Community health workers dec hypertension

A community health worker-led intervention in Argentina led to dramatic improvements in hypertension control (see doi:10.1001/jama.2017.11358 ).

Details:

--18 primary health care centers within the national public system, which provides free medications and health care to uninsured patients

--1432 low-income patients with uncontrolled hypertension, recruited from 2013-15 and followed 18 months

--9 centers (743 patients) were randomized to the intervention:

    --community health worker-led multicomponent intervention, including health coaching on lifestyle modification, home BP monitoring and medication adherence, and BP audit and feedback; these workers generally functioned as case managers for the patients and their families. Initial 90-minute home visit when all family members were available, then 60-minute monthly or bimonthly follow-up visits, with tailored counseling, including strategies to help people lose weight, restrict dietary sodium, increase physical activity, moderate alcohol consumption, and follow DASH diet.  All patients were given an automatic home BP monitor and 7-day pill-organizer.

    --primary care physician received training on standard BP treatment algorithms for stepped-care BP management, and were given feedback from the community health workers about the patients' blood pressures, as a basis for medication adjustment

    ​--weekly text-messaging to patients to promote lifestyle changes and reinforce medication adherence

--9 centers (689 patients) continued with usual care

--mean age 56, 53% women, 95% completed trial. 19% current smokers, mean 8 MET/wk exercise, 12% history MI or stroke/40% hypercholesterolemia, 22% diabetes.

--baseline BP 151/91, 85% on meds

--main outcome: differences in systolic and diastolic BP; secondary outcome was proportion of patients with controlled hypertension (BP <140/90)

Results:

--at month 18:

    --systolic BP decreased 19.3 mmHg in intervention group, 12.7 mmHg in usual care, a 6.6 mmHg difference

    ​--diastolic BP decreased 12.2 mmHg in intervention group, 6.9 mmHg in usual care, a 5.4 mmHg difference

    --the proportion of patients with controlled BP: 

        --increased from 17.0% at baseline to 72.9% in the intervention group

        --increased from 17.6% at baseline to 52.2% in the usual care group​ (ie, a difference of 20.6%)

Commentary:

--the prevalence of uncontrolled hypertension is high and increasing in low- and middle-income countries. Estimates are that 31.1% of the world's adults had hypertension in 2010: 28.5% in high-income countries (349 million people), 31.5% in low- and middle-income countries (1.04 billion people), ie 75% of hypertensives people  lived in low- and middle-income countries. And only 7.7% of hypertensives in the low- or middle-income countries had blood pressure <140/90. (see Mills KT. Circulation. 2016; 134: 441)

--hypertension is one of the leading global modifiable risk factors for cardiovascular disease and death, increasingly so over time with the shift away from infectious diseases in resource-poor countries to more Western-type chronic diseases (heart disease, diabetes, obesity, etc)

--there was a recent article in the NY Times (9/16/17, see https://www.nytimes.com/interactive/2017/09/16/health/brazil-obesity-nestle.html?_r=0 )

showing how some Western conglomerates (Nestle, PepsiCo, and General Mills) are aggressively marketing their Western-style processed foods and sugary drinks to some of the more isolated areas in Latin America, Africa, and Asia, likely contributing to the increasing epidemics there of diabetes, heart disease, and other chronic conditions resulting from the "soaring rates of obesity" (the article was mostly about Brazil, where Nestle has been hiring thousands of people to go door-to-door to push Chandelle pudding, Kit-Kats, and Mucilon infant cereal).  Harkens back to the initiatives by Nestle to get poor women in Africa and other resource-poor countries to stop breast-feeding and use Nestle’s powdered formula in the 1970s (leading to a widespread boycott of Nestle's products).  Or the dumping of cigarettes in poorer nations after the US market was decreasing because of aggressive anti-smoking campaigns. Or .....

--issues with this study: although the centers were chosen randomly, the intervention within each center was the same (ie, the intervention centers may have been more aggressive overall in helping control the blood pressure than those randomized to usual care). hard to tease out the effect of individual components of the intervention (was it that physicians were trained more in the study centers and got better feedback to adjust meds, or the rather impressive multi-dimensional integration of community health workers functioning as community-based case managers??? )

So, there are really several important aspects of this study (despite the fact that we cannot tease out which particular intervention works best):

--a more holistic, team-approach to chronic disease management seems to work and makes sense. for one thing, some patients may change behaviors (lifestyle, med adherence) more through different types of interventions (community worker, clinician), so the multitude of approaches is more likely to influence any individual. And the combo may be even more important

--the community workers are more likely to be culturally and economically more congruent with the patients. Even clinicians from the same “culture” may not be able to relate to patients the same way as those with similar living standards who may live near the patient, have similar experiences, and perhaps even be related to the patient/family or have common friends/community. And providing intensive care in such a patient- and family-centered manner has to be a huge benefit for most patients.

--training community workers may have very positive collateral benefits: they may elevate the stature of these workers in the community, giving patients more access to more generally medically knowledgeable people, and may serve as a conduit to getting people in the community integrated overall in the health care system.  I have seen this in a couple of situations: at our health center in Boston, our medical assistants and community health advocates are often considered to be local medical experts by their communities and do help bring people in for needed care when medical issues come up.  When I have worked in a very poor area in Nicaragua and done home visits, the community workers I have gone out with clearly have an elevated stature in the community regarding general medical issues, and again serve as a conduit for getting people needed medical care, whether that is making sure they have enough medications to getting them into the clinic for further evaluation.  In all of these cases, the community workers develop increased stature in their communities regarding health issues, and community members often seek them out for advice. And patients pretty uniformly do better with their help.

--so, I think this is a win-win-win: great for patients’ health, the community health workers themselves, and our ability as clinicians to optimize patients’ care.

see http://gmodestmedblogs.blogspot.com/2015/01/community-wide-rural-cardiac-health.html for a description/assessment of a long-term very successful public health program in a poor county in rural Maine, relying on sustained community empowerment and activism, and  focusing on hypertension, lipids, smoking cessation, diet/physical activity, yielding remarkable results (eg, hypertension control increased from 18% to 43%, cholesterol control from 0.4% to 29%, and even smoking quit rates from 49% to 70%!!!