An Intersectoral Approach to Hypertension Care: Solutions for Improving Blood Pressure Control in São Paulo, Brazil.

BACKGROUND: Hypertension is the leading risk factor for cardiovascular diseases (CVDs) and a major public health issue worldwide. In Brazil, it affects approximately 52.5% of the adult population. We describe the solutions package and the impact of a population health initiative in São Paulo city, following the CARDIO4Cities approach for the management of cardiovascular risk. METHODS: Using a design thinking approach, interventions were developed with a coalition of local and international stakeholders to address needs of patients, healthcare professionals, and the health system. The resulting solution package was checked to comply with guidelines for non-communicable disease and hypertension management. Clinical impact was measured by extracting the hypertension cascade of care-monitored, diagnosis, treatment, and control-from medical records. RESULTS: Under the leadership of the municipal health authorities, nine solutions were piloted and scaled across the city. Solutions conform with local and international best-practices. Between October 2017 and December 2021, 11,406 patient records were analyzed. Results showed a 40% increase in monitored patients (patients with at least one blood pressure, BP, measurement); reduced proportions of patients diagnosed among those with available BP measurements (72%-53%) and treated among diagnosed (93%-85%); and an improvement in controlled patients among those receiving treatment (16%-27%). CONCLUSIONS: The solution package described in this study was correlated with increased BP control. The implementation methodology and results add to the body of real-world evidence supporting population health implementation science in Brazil and beyond.

Design and feasibility of an implementation strategy to address Chagas guidelines engagement focused on attending women of childbearing age and children at the primary healthcare level in Argentina: a pilot study.

BACKGROUND: Chagas is a public health problem, especially in Latin America, exacerbated by migratory movements and increasing urbanization. Argentina is among the countries with the highest estimated prevalence in the region, with 1,500,000 people infected, with mother to child as the main mode of transmission. Vertical transmission has been significantly reduced by treating women of childbearing age; several guidelines in the region recommend treatment as a primary prevention strategy for the child and a secondary prevention strategy for women and their families. Despite recommendations, women of childbearing age are not always treated, and children do not receive timely diagnosis and treatment. The objective of this research was to design an implementation strategy to improve using Chagas guidelines focused on attending women of childbearing age and children at the primary healthcare level and pilot it in three primary health care centers in Argentina. METHODS: We conducted a pilot feasibility study using the Consolidated Framework for Implementation Research. A qualitative process evaluation was conducted using semi-structured interviews with health care providers and observations in primary health care centers. RESULTS: We developed a multifaceted implementation strategy including training, flowcharts and reminders, a register of suspected and confirmed cases, and the selection of a management facilitator. The pilot study took place between September 2019 and May 2020. The implementation level was heterogeneous and varied depending on the components, being the facilitating factors, the simplicity of the intervention, professionals' willingness to expand the indication of serologic tests, and staff commitment to the adoption of intervention components. The main barriers found were the change of authorities at the local level, some professionals´ reluctance to administer etiological treatment, staff shortages, lack of diagnostic supplies, and the health emergency caused by the COVID-19 pandemic. CONCLUSIONS: Behavioral change strategies should be applied to improve implementation to address some of the main barriers, including support actions offered by opinion leaders, medical experts, and local health authorities. Rapid diagnostic tests should be readily available to maintain behavior changes. We suggest further refinement of the strategy and its implementation in more centers to assess outcomes prospectively with a hybrid implementation research design.

Estrategias de implementación para Medicinas Complementarias y/o Alternativas (MCA) en la atención primaria: síntesis rápida de evidencia / Implementation strategies for Complementary and/or Alternative Medicines (CAM) in primary care: rapid evidence synthesis

ANTECEDENTES Y OBJETIVO Las Medicinas Complementarias y Alternativas (MCA) han sido ampliamente reconocidas y, para algunas de ellas, su efectividad sobre ciertas condiciones ha sido demostrada empíricamente. Es el caso de la Acupuntura, donde se ha mostrado su efectividad para tratar migrañas, dolores lumbares y problemas osteo-articulares, esto último respaldado con evidencia local. En este contexto, el Departamento de Políticas Farmacéuticas solicita esta síntesis de evidencia con el objetivo de informar la toma de decisiones respecto del efecto de una política para las medicinas complementarias en el país. METODOLOGÍA Se formuló una estrategia de búsqueda para ser utilizada en 5 bases de datos con el objetivo de identificar revisiones sistemáticas del tema. Se incluyen documentos publicados en los últimos 5 años. Adicionalmente, se preguntó a expertos que han trabajado con el tema, tanto en el ámbito nacional como internacional. Por último, se utilizó información del Departamento de Políticas Farmacéuticas de MINSAL, para obtener datos de la realidad de Chile. RESULTADO -Contar con un proceso de formación de especialistas en MCA y el rol de las Universidades en este proceso son 2 aspectos claves para la implementación. -La colaboración entre profesionales de medicina convencional y de MCA se favorecería con otorgar roles importantes a las enfermeras, facilitar acceso a lugares comunes y establecer claramente los roles para cada MCA. -Se ha propuesta avanzar en sistemas de monitoreo y evaluación, protocolización y definición de roles, de manera de entregar una buena calidad de MCA. -Se recomienda la construcción de una institucionalidad en el Gobierno Central para la administrar las MCA. -Se propone regular los criterios de derivación de pacientes y avanzar en la convergencia entre las medicinas convencionales y alternativas. -La provisión de MCA debe avanzar en resguardar la seguridad de los pacientes, respaldar con evidencia científica las prácticas clínicas y definir las responsabilidades legales de cada profesional, la calidad de los recursos necesarios para la atención y certificación de profesionales. -Los pacientes perciben de mejor forma la atención de acupuntura que la medicina convencional. -Contar con una relación horizontal médico-paciente en las MCA impacta directamente sobre el autocuidado responsable del paciente.