RESUMEN
PURPOSE OF REVIEW: HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation. RECENT FINDINGS: Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation. Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.
Asunto(s)
Hipertensión , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Hipertensión/prevención & control , Atención a la SaludRESUMEN
Purpose of review: HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation. Recent findings: Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation. Summary: Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.
Propósito da revisão: HEARTS nas Américas é uma adaptação regional da iniciativa mundial HEARTS, da Organização Mundial da Saúde, voltada para prevenção e controle das doenças cardiovasculares (DCV) na Região das Américas. Seu objetivo geral é promover mudanças na prática clínica e na gestão da atenção primária pelos serviços de saúde a fim de melhorar o controle da hipertensão arterial e reduzir o risco de DCV. Esta revisão descreve a iniciativa HEARTS nas Américas. Primeiro, é apresentado um resumo da situação epidemiológica regional relativa à mortalidade por DCV e das tendências no controle da hipertensão arterial em nível populacional. Em seguida, são explicados os motivos por trás dos principais componentes da intervenção: o sistema de manejo focado na atenção primária e o componente clínico da HEARTS. Por fim, são examinados os principais fatores para acelerar a ampliação da HEARTS: medicamentos, atenção baseada no trabalho em equipe e um sistema de monitoramento e avaliação. Resultados recentes: Até o momento, 33 países e territórios da América Latina e do Caribe se comprometeram a integrar esse programa em toda sua rede de atenção primária à saúde até 2025. Comparado com o modelo tradicional, o aumento da cobertura e do controle da hipertensão arterial nos ambientes de atenção primária à saúde é promissor e confirma que as intervenções promovidas pela HEARTS são exequíveis e aceitas por comunidades, pacientes, prestadores de serviços de saúde, tomadores de decisão e financiadores. Nesta revisão, destacamos alguns casos nos quais a implementação foi satisfatória. Conclusões: Ampliar a aplicação de um tratamento eficaz contra a hipertensão arterial e otimizar o controle do risco de DCV são medidas pragmáticas para acelerar a redução da mortalidade por DCV e, ao mesmo tempo, fortalecer os sistemas de atenção primária à saúde para responder com qualidade, eficácia e equidade ao desafio apresentado pelas doenças não transmissíveis, não apenas nos países de baixa ou média renda, mas no mundo todo.
RESUMEN
HEARTS in the Americas is the Pan American Health Organization flagship program to accelerate the reduction of the cardiovascular disease (CVD) burden by improving hypertension control and CVD secondary prevention in primary health care. A monitoring and evaluation (M&E) platform is needed for program implementation, benchmarking, and informing policy-makers. This paper describes the conceptual bases of the HEARTS M&E platform including software design principles, contextualization of data collection modules, data structure, reporting, and visualization. The District Health Information Software 2 (DHIS2) web-based platform was chosen to implement aggregate data entry of CVD outcome, process, and structural risk factor indicators. In addition, PowerBI was chosen for data visualization and dashboarding for the analysis of performance and trends above the health care facility level. The development of this new information platform was focused on primary health care facility data entry, timely data reporting, visualizations, and ultimately active use of data to drive decision-making for equitable program implementation and improved quality of care. Additionally, lessons learnt and programmatic considerations were assessed through the experience of the M&E software development. Building political will and support is essential to developing and deploying a flexible platform in multiple countries which is contextually specific to the needs of various stakeholders and levels of the health care system. The HEARTS M&E platform supports program implementation and reveals structural and managerial limitations and care gaps. The HEARTS M&E platform will be central to monitoring and driving further population-level improvements in CVD and other noncommunicable disease-related health.
A iniciativa HEARTS nas Américas é o principal programa da Organização Pan-Americana da Saúde para acelerar a redução da carga de doenças cardiovasculares (DCV) por meio do melhoramento do controle da hipertensão e da prevenção secundária de DCV na atenção primária à saúde. Uma plataforma de monitoramento e avaliação (M&E, na sigla em inglês) é necessária para a implementação do programa, para fazer a avaliação comparativa e para informar os formuladores de políticas. Este documento descreve as bases conceituais da plataforma de M&E do HEARTS, incluindo princípios de design de software, contextualização dos módulos de coleta de dados, estrutura de dados, relatórios e visualização. A plataforma baseada na web do District Health Information Software 2 (DHIS2) foi escolhida para implementar a inserção de dados agregados de indicadores de fatores de risco estruturais, processos e desfechos de DCV. Além disso, o PowerBI foi escolhido para a visualização de dados e para fazer o dashboard da análise de desempenho e tendências para além do nível da unidade de saúde. O desenvolvimento desta nova plataforma de informações teve como foco a inserção de dados da unidade de atenção primária à saúde, a notificação oportuna de dados, visualizações e o uso ativo dos dados para orientar a tomada de decisões para a implementação equitativa do programa e a melhoria da qualidade do atendimento. Além disso, as lições aprendidas e as considerações programáticas foram avaliadas por meio da experiência do desenvolvimento do software de M&E. Fomentar vontade política e apoio é essencial para desenvolver e implantar uma plataforma flexível em vários países, que seja contextualmente específica para as necessidades das diferentes partes interessadas e níveis do sistema de saúde. A plataforma de M&E do HEARTS ampara a implementação do programa e revela limitações estruturais e gerenciais, bem como lacunas na atenção à saúde. A plataforma de M&E do HEARTS será central para monitorar e impulsionar mais melhorias no nível populacional em DCV e outras doenças não transmissíveis.
RESUMEN
Cardiovascular diseases are the leading cause of mortality and morbidity in the Region of the Americas, and hypertension represents its main risk factor. However, population hypertension control rates in the Region are poor. Global Hearts is the World Health Organization's flagship initiative to reduce the burden of cardiovascular diseases. HEARTS in the Americas Initiative is its regional adaptation that seeks to be the cardiovascular disease risk management model, including hypertension and diabetes, in primary health care throughout the Americas by 2025. HEARTS in the Americas is being implemented in 22 countries and over 2 095 primary care centers. All implementing countries have defined their treatment protocols, and HEARTS in the Americas has supported continuous improvement. Because WHO recently released the 2021 Guideline for the Pharmacological Treatment of Hypertension in Adults and HEARTS in the Americas introduced the key drivers for hypertension control, the initiative generated a methodology to help countries update and strengthen their treatment protocols. This article describes the process of developing the treatment protocol appraisal checklist and defines the resulting clinical pathway. This tool can help countries and primary care centers to improve their protocols by identifying the improvement points and upgrading clinical pathways.
