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.

Matthew D Hickey,Fredrick J Opel,Diane V Havlir,James Ayieko,Gabriel Chamie,Erick Wafula,Dalsone Kwarisiima,James Peng,Elizabeth A Bukusi,Jane Kabami,Vivek Jain,Mucunguzi Atukunda,Asiphas Owaraganise,Craig R Cohen,Carol S Camlin,Edwin D Charlebois,Marilyn Nyabuti,Nicholas Sim,Moses R Kamya,Laura B Balzer,Lillian B Brown ,Maya Petersen

doi:10.1371/journal.pmed.1003803

Abstract

BackgroundHypertension 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.Methods and findingsThis 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.ConclusionsIn 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.Trial registrationClinicalTrials.gov NCT01864603.

Highlights

Hypertension is the most important risk factor for cardiovascular disease (CVD) and accounts for 14% of global mortality [1]
Among 86,078 nonpregnant adults screened at baseline, we identified 10,928 (13%) with uncontrolled hypertension, all of whom were referred to the nearest governmentrun health facility for hypertension care
We evaluated the effect of the Sustainable East Africa Research in Community Health (SEARCH) intervention on 3-year mortality among nonpregnant adults with uncontrolled hypertension identified at baseline populationlevel screening

Summary

Introduction

Hypertension is the most important risk factor for cardiovascular disease (CVD) and accounts for 14% of global mortality [1]. In sub-Saharan Africa (SSA), the prevalence of hypertension has been steadily increasing [2,3], contributing to a significant rise in CVD-associated mortality [4]. In contrast to limited implementation of hypertension treatment, the HIV response has created a broad chronic care delivery system across much of SSA, providing a clear opportunity to leverage this infrastructure for other high-burden chronic diseases [9,10]. AHUyp:ePrtleenaseiocnontfrieramttmhaetnatllrheedaudcinegslemveolrsbairdeirtyeparnesdenmteodrctaolritryecytelyt:has not been broadly implemented in many low-resource settings, including sub-Saharan Africa (SSA).

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