Hypertension management using mobile technology and home blood pressure monitoring: results of a randomized trial in two low/middle-income countries. A cluster-randomized trial of task shifting and blood pressure control in Ghana: study protocol Implementation of shared decision making by physician training to optimise hypertension treatment. Study protocol of a cluster-RCT Community-Based Interventions to Promote Blood Pressure Control in a Developing Country Control of blood pressure and risk attenuation: a public health intervention in rural Bangladesh, Pakistan, and Sri Lanka feasibility trial results Electronic communications and home blood pressure monitoring (e-BP) study: design, delivery, and evaluation framework. Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana Is a shared decision-making approach effective in improving hypertension management? A randomized controlled trial of an information booklet for hypertensive patients in general practice. Hypertension management in rural primary care facilities in Zambia: a mixed methods study A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045 Coordinating and standardizing long-term care: evaluation of the west of Scotland shared-care scheme for hypertension. Optimizing linkage and retention to hypertension care in rural Kenya (LARK hypertension study): study protocol for a randomized controlled trial Development and evaluation of a nurse-led hypertension management model: A randomized controlled trial. A Randomized Trial to Improve Patient-Centered Care and Hypertension Control in Underserved Primary Care Patients Health Coaching to Improve Hypertension Treatment in a Low-Income, Minority Population Two self-management interventions to improve hypertension control: a randomized trial.
OBJECTIVE Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries ( LMICs ) . Mobile health technologies may improve noncommunicable disease outcomes , but LMICs lack re sources to provide these services . We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure ( BP ) monitoring as a strategy for improving systolic BPs ( SBPs ) and other outcomes of hypertensive patients in two LMICs . SUBJECTS AND METHODS This was a r and omized trial with a 6-week follow-up . Participants with high SBPs ( ≥140 mm Hg if nondiabetic and ≥130 mm Hg if diabetic ) were enrolled from clinics in Honduras and Mexico . Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States , plus a home BP monitor . At baseline , control patients received BP results , hypertension information , and usual healthcare . The primary outcome , SBP , was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs . Secondary outcomes included perceived health status and medication-related problems . RESULTS Of the 200 patients recruited , 181 ( 90 % ) completed follow-up , and 117 of 181 had low literacy or high hypertension information needs . The median annual income was $ 2,900 USD , and average educational attainment was 6.5 years . At follow-up intervention patients ' SBPs decreased 4.2 mm Hg relative to controls ( 95 % confidence interval -9.1 , 0.7 ; p=0.09 ) . In the subgroup with high information needs , intervention patients ' average SBPs decreased 8.8 mm Hg ( -14.2 , -3.4 , p=0.002 ) . Compared with controls , intervention patients at follow-up reported fewer depressive symptoms ( p=0.004 ) , fewer medication problems ( p<0.0001 ) , better general health ( p<0.0001 ) , and greater satisfaction with care ( p≤0.004 ) . CONCLUSIONS Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs . A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support Background Countries in sub-Saharan Africa ( SSA ) are experiencing an epidemic of cardiovascular disease ( CVD ) propelled by rapidly increasing rates of hypertension . Barriers to hypertension control in SSA include poor access to care and high out-of-pocket costs . Although SSA bears 24 % of the global disease burden , it has only 3 % of the global health workforce . Given such limited re sources , cost-effective strategies , such as task shifting , are needed to mitigate the rising CVD epidemic in SSA . Ghana , a country in SSA with an established community health worker program integrated within a national health insurance scheme provides an ideal platform to evaluate implementation of the World Health Organization ( WHO ) task-shifting strategy . This study will evaluate the comparative effectiveness of the implementation of the WHO Package targeted at CV risk assessment versus provision of health insurance coverage , on blood pressure ( BP ) reduction . Methods Using a cluster r and omized design , 32 community health centers ( CHCs ) and district hospitals in Ghana will be r and omized to either the  intervention  group ( 16 CHCs ) or the control group ( 16 CHCs ) . A total of 640 patients with uncomplicated hypertension ( BP 140–179/90–99 mm Hg and absence of target organ damage ) will be enrolled in this study ( 20 patients per CHC ) . The intervention consists of WHO Package of CV risk assessment , patient education , initiation and titration of antihypertensive medications , behavioral counseling on lifestyle behaviors , and medication adherence every three months for 12 months . The primary outcome is the mean change in systolic BP from baseline to 12 months . The secondary outcomes are rates of BP control at 12 months ; levels of physical activity , percent change in weight , and dietary intake of fruits and vegetables at 12 months ; and sustainability of intervention effects at 24 months . All outcomes will be assessed at baseline , six months and 12 months . Trained community health nurses will deliver the intervention as part of Ghana ’s community-based health planning and services ( CHPS ) program . Discussion Findings from this study will provide policy makers and other stakeholders needed information to recommend scalable and cost-effective policy with respect to comprehensive CV risk reduction and hypertension control in re source -poor setting s . Trial registration NCT01802372 Background Hypertension is one of the key factors causing cardiovascular diseases which make up the most frequent cause of death in industrialised nations . However about 60 % of hypertensive patients in Germany treated with antihypertensives do not reach the recommended target blood pressure . The involvement of patients in medical decision making fulfils not only an ethical imperative but , furthermore , has the potential of higher treatment success . One concept to enhance the active role of patients is shared decision making . Until now there exists little information on the effects of shared decision making trainings for general practitioners on patient participation and on lowering blood pressure in hypertensive patients . Methods / Design In a cluster-r