Las enfermedades cardiovasculares son la principal causa de mortalidad y morbilidad en la Región de las Américas, y la hipertensión representa su principal factor de riesgo. Sin embargo, las tasas de control de la hipertensión arterial en la Región son desalentadoras. Global Hearts es la iniciativa insignia de la Organización Mundial de la Salud para reducir la carga de las enfermedades cardiovasculares. La iniciativa HEARTS en las Américas es su adaptación regional, y tiene como objetivo ser el modelo de manejo del riesgo de enfermedades cardiovasculares, incluida la hipertensión y la diabetes, en la atención primaria de salud en la Región para el año 2025.HEARTS en las Américas se está aplicando en 22 países y más de 2 095 centros de atención primaria. Todos los países que están aplicando esta iniciativa han definido sus protocolos de tratamiento, y HEARTS en las Américas ha brindado apoyo para la mejora continua. Debido a que la OMS publicó recientemente la guía para el tratamiento farmacológico de la hipertensión en adultos (2021) y HEARTS en las Américas determinó cuáles son los impulsores clave para el control de la hipertensión, la iniciativa elaboró una metodología para ayudar a los países a actualizar y fortalecer sus protocolos de tratamiento.En este artículo se describe el proceso de elaboración de la lista de verificación para la evaluación del protocolo de tratamiento y se define la vía clínica resultante. Esta herramienta puede ayudar a los países y los centros de atención primaria a mejorar sus protocolos para que determinen cuáles son los puntos que se deben mejorar y elaboren las vías clínicas.
A iniciativa HEARTS nas Américas está sendo implementada em 22 países e mais de 2 095 centros de atenção primária à saúde. Todos os países que estão implementando a iniciativa definiram seus protocolos de tratamento, e a HEARTS nas Américas contribuiu para a melhoria contínua. Como a OMS lançou recentemente as Diretrizes de 2021 para o tratamento medicamentoso da hipertensão arterial em adultos e a HEARTS nas Américas desenvolveu os elementos essenciais para o controle da hipertensão, a iniciativa criou uma metodologia para auxiliar os países na atualização e no fortalecimento de seus protocolos de tratamento.Este artigo descreve o processo de elaboração da lista de verificação para avaliação do protocolo de tratamento e define o caminho clínico resultante. Esta ferramenta pode ajudar os países e os centros de atenção primária à saúde a aprimorarem seus protocolos mediante a identificação dos pontos para melhoria e o desenvolvimento de caminhos clínicos.As doenças cardiovasculares são a principal causa de morbimortalidade na Região das Américas, e a hipertensão é seu principal fator de risco. Entretanto, as taxas de controle da hipertensão na população da Região são baixas. Global Hearts é a principal iniciativa da Organização Mundial da Saúde para reduzir a carga de doenças cardiovasculares. A iniciativa HEARTS nas Américas é sua adaptação regional, que almeja ser o modelo para o gerenciamento de risco de doenças cardiovasculares, incluindo a hipertensão e o diabetes, na atenção primária à saúde em toda a Região das Américas até 2025.
RESUMEN
HEARTS in the Americas is the Pan American Health Organization flagship program to accelerate the reduction of the cardiovascular disease (CVD) burden by improving hypertension control and CVD secondary prevention in primary health care. A monitoring and evaluation (M&E) platform is needed for program implementation, benchmarking, and informing policy-makers. This paper describes the conceptual bases of the HEARTS M&E platform including software design principles, contextualization of data collection modules, data structure, reporting, and visualization. The District Health Information Software 2 (DHIS2) web-based platform was chosen to implement aggregate data entry of CVD outcome, process, and structural risk factor indicators. In addition, PowerBI was chosen for data visualization and dashboarding for the analysis of performance and trends above the health care facility level. The development of this new information platform was focused on primary health care facility data entry, timely data reporting, visualizations, and ultimately active use of data to drive decision-making for equitable program implementation and improved quality of care. Additionally, lessons learnt and programmatic considerations were assessed through the experience of the M&E software development. Building political will and support is essential to developing and deploying a flexible platform in multiple countries which is contextually specific to the needs of various stakeholders and levels of the health care system. The HEARTS M&E platform supports program implementation and reveals structural and managerial limitations and care gaps. The HEARTS M&E platform will be central to monitoring and driving further population-level improvements in CVD and other noncommunicable disease-related health.
HEARTS en las Américas es el programa insignia de la Organización Panamericana de la Salud para acelerar la reducción de la carga de enfermedades cardiovasculares (ECV) mediante la mejora del control de la hipertensión y la prevención secundaria de las ECV en la atención primaria de salud. Es necesaria una plataforma de monitoreo y evaluación (M&E) para ejecutar el programa, establecer puntos de referencia y notificar a los responsables de las políticas. En este artículo se describen las bases conceptuales de la plataforma HEARTS M&E, como los principios de diseño del software, la contextualización de los módulos de recopilación de datos, la estructura de los datos, la presentación de información y la visualización. Se escogió la plataforma web District Health Information Software 2 (DHIS2) para ejecutar el ingreso de los datos agregados de los indicadores de resultados, procesos y factores de riesgo estructurales de las ECV. Además, se eligió PowerBI para la visualización de datos y la elaboración del panel de control para el análisis del desempeño y las tendencias más allá del nivel de los centros de atención médica. El desarrollo de esta nueva plataforma de información se centró en el ingreso de datos de los centros de atención primaria de salud, la presentación oportuna de datos, las visualizaciones y, en última instancia, el uso activo de los datos para impulsar la toma de decisiones en la ejecución equitativa del programa y la mejora de calidad de la atención. Además, se evaluaron las enseñanzas extraídas y las consideraciones programáticas con la experiencia del desarrollo de software de M&E. Lograr el apoyo y la voluntad política es esencial para desarrollar y poner en marcha una plataforma flexible en múltiples países que sea contextualmente específica según las necesidades de las diversas partes interesadas y los niveles del sistema de atención de la salud. La plataforma HEARTS M&E brinda apoyo para la ejecución del programa y muestra las limitaciones estructurales y gerenciales, así como las brechas en la atención. Esta plataforma será fundamental para monitorear e impulsar nuevas mejoras a nivel de la población en lo que respecta a las ECV y otras enfermedades no transmisibles relacionadas.
