Pharmacy-based hypertension care employing mHealth in Lagos, Nigeria - a mixed methods feasibility study.

BACKGROUND: Access to quality hypertension care is often poor in sub-Saharan Africa. Some community pharmacies offer hypertension monitoring services, with and without involvement of medical doctors. To directly connect pharmacy staff and cardiologists a care model including a mobile application (mHealth) for remote patient monitoring was implemented and pilot tested in Lagos, Nigeria. Pharmacists provided blood pressure measurements and counselling. Cardiologists enrolled patients in the pilot program and remotely monitored them, for which patients paid a monthly fee. We evaluated the feasibility of this care model at five private community pharmacies. Outcome measures were retention in care, blood pressure change, quality of care, and patients' and healthcare providers' satisfaction with the care model. METHODS: Patients participated in the care model's pilot at one of the five pharmacies for approximately 6-8 months from February 2016. We conducted structured patient interviews and blood pressure measurements at pilot entry and exit, and used exports of the mHealth-application, in-depth interviews and focus group discussions with patients, pharmacists and cardiologists. RESULTS: Of 336 enrolled patients, 236 (72%) were interviewed at pilot entry and exit. According to the mHealth data 71% returned to the pharmacy after enrollment, with 3.3 months (IQR: 2.2-5.4) median duration of activity in the mHealth-application. Patients self-reported more visits than recorded in the mHealth data. Pharmacists mentioned use of paper records, understaffing, the application not being user-friendly, and patients' unwillingness to pay as reasons for underreporting. Mean systolic blood pressure decreased 9.9 mmHg (SD: 18). Blood pressure on target increased from 24 to 56% and an additional 10% had an improved blood pressure at endline, however this was not associated with duration of mHealth activity. Patients were satisfied because of accessibility, attention, adherence and information provision. CONCLUSION: Patients, pharmacists and cardiologists adopted the care model, albeit with gaps in mHealth data. Most patients were satisfied, and their mean blood pressure significantly reduced. Usage of the mHealth application, pharmacy incentives, and a modified financing model are opportunities for improvement. In addition, costs of implementation and availability of involved healthcare providers need to be investigated before such a care model can be further implemented.

The effect of health insurance and health facility-upgrades on hospital deliveries in rural Nigeria: a controlled interrupted time-series study.

BACKGROUND: Access to quality obstetric care is considered essential to reducing maternal and new-born mortality. We evaluated the effect of the introduction of a multifaceted voluntary health insurance programme on hospital deliveries in rural Nigeria. METHODS: We used an interrupted time-series design, including a control group. The intervention consisted of providing voluntary health insurance covering primary and secondary healthcare, including antenatal and obstetric care, combined with improving the quality of healthcare facilities. We compared changes in hospital deliveries from 1 May 2005 to 30 April 2013 between the programme area and control area in a difference-in-differences analysis with multiple time periods, adjusting for observed confounders. Data were collected through household surveys. Eligible households ( n = 1500) were selected from a stratified probability sample of enumeration areas. All deliveries during the 4-year baseline period ( n = 460) and 4-year follow-up period ( n = 380) were included. FINDINGS: Insurance coverage increased from 0% before the insurance was introduced to 70.2% in April 2013 in the programme area. In the control area insurance coverage remained 0% between May 2005 and April 2013. Although hospital deliveries followed a common stable trend over the 4 pre-programme years ( P = 0.89), the increase in hospital deliveries during the 4-year follow-up period in the programme area was 29.3 percentage points (95% CI: 16.1 to 42.6; P < 0.001) greater than the change in the control area (intention-to-treat impact), corresponding to a relative increase in hospital deliveries of 62%. Women who did not enroll in health insurance but who could make use of the upgraded care delivered significantly more often in a hospital during the follow-up period than women living in the control area ( P = 0.04). CONCLUSIONS: Voluntary health insurance combined with quality healthcare services is highly effective in increasing hospital deliveries in rural Nigeria, by improving access to healthcare for insured and uninsured women in the programme area.

