Determining the Frequency and Level of Task-Sharing for Hypertension Management in LMICs: A Systematic Review and Meta-Analysis

Abstract

Background: Hypertension is a major risk factor for cardiovascular disease (CVD) and stroke globally. Low- and middle-income countries (LMICs) bear a disproportionately higher burden of CVD and have fewer resources to address CVD and associated risk factors. A team-based care approach adds capacity to improve blood pressure(BP) control. The aim of this updated systematic review was to test team-based care efficacy at different levels of hypertension team-based care complexity and according to the healthcare worker cadre added to the clinical team. Methods: To identify factors driving team-based care efficacy, we updated a prior systematic review by searching PubMed, Embase, Cochrane Library, and CINAHL for newer articles reporting on task-sharing interventions to manage hypertension in LMICs. Levels of complexity of tasks performed by healthcare workers added to the clinical team in hypertension control programs were categorized as administrative tasks (level 1), basic clinical tasks (level 2), and/or advanced clinical tasks (level 3). Meta-analysis using an inverse variance weighted random-effects model summarized trial-based evidence on the efficacy of team-based care on BP control, compared with usual care. Findings: Forty-three RCT articles were included in the meta-analysis: 31 studies from the previous systematic review and 12 articles from the updated search. The pooled overall mean effect for team-based care was a -4.6 mm Hg (95% CI: -5.8, -3.4, I2 = 80.2%) decrease in systolic BP compared with usual care. We found similar comparative reduction among different levels of team-based care complexity, i.e., administrative and basic clinical tasks (-4.7 mm Hg, 95% CI: -6.8, -2.2; I2 = 79.8%); and advanced clinical tasks (-4.5 mmHg, 95%CI: -6.1, -3.3; I2 = 81%). Systolic BP was reduced most by team-based care involving pharmacists (-7.3 mm Hg, 95% CI: -9.2, -5.4; I2 = 67.2%); followed by nurses (-5.1 mm Hg, 95% CI: -8.0, -2.2; I2 = 72.7%), dieticians (-4.7 mmHg, 95%CI: -7.1, -2.3; I2 = 0.0%), then community health workers (-3.3 mm Hg, 95% CI: -4.8, -1.8; I2 = 77.3%). Interpretation: Overall, team-based hypertension care interventions consistently lower BP more than usual care; the effect size varies by the clinical training of the new team member. The BP-lowering effect of team-based care was not greater when new healthcare workers were assigned more complex tasks. Funding Information: Resolve To Save Lives (RTSL) Vital Strategies, Danielle Cazabon, Andrew E. Moran, Yvonne Commodore Mensah receive salary support from Resolve to Save Lives, an initiative of Vital Strategies. Resolve to Save Lives is jointly supported by grants from Bloomberg Philanthropies, the Bill & Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation. Declaration of Interests: The authors declare no conflict of interest.