Background Cardiovascular disease presents an increasing health burden to low- and middle-income countries. Although ample therapeutic options and care improvement frameworks exist to address its prime risk factor, hypertension, blood pressure control rates remain poor. We describe the results of an effectiveness study of a multisector urban population health initiative that targets hypertension in a real-world implementation setting in cities across three continents. The initiative followed the “CARDIO4Cities” approach (quality of Care, early Access, policy Reform, Data and digital technology, Intersectoral collaboration, and local Ownership). Method The approach was applied in Ulaanbaatar in Mongolia, Dakar in Senegal, and São Paulo in Brazil. In each city, a portfolio of evidence-based practices was implemented, tailored to local priorities and available data. Outcomes were measured by extracting hypertension diagnosis, treatment and control rates from primary health records. Data from 18,997 patients with hypertension in primary health facilities were analyzed. Results Over one to two years of implementation, blood pressure control rates among enrolled patients receiving medication tripled in São Paulo (from 12·3% to 31·2%) and Dakar (from 6·7% to 19·4%) and increased six-fold in Ulaanbaatar (from 3·1% to 19·7%). Conclusions This study provides first evidence that a multisectoral population health approach to implement known best-practices, supported by data and digital technologies, and relying on local buy-in and ownership, can improve hypertension control in high-burden urban primary care settings in low-and middle-income countries.

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with 80% of that mortality occurring in low- and middle-income countries. Hypertension, its primary risk factor, can be effectively addressed through multisectoral, multi-intervention initiatives. However, evidence for the population-level impact on cardiovascular (CV) event rates and mortality, and the cost-effectiveness of such initiatives is scarce as long-term longitudinal data is often lacking. Here, we model the long-term population health impact and cost-effectiveness of a multisectoral urban population health initiative designed to reduce hypertension, conducted in Ulaanbaatar (Mongolia), Dakar (Senegal), and in the district of Itaquera in São Paulo (Brazil) in collaboration with the local governments. We based our analysis on cohort-level data among hypertensive patients on treatment and control rates from a real-world effectiveness study of the CARDIO4Cities approach (built on quality of care, early access, policy reform, data and digital, Intersectoral collaboration, and local ownership). We built a decision tree model to estimate the CV event rates during implementation (1–2 years) and a Markov model to project health outcomes over 10 years. We estimated the number of CV events averted and quality-adjusted life-years gained (QALYs through the initiative and assessed its cost-effectiveness based on the costs reported by the funder using the incremental cost effectiveness ratio (ICER) and published thresholds. A one-way sensitivity analysis was performed to assess the robustness of the results. The modelled patient cohorts included 10,075 patients treated for hypertension in Ulaanbaatar, 5,236 in Dakar, and 5,844 in São Paulo. We estimated that 3.3–12.8% of strokes and 3.0–12.0% of coronary heart disease (CHD) events were averted during 1–2 years of implementation in the three cities. We estimated that over the subsequent 10 years, 3.6–9.9% of strokes, 2.8–7.8% of CHD events, and 2.7–7.9% of premature deaths would be averted. The estimated ICER was USD 748 QALY gained in Ulaanbaatar, USD 3091 in Dakar, and USD 784 in São Paulo. With that, the intervention was estimated to be cost-effective in Ulaanbaatar and São Paulo. For Dakar, cost-effectiveness was met under WHO-CHOICE standards, but not under more conservative standards adjusted for purchasing power parity (PPP) and opportunity costs. The findings were robust to the sensitivity analysis. Our results provide evidence that the favorable impact of multisector systemic interventions designed to reduce the hypertension burden extend to long-term population-level CV health outcomes and are likely cost-effective. The CARDIO4Cities approach is predicted to be a cost-effective solution to alleviate the growing CVD burden in cities across the world.

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In 2018, the Mission Lifeline North Dakota (ND) initiative adopted and began to implement Stroke Survivors Empowering Each Other, Inc.’s (SSEEO’s) Stroke Survivor to Survivor (SS2S) program. The SS2S program is a post-stroke support program that aims to facilitate survivors’ efforts to recover after stroke. Volunteers, who are themselves survivors, call participants monthly at least twice following discharge from the hospital and provide them with stroke-related resources and support. The adaptation and implementation of the Chicago-borne SS2S program in ND was embedded within a continuous quality improvement framework to ensure ongoing performance monitoring data could inform programmatic improvements as needed. Key questions: • How has the Chicago-borne SS2S program been adapted to fit the unique characteristics and environment of ND, while maintaining fidelity? • What are performance monitoring findings from the first three quarters of implementation? Between Oct 2018- Feb 2019, four of the six ND tertiary hospitals implemented the SS2S program. These hospitals provide monthly quantitative and qualitative data on program implementation. From Oct 2018 to May 2019, SS2S volunteers made 153 calls to survivors, with 57% (n = 87 of 153) of calls answered by a prospect, including stroke survivors (n=74) and their caregivers (n=13). Thirteen percent (n = 9 of 69) of stroke survivors calls required additional follow-up by hospital staff. SS2S volunteers mailed additional resources to stroke survivors for 48% percent of the calls where the prospect was reached (n= 33 of 69). Seventy percent (n = 48 of 69) of survivors reached were able to identify at least one sign of stroke. Preliminary results suggest that both volunteers and stroke survivors may benefit from the program. Importantly, performance monitoring data also identified opportunities for programmatic improvements. For example, these data informed edits to the volunteers’ phone scripts to clarify signs-of-stroke patient-education. Ongoing feedback from the hospitals have also informed improvements to the performance monitoring processes.

Background: Comprehensive workplace wellness programs (CWWPs) have the potential to improve the heart health of the US workforce. To accelerate the adoption of these programs, the American Heart Association launched the Workplace Health Achievement Index (WHAI). The WHAI is an online scorecard that evaluates a workplace’s culture of health and the aggregate heart health score of its workforce as measured by Life’s Simple 7. Evidence from other workplace scorecards indicate that smaller companies achieve lower scores. Objective: To quantify differences in WHAI scores and score components between smaller (<250 employees) and larger (250+ employees) worksites. Methods: The total WHAI score is derived from 55 structure and process measures across seven best-practice domains and performance metrics based on employee Life’s Simple 7 data. Data from the first WHAI cycle (Feb 1 - June 30, 2016) were analyzed from 239 worksites that provided structure and process information. All data were stratified according to company size (smaller vs. larger). Differences in practice and performance measures were assessed across groups using Pearson chi-square tests or paired t-tests. Results: Overall, 5% of workplaces submitted the required amount of heart health metrics data (≥25% of employees) for eligibility. Smaller companies achieved a lower total WHAI score and lower scores across all domains except for Partnerships (Table 1). Conclusion: Lower WHAI scores for smaller companies may be due to limited resources and capacity to implement CWWPs. Low submission of performance metrics highlights the challenge of including these data in a comprehensive assessment of CWWPs. To meet its 2020 Goals, AHA should consider providing smaller companies with resources to implement CWWPs and develop strategies to increase submission of employee Life’s Simple 7 data. Table 1: Differences in mean AHA Index scores between small and large companies *Sample sizes too small for meaningful comparison.