Enablers and barriers for implementing high-quality hypertension care in a rural primary care setting in Nigeria: perspectives of primary care staff and health insurance managers.

BACKGROUND: Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care. OBJECTIVE: We explored perspectives of primary care staff and health insurance managers on enablers and barriers for implementing high-quality hypertension care, in the context of a community-based health insurance programme in rural Nigeria. DESIGN: Qualitative study using semi-structured individual interviews with primary care staff (n = 11) and health insurance managers (n=4). Data were analysed using standard qualitative techniques. RESULTS: Both stakeholder groups perceived health insurance as an important facilitator for implementing high-quality hypertension care because it covered costs of care for patients and provided essential resources and incentives to clinics: guidelines, staff training, medications, and diagnostic equipment. Perceived inhibitors included the following: high staff workload; administrative challenges at facilities; discordance between healthcare provider and insurer on how health insurance and provider payment methods work; and insufficient fit between some guideline recommendations and tools for patient education and characteristics/needs of the local patient population. Perceived strategies to address inhibitors included the following: task-shifting; adequate provider payment benchmarking; good provider-insurer relationships; automated administration systems; and tailoring guidelines/patient education. CONCLUSIONS: By providing insights into perspectives of primary care providers and health insurance managers, this study offers information on potential strategies for implementing high-quality hypertension care for insured patients in SSA.

Sustained effect of health insurance and facility quality improvement on blood pressure in adults with hypertension in Nigeria: A population-based study.

BACKGROUND: Hypertension is a leading risk factor for death in sub-Saharan Africa. Quality treatment is often not available nor affordable. We assessed the effect of a voluntary health insurance program, including quality improvement of healthcare facilities, on blood pressure (BP) in hypertensive adults in rural Nigeria. METHODS: We compared changes in outcomes from baseline (2009) to midline (2011) and endline (2013) between non-pregnant hypertensive adults in the insurance program area (PA) and a control area (CA), through household surveys. The primary outcome was the difference between the PA and CA in change in BP, using difference-in-differences analysis. RESULTS: Of 1500 eligible households, 1450 (96.7%) participated, including 559 (20.8%) hypertensive individuals, of which 332 (59.4%) had follow-up data. Insurance coverage increased from 0% at baseline to 41.8% at endline in the PA and remained under 1% in the CA. The PA showed a 4.97 mm Hg (95% CI: -0.76 to +10.71 mm Hg) greater decrease in systolic BP and a 1.81 mm Hg (-1.06 to +4.68 mm Hg) greater decrease in diastolic BP from baseline to endline compared to the CA. Respondents with stage 2 hypertension showed an 11.43 mm Hg (95% CI: 1.62 to 21.23 mm Hg) greater reduction in systolic BP and 3.15 mm Hg (-1.22 to +7.53 mm Hg) greater reduction in diastolic BP in the PA compared to the CA. Attrition did not affect the results. CONCLUSION: Access to improved quality healthcare through an insurance program in rural Nigeria was associated with a significant longer-term reduction in systolic BP in subjects with moderate or severe hypertension.

Costs and Cost-Effectiveness of Hypertension Screening and Treatment in Adults with Hypertension in Rural Nigeria in the Context of a Health Insurance Program.

BACKGROUND: High blood pressure is a leading risk factor for death and disability in sub-Saharan Africa (SSA). We evaluated the costs and cost-effectiveness of hypertension care provided within the Kwara State Health Insurance (KSHI) program in rural Nigeria. METHODS: A Markov model was developed to assess the costs and cost-effectiveness of population-level hypertension screening and subsequent antihypertensive treatment for the population at-risk of cardiovascular disease (CVD) within the KSHI program. The primary outcome was the incremental cost per disability-adjusted life year (DALY) averted in the KSHI scenario compared to no access to hypertension care. We used setting-specific and empirically-collected data to inform the model. We defined two strategies to assess eligibility for antihypertensive treatment based on 1) presence of hypertension grade 1 and 10-year CVD risk of >20%, or grade 2 hypertension irrespective of 10-year CVD risk (hypertension and risk based strategy) and 2) presence of hypertension in combination with a CVD risk of >20% (risk based strategy). We generated 95% confidence intervals around the primary outcome through probabilistic sensitivity analysis. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the reference scenario. RESULTS: Screening and treatment for hypertension was potentially cost-effective but the results were sensitive to changes in underlying assumptions with a wide range of uncertainty. The incremental cost-effectiveness ratio for the first and second strategy respectively ranged from US$ 1,406 to US$ 7,815 and US$ 732 to US$ 2,959 per DALY averted, depending on the assumptions on risk reduction after treatment and compared to no access to antihypertensive treatment. CONCLUSIONS: Hypertension care within a subsidized private health insurance program may be cost-effective in rural Nigeria and public-private partnerships such as the KSHI program may provide opportunities to finance CVD prevention care in SSA.

