Effect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH, a community-randomized trial in rural Kenya and Uganda.
<h4>Background</h4>Hypertension treatment reduces morbidity and mortality yet has not been broadly implemented in many low-resource settings, including sub-Saharan Africa (SSA). We hypothesized that a patient-centered integrated chronic disease model that included hypertension treatment...
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oai:doaj.org-article:1ac4013a8f134447a349484ee972c0862021-12-02T19:56:04ZEffect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH, a community-randomized trial in rural Kenya and Uganda.1549-12771549-167610.1371/journal.pmed.1003803https://doaj.org/article/1ac4013a8f134447a349484ee972c0862021-09-01T00:00:00Zhttps://doi.org/10.1371/journal.pmed.1003803https://doaj.org/toc/1549-1277https://doaj.org/toc/1549-1676<h4>Background</h4>Hypertension treatment reduces morbidity and mortality yet has not been broadly implemented in many low-resource settings, including sub-Saharan Africa (SSA). We hypothesized that a patient-centered integrated chronic disease model that included hypertension treatment and leveraged the HIV care system would reduce mortality among adults with uncontrolled hypertension in rural Kenya and Uganda.<h4>Methods and findings</h4>This is a secondary analysis of the SEARCH trial (NCT:01864603), in which 32 communities underwent baseline population-based multidisease testing, including hypertension screening, and were randomized to standard country-guided treatment or to a patient-centered integrated chronic care model including treatment for hypertension, diabetes, and HIV. Patient-centered care included on-site introduction to clinic staff at screening, nursing triage to expedite visits, reduced visit frequency, flexible clinic hours, and a welcoming clinic environment. The analytic population included nonpregnant adults (≥18 years) with baseline uncontrolled hypertension (blood pressure ≥140/90 mm Hg). The primary outcome was 3-year all-cause mortality with comprehensive population-level assessment. Secondary outcomes included hypertension control assessed at a population level at year 3 (defined per country guidelines as at least 1 blood pressure measure <140/90 mm Hg on 3 repeated measures). Between-arm comparisons used cluster-level targeted maximum likelihood estimation. Among 86,078 adults screened at study baseline (June 2013 to July 2014), 10,928 (13%) had uncontrolled hypertension. Median age was 53 years (25th to 75th percentile 40 to 66); 6,058 (55%) were female; 677 (6%) were HIV infected; and 477 (4%) had diabetes mellitus. Overall, 174 participants (3.2%) in the intervention group and 225 participants (4.1%) in the control group died during 3 years of follow-up (adjusted relative risk (aRR) 0.79, 95% confidence interval (CI) 0.64 to 0.97, p = 0.028). Among those with baseline grade 3 hypertension (≥180/110 mm Hg), 22 (4.9%) in the intervention group and 42 (7.9%) in the control group died during 3 years of follow-up (aRR 0.62, 95% CI 0.39 to 0.97, p = 0.038). Estimated population-level hypertension control at year 3 was 53% in intervention and 44% in control communities (aRR 1.22, 95% CI 1.12 to 1.33, p < 0.001). Study limitations include inability to identify specific causes of death and control conditions that exceeded current standard hypertension care.<h4>Conclusions</h4>In this cluster randomized comparison where both arms received population-level hypertension screening, implementation of a patient-centered hypertension care model was associated with a 21% reduction in all-cause mortality and a 22% improvement in hypertension control compared to standard care among adults with baseline uncontrolled hypertension. Patient-centered chronic care programs for HIV can be leveraged to reduce the overall burden of cardiovascular mortality in SSA.<h4>Trial registration</h4>ClinicalTrials.gov NCT01864603.Matthew D HickeyJames AyiekoAsiphas OwaraganiseNicholas SimLaura B BalzerJane KabamiMucunguzi AtukundaFredrick J OpelErick WafulaMarilyn NyabutiLillian BrownGabriel ChamieVivek JainJames PengDalsone KwarisiimaCarol S CamlinEdwin D CharleboisCraig R CohenElizabeth A BukusiMoses R KamyaMaya L PetersenDiane V HavlirPublic Library of Science (PLoS)articleMedicineRENPLoS Medicine, Vol 18, Iss 9, p e1003803 (2021) |
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EN |
| topic |
Medicine R |
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Medicine R Matthew D Hickey James Ayieko Asiphas Owaraganise Nicholas Sim Laura B Balzer Jane Kabami Mucunguzi Atukunda Fredrick J Opel Erick Wafula Marilyn Nyabuti Lillian Brown Gabriel Chamie Vivek Jain James Peng Dalsone Kwarisiima Carol S Camlin Edwin D Charlebois Craig R Cohen Elizabeth A Bukusi Moses R Kamya Maya L Petersen Diane V Havlir Effect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH, a community-randomized trial in rural Kenya and Uganda. |