A iniciativa HEARTS nas Américas é o principal programa da Organização Pan-Americana da Saúde para acelerar a redução da carga de doenças cardiovasculares (DCV) por meio do melhoramento do controle da hipertensão e da prevenção secundária de DCV na atenção primária à saúde. Uma plataforma de monitoramento e avaliação (M&E, na sigla em inglês) é necessária para a implementação do programa, para fazer a avaliação comparativa e para informar os formuladores de políticas. Este documento descreve as bases conceituais da plataforma de M&E do HEARTS, incluindo princípios de design de software, contextualização dos módulos de coleta de dados, estrutura de dados, relatórios e visualização. A plataforma baseada na web do District Health Information Software 2 (DHIS2) foi escolhida para implementar a inserção de dados agregados de indicadores de fatores de risco estruturais, processos e desfechos de DCV. Além disso, o PowerBI foi escolhido para a visualização de dados e para fazer o dashboard da análise de desempenho e tendências para além do nível da unidade de saúde. O desenvolvimento desta nova plataforma de informações teve como foco a inserção de dados da unidade de atenção primária à saúde, a notificação oportuna de dados, visualizações e o uso ativo dos dados para orientar a tomada de decisões para a implementação equitativa do programa e a melhoria da qualidade do atendimento. Além disso, as lições aprendidas e as considerações programáticas foram avaliadas por meio da experiência do desenvolvimento do software de M&E. Fomentar vontade política e apoio é essencial para desenvolver e implantar uma plataforma flexível em vários países, que seja contextualmente específica para as necessidades das diferentes partes interessadas e níveis do sistema de saúde. A plataforma de M&E do HEARTS ampara a implementação do programa e revela limitações estruturais e gerenciais, bem como lacunas na atenção à saúde. A plataforma de M&E do HEARTS será central para monitorar e impulsionar mais melhorias no nível populacional em DCV e outras doenças não transmissíveis.
RESUMEN
Cardiovascular disease (CVD) is the leading cause of death in the Americas and raised blood pressure accounts for over 50% of CVD. In the Americas over a quarter of adult women and four in ten adult men have hypertension and the diagnosis, treatment and control are suboptimal. In 2021, the World Health Organization (WHO) released an updated guideline for the pharmacological treatment of hypertension in adults. This policy paper highlights the facilitating role of the WHO Global HEARTS initiative and the HEARTS in the Americas initiative to catalyze the implementation of this guideline, provides specific policy advice for implementation, and emphasizes that an overarching strategic approach for hypertension control is needed. The authors urge health advocates and policymakers to prioritize the prevention and control of hypertension to improve the health and wellbeing of their populations and to reduce CVD health disparities within and between populations of the Americas.
Las enfermedades cardiovasculares son la principal causa de muerte en la Región de las Américas y la hipertensión es la causa de más del 50% de ellas. En la Región, más de una cuarta parte de las mujeres adultas y cuatro de cada diez hombres adultos tienen hipertensión y su diagnóstico, tratamiento y control son deficientes. En el 2021, la Organización Mundial de la Salud (OMS) publicó directrices actualizadas sobre el tratamiento farmacológico de la hipertensión en personas adultas. En este artículo se destaca el papel facilitador de la iniciativa mundial HEARTS de la OMS y la iniciativa HEARTS en las Américas para catalizar la implementación de estas directrices, a la vez que se proporciona asesoramiento específico sobre políticas para dicha implementación y se destaca la necesidad de adoptar un enfoque estratégico general para el control de la hipertensión. Los autores instan a quienes abogan por la salud y a los responsables de las políticas a priorizar la prevención y el control de la hipertensión para mejorar la salud y el bienestar de la población, y a reducir las disparidades de salud en relación con las enfermedades cardiovasculares dentro de la población y entre las poblaciones de la Región de las Américas.
RESUMEN
Background: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the Americas, and hypertension is the most significant modifiable risk factor. However, hypertension control rates remain low, and CVD mortality is stagnant or rising after decades of continuing reduction. In 2016, the World Health Organization (WHO) launched the HEARTS technical package to improve hypertension control. The Pan American Health Organization (PAHO) designed the HEARTS in the Americas Initiative to improve CVD risk management, emphasizing hypertension control, to date implemented in 21 countries. Methods: To advance implementation, an interdisciplinary group of practitioners was engaged to select the key evidence-based drivers of hypertension control and to design a comprehensive scorecard to monitor their implementation at primary care health facilities (PHC). The group studied high-performing health systems that achieve high hypertension control through quality improvement programs focusing on specific process measures, with regular feedback to providers at health facilities. Findings: The final selected eight drivers were categorized into five main domains: (1) diagnosis (blood pressure measurement accuracy and CVD risk evaluation); (2) treatment (standardized treatment protocol and treatment intensification); (3) continuity of care and follow-up; (4) delivery system (team-based care, medication refill), and (5) system for performance evaluation. The drivers and recommendations were then translated into process measures, resulting in two interconnected scorecards integrated into the HEARTS in the Americas monitoring and evaluation system. Interpretation: Focus on these key hypertension drivers and resulting scorecards, will guide the quality improvement process to achieve population control goals at the participating health centers in HEARTS implementing countries.
Antecedentes: Las enfermedades cardiovasculares (ECV) son la principal causa de morbilidad y mortalidad en la Región de las Américas y la hipertensión es el factor de riesgo modificable asociado más importante. Sin embargo, las tasas de control de la hipertensión siguen siendo bajas y la mortalidad por ECV está estancada o en aumento después de décadas de reducción continua. En el 2016, la Organización Mundial de la Salud (OMS) presentó el paquete técnico HEARTS para mejorar el control de la hipertensión. La Organización Panamericana de la Salud (OPS) diseñó la iniciativa HEARTS en las Américas para mejorar el control del riesgo de ECV, que hace hincapié en el control de la hipertensión y que, hasta la fecha, se ha implementado en 21 países. Métodos: Para avanzar en la implementación, se creó un grupo interdisciplinario de profesionales de la salud con el objetivo de seleccionar los factores impulsores claves del control de la hipertensión basados en la evidencia y diseñar un método de puntuación integral para dar seguimiento a su implementación en los centros de atención de salud primaria (APS). El grupo estudió los sistemas de salud de alto desempeño que logran un control elevado de la hipertensión mediante programas de mejora de la calidad que se centran en medidas específicas con respecto a los procesos, con retroalimentación regular a los prestadores en los centros de salud. Resultados: Los ocho factores impulsores finales seleccionados se clasificaron en cinco dominios principales: 1) diagnóstico (exactitud de la medición de la presión arterial y evaluación del riesgo de ECV); 2) tratamiento (protocolo de tratamiento e intensificación del tratamiento estandarizados); 3)â¯continuidad de la atención y seguimiento; 4) sistema de prestación del tratamiento (atención basada en un trabajo en equipo, reposición de la medicación) y 5) sistema para la evaluación del desempeño. Los factores impulsores y las recomendaciones se tradujeron en medidas con respecto a los procesos, lo que llevó a dos métodos de puntuación integrados e interconectados en el sistema de seguimiento y evaluación del programa HEARTS en las Américas. Conclusiones: El enfoque que se centra en estos factores impulsores clave de la hipertensión y los métodos de puntuación resultantes servirá de guía para el proceso de mejora de la calidad con objeto de alcanzar los objetivos de control a nivel poblacional en los centros de salud participantes de los países que implementan el programa HEARTS.