and omised controlled trial 1800 patients receiving antihypertensives will be screened with 24 h ambulatory blood pressure monitoring in their general practitioners ’ practice s. Only patients who have not reached their blood pressure target ( approximately 1200 ) will remain in the study ( T1 – T3 ) . General practitioners of the intervention group will take part in a shared decision making-training after baseline assessment ( T0 ) . General practitioners of the control group will treat their patients as usual . Primary endpoints are change of systolic blood pressure and change of patients ’ perceived participation . Secondary endpoints are changes of diastolic blood pressure , knowledge , medical adherence and cardiovascular risk . Data analysis will be performed with mixed effects models . Discussion The hypothesis underlying this study is that shared decision making , realised by a shared decision making training for general practitioners , activates patients , facilitates patients ’ empowerment and contributes to a better hypertension control . This study is the first one that tests this hypothesis with a ( cluster- ) r and omised trial and a large sample size . Trial registration WHO International Clinical Trials : http://apps.who.int/trial search /Trial.aspx?TrialID = Context Physician education and community-based interventions to educate people with hypertension may improve hypertension care in re source -poor setting s. Contribution Among 1341 patients living in 12 communities in Pakistan that were r and omly assigned to general practitioner education , home health visits by trained lay workers , both , or neither , patients in communities assigned to both interventions had the greatest improvements in systolic blood pressure ( 10.8 mm Hg ) after 2 years . Improvements were similar in all other groups ( about 5 mm Hg ) . Caution Twenty-two percent of patients were lost to follow-up . Implication Home visits by trained lay workers plus physician education deserves further study as a way to improve hypertension control in re source -poor setting s. The Editors Cardiovascular disease has , in just a few decades , become the leading cause of death in adults worldwide , accounting for 1 in 5 deaths . Hypertension confers the highest attributable risk for death and disease associated with cardiovascular disease ( 1 , 2 ) . Despite the demonstrated benefits of effective drug treatment ( 3 , 4 ) and the existence of many clinical practice guidelines ( 5 ) , hypertension prevention , treatment , and control rates remain suboptimal worldwide ( 6 ) . The situation is particularly acute in developing countries , such as Pakistan , India , and China , where hypertension has reached epidemic proportionsaffecting more than 20 % of the adult population (7)yet control rates are less than 6 % ( 8) . Poor health literacy and unhealthy lifestyles , compounded by lack of awareness of hypertension ( 7 ) , are part of the cause . In addition , the health systems in these countries are often dysfunctional : More than 80 % of the expenditure for chronic disease care is out-of-pocket ; private care general practitioners ( GPs ) , who primarily treat acute conditions , are the front-line service providers ; and national programs for preventing and controlling hypertension are inadequate . Serious deficiencies in management of hypertension also have been identified in the knowledge and practice of health care providers . ( 9 ) However , evidence for public health interventions to improve hypertension control rates through patient or physician education in Indo-Asian countries is lacking . We conducted the COBRA-1 ( Control of Blood Pressure and Risk Attenuation-1 ) trial in Karachi , Pakistan , to test the effectiveness of 2 community-based strategies : family-based home health education ( HHE ) , delivered by trained community health workers , to improve population -level health literacy and behaviors , and hypertension management training for GPs . We tested the effect of these interventions , alone and in combination , on blood pressure in adults with hypertension . We hypothesized that HHE would be more effective than no education , that the specially trained GPs would provide more effective care than that usually received in Karachi , and that the combined interventions would provide additional benefit . Methods Study Design and Setting We performed a cluster r and omized , controlled trial with a 22 factorial design to determine the effect of  family-based HHE and special training for GPs  on blood pressure in adults 40 years or older with hypertension . We used a cluster approach because our objective was to assess the effectiveness of both HHE and GP training as health system interventions at a population level , and an individual approach would be prone to contamination of interventions and biased outcomes ( 10 ) . The Aga Khan University Ethics Review Committee granted ethical approval . The sampling frame is described elsewhere ( 11 ) . In brief , we used a multistage r and om sampling technique to select 12 of 4200 low- to middle-income , geographic census-based clusters ( mean household monthly income , $ 70 ; about 250 households in each cluster ) in Karachi , the most populous city in Pakistan ( about 16 million inhabitants ) . We ensured at least a 10-km distance between clusters to minimize the risk for contamination by the intervention . Participants Persons 40 years or older who resided in the 12 clusters and had known hypertension or consistently elevated blood pressure on 2 separate visits ( mean of 2 of past 3 measurements of systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg ) were eligible for inclusion . We excluded pregnant women , persons who could not give informed consent , and bed-bound persons . R and omization and Intervention We used computer-generated codes to r and omly assign 3 clusters each to the following groups : HHE alone , GP alone , HHE and GP combined , and no intervention . Home Health Education We trained 6 community health workers ( 1 for each cluster ) over 6 weeks in methods for using behavior-changing communication strategies to convey st and ardized health education messages to all households in clusters assigned to receive HHE . The education status of the workers we employed was consistent with the requirements of the government-sponsored Lady Health Workers Programme of Pakistan ( 8 or preferably 10 years of schooling ) ( 12 ) . Salary scales and assigned workload were similarly consistent . The health messages included information on the deleterious effects of hypertension and nonpharmacologic interventions for preventing and controlling hypertension and cardiovascular disease , as well as advice on the importance of engaging in moderate physical activity ; maintaining normal body weight ; reducing salt intake ; consuming a diet rich in fruit , vegetables , and low-fat dairy products ; reducing intake of saturated and total fat ( including suggestions on sample recipes for culturally acceptable and economically feasible food products ) ; and smoking cessation ( Appendix 1 ) . The importance of achieving blood pressure targets and adhering to medication and physician follow-up was emphasized . The first HHE session , lasting 90 minutes , was held at a time when all members of the household could be present . Follow-up reinforcement visits of 30 minutes were made every 3 months . Appendix 1 . Training Manual for Community Health Workers General Practitioner Education We invited all GPs in the 6 study areas assigned to this intervention to receive training , with the aim of training at least two thirds of the GPs in each area . We considered this proportion to be feasible both for future uptake of the strategy and for assessing the effectiveness of training . Training was a 1-day session that focused on st and ard treatment algorithms for the stepped-care management of hypertension , which were based on the seventh report of the Joint National Committee ( 3 ) and the Fourth Working Party of the British Hypertension Society guidelines ( 4 ) and modified for the Indo-Asian population ( Appendix 2 ) . The course included components on nonpharmacologic ( diet , exercise , weight loss , and smoking cessation ) and pharmacologic interventions , prescription of low-cost and appropriate generic drugs , preferential use of single-dose drug regimens , scheduled follow-up visits guided by blood pressure , the stepped-care approach for titrating drugs to achieve target blood pressure , and satisfactory consultation sessions for patients , with explanations of treatment and use of appropriate communication strategies . For managing persons with known hypertension , GPs were advised to review medication and blood pressure ; simplify regimens ; and aim to return to a regimen that was in line , as reasonably as possible , with that recommended for those with newly diagnosed hypertension . The recommended target blood pressure was < 140/90 mm Hg for all patients . Although this diverges from recent guidelines for special subgroups ( such as diabetic persons or those with end-organ damage ) , we reasoned that we needed to keep the intervention , guidelines , and targets simple for both patients and practitioners in a setting where blood pressure control rates are less than 3 % ( 7 ) . The training sessions for GPs used a case-based curriculum and were interactive . We provided a certificate of training at the end of the course . Appendix 2 . Training Manual for General Practitioner All study participants were advised to consult a local GP . If participants in the clusters r and omly assigned to a trained GP group did not already have a preferred GP , we gave them a list of trained GPs in their cluster from which to choose . However , it remained the participant 's choice whether they attended a physician on the list . We did not provide for medications or fee-for-health care services . Participants were blinded to intervention status ( training of GP ) . Neither the patients nor the GPs received reimbursement for participation . Screening and Recruitment All households in each cluster were visited , and we obtained informed consent for screening from all adults 40 years and older , whose blood pressure was then measured 3 times with a calibrated automated device ( Omron HEM-737 IntelliSense ; Omron Healthcare , Vernon Hills , Illinois ) in the sitting position after 5 minutes of rest . Those with known hypertension were invited to participate . Those with elevated blood pressure who were not receiving antihypertensive medication were visited again for remeasurement of blood pressure 1 to 4 weeks after the initial visit . If mean blood pressure remained elevated , these persons were also invited to participate . A routine physical examination was performed , and the following information was collected : smoking status , food frequency , and physical activity by question naire , the latter by using the international physical activity question naire ; blood pressure , measured as described above ; anthropometric characteristics ( height , weight , and waist and hip circumferences ) ; and fasting blood glucose level ( Synchron Cx-7/Delta , Beckman Coulter , Fullerton , California ) and lipid profile ( Hitachi-912 , Roche , Basel , Switzerl and ) ( 11 ) . Follow-up Procedures Trained outcomes assessors ( who were not part of and had no relationship with the community health worker team ) evaluated Background : High blood pressure ( BP ) is the leading attributable risk for cardiovascular disease globally . There is little information on effective and sustainable public health system strategies for managing hypertension in South Asian countries . We conducted a feasibility study to gather preliminary data to optimize BP-lowering strategies for a public health intervention in rural communities in Bangladesh , Pakistan , and Sri Lanka . Methods : A mixed method feasibility study comprised a 3-month pre and postevaluation of a multicomponent intervention ( MCI ) , including BP screening and home health education by trained government community health worker ( CHW ) ; providers trained in hypertension management , and compensation of CHW for additional services . Checklists were used to document care . Stakeholder interviews were also conducted . Individuals aged 40 years and above with high BP ( systolic ≥140 mmHg or diastolic ≥90 mmHg based on two readings from 2 separate days , or receiving antihypertensive medications ) were enrolled from rural communities in Bangladesh , Pakistan , and Sri Lanka . BP was measured at baseline and 3 months postintervention . Results : A total of 412 ( 90 % ) of the 454 eligible individuals were recruited . Of those recruited , 90 % received home health education session by trained CHWs , 80 % were referred to trained providers , of whom 83 % completed the management checklist . A follow-up rate of 95.6 % was achieved . The mean SBP declined significantly by 4.5 mmHg 95 % confidence interval ( 2.3 , 6.7 ) mmHg ( P < 0.001 ) in the overall pooled analysis in three countries ; however , it varied among countries . BP decline was 10.5 mmHg ( 8.1 , 13.0 mmHg ) ( P < 0.001 ) in the pooled analysis of individuals with uncontrolled hypertension at baseline , and was also significant each of the three countries . All 98 stakeholders strongly supported upscaling the proposed MCI strategies . Conclusion : The proposed MCI is feasible for implementation and requires long-term , large-scale evaluation in the rural public health infrastructure in South Asian countries