| description |
<h4>Background</h4>Hypertension treatment reduces morbidity and mortality yet has not been broadly implemented in many low-resource settings, including sub-Saharan Africa (SSA). We hypothesized that a patient-centered integrated chronic disease model that included hypertension treatment and leveraged the HIV care system would reduce mortality among adults with uncontrolled hypertension in rural Kenya and Uganda.<h4>Methods and findings</h4>This is a secondary analysis of the SEARCH trial (NCT:01864603), in which 32 communities underwent baseline population-based multidisease testing, including hypertension screening, and were randomized to standard country-guided treatment or to a patient-centered integrated chronic care model including treatment for hypertension, diabetes, and HIV. Patient-centered care included on-site introduction to clinic staff at screening, nursing triage to expedite visits, reduced visit frequency, flexible clinic hours, and a welcoming clinic environment. The analytic population included nonpregnant adults (≥18 years) with baseline uncontrolled hypertension (blood pressure ≥140/90 mm Hg). The primary outcome was 3-year all-cause mortality with comprehensive population-level assessment. Secondary outcomes included hypertension control assessed at a population level at year 3 (defined per country guidelines as at least 1 blood pressure measure <140/90 mm Hg on 3 repeated measures). Between-arm comparisons used cluster-level targeted maximum likelihood estimation. Among 86,078 adults screened at study baseline (June 2013 to July 2014), 10,928 (13%) had uncontrolled hypertension. Median age was 53 years (25th to 75th percentile 40 to 66); 6,058 (55%) were female; 677 (6%) were HIV infected; and 477 (4%) had diabetes mellitus. Overall, 174 participants (3.2%) in the intervention group and 225 participants (4.1%) in the control group died during 3 years of follow-up (adjusted relative risk (aRR) 0.79, 95% confidence interval (CI) 0.64 to 0.97, p = 0.028). Among those with baseline grade 3 hypertension (≥180/110 mm Hg), 22 (4.9%) in the intervention group and 42 (7.9%) in the control group died during 3 years of follow-up (aRR 0.62, 95% CI 0.39 to 0.97, p = 0.038). Estimated population-level hypertension control at year 3 was 53% in intervention and 44% in control communities (aRR 1.22, 95% CI 1.12 to 1.33, p < 0.001). Study limitations include inability to identify specific causes of death and control conditions that exceeded current standard hypertension care.<h4>Conclusions</h4>In this cluster randomized comparison where both arms received population-level hypertension screening, implementation of a patient-centered hypertension care model was associated with a 21% reduction in all-cause mortality and a 22% improvement in hypertension control compared to standard care among adults with baseline uncontrolled hypertension. Patient-centered chronic care programs for HIV can be leveraged to reduce the overall burden of cardiovascular mortality in SSA.<h4>Trial registration</h4>ClinicalTrials.gov NCT01864603. |
| format |
article |
| author |
Matthew D Hickey James Ayieko Asiphas Owaraganise Nicholas Sim Laura B Balzer Jane Kabami Mucunguzi Atukunda Fredrick J Opel Erick Wafula Marilyn Nyabuti Lillian Brown Gabriel Chamie Vivek Jain James Peng Dalsone Kwarisiima Carol S Camlin Edwin D Charlebois Craig R Cohen Elizabeth A Bukusi Moses R Kamya Maya L Petersen Diane V Havlir |
| author_facet |
Matthew D Hickey James Ayieko Asiphas Owaraganise Nicholas Sim Laura B Balzer Jane Kabami Mucunguzi Atukunda Fredrick J Opel Erick Wafula Marilyn Nyabuti Lillian Brown Gabriel Chamie Vivek Jain James Peng Dalsone Kwarisiima Carol S Camlin Edwin D Charlebois Craig R Cohen Elizabeth A Bukusi Moses R Kamya Maya L Petersen Diane V Havlir |
| author_sort |
Matthew D Hickey |
| title |
Effect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH, a community-randomized trial in rural Kenya and Uganda. |
| title_short |
Effect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH, a community-randomized trial in rural Kenya and Uganda. |
| title_full |
Effect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH, a community-randomized trial in rural Kenya and Uganda. |
| title_fullStr |
Effect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH, a community-randomized trial in rural Kenya and Uganda. |
| title_full_unstemmed |
Effect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH, a community-randomized trial in rural Kenya and Uganda. |
| title_sort |
effect of a patient-centered hypertension delivery strategy on all-cause mortality: secondary analysis of search, a community-randomized trial in rural kenya and uganda. |
| publisher |
Public Library of Science (PLoS) |
| publishDate |
2021 |
| url |
https://doaj.org/article/1ac4013a8f134447a349484ee972c086 |
| work_keys_str_mv |
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1718375826763808768 |