Implementing a multisector public-private partnership to improve urban hypertension management in low-and middle- income countries

Abstract

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.

Population health impact and economic evaluation of the CARDIO4Cities approach to improve urban hypertension management

“…Details on the approach of the urban population health initiative and its outcomes on hypertension care have been reported previously [ 28 , 29 ]. Following needs assessments and stakeholder alignments locally, data collection began at different time points in the three cities.…”

“…Demographic data were available on patients’ sex, age, and BP. Further, patients’ CV risk was evaluated by physicians during their initial medical assessment, and categorized as low, medium, or high (see [ 29 ] S1 Table ), implicitly capturing the effects of age, risk behaviors, and comorbidities. Systolic BP was collected longitudinally from de-identified primary health records of patients ≥18 years old.…”

“…Systolic BP was collected longitudinally from de-identified primary health records of patients ≥18 years old. Patient and relevant population characteristics have been described previously [ 29 ] and are summarized in Table 1 . The definition of hypertension followed national guidelines: in Dakar and São Paulo, a BP threshold of ≥140/90 mmHg was used, in Ulaanbaatar hypertension was defined as BP ≥ 130/80 mmHg.…”

“…Based on patients’ BP values at their first reported visit, previously diagnosed patients were classified as controlled or uncontrolled for hypertension, and newly diagnosed patients as uncontrolled. Anti-hypertensive therapy was prescribed according to available national guidelines [ 29 ]. For patients treated with medication who had at least two reported consultations with BP measurement within the study period [ 29 ], the last reported BP value was used to evaluate whether hypertension control was achieved.…”

“…Specific interventions in each city are summarized in S1 Table . Following less than two years implementation of the CARDIO4Cities approach, BP control rates among patients in primary health centers increased from 12% to 31% in São Paulo, from 7% to 19% in Dakar, and from 3% to 19% in Ulaanbaatar [ 29 ].…”