to determine sustainability of health system changes and BP control . If these long-term effects are confirmed , MCI may be a long-term strategy for tackling rising rates of cardiovascular disease in low-re source d countries . Clintrial.gov BACKGROUND R and omized controlled trials have provided unequivocal evidence that treatment of hypertension decreases mortality and major disability from cardiovascular disease ; however , blood pressure remains inadequately treated in most affected individuals . This large gap continues despite the facts that more than 90 % of adults with hypertension have health insurance , and hypertension is the leading cause of visits to the doctor . New approaches are needed to improve hypertension care . OBJECTIVES The Electronic Communications and Home Blood Pressure Monitoring ( e-BP ) study is a three-arm r and omized controlled trial design ed to determine whether care based on the Chronic Care Model and delivered over the Internet improves hypertension care . The primary study outcomes are systolic , diastolic , and blood pressure control ; secondary outcomes are medication adherence , patient self-efficacy , satisfaction and quality of life , and healthcare utilization and costs . METHODS Hypertensive patients receiving care at Group Health medical centers are eligible if they have uncontrolled blood pressure on two screening visits and access to the Web and an e-mail address . Study participants are r and omly assigned to three intervention groups : ( a ) usual care ; ( b ) home blood pressure monitoring receipt and proficiency training on its use and the Group Health secure patient website ( with secure e-mail access to their healthcare provider , access to a shared medical record , prescription refill and other services ) ; or ( c ) this plus pharmacist care management ( collaborative care management between the patient , the pharmacist , and the patient 's physician via a secure patient website and the electronic medical record ) . CONCLUSION We will determine whether a new model of patient-centered care that leverages Web communications , self-monitoring , and collaborative care management improves hypertension control . If this model proves successful and cost-effective , similar interventions could be used to improve the care of large numbers of patients with uncontrolled hypertension Background Poor access to care and physician shortage are major barriers to hypertension control in sub-Saharan Africa . Implementation of evidence -based systems-level strategies targeted at these barriers are lacking . We conducted a study to evaluate the comparative effectiveness of provision of health insurance coverage ( HIC ) alone versus a nurse-led task shifting strategy for hypertension control ( TASSH ) plus HIC on systolic blood pressure ( SBP ) reduction among patients with uncontrolled hypertension in Ghana . Methods and findings Using a pragmatic cluster r and omized trial , 32 community health centers within Ghana ’s public healthcare system were r and omly assigned to either HIC alone or TASSH + HIC .  A total of 757 patients with uncontrolled hypertension were recruited between November 28 , 2012 , and June 11 , 2014 , and followed up to October 7 , 2016 . Both intervention groups received health insurance coverage plus scheduled nurse visits , while TASSH + HIC comprised cardiovascular risk assessment , lifestyle counseling , and initiation/titration of antihypertensive medications for 12 months , delivered by trained nurses within the healthcare system . The primary outcome was change in SBP from baseline to 12 months . Secondary outcomes included lifestyle behaviors and blood pressure control at 12 months and sustainability of SBP reduction at 24 months . Of the 757 patients ( 389 in the HIC group and 368 in the TASSH + HIC group ) , 85 % had 12-month data available ( 60 % women , mean BP 155.9/89.6 mm Hg ) . In intention-to-treat analyses adjusted for clustering , the TASSH + HIC group had a greater SBP reduction ( −20.4 mm Hg ; 95 % CI −25.2 to −15.6 ) than the HIC group ( −16.8 mm Hg ; 95 % CI −19.2 to −15.6 ) , with a statistically significant between-group difference of −3.6 mm Hg ( 95 % CI −6.1 to −0.5 ; p = 0.021 ) . Blood pressure control improved significantly in both groups ( 55.2 % , 95 % CI 50.0 % to 60.3 % , for the TASSH + HIC group versus 49.9 % , 95 % CI 44.9 % to 54.9 % , for the HIC group ) , with a non-significant between-group difference of 5.2 % ( 95 % CI −1.8 % to 12.4 % ; p = 0.29 ) . Lifestyle behaviors did not change appreciably in either group . Twenty-one adverse events were reported ( 9 and 12 in the TASSH + HIC and HIC groups , respectively ) . The main study limitation is the lack of cost-effectiveness analysis to determine the additional costs and benefits , if any , of the TASSH + HIC group . Conclusions Provision of health insurance coverage plus a nurse-led task shifting strategy was associated with a greater reduction in SBP than provision of health insurance coverage alone , among patients with uncontrolled hypertension in Ghana . Future scale-up of these systems-level strategies for hypertension control in sub-Saharan Africa requires a cost – benefit analysis . Trial registration Clinical Trials.gov The authors assessed whether patient empowerment in the management of hypertension improved more with the practice of shared decision making ( SDM ) than by education programs . In a prospect i ve controlled clinical study , 15 general practitioners in Nuremberg , Germany who were specially trained to conduct SDM consultations participated in a 12-month study . Hypertensive patients ( N=86 ) were included ; N=40 were in the SDM group and N=46 were in the control group , if blood pressures were > or = 135 / 85 mm Hg ( self measurement ) and patients had no signs of cardiovascular complications or severe hypertension . All participants in the SDM group and the control group were enrolled in an education program on hypertension in small groups . The SDM group participants also had 4 special consultations to share medical decisions . The main outcome measures were the effect of SDM on blood pressure control . After 1 year blood pressure had decreased in all participants : Delta-9.26 + /- 10.2 mm Hg/Delta-5.33 + /- 9.5 mm Hg in the SDM group ( P<0.001 ) compared to Delta-6.0 + /- 11.8 mm Hg/Delta-3.0 + /- 8.3 mm Hg in the control group . There was no significant difference between the 2 groups . The study group practice d more  SDM  than controls , but blood pressure control was not significantly better . Patient empowerment by means of an education program in small groups and creating awareness of hypertensive disease helps to improve the outcome of hypertension treatment .  