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.

Regulated expression and effect of galectin-1 on Trypanosoma cruzi-infected macrophages: modulation of microbicidal activity and survival

Galectin-1 is a beta-galactoside-binding protein with potent anti-inflammatory and immunoregulatory effects. However, its expression and function have not been assessed in the context of an infectious disease. The present study documents, for the first time, the regulated expression of galectin-1 in the context of an infectious process and its influence in the modulation of macrophage microbicidal activity and survival. A biphasic modulation in parasite replication and cell viability was observed when macrophages isolated from Trypanosoma cruzi-infected mice were exposed to increasing concentrations of galectin-1. While low concentrations of this protein increased parasite replication and did not affect macrophage survival, higher inflammatory doses of galectin-1 were able to commit cells to apoptosis and inhibited parasite replication. Furthermore, galectin-1 at its lowest concentration was able to down-regulate critical mediators for parasite killing, such as interleukin 12 (IL-12) and nitric oxide, while it did not affect IL-10 secretion. Finally, endogenous galectin-1 was found to be up-regulated and secreted by the J774 macrophage cell line cultured in the presence of trypomastigotes. This result was extended in vivo by Western blot analysis, flow cytometry, and reverse transcription-PCR using macrophages isolated from T. cruzi-infected mice. This study documents the first association between galectin-1's immunoregulatory properties and its role in infection and provides new clues to the understanding of the mechanisms implicated in host-parasite interactions during Chagas' disease and other parasite infections.

Antibodies against Trypanosoma cruzi alkaline antigens are elicited in sera from acute but not chronic human chagasic patients

The aim of this work was to study the antibody response of acute and chronic chagasic patients against a Trypanosoma cruzi alkaline fraction (FI) in comparison with the reactivity against a T. cruzi acidic antigen, the main cystein proteinase of the parasite named cruzipain, and "natural" antigens. FI-specific antibodies were detected only during the acute phase of the infection and IgM was the main isotype produced, whereas cruzipain-specific antibodies were detected during all phases of the infection. By means of immunoblot and sequencing analysis we identified a 47-kDa FI proteic band recognized by IgM from acute chagasic patients as the T. cruzi glutamate dehydrogenase (GluDH). Furthermore, the antibody response against isolated GluDH showed similar characteristics as the one against FI. We also observed a strict association between the reactivity of IgM against FI and GluDH and IgM natural antibodies. However, reactivity against these alkaline antigens was not modified after absorption of natural antibodies in sera from acute chagasic patients, indicating that these parasite antigens are not recognized by the polyspecific natural antibodies. The most important goal of this report is that for the first time the T. cruzi antigen isoelectric point has been associated with its ability to trigger immunological memory, raising a novel antigen property that should be considered in the selection of antigens used in Chagas' disease diagnostic test and in the design of a vaccine against T. cruzi infection.

["We do what we can": health service providers facing the utilization problem]

This study presents the second part of the general results obtained by a qualitative study conducted within the National Health Survey II. The object of this study was to identify main patterns and micro-social determinants which affect the process of selection and utilization of health services in order to propose policies aimed at more equity, quality and efficiency in health service delivery. The study was conducted in urban areas among the middle and middle-low class sectors. A total of 192 individual open-ended interviews and eight focus groups were completed among health users in four cities. Also, 61 service providers both from public and private services were interviewed. Since a previous work reported findings related to health service users, this study focuses only on the results pertaining to health service providers. The first part briefly discusses the study design which allowed to explore the meaning that actors--health service providers--attach to their job and working conditions. The second part presents the main findings. The sense of economic and material precariousness with which health providers from public institutions do their work is among the most important results. Common conflicts between health service users and providers are also mentioned, mainly those which arise from the organizational problems of the health center and from the scarcity of the basic drug stock. The third part reports the main coincidences and divergences between health service users and providers. Some of the divergences may be the reason for the under-utilization of health services. The work concludes with a series of policy recommendations aimed at improving the quality and opportunity of health services provided by public institutions for the needs of the population.

[From "how many" to "why": the utilization of health services from the perspective of the users]

Parallel to the National Health Survey-II, in 1994 a qualitative study was conducted on the patterns and microsocial determinants of health services utilization. The study was conducted in eight urban areas from all over the country among middle class and middle-low class sectors. A total of 192 individual open-ended interviews and eight focus groups were completed among users of health services; 61 service providers both from public and private services were also interviewed. This paper reports the main findings regarding the users' perspective. The first part summarizes the conceptual and methodological design. The second part presents the results from the users' point of view. Individuals distinguish between "becoming sick" and "falling sick"; preventive measures are adopted when becoming sick, in order to avoid falling sick. Another finding refers to the population tendency to add up different and even contradictory curative paradigms, as opposed to the modern medical paradigm which tends to exclude any competing alternative knowledge. A third series of findings refers to the dilemmas that utilizing health services poses for the population, given the high costs, and the low quality that characterize these services, according to the users' point of view. This paper concludes with a series of recommendations for policies, aimed at improving the quality of the health services provided to the population.