Integration of a multicomponent intervention for hypertension into primary healthcare services in Singapore-A cluster randomized controlled trial.

Autor: Jafar TH; Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore.; Department of Renal Medicine, Singapore General Hospital, Singapore.; Duke Global Health Institute, Durham, North Carolina, United States of America., Tan NC; SingHealth Polyclinics, Singapore., Shirore RM; Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore., Allen JC; Center for Quantitative Medicine, Office of Research, Duke-NUS Medical School, Singapore., Finkelstein EA; Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore., Hwang SW; SingHealth Polyclinics, Singapore., Koong AYL; SingHealth Polyclinics, Singapore., Moey PKS; SingHealth Polyclinics, Singapore., Kang GC; SingHealth Polyclinics, Singapore., Goh CWT; SingHealth Polyclinics, Singapore., Subramanian RC; SingHealth Polyclinics, Singapore., Thiagarajah AG; National University Polyclinics, Singapore., Ramakrishnan C; Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore., Lim CW; Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore., Liu J; SingHealth Polyclinics, Singapore.
Jazyk: angličtina
Zdroj: PLoS medicine [PLoS Med] 2022 Jun 13; Vol. 19 (6), pp. e1004026. Date of Electronic Publication: 2022 Jun 13 (Print Publication: 2022).
DOI: 10.1371/journal.pmed.1004026
Abstrakt: Background: Despite availability of clinical practice guidelines for hypertension management, blood pressure (BP) control remains sub-optimal (<30%) even in high-income countries. This study aims to assess the effectiveness of a potentially scalable multicomponent intervention integrated into primary care system compared to usual care on BP control.
Methods and Findings: A cluster-randomized controlled trial was conducted in 8 government clinics in Singapore. The trial enrolled 916 patients aged ≥40 years with uncontrolled hypertension (systolic BP (SBP) ≥140 mmHg or diastolic BP (DBP) ≥90 mmHg). Multicomponent intervention consisted of physician training in risk-based treatment of hypertension, subsidized losartan-HCTZ single-pill combination (SPC) medications, nurse training in motivational conversations (MCs), and telephone follow-ups. Usual care (controls) comprised of routine care in the clinics, no MC or telephone follow-ups, and no subsidy on SPCs. The primary outcome was mean SBP at 24 months' post-baseline. Four clinics (447 patients) were randomized to intervention and 4 (469) to usual care. Patient enrolment commenced in January 2017, and follow-up was during December 2018 to September 2020. Analysis used intention-to-treat principles. The primary outcome was SBP at 24 months. BP at baseline, 12 and 24 months was modeled at the patient level in a likelihood-based, linear mixed model repeated measures analysis with treatment group, follow-up, treatment group × follow-up interaction as fixed effects, and random cluster (clinic) effects. A total of 766 (83.6%) patients completed 2-year follow-up. A total of 63 (14.1%) and 87 (18.6%) patients in intervention and in usual care, respectively, were lost to follow-up. At 24 months, the adjusted mean SBP was significantly lower in the intervention group compared to usual care (-3.3 mmHg; 95% CI: -6.34, -0.32; p = 0.03). The intervention led to higher BP control (odds ratio 1.51; 95% CI: 1.10, 2.09; p = 0.01), lower odds of high (>20%) 10-year cardiovascular risk score (OR 0.67; 95% CI: 0.47, 0.97; p = 0.03), and lower mean log albuminuria (-0.22; 95% CI: -0.41, -0.02; p = 0.03). Mean DBP, mortality rates, and serious adverse events including hospitalizations were not different between groups. The main limitation was no masking in the trial.
Conclusions: A multicomponent intervention consisting of physicians trained in risk-based treatment, subsidized SPC medications, nurse-delivered motivational conversation, and telephone follow-ups improved BP control and lowered cardiovascular risk. Wide-scale implementation of a multicomponent intervention such as the one in our trial is likely to reduce hypertension-related morbidity and mortality globally.
Trial Registration: Trial Registration: Clinicaltrials.gov NCT02972619.
Competing Interests: The authors have declared that no competing interests exist. Author Agnes Koong was unable to confirm their authorship contributions. On their behalf, the corresponding author has reported their contributions to the best of their knowledge.
Databáze: MEDLINE
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