RESUMEN
Cardiovascular disease (CVD) is the leading cause of death in the Americas and raised blood pressure accounts for over 50% of CVD. In the Americas over a quarter of adult women and four in ten adult men have hypertension and the diagnosis, treatment and control are suboptimal. In 2021, the World Health Organization (WHO) released an updated guideline for the pharmacological treatment of hypertension in adults. This policy paper highlights the facilitating role of the WHO Global HEARTS initiative and the HEARTS in the Americas initiative to catalyze the implementation of this guideline, provides specific policy advice for implementation, and emphasizes that an over-arching strategic approach for hypertension control is needed. The authors urge health advocates and policymakers to prioritize the prevention and control of hypertension to improve the health and wellbeing of their populations and to reduce CVD health disparities within and between populations of the Americas.
A doença cardiovascular (DCV) é a principal causa de morte nas Américas, e a pressão arterial elevada é responsável por mais de 50% dos casos de DCV. Nas Américas, mais de um quarto das mulheres adultas e quatro de cada dez homens adultos têm hipertensão arterial, sendo que diagnóstico, tratamento e controle estão abaixo do ideal. Em 2021, a Organização Mundial da Saúde (OMS) divulgou uma atualização das diretrizes para o tratamento medicamentoso da hipertensão arterial em adultos. Essa publicação ressalta o papel facilitador da iniciativa Global HEARTS da OMS e da iniciativa HEARTS nas Américas para catalisar a implementação dessas diretrizes, oferece recomendações específicas de políticas para sua implementação e enfatiza a necessidade de uma abordagem estratégica abrangente para o controle da hipertensão arterial. Os autores clamam para que tanto as pessoas que advogam pela Saúde, quanto as autoridades responsáveis, priorizem a prevenção e o controle da hipertensão arterial como forma de melhorar a saúde e o bem-estar das populações e reduzir as disparidades de saúde cardiovascular dentro das populações das Américas e entre elas.
RESUMEN
Background: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the Americas, and hypertension is the most significant modifiable risk factor. However, hypertension control rates remain low, and CVD mortality is stagnant or rising after decades of continuing reduction. In 2016, the World Health Organization (WHO) launched the HEARTS technical package to improve hypertension control. The Pan American Health Organization (PAHO) designed the HEARTS in the Americas Initiative to improve CVD risk management, emphasizing hypertension control, to date implemented in 21 countries. Methods: To advance implementation, an interdisciplinary group of practitioners was engaged to select the key evidence-based drivers of hypertension control and to design a comprehensive scorecard to monitor their implementation at primary care health facilities (PHC). The group studied high-performing health systems that achieve high hypertension control through quality improvement programs focusing on specific process measures, with regular feedback to providers at health facilities. Findings: The final selected eight drivers were categorized into five main domains: (1) diagnosis (blood pressure measurement accuracy and CVD risk evaluation); (2) treatment (standardized treatment protocol and treatment intensification); (3) continuity of care and follow-up; (4) delivery system (team-based care, medication refill), and (5) system for performance evaluation. The drivers and recommendations were then translated into process measures, resulting in two interconnected scorecards integrated into the HEARTS in the Americas monitoring and evaluation system. Interpretation: Focus on these key hypertension drivers and resulting scorecards, will guide the quality improvement process to achieve population control goals at the participating health centers in HEARTS implementing countries.
Fundamentos: As doenças cardiovasculares (DCV) são as principais causas de morbimortalidade nas Américas, e a hipertensão arterial (HÁ) é o fator de risco modificável mais importante. Porém, as taxas de controle da HA continuam baixas, e a mortalidade por DCV está estagnada ou aumentando após décadas de redução contínua. Em 2016, a Organização Mundial da Saúde (OMS) lançou o pacote de medidas técnicas HEARTS para melhorar o controle da HA. A Organização Pan-Americana da Saúde (OPAS) criou a iniciativa HEARTS nas Américas para melhorar a gestão do risco cardiovascular (RCV), com ênfase no controle da HA. Até agora, essa iniciativa foi implementada em 21 países. Métodos: Para impulsionar a implementação, recrutou-se um grupo multidisciplinar de profissionais para selecionar impulsionadores-chave do controle da HA com base em evidências e elaborar um scorecard completo para monitorar sua implementação em unidades de atenção primária à saúde (APS). O grupo estudou sistemas de saúde com alto desempenho que haviam conseguido atingir um alto nível de controle da HA por meio de programas de melhoria da qualidade focados em medidas específicas de processo, com feedback regular para os profissionais das unidades de saúde. Resultados: Os oito fatores impulsionadores incluídos na seleção final foram categorizados em cinco domínios principais: (1) diagnóstico (exatidão da medição da pressão arterial e avaliação do RCV); (2) tratamento (protocolo padronizado de tratamento e intensificação do tratamento); (3) continuidade do cuidado e acompanhamento; (4) modelo de atenção (atendimento baseado em equipe, renovação da prescrição); e (5) sistema de avaliação do desempenho. Em seguida, os impulsionadores e as recomendações foram transformados em medidas de processo, gerando dois scorecards inter-relacionados integrados ao sistema de monitoramento e avaliação da Iniciativa HEARTS nas Américas. Interpretação: O foco nesses impulsionadores-chave da HA e nos scorecards resultantes orientará o processo de melhoria da qualidade para atingir as metas de controle, em nível populacional, dos centros de saúde participantes nos países que estão implementando a iniciativa HEARTS.
