Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana

Abstract

BackgroundPoor 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 findingsUsing a pragmatic cluster randomized trial, 32 community health centers within Ghana’s public healthcare system were randomly 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.ConclusionsProvision 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 registrationClinicalTrials.gov NCT01802372

Hypertension testing and treatment in Uganda and Kenya through the SEARCH study: An implementation fidelity and outcome evaluation

“…Recent studies demonstrate that programs for control of HIV can be leveraged for the control of chronic diseases such as HTN [18,19], though quantitative data on care linkage, blood pressure control, and other operational outcomes are scarce [20,21,22]. Pilot projects to date have been small and local in scope, with mixed results in linking HTN patients to care and achieving blood pressure control [2,3,4,23,24,25,26]. These inconsistent findings may be due to incomplete program fidelity: projects designed to screen and treat patients for HTN and CVD are not consistently implemented as intended, precluding accurate assessment of their impact.…”

Adapting a nurse-led primary care initiative to cardiovascular disease control in Ghana: A qualitative study

“…Our use of IDIs allowed for a nuanced understanding of barriers to implementing the HEARTS package, which include inadequate CHO training; poor health literacy among community members; lack of access to CVD medications and other necessary resources; a high burden of CVD risk factors; and difficulty accessing CHPS compounds and referral centers. Although previous pilot studies have implemented elements of the HEARTS protocol through CHPS [62], our work suggests means to adapt CHPS itself from a program primarily focused on infectious disease and child and maternal health to that which functions across the lifespan to accommodate all aspects of this integrated CVD care model, as well as the care of other NCDs. These approaches include, among others, improved 1) access to essential medications;…”

Adapting a nurse-led primary care initiative to cardiovascular disease control in Ghana: A qualitative study

“…Although previous pilot studies have implemented elements of the HEARTS protocol through CHPS [50], our work suggests means to adapt CHPS itself from a program primarily focused on infectious disease and child and maternal health to that which functions across the lifespan to accommodate all aspects of this integrated CVD care model, as well as the care of other NCDs. These approaches include, among others, improved 1) access to essential medications; 2) provider training; 3) community member education; and 4) means of transportation to referral sites, as detailed below.…”