SEPTEMBER 2017
GAZETTE
A study showed that an intervention led by health promoters or health agents increases the proportion of hypertensive patients who manage to normalize their blood pressure values by a little more than 20%. The study, published in the latest edition of JAMA (one of the most influential medical journals in the world), was carried out by researchers from the Institute of Clinical and Health Effectiveness (IECS), in Argentina, and Tulane University, United States. The novel strategy to improve hypertension control includes five measures, among which are the delivery of blood pressure monitors for home use, periodic visits by health promoters and the sending of motivational text messages to hypertensive people. 
A clinical trial conducted on more than 1400 low-income patients from 18 public health centers in Argentina demonstrated that a comprehensive care program can improve the treatment of hypertension arterial, a condition suffered by 43% of the Argentine adult population. In this studio, 5 interventions increased the proportion of patients who achieved satisfactory control by 20,6% of hypertension.[I]
The initiative consists of implementing a set of strategies led by health promoters or health agents: personnel from the primary health care team with a strong insertion in the community. The fact that there are several strategies (and not just one) is what makes this type of intervention called “multicomponent”.
“Although our health system is focused on the figure of the doctor, a very important aspect of this study is that it highlights the relevant role that health promoters can play in the management of hypertension", supports the Dr. Vilma Irazola, co-author of the work and director of the Chronic Diseases Research Department of the IECS.
“Health promoters or health agents can have greater reach and better communication with patients. "They should have greater participation in health teams," adds Irazola, who is also the academic coordinator of the Master in Clinical Effectiveness from the UBA Faculty of Medicine.
The five measures that make up this comprehensive care program to improve hypertension control are:
1) A periodic visit by specially trained health promoters to the patients' homes. It is carried out every one or two months with the aim of providing them with advice and information about lifestyle changes, so that they can measure their pressure and also take medication to control it. Promoters can also help improve attendance at medical appointments and even bring medication when necessary.
2) Free delivery of digital blood pressure monitors to facilitate the measurement of pressure values at home.
3) Free delivery of pill boxes or weekly medication organizers.
4) Sending weekly text messages individualized, aimed at reinforcing the promoter's interventions and thus, for example, motivating patients to adopt healthy habits (such as eating with less salt and engaging in physical activity).
5) Training (remote and in-person) of primary care doctors in the management of hypertension. The objective is that patient care follows what clinical practice guidelines indicate.
But it is not just about turning to health promoters. The concept of “multicomponent” intervention aligns with the growing perception that “complex diseases (such as hypertension) must be addressed with complex interventions”, as highlighted by Irazola, who adds: “The combination of these measures produces greater effects than the sum of individual isolated measures.”
The findings of this research study are relevant to public health. “The larger scale application of this intervention (proven effective in low- and middle-income countries like Argentina) "should result in a substantial reduction in poorly controlled hypertension and associated cardiovascular disease," the study authors stated in the journal JAMA. Along these lines, Irazola adds: “I have no doubt that the same model could be transferred to the management of diabetes and other chronic diseases.”
STUDY DETAILS
This approach to combating hypertension was tested in 1432 patients with an average age of 55.8 years, treated in 18 public health centers in Tucumán, Misiones, Corrientes, Entre Ríos and three districts of the Province of Buenos Aires. All were diagnosed with uncontrolled blood pressure (systolic or maximum greater than or equal to 140 mmHg; diastolic or minimum, less than or equal to 90 mmHg.) Randomly, half of the participants received the intervention program. The rest were cared for in the usual way (without said program).
After 18 months, the differences were noticeable. In the group that received the program, mean systolic and diastolic blood pressure decreased by 19,3 mmHg and 12,7 mmHg, respectively. On the other hand, the decreases were significantly less marked in the control group (the one that did not receive the multicomponent abutments): 12,1 mmHg for systolic pressure and 6,4 mmHg for diastolic pressure.
The other documented effect of the new study, after the same 18-month period, was the greater proportion of patients under the multicomponent intervention who achieved adequate blood pressure control: 72,9% versus 52,2% of the control group. A difference of 20,6%, which, the researchers believe, could be even wider in the “real world” (that is, if this intervention were applied at the population level).
The authors of the work also carried out a economic analysis of the intervention. They calculated that, over 18 months, the cost difference compared to usual care is US$102,7 per patient: less than US$6 per month. “It is a very cost-effective intervention,” Dr. Irazola stressed in this sense.
In an editorial comment published in the same issue of JAMA, Mark D. Huffman, a member of the Department of Preventive Medicine at Northwestern University (Chicago, United States), characterized the study, along with two colleagues, as “well designed and driven", beyond the fact that it does not allow us to identify which of the measures of the comprehensive care program produces the greatest effects. In any case, Argentine researchers are currently conducting an analysis of the process to try to infer which of the components of the intervention may be the most beneficial. “The next steps, perhaps the most challenging, appear to be how to scale up, adapt and sustain these types of interventions (…) to move from a reduction in blood pressure to a reduction in premature deaths and disability from cardiovascular diseases ”, concluded Huffman and his colleagues.
El principal investigator of the study published by JAMA was the Dr. Adolfo Rubinstein, former director general of the IECS and current secretary of Health Promotion, Prevention and Risk Control of the national health portfolio. Other researchers of the IECS that were part of this study are: Dr. Andrea Beratarrechea, Dr. Rosana Poggio, Ms. Luz Gibbons, Dr. Pablo Gulayin, Dr. Marilina Santero, Dr. Analía Nejamis and the Dr. Federico Augustovski.
ADDITIONAL INFORMATION ON ARTERIAL HYPERTENSION IN ARGENTINA AND THE WORLD
*43 percent of the population of Argentina between 35 and 75 years old has hypertension and 55 percent of these people do not know it, according to a study by the IECS (called CESCAS 1), published in 2015 in the International Journal of Cardiology, (http://www.internationaljournalofcardiology.com/article/S0167-5273(15)00089-3/abstract)
*In the world, just over 30% of the adult population has hypertension. 75% live in low- and middle-income countries, such as Argentina, although the majority does not know their condition. Of all of them, only 7,7% have it under control.
*In 2015, it was estimated that 1.000 million people over 25 years of age in the world have systolic or maximum blood pressure above 140 mmHg. And that was associated with 7,8 million deaths.
*High blood pressure is associated with more than 50% of heart attacks and two thirds of cerebrovascular accidents (CVA).
*According to the Argentine Society of Arterial Hypertension (SAHA), the ten recommendations to have pressure under control are: measure it; maintain an adequate weight; walk daily; Reduce the consumption of salt; limit alcohol intake and do not smoke; understand that many times there is no known cause; control other risk factors; take the medications prescribed by the doctor; not abandon treatment; and assume that hypertension must be controlled.
IECS PRESS CONTACT: Lic. Mariana Comolli, coordinator of the IECS Communication Unit. Tel.: (011) 4777-8767 ext. 44. Email: mcomolli@iecs.org.ar
[I] He J, Irazola V, Mills KT, et al. Effect of a community health worker–led multicomponent intervention on blood pressure control in low-income patients in Argentina: a randomized clinical trial. JAMA. doi:10.1001/jama.2017.11358