RESUMEN
Global Hearts is the flagship initiative of the World Health Organization to reduce the burden of cardiovascular diseases, the leading cause of death and disability worldwide. HEARTS in the Americas Initiative is the regional adaptation that envisions HEARTS as the model for cardiovascular disease risk management, including hypertension and diabetes, in primary health care in the Americas by 2025. This initiative is entering its sixth year of implementation and now includes 22 countries and 1 380 primary health care centers. The objectives of this report are three-fold. First, it describes the emergence and the main elements of HEARTS in the Americas. Secondly, it summarizes the main innovations developed to catalyze and sustain implementation of the initiative. These innovations include: a) introduction of hypertension control drivers; b) development of a comprehensive and practical clinical pathway; c) development of a strategy to improve the accuracy of blood pressure measurement; d) creation of a monitoring and evaluation platform; and e) development of a standardized set of training and education resources. Thirdly, this report discusses future priorities of the initiative. The goal of implementing these innovative and pragmatic solutions is to create a more effective health system and shift the focus of cardiovascular and hypertension programs from the highly specialized care level to primary health care. In addition, HEARTS in the Americas can serve as a model for more comprehensive, effective, and sustainable noncommunicable disease prevention and treatment practices.
Global Hearts es la iniciativa emblemática de la Organización Mundial de la Salud para reducir la carga de las enfermedades cardiovasculares, la principal causa de muerte y discapacidad en todo el mundo. La iniciativa HEARTS en las Américas es la adaptación regional que propone HEARTS como modelo para el manejo del riesgo de enfermedades cardiovasculares, incluida la hipertensión, y la diabetes en la atención primaria de salud en la Región de las Américas para el año 2025. Esta iniciativa está iniciando su sexto año de aplicación y ya incluye a 22 países y 1 380 centros de atención primaria de salud. Son tres los objetivos de este informe. En primer lugar, describir cómo surgió la iniciativa HEARTS en las Américas y cuáles son sus principales elementos. En segundo lugar, resumir las principales innovaciones logradas para catalizar la iniciativa y mantener su aplicación. Entre estas innovaciones se encuentran: a) la introducción de factores impulsores del control de la hipertensión; b) el desarrollo de una vía clínica integral y práctica; c) la elaboración de una estrategia para mejorar la precisión de la medición de la presión arterial; d) la creación de un marco de seguimiento y evaluación; y e) la elaboración de un conjunto estandarizado de recursos de capacitación y formación. En tercer lugar, en este informe se examinan las futuras prioridades de la iniciativa. El objetivo de poner en marcha estas soluciones innovadoras y pragmáticas es crear un sistema de salud más efectivo y trasladar el enfoque de los programas cardiovasculares y de hipertensión del nivel de atención altamente especializada a la atención primaria de salud. Además, HEARTS en las Américas puede servir como modelo para unas prácticas más integrales, efectivas y sostenibles en la prevención y el tratamiento de las enfermedades no transmisibles.
Global Hearts é a iniciativa mais importante da Organização Mundial da Saúde para reduzir a carga de doenças cardiovasculares, que são a principal causa de morte e incapacidade em todo o mundo. A iniciativa HEARTS nas Américas é a adaptação regional que pressupõe a HEARTS como o modelo para a gestão do risco de doenças cardiovasculares, incluindo hipertensão e diabetes, na atenção primária à saúde nas Américas até 2025. Essa iniciativa está entrando em seu sexto ano de implementação e agora inclui 22 países e 1 380 centros de atenção primária à saúde. Os objetivos deste relatório são três. Primeiramente, ele descreve o surgimento e os principais elementos da iniciativa HEARTS nas Américas. Em segundo lugar, resume as principais inovações desenvolvidas para catalisar e sustentar a implementação da iniciativa. Essas inovações incluem: a) introdução de fatores impulsionadores de controle da hipertensão; b) desenvolvimento de um caminho clínico abrangente e prático; c) desenvolvimento de uma estratégia para melhorar a exatidão da aferição da pressão arterial; d) criação de uma plataforma de monitoramento e avaliação; e e) desenvolvimento de um conjunto padronizado de recursos para treinamento e educação. Em terceiro lugar, este relatório discute as futuras prioridades da iniciativa. O objetivo de implementar essas soluções inovadoras e pragmáticas é criar um sistema de saúde mais eficaz e mudar o foco dos programas cardiovasculares e de hipertensão do nível de atendimento altamente especializado para a atenção primária à saúde. Além disso, a iniciativa HEARTS nas Américas pode servir de modelo para práticas mais abrangentes, efetivas e sustentáveis de prevenção e tratamento de doenças não transmissíveis.
RESUMEN
Global Hearts is the flagship initiative of the World Health Organization to reduce the burden of cardiovascular diseases, the leading cause of death and disability worldwide. HEARTS in the Americas Initiative is the regional adaptation that envisions HEARTS as the model for cardiovascular disease risk management, including hypertension and diabetes, in primary health care in the Americas by 2025. This initiative is entering its sixth year of implementation and now includes 22 countries and 1 380 primary health care centers. The objectives of this report are three-fold. First, it describes the emergence and the main elements of HEARTS in the Americas. Secondly, it summarizes the main innovations developed to catalyze and sustain implementation of the initiative. These innovations include: a) introduction of hypertension control drivers; b) development of a comprehensive and practical clinical pathway; c) development of a strategy to improve the accuracy of blood pressure measurement; d) creation of a monitoring and evaluation platform; and e) development of a standardized set of training and education resources. Thirdly, this report discusses future priorities of the initiative. The goal of implementing these innovative and pragmatic solutions is to create a more effective health system and shift the focus of cardiovascular and hypertension programs from the highly specialized care level to primary health care. In addition, HEARTS in the Americas can serve as a model for more comprehensive, effective, and sustainable noncommunicable disease prevention and treatment practices.
