proportionate catastrophic healthcare expenditure of 41.83% was noted among uninsured patients. CONCLUSION Despite this study being conducted in facilities that had an ongoing NCDs care project that increased access to subsidised medication, we still reported a substantially high cost of managing diabetes and hypertension among patients attending primary healthcare facilities in Western Kenya, with a greater burden among those with comorbidities.Contribution: Evidenced by the results that there is enormous financial burden borne by patients with chronic diseases such as hypertension and diabetes; we recommend that universal healthcare coverage that offers comprehensive care for NCDs be urgently rolled out alongside strengthening of lower-level public healthcare systems.
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Rosende A, DiPette DJ, Martinez R, Brettler JW, Rodriguez G, Zuniga E, Ordunez P. HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings. Front Cardiovasc Med 2023; 10:1102482. [PMID: 37180772 PMCID: PMC10169833 DOI: 10.3389/fcvm.2023.1102482] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/27/2023] [Indexed: 05/16/2023] Open
Abstract
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.
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Affiliation(s)
- Andres Rosende
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, United States
| | - Donald J. DiPette
- School of Medicine Columbia, University of South Carolina, Columbia, SC, United States
| | - Ramon Martinez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, United States
| | - Jeffrey W. Brettler
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
- Southern California Permanente Medical Group, Los Angeles, CA, United States
| | - Gonzalo Rodriguez
- Consultant for HEARTS in the Americas, PAHO/WHO Office in Argentina, Buenos Aires, Argentina
| | - Eric Zuniga
- Antofagasta Health Service, University of Antofagasta, Antofagasta, Chile
| | - Pedro Ordunez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, United States
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