An intervention tailored to communities and delivered by non-physician health workers has been shown to reduce cardiovascular risk over one year in patients with new or poorly controlled hypertension in Colombia and Malaysia.
This late breaking result of the community-based, cluster, randomized, controlled Heart Outcomes Prevention and Evaluation 4 (HOPE 4) study was reported at last week’s European Society of Cardiology (ESC) Congress 2019 and World Congress of Cardiology in Paris.
Jon-David Schwalm, MD, of the Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada, explained that there was a 75% greater cardiovascular risk reduction in the intervention group due to the development of a comprehensive care model designed to address multiple implementation barriers.
According to Dr. Schwalm, the intervention was led by non-physician health workers and integrated efforts of the patient, family/friends, and the primary care physician.
He also noted that previous studies using non-physician health workers resulted in modest effects on cardiovascular risk factors. The current study was designed to test whether an intervention involving general practitioners, health workers, and family, and including evidence-based medications, can lead to substantially and safely reduced individual cardiovascular risk.”
HOPE 4 included 1371 patients age 50 years and older with new or poorly controlled hypertension from 30 communities in Colombia and Malaysia. A total of 16 communities were randomized to usual care (control group) and 14 communities, to a multifaceted intervention for 1 year.
The intervention entailed:
· Community screening to detect those with new or poorly controlled hypertension
· Initiation and monitoring of treatments and control of multiple risk factors by non-physician health workers using tablet-based management algorithms and counselling
· Free antihypertensive and statin medications recommended by non-physician health workers under physician supervision
· A treatment supporter (friend or family member) to enhance adherence to medications and lifestyle advice
Tablets were used to collect data and to support health worker counselling concerning health behaviours and decision making at the point of care. Simplified management algorithms were used to initiate and up-titrate antihypertensive medications and statins.
The primary outcome measure was a change in Framingham risk score (an estimate of 10-year risk of cardiovascular disease) from baseline to 12 months.
In the intervention arm, the Framingham risk score estimate was reduced by an absolute 11.2% at 12 months (relative risk reduction, 34.2%; P < .001). This reduction corresponded to 75% greater reduction than control (absolute risk reduction in the control group, -6.4%; P < .001).
An absolute 11.5 mm Hg greater reduction in systolic blood pressure, and a 0.4 mmoL/L larger reduction in serum LDL cholesterol were observed in the intervention than in the control group (both statistically significant).
The proportion of patients with controlled hypertension was significantly higher, and more than twice as great in the intervention group (69%) than in the control group (31%).
A trend toward benefit in most health behaviours was observed in the intervention arm. This improvement translated into significantly greater reductions in INTERHEART risk score after 6 and 12 months. In particular, important improvements in physical activity and diet were seen.