Global Hearts é a iniciativa mais importante da Organização Mundial da Saúde para reduzir a carga de doenças cardiovasculares, que são a principal causa de morte e incapacidade em todo o mundo. A Iniciativa HEARTS nas Américas é a adaptação regional que pressupõe a HEARTS como o modelo para a gestão do risco de doenças cardiovasculares, incluindo hipertensão e diabetes, na atenção primária à saúde nas Américas até 2025. Essa iniciativa está entrando em seu sexto ano de implementação e agora inclui 22 países e 1 380 centros de atenção primária à saúde. Os objetivos deste relatório são três. Primeiramente, ele descreve o surgimento e os principais elementos da Iniciativa HEARTS nas Américas. Em segundo lugar, resume as principais inovações desenvolvidas para catalisar e sustentar a implementação da iniciativa. Essas inovações incluem: a) introdução de fatores impulsionadores de controle da hipertensão; b) desenvolvimento de um caminho clínico abrangente e prático; c) desenvolvimento de uma estratégia para melhorar a exatidão da aferição da pressão arterial; d) criação de uma plataforma de monitoramento e avaliação; e e) desenvolvimento de um conjunto padronizado de recursos para treinamento e educação. Em terceiro lugar, este relatório discute as futuras prioridades da iniciativa. O objetivo de implementar essas soluções inovadoras e pragmáticas é criar um sistema de saúde mais eficaz e mudar o foco dos programas cardiovasculares e de hipertensão do nível de atendimento altamente especializado para a atenção primária à saúde. Além disso, a Iniciativa HEARTS nas Américas pode servir de modelo para práticas mais abrangentes, efetivas e susten- táveis de prevenção e tratamento de doenças não transmissíveis.
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BACKGROUND: Uncontrolled hypertension is a major problem among non-Hispanic black men, who are underrepresented in pharmacist intervention trials in traditional health care settings. METHODS: We enrolled a cohort of 319 black male patrons with systolic blood pressure of 140 mm Hg or more from 52 black-owned barbershops (nontraditional health care setting) in a cluster-randomized trial in which barbershops were assigned to a pharmacist-led intervention (in which barbers encouraged meetings in barbershops with specialty-trained pharmacists who prescribed drug therapy under a collaborative practice agreement with the participants' doctors) or to an active control approach (in which barbers encouraged lifestyle modification and doctor appointments). The primary outcome was reduction in systolic blood pressure at 6 months. RESULTS: At baseline, the mean systolic blood pressure was 152.8 mm Hg in the intervention group and 154.6 mm Hg in the control group. At 6 months, the mean systolic blood pressure fell by 27.0 mm Hg (to 125.8 mm Hg) in the intervention group and by 9.3 mm Hg (to 145.4 mm Hg) in the control group; the mean reduction was 21.6 mm Hg greater with the intervention (95% confidence interval, 14.7 to 28.4; P<0.001). A blood-pressure level of less than 130/80 mm Hg was achieved among 63.6% of the participants in the intervention group versus 11.7% of the participants in the control group (P<0.001). In the intervention group, the rate of cohort retention was 95%, and there were few adverse events (three cases of acute kidney injury). CONCLUSIONS: Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in larger blood-pressure reduction when coupled with medication management in barbershops by specialty-trained pharmacists. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT02321618 .).
Asunto(s)
Antihipertensivos/uso terapéutico , Peluquería , Negro o Afroamericano , Promoción de la Salud/métodos , Hipertensión/etnología , Farmacéuticos , Presión Sanguínea/efectos de los fármacos , Estudios de Cohortes , Quimioterapia Combinada , Promoción de la Salud/estadística & datos numéricos , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/terapia , Estilo de Vida , Masculino , Persona de Mediana Edad , Autoinforme , Factores SocioeconómicosRESUMEN
BACKGROUND: We developed a new model of hypertension care for non-Hispanic black men that links health promotion by barbers to medication management by American Society of Hypertension-certified pharmacists and demonstrated efficacy in a 6-month cluster-randomized trial. The marked reduction in systolic blood pressure (BP) seen at 6 months warranted continuing the trial through 12 months to test sustainability, a necessary precondition for implementation research. METHODS: We enrolled a cohort of 319 black male patrons with systolic BP ≥140 mm Hg at baseline. Fifty-two Los Angeles County barbershops were assigned to either a pharmacist-led intervention or an active control group. In the intervention group, barbers promoted follow-up with pharmacists who prescribed BP medication under a collaborative practice agreement with patrons' primary care providers. In the control group, barbers promoted follow-up with primary care providers and lifestyle modification. After BP assessment at 6 months, the intervention continued with fewer in-person pharmacist visits to test whether the intervention effect could be sustained safely for 1 year while reducing pharmacist travel time. Final BP and safety outcomes were assessed in both groups at 12 months. RESULTS: At baseline, mean systolic BP was 152.4 mm Hg in the intervention group and 154.6 mm Hg in the control group. At 12 months, mean systolic BP fell by 28.6 mm Hg (to 123.8 mm Hg) in the intervention group and by 7.2 mm Hg (to 147.4 mm Hg) in the control group. The mean reduction was 20.8 mm Hg greater in the intervention (95% CI, 13.9-27.7; P<0.0001). A BP <130/80 mm Hg was achieved by 68.0% of the intervention group versus 11.0% of the control group ( P<0.02). These new 12-month efficacy data are statistically indistinguishable from our previously reported 6-month data. No treatment-related serious adverse events occurred in either group over 12 months. Cohort retention at 12 months was 90% in both groups. CONCLUSIONS: Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in large and sustained BP reduction over 12 months when coupled with medication management by American Society of Hypertension-certified pharmacists. Broad-scale implementation research is both justified and warranted. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT 02321618.
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Antihipertensivos/uso terapéutico , Peluquería , Negro o Afroamericano , Presión Sanguínea/efectos de los fármacos , Servicios Comunitarios de Farmacia/organización & administración , Promoción de la Salud/organización & administración , Hipertensión/tratamiento farmacológico , Farmacéuticos/organización & administración , Adulto , Negro o Afroamericano/psicología , Anciano , Características Culturales , Conocimientos, Actitudes y Práctica en Salud/etnología , Humanos , Hipertensión/etnología , Hipertensión/fisiopatología , Hipertensión/psicología , Los Angeles , Masculino , Persona de Mediana Edad , Aceptación de la Atención de Salud/etnología , Rol Profesional , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: This review summarizes the results of recent barbershop-based studies focusing on the diagnosis and management of hypertension (HTN) in black adults. The pitfalls of prior attempts and opportunities for the development of future programs to address health disparities on a larger scale are also reviewed. RECENT FINDINGS: While barbershop health outreach has become a commonplace in recent years, the quality of the evidence on the effectiveness of such programs has been weak, until the Los Angeles Barbershop Blood Pressure Study (LABBPS), a rigorously carried out cluster-randomized trial, demonstrated a - 21 mmHg greater reduction in BP among black hypertensive men who were assigned to a pharmacist-led HTN intervention when compared with usual care. Given the available evidence, barber health promotion paired with focused hypertension-specialty care has the potential to reduce, if not eliminate, the present wide gap in hypertension care and ultimately lead to a reduction of hypertension-related complications among blacks. Future research should seek to improve the scalability and transferability of the LABBPS model both to other geographic regions and to other at-risk groups.