SDM , however , did not improve management when compared to an education program , which is much easier to implement in general practice A r and omized controlled trial of an information and medical record booklet design ed to improve patient underst and ing and participation in the management of hypertension was conducted in six inner London general practice s. After one year there were no significant differences between the group who had received the booklets and the control group in mean systolic or diastolic blood pressure , but the study group scored significantly higher on knowledge about hypertension and its management . However , the difference between the two groups was small , possibly because both groups started with a high level of underst and ing about hypertension and its management . In addition , the mean diastolic blood pressure in the control group showed that the treatment provided was already satisfactory , and that there was little need for improvement . Nevertheless , the information booklet evaluated in this study provides health professionals with a highly acceptable method of informing the patient about hypertension and its management and could be used both in hospital and general practice Background Improved primary health care is needed in developing countries to effectively manage the growing burden of hypertension . Our objective was to evaluate hypertension management in Zambian rural primary care clinics using process and outcome indicators to assess the screening , monitoring , treatment and control of high blood pressure . Methods Better Health Outcomes through Mentoring and Assessment ( BHOMA ) is a 5-year , r and omized stepped-wedge trial of improved clinical service delivery underway in 46 rural Zambian clinics . Clinical data were collected as part of routine patient care from an electronic medical record system , and review ed for site performance over time according to hypertension related indicators : screening ( blood pressure measurement ) , management ( recorded diagnosis , physical exam or urinalysis ) , treatment ( on medication ) , and control . Quantitative data was used to develop guides for qualitative in-depth interviews , conducted with health care providers at a proportional sample of half ( 20 ) of clinics . Qualitative data was iteratively analyzed for thematic content . Results From January 2011 to December 2014 , 318,380 visits to 46 primary care clinics by adults aged ≥ 25 years with blood pressure measurements were included  . Blood pressure measurement at vital sign screening was initially high at 89.1 % overall ( range : 70.1–100 % ) , but decreased to 62.1 % ( range : 0–100 % ) by 48 months after intervention start . The majority of hypertensive patients made only one visit to the clinics ( 57.8 % ) . Out of 9022 patients with at least two visits with an elevated blood pressure , only 49.3 % had a chart recorded hypertension diagnosis . Process indicators for monitoring hypertension were < 10 % and did not improve with time . In in-depth interviews , antihypertensive medication shortages were common , with 15/20 clinics reporting hydrochlorothiazide-amiloride stockouts . Principal challenges in hypertension management included 1 ) equipment and personnel shortages , 2 ) provider belief that multiple visits were needed before official management , 3 ) medication stock-outs , leading to improper prescriptions and 4 ) poor patient visit attendance . Conclusions Our findings suggest that numerous barriers st and in the way of hypertension diagnosis and management in Zambian primary health facilities . Future work should focus on performance indicator development and validation in low re source context s , to facilitate regular and systematic data review to improve patient outcomes .Trial registration Clinical Trials.gov , Identifier NCT01942278 . Date of Registration : September 2013 Background Disparities in health and healthcare are extensively documented across clinical conditions , setting s , and dimensions of healthcare quality . In particular , studies show that ethnic minorities and persons with low socioeconomic status receive poorer quality of interpersonal or patient-centered care than whites and persons with higher socioeconomic status . Strong evidence links patient-centered care to improvements in patient adherence and health outcomes ; therefore , interventions that enhance this dimension of care are promising strategies to improve adherence and overcome disparities in outcomes for ethnic minorities and poor persons . Objective This paper describes the design of the Patient-Physician Partnership ( Triple P ) Study . The goal of the study is to compare the relative effectiveness of the patient and physician intensive interventions , separately , and in combination with one another , with the effectiveness of minimal interventions . The main hypothesis is that patients in the intensive intervention groups will have better adherence to appointments , medication , and lifestyle recommendations at three and twelve months than patients in minimal intervention groups . The study also examines other process and outcome measures , including patient-physician communication behaviors , patient ratings of care , health service utilization , and blood pressure control . Methods A total of 50 primary care physicians and 279 of their ethnic minority or poor patients with hypertension were recruited into a r and omized controlled trial with a two by two factorial design . The study used a patient-centered , culturally tailored , education and activation intervention for patients with active follow-up delivered by a community health worker in the clinic . It also included a computerized , self- study communication skills training program for physicians , delivered via an interactive CD-ROM , with tailored feedback to address their individual communication skills needs . Conclusion The Triple P study will provide new knowledge about how to improve patient adherence , quality of care , and cardiovascular outcomes , as well as how to reduce disparities in care and outcomes of ethnic minority and poor persons with hypertension BACKGROUND The long-term management of patients with chronic conditions such as hypertension presents problems for the health services . Shared care addresses these by coordinating care and defining responsibilities . AIM This study set out to investigate the feasibility , acceptability and cost effectiveness of shared general practitioner-hospital care for well-controlled hypertensive patients in an urban area by comparing three matched groups of patients . METHOD A total of 554 outpatient clinic attenders , considered suitable for shared care by their consultant  , were r and omly allocated to shared care or follow up in the outpatient clinic ; a third group of 277 patients was selected