Integration of a multicomponent intervention for hypertension into primary healthcare services in Singapore-A cluster randomized controlled trial.

BACKGROUND: Despite availability of clinical practice guidelines for hypertension management, blood pressure (BP) control remains sub-optimal (<30%) even in high-income countries. This study aims to assess the effectiveness of a potentially scalable multicomponent intervention integrated into primary care system compared to usual care on BP control. METHODS AND FINDINGS: A cluster-randomized controlled trial was conducted in 8 government clinics in Singapore. The trial enrolled 916 patients aged ≥40 years with uncontrolled hypertension (systolic BP (SBP) ≥140 mmHg or diastolic BP (DBP) ≥90 mmHg). Multicomponent intervention consisted of physician training in risk-based treatment of hypertension, subsidized losartan-HCTZ single-pill combination (SPC) medications, nurse training in motivational conversations (MCs), and telephone follow-ups. Usual care (controls) comprised of routine care in the clinics, no MC or telephone follow-ups, and no subsidy on SPCs. The primary outcome was mean SBP at 24 months' post-baseline. Four clinics (447 patients) were randomized to intervention and 4 (469) to usual care. Patient enrolment commenced in January 2017, and follow-up was during December 2018 to September 2020. Analysis used intention-to-treat principles. The primary outcome was SBP at 24 months. BP at baseline, 12 and 24 months was modeled at the patient level in a likelihood-based, linear mixed model repeated measures analysis with treatment group, follow-up, treatment group × follow-up interaction as fixed effects, and random cluster (clinic) effects. A total of 766 (83.6%) patients completed 2-year follow-up. A total of 63 (14.1%) and 87 (18.6%) patients in intervention and in usual care, respectively, were lost to follow-up. At 24 months, the adjusted mean SBP was significantly lower in the intervention group compared to usual care (-3.3 mmHg; 95% CI: -6.34, -0.32; p = 0.03). The intervention led to higher BP control (odds ratio 1.51; 95% CI: 1.10, 2.09; p = 0.01), lower odds of high (>20%) 10-year cardiovascular risk score (OR 0.67; 95% CI: 0.47, 0.97; p = 0.03), and lower mean log albuminuria (-0.22; 95% CI: -0.41, -0.02; p = 0.03). Mean DBP, mortality rates, and serious adverse events including hospitalizations were not different between groups. The main limitation was no masking in the trial. CONCLUSIONS: A multicomponent intervention consisting of physicians trained in risk-based treatment, subsidized SPC medications, nurse-delivered motivational conversation, and telephone follow-ups improved BP control and lowered cardiovascular risk. Wide-scale implementation of a multicomponent intervention such as the one in our trial is likely to reduce hypertension-related morbidity and mortality globally. TRIAL REGISTRATION: Trial Registration: Clinicaltrials.gov NCT02972619.

Accuracy of urinary symptoms and urine microscopy in diagnosing urinary tract infection in women.

BACKGROUND: Women with urinary tract infections (UTIs) often present with urinary complaints such as frequency of micturition, dysuria, foul-smelling urine and other non-specific symptoms like fever. Physicians may order urine microscopy to guide empirical antibiotic prescription. However, the performance of this approach has not been assessed. OBJECTIVES: This study aimed to determine the accuracy of UTI symptoms and urine microscopy associated with culture-positive UTI in Asian women. METHODS: A cross-sectional study of adult women who presented with UTI-related symptoms was conducted at three public primary care clinics in Singapore. Demographic data and information on their symptoms were collected, followed by urine microscopy and culture to diagnose UTI. The sensitivity, specificity, positive (PPV), negative predictive values (NPV), accuracy (ACC) and area under curve (AUC) of combinations of symptom and urine investigations were analysed in association with culture-positive UTI, which was regarded as a benchmark. RESULTS: Data on 564 women (73.9% Chinese, 11.5% Malay, 8.2% Indian) were analysed, of which 259 (45.9%) had culture-positive UTI. Frequency and foul-smelling urine, pyuria (WBC ≥10/hpf) and semi-quantitative bacterial count (≥2+) were significantly associated with positive urine culture. The ACC and AUC for single or multiple urinary and/or general symptoms were low. Urine pyuria (minimally >10/hpf) alone or in combination with symptoms and/or semi-quantitative bacterial count achieved high sensitivity (>85%) and PPV, NPV, ACC and AUC of >70%. CONCLUSION: Urinary symptoms have limited accuracy in diagnosing culture-positive UTI. Concurrent urine microscopy showing presence of pyuria and/or bacterial count increased the diagnostic accuracy of culture-positive UTI.

Wireless Home Blood Pressure Monitoring System With Automatic Outcome-Based Feedback and Financial Incentives to Improve Blood Pressure in People With Hypertension: Protocol for a Randomized Controlled Trial.

BACKGROUND: Hypertension is prevalent in Singapore and is a major risk factor for cardiovascular morbidity and mortality and increased health care costs. Strategies to lower blood pressure include lifestyle modifications and home blood pressure monitoring. Nonetheless, adherence to home blood pressure monitoring remains low. This protocol details an algorithm for remote management of primary care patients with hypertension. OBJECTIVE: The objective of this study was to determine whether wireless home blood pressure monitoring with or without financial incentives is more effective at reducing systolic blood pressure than nonwireless home blood pressure monitoring (usual care). METHODS: This study was designed as a randomized controlled open-label superiority study. A sample size of 224 was required to detect differences of 10 mmHg in average systolic blood pressure. Participants were to be randomized, in the ratio of 2:3:3, into 1 of 3 parallel study arms :(1) usual care, (2) wireless home blood pressure monitoring, and (3) wireless home blood pressure monitoring with financial incentives. The primary outcome was the mean change in systolic blood pressure at month 6. The secondary outcomes were the mean reduction in diastolic blood pressure, cost of financial incentives, time taken for the intervention, adherence to home blood pressure monitoring, effectiveness of the framing of financial incentives in decreasing nonadherence to blood pressure self-monitoring and the adherence to antihypertensive medication at month 6. RESULTS: This study was approved by SingHealth Centralised Institutional Review Board and registered. Between January 24, 2018 and July 10, 2018, 42 participants (18.75% of the required sample size) were enrolled, and 33 participants completed the month 6 assessment by January 31, 2019. CONCLUSIONS: Due to unforeseen events, the study was stopped prematurely; therefore, no results are available. Depending on the blood pressure information received from the patients, the algorithm can trigger immediate blood pressure advice (eg, Accident and Emergency department visit advice for extremely high blood pressure), weekly feedback on blood pressure monitoring, medication titration, or skipping of routine follow-ups. The inclusion of financial incentives framed as health capital provides a novel idea on how to promote adherence to remote monitoring, and ultimately, improve chronic disease management. TRIAL REGISTRATION: ClinicalTrials.gov NCT03368417; https://clinicaltrials.gov/ct2/show/NCT03368417. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/27496.