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Peluquería , Hipertensión , Adulto , Negro o Afroamericano , Presión Sanguínea , Promoción de la Salud , Humanos , MasculinoRESUMEN
INTRODUCTION: Hyperaldosteronism (HA) is a common cause of secondary hypertension and may contribute to resistant hypertension (RH). The authors sought to determine and characterize HA screening, positivity rates, and mineralocorticoid receptor antagonist (MRA) use among patients with RH. METHODS: A cross-sectional study was performed within Kaiser Permanente Southern California (7/1/2012-6/30/2017). Using contemporary criteria, RH was defined as blood pressure uncontrolled (≥ 130/80) on ≥ 3 medications or requiring ≥ 4 antihypertensive medications. The primary outcome was screening rate for HA defined as any aldosterone and plasma renin activity measurement. Secondary outcomes were HA screen positive rates and MRA use among all patients with RH. Multivariable logistic regression analysis was used to estimate odds ratio (with 95% confidence intervals) for factors associated with HA screening and for patients that screened positive. RESULTS: Among 102,480 patients identified as RH, 1977 (1.9%) were screened for HA and 727 (36.8%) screened positive for HA. MRA use was 6.5% among all patients with RH (22.5% among screened, 31.2% among screened positive). Black race, potassium < 4, bicarbonate > 29, chronic kidney disease, obstructive sleep apnea, and systolic blood pressure were associated with HA screening, but only Black race (1.55 [1.20-2.01]), potassium (1.82 [1.48-2.24]), bicarbonate levels (1.39 [1.10-1.75]), and diastolic blood pressure (1.15 [1.03-1.29]) were associated with positive screenings. CONCLUSION: The authors' findings demonstrate low screening rates for HA among patients with difficult-to-control hypertension yet a high positivity rate among those screened. Factors associated with screening did not always correlate with screening positive. Screening and targeted use of MRA may lead to improved blood pressure control and outcomes among patients with RH.
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Prestación Integrada de Atención de Salud , Hiperaldosteronismo , Hipertensión , Humanos , Estudios Transversales , Bicarbonatos/uso terapéutico , Hipertensión/diagnóstico , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Hiperaldosteronismo/complicaciones , Hiperaldosteronismo/diagnóstico , Potasio/uso terapéuticoRESUMEN
Background: HEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative. It is implemented in 24 countries and over 2,000 primary healthcare facilities. This paper describes the results of a multicomponent, stepwise, quality improvement intervention designed by the HEARTS in the Americas to support advances in hypertension treatment protocols and evolution towards the Clinical Pathway. Methods: The quality improvement intervention comprised: 1) the use of the appraisal checklist to evaluate the current hypertension treatment protocols, 2) a peer-to-peer review and consensus process to resolve discrepancies, 3) a proposal of a clinical pathway to be considered by the countries, and 4) a process of review, adopt/adapt, consensus and approval of the clinical pathway by the national HEARTS protocol committee. A year later, 16 participants countries (10 and 6 from each cohort, respectively) were included in a second evaluation using the HEARTS appraisal checklist. We used the median and interquartile scores range and the percentages of the maximum possible total score for each domain as a performance measure to compare the results pre and post-intervention. Results: Among the eleven protocols from the ten countries in the first cohort, the baseline assessment achieved a median overall score of 22 points (ICR 18 -23.5; 65% yield). After the intervention, the overall score reached a median of 31.5 (ICR 28.5 -31.5; 93% yield). The second cohort of countries developed seven new clinical pathways with a median score of 31.5 (ICR 31.5 -32.5; 93% yield). The intervention was effective in three domains: 1. implementation (clinical follow-up intervals, frequency of drug refills, routine repeat blood pressure measurement when the first reading is off-target, and a straightforward course of action). 2. treatment (grouping all medications in a single daily intake and using a combination of two antihypertensive medications for all patients in the first treatment step upon the initial diagnosis of hypertension) and 3. management of cardiovascular risk (lower BP thresholds and targets based on CVD risk level, and the use of aspirin and statins in high-risk patients). Conclusion: This study confirms that this intervention was feasible, acceptable, and instrumental in achieving progress in all countries and all three domains of improvement: implementation, blood pressure treatment, and cardiovascular risk management. It also highlights the challenges that prevent a more rapid expansion of HEARTS in the Americas and confirms that the main barriers are in the organization of health services: drug titration by non-physician health workers, the lack of long-acting antihypertensive medications, lack of availability of fixed-doses combination in a single pill and cannot use high-intensity statins in patients with established cardiovascular diseases. Adopting and implementing the HEARTS Clinical Pathway can improve the efficiency and effectiveness of hypertension and cardiovascular disease risk management programs.
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Hypertension is one of the most important risk factors that contribute to incident cardiovascular events. A multitude of US and international hypertension guidelines, scientific statements, and policy statements have recommended evidence-based approaches for hypertension management and improved blood pressure (BP) control. These recommendations are based largely on high-quality observational and randomized controlled trial data. However, recent published data demonstrate troubling temporal trends with declining BP control in the United States after decades of steady improvements. Therefore, there is a widening disconnect between what hypertension experts recommend and actual BP control in practice. This scientific statement provides information on the implementation strategies to optimize hypertension management and to improve BP control among adults in the United States. Key approaches include antiracism efforts, accurate BP measurement and increased use of self-measured BP monitoring, team-based care, implementation of policies and programs to facilitate lifestyle change, standardized treatment protocols using team-based care, improvement of medication acceptance and adherence, continuous quality improvement, financial strategies, and large-scale dissemination and implementation. Closing the gap between scientific evidence, expert recommendations, and achieving BP control, particularly among disproportionately affected populations, is urgently needed to improve cardiovascular health.