Costs of cardiovascular disease prevention care and scenarios for cost saving: a micro-costing study from rural Nigeria.

OBJECTIVE: To assess the costs of cardiovascular disease (CVD) prevention care according to international guidelines, in a primary healthcare clinic in rural Nigeria, participating in a health insurance programme. METHODS: A micro-costing study was conducted from a healthcare provider perspective. Activities per patient per year (e.g., consultations, diagnostic tests) were based on clinical practice in the study clinic. Direct (e.g., staff, drugs) and indirect cost items (overheads) for each activity were measured. A cohort study, patient and staff observations, and interviews in the study clinic provided patient resource utilization data. Univariate sensitivity analyses were performed. Scenario analyses evaluated cost-saving options. The main outcome was the costs of CVD prevention care per patient per year. RESULTS: The costs of CVD prevention care were United States dollars (USD) 144 (range 130-158) per patient per year. Direct costs were USD 82 and indirect costs were USD 62. The main cost drivers were drugs (USD 39) and diagnostic tests (USD 36). The costs of hypertension care were USD 118 (107-132) and that of diabetes care USD 263 (236-289) per patient per year. A combination of task-shifting from doctors to nurses, reduction of appointment frequencies, and minimal organ damage screening would result in a direct cost reduction of 42%. CONCLUSION: This is the first study to report the costs of CVD prevention care in sub-Saharan Africa, based on prospectively collected operational data. The costs observed in our study are unaffordable in many countries in sub-Saharan Africa, highlighting the need for innovative financing mechanisms to fund CVD prevention care.

Improving Maternal Care through a State-Wide Health Insurance Program: A Cost and Cost-Effectiveness Study in Rural Nigeria.

BACKGROUND: While the Nigerian government has made progress towards the Millennium Development Goals, further investments are needed to achieve the targets of post-2015 Sustainable Development Goals, including Universal Health Coverage. Economic evaluations of innovative interventions can help inform investment decisions in resource-constrained settings. We aim to assess the cost and cost-effectiveness of maternal care provided within the new Kwara State Health Insurance program (KSHI) in rural Nigeria. METHODS AND FINDINGS: We used a decision analytic model to simulate a cohort of pregnant women. The primary outcome is the incremental cost effectiveness ratio (ICER) of the KSHI scenario compared to the current standard of care. Intervention cost from a healthcare provider perspective included service delivery costs and above-service level costs; these were evaluated in a participating hospital and using financial records from the managing organisations, respectively. Standard of care costs from a provider perspective were derived from the literature using an ingredient approach. We generated 95% credibility intervals around the primary outcome through probabilistic sensitivity analysis (PSA) based on a Monte Carlo simulation. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the base case separately through a scenario analysis. Finally, we assessed the sustainability and feasibility of this program's scale up within the State's healthcare financing structure through a budget impact analysis. The KSHI scenario results in a health benefit to patients at a higher cost compared to the base case. The mean ICER (US$46.4/disability-adjusted life year averted) is considered very cost-effective compared to a willingness-to-pay threshold of one gross domestic product per capita (Nigeria, US$ 2012, 2,730). Our conclusion was robust to uncertainty in parameters estimates (PSA: median US$49.1, 95% credible interval 21.9-152.3), during one-way sensitivity analyses, and when cost, quality, cost and utilization parameters of the base case scenario were changed. The sustainability of this program's scale up by the State is dependent on further investments in healthcare. CONCLUSIONS: This study provides evidence that the investment made by the KSHI program in rural Nigeria is likely to have been cost-effective; however, further healthcare investments are needed for this program to be successfully expanded within Kwara State. Policy makers should consider supporting financial initiatives to reduce maternal mortality tackling both supply and demand issues in the access to care.