from a nurse practitioner clinic . Main outcome measures were the proportion of patients in the second year of follow up who had undergone a complete review ( blood pressure measurement , serum creatinine level result and electrocardiograph report ) , acceptability to patients and general practitioners as assessed by question naire , and cost per complete review in year two ( National Health Service and patient costs ) . RESULTS After two years 220 ( 82 % ) shared care patients had had a complete review compared with 146 ( 54 % ) outpatient clinic attenders and 202 ( 75 % ) nurse practitioner clinic attenders . Blood pressure control was similar in each group . Of 297 general practitioners invited , 85 % wished to participate in the study ; 61 % of question naire respondents subsequently wanted shared care to continue while 25 % were unsure . Half of the patients receiving shared care preferred this method of follow up . The rank order of cost-effectiveness ratios was shared care , nurse practitioner care and conventional outpatient care , relative differences being most marked when only patient costs were considered . CONCLUSION Shared care for hypertension is feasible in an urban setting , acceptable to the majority of participants and is a cost-effective method of long-term follow up Background Hypertension is the leading global risk factor for mortality . Hypertension treatment and control rates are low worldwide , and delays in seeking care are associated with increased mortality . Thus , a critical component of hypertension management is to optimize linkage and retention to care . Methods / Design This study investigates whether community health workers , equipped with a tailored behavioral communication strategy and smartphone technology , can increase linkage and retention of hypertensive individuals to a hypertension care program and significantly reduce blood pressure among them . The study will be conducted in the Kosirai and Turbo Divisions of western Kenya . An initial phase of qualitative inquiry will assess facilitators and barriers of linkage and retention to care using a modified Health Belief Model as a conceptual framework . Subsequently , we will conduct a cluster r and omized controlled trial with three arms : 1 ) usual care ( community health workers with the st and ard level of hypertension care training ) ; 2 ) community health workers with an additional tailored behavioral communication strategy ; and 3 ) community health workers with a tailored behavioral communication strategy who are also equipped with smartphone technology . The co- primary outcome measures are : 1 ) linkage to hypertension care , and 2 ) one-year change in systolic blood pressure among hypertensive individuals . Cost-effectiveness analysis will be conducted in terms of costs per unit decrease in blood pressure and costs per disability-adjusted life year gained . Discussion This study will provide evidence regarding the effectiveness and cost-effectiveness of strategies to optimize linkage and retention to hypertension care that can be applicable to non-communicable disease management in low- and middle-income countries . Trial registration This trial is registered with ( NCT01844596 ) on 30 April 2013 BACKGROUND The hypertension prevalence rate is increasing but the control rate is unsatisfactory . Nurse-led healthcare may be an effective way to improve outcomes for hypertensive patients but more evidence is required especially at the community level . OBJECTIVE This study aims to establish a nurse-led hypertension management model and to test its effectiveness at the community level . DESIGN A single-blind , r and omized controlled trial was performed in an urban community healthcare center in China . Hypertensive patients with uncontrolled blood pressure ( systolic blood pressure ≥140mmHg and /or diastolic blood pressure ≥90mmHg ) were r and omly allocated into two groups : the study group ( n=67 ) and the control  group ( n=67 ) . The nurse-led hypertension management model included four components ( delivery system design , decision support , clinical information system and self-management support ) . Patients in the control group received usual care . Patients in the study group received a 12-week period of hypertension management . The patient outcomes , which involved blood pressure , self-care behaviors , self-efficacy , quality of life and satisfaction , were assessed at three time points : the baseline , immediately after the intervention and 4 weeks after the intervention . RESULTS After the intervention , the blood pressure of patients in the study group decreased significantly compared to those in the control group , and the mean reduction of systolic/diastolic blood pressure in the study and control groups was 14.37/7.43mmHg and 5.10/2.69mmHg , respectively ( p<0.01 ) . In addition , patients in the study group had significantly greater improvement in self-care behaviors than those in the control group ( p<0.01 ) . The study group had a higher level of satisfaction with hypertensive care than the control group ( p<0.01 ) . No statistically significant difference in self-efficacy and quality of life was detected between the two groups after the intervention . CONCLUSIONS The nurse-led hypertension management model is feasible and effective in improving the outcomes of patients with uncontrolled blood pressure at the community level BACKGROUND African Americans and persons with low socioeconomic status ( SES ) are disproportionately affected by hypertension and receive less patient-centered care than less vulnerable patient population s. Moreover , continuing medical education ( CME ) and patient-activation interventions have infrequently been directed to improve the processes of care for these population s. OBJECTIVE To compare the effectiveness of patient-centered interventions targeting patients and physicians with the effectiveness of minimal interventions for underserved groups . DESIGN R and omized controlled trial conducted from January 2002 through August 2005 , with patient follow-up at 3 and 12 months , in 14 urban , community-based practice s in Baltimore , Maryl and . PARTICIPANTS Forty-one primary care physicians and 279 hypertension patients . INTERVENTIONS Physician communication skills training and patient coaching by community health workers . MAIN MEASURES Physician communication behaviors ; patient ratings of physicians ’ participatory decision-making ( PDM ) , patient involvement in care ( PIC ) , reported adherence to medications ; systolic and diastolic blood pressure ( BP ) and BP control . KEY RESULTS Visits of trained versus control group physicians demonstrated more positive communication change scores from baseline ( −0.52 vs. −0.82 , p = 0.04 ) . At 12 months , the