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American Heart Association , Hipertensión , Estados Unidos/epidemiología , Adulto , Humanos , Presión Sanguínea , American Medical Association , Hipertensión/diagnóstico , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Determinación de la Presión SanguíneaRESUMEN
Importance: A higher percentage of non-Hispanic Black (hereinafter, Black) adults vs non-Hispanic White (hereinafter, White) adults with hypertension have uncontrolled blood pressure (BP) contributing to racial and ethnic disparities in cardiovascular disease. In 2010, Kaiser Permanente Southern California began implementing quality improvement (QI) strategies aimed at reducing this disparity. Objective: To examine the change in BP control between Black and White patients before and after the implementation of a QI program. Design, Setting, and Participants: A QI quasi-experimental, difference-in-difference analysis was conducted of Kaiser Permanente Southern California patients 18 years or older included in the population care management hypertension registry. The study was conducted from December 31, 2008, to December 31, 2019. Data analysis was performed from November 20, 2020, to November 7, 2022. Interventions: Quality improvement program implementation began in 2010. Main Outcomes and Measures: Blood pressure control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg) was assessed using the last outpatient BP measurement in each calendar year. Changes in BP control between Black and White patients from before (2008-2009) to after (2016-2019) implementation of the QI program were examined using a difference-in-difference analysis. Blood pressure control disparities from 2008 through 2019 by age, sex, race and ethnicity, and factors associated with BP control were examined. Results: The number of patients with hypertension increased from 624â¯094 in 2008 (mean [SD] age, 61.8 [13.5] years; 330 551 [53.0%] female patients; 89 407 [14.3%] Black and 284 116 [45.5%] White patients) to 855â¯257 in 2019 (mean [SD] age, 64.5 [13.6] years; 444 422 [52.0%] female patients; 107 054 [12.5%] Black and 331 932 [38.8%] White patients). Blood pressure control increased an absolute 4.6% (95% CI, 4.3%-4.8%) among Black patients and 2.1% (95% CI, 2.0%-2.2%) among White patients from before to after the QI program implementation (difference-in-difference: 2.5%; 95% CI, 2.2%-2.8%). The largest reduction in BP control disparity between Black and White female patients was for those aged 50 to 64 years (difference-in-difference: 3.8%; 95% CI, 3.2%-4.4%) and for those aged 18 to 49 years between Black and White male patients (difference-in-difference: 4.2%; 95% CI, 3.0%-5.5%). The proportion of BP control among Black male patients aged 18 to 49 years was the lowest throughout 2008-2019 compared with male and female patients in other age and racial and ethnic groups. In 2019, uncontrolled BP was more common among Black vs White patients (prevalence ratio: 1.13; 95% CI, 1.12-1.14). Conclusions and Relevance: This QI program noted that disparities in BP control between Black and White patients were decreased but not eliminated following implementation of QI strategies aimed at reducing disparities in BP control. These findings suggest that more focused interventions may be needed to increase BP control among Black individuals.
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Prestación Integrada de Atención de Salud , Hipertensión , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Presión Sanguínea , Hipertensión/epidemiología , Mejoramiento de la Calidad , Población Blanca , Población NegraRESUMEN
Cardiovascular disease (CVD) is the leading cause of death in the Americas and raised blood pressure accounts for over 50% of CVD. In the Americas over a quarter of adult women and four in ten adult men have hypertension and the diagnosis, treatment and control are suboptimal. In 2021, the World Health Organization (WHO) released an updated guideline for the pharmacological treatment of hypertension in adults. This policy paper highlights the facilitating role of the WHO Global HEARTS initiative and the HEARTS in the Americas initiative to catalyze the implementation of this guideline, provides specific policy advice for implementation, and emphasizes that an overarching strategic approach for hypertension control is needed. The authors urge health advocates and policymakers to prioritize the prevention and control of hypertension to improve the health and wellbeing of their populations and to reduce CVD health disparities within and between populations of the Americas.
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BACKGROUND: Therapy with angiotensinconverting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) requires laboratory monitoring to avoid hyperkalemia and acute kidney failure. OBJECTIVE: To assess the frequency of recommended annual serum potassium and creatinine monitoring and determine potential factors associated with care gaps among adults dispensed an ACEI or ARB. METHODS: This mixed-methods study integrated findings from a retrospective cohort study and individual patient interviews. Adults aged 21 years and over within Kaiser Permanente Southern California with at least 180 treatment days of an ACEI and/or ARB in 2015 were included. Patients invited for qualitative interviews included those who did and did not complete the recommended laboratory tests. We assessed the proportion of patients completing both recommended laboratory tests, factors associated with not receiving laboratory monitoring, and patients' insights into barriers and facilitators of recommended monitoring. RESULTS: Of 437,544 patients who received an ACEI or ARB, 9.0% did not receive both a serum potassium and creatinine laboratory test during treatment (defined as a care gap). Lower risk of a care gap was observed for patients with increasing age (rate ratio [RR] per 10-year increase = 0.78, 95% CI = 0.77-0.79); diabetes mellitus (RR = 0.62, 95% CI = 0.60-0.64); hypertension (RR = 0.71, 95% CI = 0.71-0.74); Charlson Comorbidity Index score of at least 2 (RR = 0.62, 95% CI = 0.60-0.64); those who changed medication classes (RR = 0.53, 95% CI = 0.51-0.56); and patients with a cardiologist (RR = 0.81, 95% CI = 0.73-0.90) or nephrologist (RR = 0.60, 95% CI = 0.52-0.69) as their prescribing provider. Twenty-five patients completed the qualitative interviews. Patients often lacked knowledge about the need for laboratory monitoring, cited logistical barriers to accessing the laboratory, and deemed the reminders they received through an outpatient safety program as a facilitator to completing tests. CONCLUSIONS: Given the large patient population on ACEI and ARB medications, monitoring and support strategies such as electronic clinical surveillance could be important in addressing care gaps and potentially reducing adverse drug effects. DISCLOSURES: This project was supported by grant number R01HS024437 from the Agency for Healthcare Research and Quality. The funder had no role in the design of the study; collection, analyses, or interpretation of the data, or decision to submit this manuscript for publication. Harrison, Reynolds, Hahn, Munoz-Plaza, Yi, Fischer, Luong, Sim, Brettler, Handler, and Mittman are employees of the Southern California Permanente Medical Group. Danworth was employed by the Southern California Permanente Medical Group at the time of this study. Singh was partially supported by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN13-413). Reynolds reports grants from Novartis, Amgen Inc., and Vital Strategies, Resolve to Save Lives, unrelated to this work. Yi reports grants from Novartis unrelated to this work. Kanter has nothing to disclose.