Feasibility and quality of cardiovascular disease prevention within a community-based health insurance program in rural Nigeria: an operational cohort study.

OBJECTIVE: To assess the feasibility of providing guideline-based cardiovascular disease (CVD) prevention care within the context of a community-based health insurance program (CBHI) in rural Nigeria. METHODS: A prospective operational cohort study was conducted in a primary healthcare clinic in rural Nigeria, participating in a CBHI program. The insurance program provided access to care and improved the quality of the clinics participating in the program, including CVD prevention guideline implementation. Insured adults at risk of CVD were consecutively included upon clinic attendance. The primary outcome was quality of care determined by scoring of quality indicators on patient files of the cohort, 1.5 year after guideline implementation. RESULTS: Of the 368 screened patients, 349 were included and 323 (93%) completed 1 year of follow-up. The majority of patients (331, 95%) had hypertension. Process indicators showed that 114/115 (99%) new hypertension cases had a record of CVD risk assessment and 249/333 (75%) eligible cases a record of lifestyle advice. Outcome indicators showed that in 292/328 (64%) hypertension cases, blood pressure was on target. Barriers to care included limited human resources, limited affordability of diagnostic tests and multidrug regimes for the healthcare provider, frequent doctor's appointments, and inefficient drug supplies. CONCLUSION: Implementation of CVD prevention care within the context of a CBHI program resulted in high-quality care in rural sub-Saharan Africa, comparable to high-income countries. However, guideline implementation was resource-intense and specific recommendations were not feasible. Simple models of care delivery are needed for rapid scale-up of CVD prevention services in sub-Saharan Africa.

Effect of health insurance and facility quality improvement on blood pressure in adults with hypertension in Nigeria: a population-based study.

IMPORTANCE Hypertension is a major public health problem in sub-Saharan Africa, but the lack of affordable treatment and the poor quality of health care compromise antihypertensive treatment coverage and outcomes. OBJECTIVE To report the effect of a community-based health insurance (CBHI) program on blood pressure in adults with hypertension in rural Nigeria. DESIGN, SETTING, AND PARTICIPANTS We compared changes in outcomes from baseline (2009) between the CBHI program area and a control area in 2011 through consecutive household surveys. Households were selected from a stratified random sample of geographic areas. Among 3023 community-dwelling adults, all nonpregnant adults (aged ≥18 years) with hypertension at baseline were eligible for this study. INTERVENTION Voluntary CBHI covering primary and secondary health care and quality improvement of health care facilities. MAIN OUTCOMES AND MEASURES The difference in change in blood pressure from baseline between the program and the control areas in 2011, which was estimated using difference-in-differences regression analysis. RESULTS Of 1500 eligible households, 1450 (96.7%) participated, including 564 adults with hypertension at baseline (313 in the program area and 251 in the control area). Longitudinal data were available for 413 adults (73.2%) (237 in the program area and 176 in the control area). Baseline blood pressure in respondents with hypertension who had incomplete data did not differ between areas. Insurance coverage in the hypertensive population increased from 0% to 40.1% in the program area (n = 237) and remained less than 1% in the control area (n = 176) from 2009 to 2011. Systolic blood pressure decreased by 10.41 (95% CI, -13.28 to -7.54) mm Hg in the program area, constituting a 5.24 (-9.46 to -1.02)-mm Hg greater reduction compared with the control area (P = .02), where systolic blood pressure decreased by 5.17 (-8.29 to -2.05) mm Hg. Diastolic blood pressure decreased by 4.27 (95% CI, -5.74 to -2.80) mm Hg in the program area, a 2.16 (-4.27 to -0.05)-mm Hg greater reduction compared with the control area, where diastolic blood pressure decreased by 2.11 (-3.80 to -0.42) mm Hg (P = .04). CONCLUSIONS AND RELEVANCE Increased access to and improved quality of health care through a CBHI program was associated with a significant decrease in blood pressure in a hypertensive population in rural Nigeria. Community-based health insurance programs should be included in strategies to combat cardiovascular disease in sub-Saharan Africa.