patient+physician intensive group compared to the minimal intervention group showed significantly greater improvements in patient report of physicians ’ PDM ( β = + 6.20 vs. −5.24 , p = 0.03 ) and PIC dimensions related to doctor facilitation ( β = + 0.22 vs. −0.17 , p = 0.03 ) and information exchange ( β = + 0.32 vs. −0.22 , p = 0.005 ) . Improvements in patient adherence and BP control did not differ across groups for the overall patient sample . However , among patients with uncontrolled hypertension at baseline , non-significant reductions in systolic BP were observed among patients in all intervention groups — the patient+physician intensive ( −13.2 mmHg ) , physician intensive/patient minimal ( −10.6 mmHg ) , and the patient intensive/physician minimal ( −16.8 mmHg ) , compared to the patient+physician minimal group ( −2.0 mmHg ) . CONCLUSION Interventions that enhance physicians ’ communication skills and activate patients to participate in their care positively affect patient-centered communication , patient perceptions of engagement in care , and may improve systolic BP among urban African-American and low SES patients with uncontrolled hypertension PURPOSE Poor blood pressure control is common in the United States . We conducted a study to determine whether health coaching with home titration of antihypertensive medications can improve blood pressure control compared with health coaching alone in a low-income , predominantly minority population . METHODS We r and omized 237 patients with poorly controlled hypertension at a primary care clinic to receive either home blood pressure monitoring , weekly health coaching , and home titration of blood pressure medications if blood pressures were elevated ( n = 129 ) vs home blood pressure monitoring and health coaching but no home titration ( n = 108 ) . The primary outcome was change in systolic blood pressure from baseline to 6 months . RESULTS Both the home-titration arm and the no – home-titration arm had a reduction in systolic blood pressure , with no significant difference between them . When both arms were combined and analyzed as a before-after study , there was a mean decrease in systolic blood pressure of 21.8 mm Hg ( P < .001 ) as well as a decrease in the number of primary care visits from 3.5 in the 6 months before the study to 2.6 during the 6-month study period ( P < .001 ) and 2.4 in the 6 months after the study ( P < .001 ) . The more coaching encounters patients had , the greater their reduction in blood pressure . CONCLUSIONS Blood pressure control in a low-income , minority population can be improved by teaching patients to monitor their blood pressure at home and having nonprofessional health coaches assist patients , in particular , by counseling them on medication adherence . The improved blood pressure control can be achieved while reducing the time spent by physicians Context Can self-management interventions help improve blood pressure control in hypertensive patients ? Contribution In this trial , 636 patients with hypertension were r and omly assigned to receive usual care ; a telephone-delivered , nurse-administered behavioral self-management intervention ; home blood pressure self-monitoring ; or both of the latter 2 interventions . Compared with usual care , the adjusted improvement in the proportion of patients with blood pressure control at 24 months was 4.3 % for the behavioral intervention group , 7.6 % for the blood pressure monitoring group , and 11.0 % for the combined intervention group . Caution Patients were recruited from 2 university-affiliated clinics , and most ( 73 % ) already had reasonable blood pressure control at trial entry . The Editors Although multiple treatment options are available for hypertension , only one third of U.S. patients with hypertension have their blood pressure ( BP ) under effective control ( 1 ) . Home BP monitoring is a potentially important aspect of successful hypertension management ( 2 ) . Adopting a healthy lifestyle and adhering to provider recommendations are also important in managing hypertension . Few educational and BP monitoring studies have provided long-term follow-up ( > 12 months ) or implemented a multidimensional intervention that is tailored to patients ' needs and delivered by telephone ( 3 ) . A tailored telephone behavioral intervention and home BP monitoring may be a cost-effective method for improving BP outcomes ( 4 ) . We compared the effectiveness of BP self-monitoring , a tailored , nurse-administered behavior self-management intervention , and a combination of the 2 interventions with that of usual care . Methods The study was approved by the Duke University Institutional Review Board , and all patients provided written informed consent . Setting and Participants Recruitment occurred from May 2004 to December 2005 , with follow-up from November 2004 to January 2008 . Potentially eligible study patients were identified through weekly data extraction s from the billing and appointment data base for 2 Duke University Health System primary care clinics . Patients were cared for by 7 faculty general internists in 1 clinic and 85 residents under the supervision of faculty at the other clinic . Initial inclusion criteria were hypertension diagnosed at least 12 months before the data extraction date ( International Classification of Diseases , 9th revision , codes 401.0 , 401.1 , or 401.9 ) , enrollment with a primary care physician at the included clinic for at least 12 months before data extraction , self-report of current antihypertensive medication use , a scheduled appointment with a nonlaboratory primary care provider during the next 30 days , and residence in 1 of 32 specified ZIP codes in the areas around Duke University Health System . Exclusion criteria applied before r and omization were a diagnosis of dementia , Parkinson disease , atrial fibrillation , or end-stage renal disease ; patient of a study investigator or physician not expected to remain at the practice during the entire study period ; resident in nursing home or receiving home health care ; hospitalization for stroke or heart attack , surgery for blocked arteries , or diagnosis of metastatic cancer in the previous 3 months ; poor vision or difficulty hearing on the telephone ; difficulty underst and ing English on the telephone ; participant in another BP study ; spouse participating in current study ; arm circumference greater than 17 inches and wrist circumference greater than 8.5 inches ; pregnant or planning to become pregnant in the next 2 years ; or not receiving most medical care from Duke clinics . Patients also were excluded after r and omization because they were no longer receiving medical care at the Duke clinics , had initiated dialysis , had received an organ transplant in the