Scaling up effective treatment of hypertension—A pathfinder for universal health coverage

Objective To evaluate evidence from published randomised controlled trials (RCTs) for the use of task-shifting strategies for cardiovascular disease (CVD) risk reduction in low-income and middle-income countries (LMICs). Design Systematic review of RCTs that utilised a task-shifting strategy in the management of CVD in LMICs. Data Sources We searched the following databases for relevant RCTs: PubMed from the 1940s, EMBASE from 1974, Global Health from 1910, Ovid Health Star from 1966, Web of Knowledge from 1900, Scopus from 1823, CINAHL from 1937 and RCTs from ClinicalTrials.gov. Eligibility criteria for selecting studies We focused on RCTs published in English, but without publication year. We included RCTs in which the intervention used task shifting (non-physician healthcare workers involved in prescribing of medications, treatment and/or medical testing) and non-physician healthcare providers in the management of CV risk factors and diseases (hypertension, diabetes, hyperlipidaemia, stroke, coronary artery disease or heart failure), as well as RCTs that were conducted in LMICs. We excluded studies that are not RCTs. Results Of the 2771 articles identified, only three met the predefined criteria. All three trials were conducted in practice-based settings among patients with hypertension (2 studies) and diabetes (1 study), with one study also incorporating home visits. The duration of the studies ranged from 3 to 12 months, and the task-shifting strategies included provision of medication prescriptions by nurses, community health workers and pharmacists and telephone follow-up posthospital discharge. Both hypertension studies reported a significant mean blood pressure reduction (2/1 mm Hg and 30/15 mm Hg), and the diabetes trial reported a reduction in the glycated haemoglobin levels of 1.87%. Conclusions There is a dearth of evidence on the implementation of task-shifting strategies to reduce the burden of CVD in LMICs. Effective task-shifting interventions targeted at reducing the global CVD epidemic in LMICs are urgently needed.

Healthcare reform plans refer to improved quality, but there is little quantification of potential health benefits of quality care. This paper aims to estimate the health benefits by greater use of clinical preventive services. Two mathematical models were developed to estimate the number of deaths potentially prevented per year by increasing use of nine clinical preventive services. One model estimated preventable deaths from all causes, and the other estimated preventable deaths from specific categories of causes. Models were based on estimates of the prevalence of risk factors for which interventions are recommended, the effect of those risk factors on mortality, the effect of the interventions on mortality in those at risk, and current and achievable rates of utilization of the interventions. Both models predicted substantial numbers of deaths prevented by greater use of the preventive services, with the greatest increases from services that prevent cardiovascular disease. For example, the all-cause model predicted that every 10% increase in hypertension treatment would lead to an additional 14,000 deaths prevented and every 10% increase in treatment of elevated low-density lipoprotein cholesterol or aspirin prophylaxis would lead to 8000 deaths prevented in those aged <80 years, per year. Overall, the models suggest that optimal use of all of these interventions could prevent 50,000-100,000 deaths per year in those aged <80 years and 25,000-40,000 deaths per year in those aged <65 years. Substantial improvements in population health are achievable through greater use of a small number of preventive services. Healthcare systems should maximize use of these services. 2010 American Journal of Preventive Medicine. All rights reserved.