Step-by-step guideline for disease-specific costing studies in low- and middle-income countries: a mixed methodology.

BACKGROUND: Disease-specific costing studies can be used as input into cost-effectiveness analyses and provide important information for efficient resource allocation. However, limited data availability and limited expertise constrain such studies in low- and middle-income countries (LMICs). OBJECTIVE: To describe a step-by-step guideline for conducting disease-specific costing studies in LMICs where data availability is limited and to illustrate how the guideline was applied in a costing study of cardiovascular disease prevention care in rural Nigeria. DESIGN: The step-by-step guideline provides practical recommendations on methods and data requirements for six sequential steps: 1) definition of the study perspective, 2) characterization of the unit of analysis, 3) identification of cost items, 4) measurement of cost items, 5) valuation of cost items, and 6) uncertainty analyses.Please provide the significance of asterisk given in table body. RESULTS: We discuss the necessary tradeoffs between the accuracy of estimates and data availability constraints at each step and illustrate how a mixed methodology of accurate bottom-up micro-costing and more feasible approaches can be used to make optimal use of all available data. An illustrative example from Nigeria is provided. CONCLUSIONS: An innovative, user-friendly guideline for disease-specific costing in LMICs is presented, using a mixed methodology to account for limited data availability. The illustrative example showed that the step-by-step guideline can be used by healthcare professionals in LMICs to conduct feasible and accurate disease-specific cost analyses.

Target organ damage among hypertensive adults in rural Nigeria: a cross-sectional study.

OBJECTIVES: To study the prevalence of target organ damage (TOD) in hypertensive adults in a general population in rural Nigeria, to assess determinants of TOD and the contribution of TOD screening to assess eligibility for antihypertensive treatment. METHODS: All adults diagnosed with hypertension (n=387) and a random sample (n=540) out of all nonhypertensive adults, classified during a household survey in 2009, had a blood pressure measurement and were invited for TOD (myocardial infarction, left ventricular hypertrophy, angina pectoris, kidney disease) screening in 2011. RESULTS: Participation in TOD screening was 51% (n=196) in respondents with hypertension and 33% (n=179) in those without hypertension. TOD prevalence in hypertensive and nonhypertensive adults was 32 and 15%, respectively. Hypertension severity was a strong determinant for TOD [grade 1 odds ratio (OR) 2.66, 95% confidence interval (CI)1.04-6.84; grade 2 OR 3.82, 95% CI 1.41-10.36]. Out of 196 hypertensive patients, 151 were untreated, of whom all grade 2 hypertensive patients (n=71) were eligible for treatment. Screening revealed TOD in 19 out of 80 grade 1 hypertensive respondents (24%), therefore also classifying them as eligible for treatment. TOD screening hypertensive nonrespondents had more severe hypertension than hypertensive respondents, which may have resulted in an underestimation of the true prevalence of TOD among adults with hypertension. CONCLUSION: A high prevalence of 32% TOD in hypertensive adults in rural Nigeria was observed. Almost a quarter of respondents with grade 1 hypertension were eligible for antihypertensive treatment based on TOD screening findings. As TOD screening is mostly unavailable in sub-Saharan Africa, we propose antihypertensive treatment for all patients with hypertension.

A community-based intervention for primary prevention of cardiovascular diseases in the slums of Nairobi: the SCALE UP study protocol for a prospective quasi-experimental community-based trial.