previous 6 months , resided in a nursing home or receiving home health care , had no telephone , or received a diagnosis of pulmonary hypertension in the previous 6 months . The study team mailed qualifying patients a letter from the patient 's primary care provider that gave information about the study and stated that the study team may contact them to participate . Research assistants made weekly screening telephone calls to patients from a r and omly ordered list of eligible patients with upcoming clinic appointments . Figure 1 shows the flow of participants in the study . Overall , 2060 invitation letters were mailed to patients . Research assistants attempted to contact 1728 potential participants by telephone . Six hundred fifty-six patients were enrolled and consented to participate ; the remaining 1072 were not enrolled for various reasons . Twenty additional patients were excluded at the time of the baseline interview . Figure 1 . Study flow diagram . BP = blood pressure . * No longer receiving care at Duke clinics , receiving dialysis , received an organ transplant , residing in a nursing home or receiving home health care , had no telephone , or had pulmonary hypertension . R and omization and Intervention The 636 eligible patients were r and omly assigned to receive usual care , a tailored behavioral telephone intervention , home BP monitoring , or the behavioral intervention plus BP monitoring . In a 22 design , r and omization was stratified at baseline by enrollment site ( 2 primary care clinics ) and health literacy status , as determined by using the Rapid Estimate of Adult Literacy in Medicine ( 5 ) ( low literacy , score of 0 to 60 [ 9th- grade level or less ] [ 6 ] , vs. adequate literacy , score of 61 to 66 [ greater than 9th- grade level ] [ 7 ] ) . Consecutively numbered envelopes were used to r and omly assign patients in each stratum . R and omization blocks of 16 were computer generated by the study statistician and used to ensure ongoing balanced enrollment across the 4 groups . The research assistants were blinded to block size , and patient r and omization sequences were maintained by the study statistician in a separate office from the clinics . At completion of the baseline interview , a research assistant opened an envelope and disclosed the patient 's r and omization status . Participants were reimbursed $ 25 for the baseline visit and for each of the 4 subsequent 6-month BP measurement visits ( $ 125 total ) . Usual Care Patients assigned to usual care received hypertension care from their primary care provider . They were not provided home BP monitors and did not have access to the nurse-administered behavioral intervention . They underwent the same 6-month outcome assessment measurements as the other groups . Tailored Behavioral Self-management Intervention Patient factors targeted in the behavioral intervention included perceived risk for hypertension , memory , literacy , social support , patients ' relationships with their health care providers , and side effects of antihypertension medication . In addition , the intervention focused on improving  adherence to the Dietary Approaches to Stop Hypertension ( DASH ) dietary pattern  ( 811 ) ,  weight loss  ( 12 , 13 ) ,  reduced sodium intake  ( 13 , 14 ) ,  regular moderate-intensity physical activity  ( 15 , 16 ) ,  smoking cessation  , and moderation of alcohol intake  ( 17 ) . The intervention was delivered by 1 nurse during bimonthly telephone calls . All information was presented in an easily understood format with a FleschKincaid readability score of less than 9th grade ( 18 ) . Each encounter included a core group of modules potentially implemented during each call ( for example , medication and side effects ) plus additional modules activated at specific intervals ( for example , diet and social support ) ( 19 ) . Home BP Monitoring Intervention Patients assigned to home BP monitoring received an Omron HEM 773AC arm monitor ( OMRON Healthcare , Bannockburn , Illinois ) if arm circumference was 17 inches or less or an Omron HEM 637 wrist monitor if arm circumference was greater than 17 inches and wrist circumference was less than 8.5 inches . Two research assistants trained patients in proper use of the home BP devices . At each 6-month assessment , patients were retrained if their BP assessment procedure was incorrect . Patients were asked to measure their BP 3 times weekly on 3 separate days , at the same time of day , and record their values in a log . Patients were asked to mail their logs in every 2 months by using study -provided , preaddressed , stamped envelopes . Combined Intervention Patients assigned to the combined intervention received a home BP monitor , training on its use , and the behavioral self-management intervention . The nurse did not examine home BP values and did not use the home BP values to adjust the intervention . Outcomes and Measurements Baseline Measurement Patient demographic information and diagnosis of diabetes were obtained from patients during a face-to-face baseline interview . Inadequate income was assessed by asking patients to report whether they had enough money to pay bills only by cutting back on things or had difficulty paying bills ( 20 ) . Health literacy was evaluated as a dichotomous variable ( 7 ) . Body weight abstract ed from the medical record and self-reported height were used to calculate body mass index . Study Outcomes : BP Control and Systolic and Diastolic BP The primary outcome was the proportion of participants with adequate BP control at each study time point ( baseline and 6 , 12 , 18 , and 24 months ) . Blood pressure control was defined as systolic BP less than 140 mm Hg and diastolic BP less than 90 mm Hg for patients without diabetes , and systolic BP less than 130 mm Hg and diastolic BP less than 80 mm Hg for patients with diabetes ( 21 ) . Secondary outcomes were systolic and diastolic BP at each time point over 24 months . At each time point , a research assistant who was blinded to the patient 's group assignment obtained 2 BP measurements with a digital sphygmomanometer ( BPTRU Automated Non-invasive BP monitor , Model BPM-100 , BpTRU Medical Devices Headquarters , Coquitlam , British Columbia , Canada ) ; the first was obtained after patients were
The overall quality of evidence based on GRADE criteria was moderate for systolic blood pressure , but low for diastolic blood pressure .
INTERPRETATION Task-sharing interventions are effective in reducing blood pressure .
BACKGROUND Task sharing for the management of hypertension could be useful for understaffed and re source -poor health systems .
We assessed the effectiveness of task-sharing interventions in improving blood pressure control among adults in low-income and middle-income countries .