BACKGROUND: The burden of cardiovascular disease is rising in sub-Saharan Africa with hypertension being the main risk factor. However, context-specific evidence on effective interventions for primary prevention of cardiovascular diseases in resource-poor settings is limited. This study aims to evaluate the feasibility and cost-effectiveness of one such intervention--the "Sustainable model for cardiovascular health by adjusting lifestyle and treatment with economic perspective in settings of urban poverty". DESIGN: A prospective quasi-experimental community-based intervention study. SETTING: Two slum settlements (Korogocho and Viwandani) in Nairobi, Kenya. STUDY POPULATION: Adults aged 35 years and above in the two communities. INTERVENTION: The intervention community (Korogocho) will be exposed to an intervention package for primary prevention of cardiovascular disease that comprises awareness campaigns, household screening for cardiovascular diseases risk factors, and referral and treatment of people with high cardiovascular diseases risk at a primary health clinic. The control community (Viwandani) will continue accessing the usual standard of care for primary prevention of cardiovascular diseases in Kenya. DATA: Demographic and socioeconomic data; anthropometric and clinical measurements including blood pressure. Population-based data will be collected at the baseline and endline--12 months after implementing the intervention. These data will be collected from a random sample of 1,610 adults aged 35 years and above in the intervention and control sites at both baseline and endline. Additionally, operational (including cost) and clinic-based data will be collected on an ongoing basis. MAIN OUTCOMES: (1) A positive difference in the change in the proportion of the intervention versus control study populations that are at moderate or high risk of cardiovascular disease; (2) a difference in the change in mean systolic blood pressure in the intervention versus control study populations; (3) the net cost of the complete intervention package per disability-adjusted life year gained. ANALYSIS: Primary outcomes comparing pre- and post-, and operational data will be analyzed descriptively and "impact" of the intervention will be calculated using double-difference methods. We will also conduct a cost-effectiveness analysis of the intervention using World Health Organization guidelines. DISCUSSION: The outcomes of the study will be disseminated to local policy makers and health planners. TRIAL REGISTRATION: Current controlled trials ISRCTN84424579.

Hypertension in sub-Saharan Africa: cross-sectional surveys in four rural and urban communities.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of adult mortality in low-income countries but data on the prevalence of cardiovascular risk factors such as hypertension are scarce, especially in sub-Saharan Africa (SSA). This study aims to assess the prevalence of hypertension and determinants of blood pressure in four SSA populations in rural Nigeria and Kenya, and urban Namibia and Tanzania. METHODS AND FINDINGS: We performed four cross-sectional household surveys in Kwara State, Nigeria; Nandi district, Kenya; Dar es Salaam, Tanzania and Greater Windhoek, Namibia, between 2009-2011. Representative population-based samples were drawn in Nigeria and Namibia. The Kenya and Tanzania study populations consisted of specific target groups. Within a final sample size of 5,500 households, 9,857 non-pregnant adults were eligible for analysis on hypertension. Of those, 7,568 respondents ≥ 18 years were included. The primary outcome measure was the prevalence of hypertension in each of the populations under study. The age-standardized prevalence of hypertension was 19.3% (95%CI:17.3-21.3) in rural Nigeria, 21.4% (19.8-23.0) in rural Kenya, 23.7% (21.3-26.2) in urban Tanzania, and 38.0% (35.9-40.1) in urban Namibia. In individuals with hypertension, the proportion of grade 2 (≥ 160/100 mmHg) or grade 3 hypertension (≥ 180/110 mmHg) ranged from 29.2% (Namibia) to 43.3% (Nigeria). Control of hypertension ranged from 2.6% in Kenya to 17.8% in Namibia. Obesity prevalence (BMI ≥ 30) ranged from 6.1% (Nigeria) to 17.4% (Tanzania) and together with age and gender, BMI independently predicted blood pressure level in all study populations. Diabetes prevalence ranged from 2.1% (Namibia) to 3.7% (Tanzania). CONCLUSION: Hypertension was the most frequently observed risk factor for CVD in both urban and rural communities in SSA and will contribute to the growing burden of CVD in SSA. Low levels of control of hypertension are alarming. Strengthening of health care systems in SSA to contain the emerging epidemic of CVD is urgently needed.