HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings

Abstract

BackgroundHEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative. It is implemented in 24 countries and over 2,000 primary healthcare facilities. This paper describes the results of a multicomponent, stepwise, quality improvement intervention designed by the HEARTS in the Americas to support advances in hypertension treatment protocols and evolution towards the Clinical Pathway.MethodsThe quality improvement intervention comprised: 1) the use of the appraisal checklist to evaluate the current hypertension treatment protocols, 2) a peer-to-peer review and consensus process to resolve discrepancies, 3) a proposal of a clinical pathway to be considered by the countries, and 4) a process of review, adopt/adapt, consensus and approval of the clinical pathway by the national HEARTS protocol committee. A year later, 16 participants countries (10 and 6 from each cohort, respectively) were included in a second evaluation using the HEARTS appraisal checklist. We used the median and interquartile scores range and the percentages of the maximum possible total score for each domain as a performance measure to compare the results pre and post-intervention.ResultsAmong the eleven protocols from the ten countries in the first cohort, the baseline assessment achieved a median overall score of 22 points (ICR 18 −23.5; 65% yield). After the intervention, the overall score reached a median of 31.5 (ICR 28.5 −31.5; 93% yield). The second cohort of countries developed seven new clinical pathways with a median score of 31.5 (ICR 31.5 −32.5; 93% yield). The intervention was effective in three domains: 1. implementation (clinical follow-up intervals, frequency of drug refills, routine repeat blood pressure measurement when the first reading is off-target, and a straightforward course of action). 2. treatment (grouping all medications in a single daily intake and using a combination of two antihypertensive medications for all patients in the first treatment step upon the initial diagnosis of hypertension) and 3. management of cardiovascular risk (lower BP thresholds and targets based on CVD risk level, and the use of aspirin and statins in high-risk patients).ConclusionThis study confirms that this intervention was feasible, acceptable, and instrumental in achieving progress in all countries and all three domains of improvement: implementation, blood pressure treatment, and cardiovascular risk management. It also highlights the challenges that prevent a more rapid expansion of HEARTS in the Americas and confirms that the main barriers are in the organization of health services: drug titration by non-physician health workers, the lack of long-acting antihypertensive medications, lack of availability of fixed-doses combination in a single pill and cannot use high-intensity statins in patients with established cardiovascular diseases. Adopting and implementing the HEARTS Clinical Pathway can improve the efficiency and effectiveness of hypertension and cardiovascular disease risk management programs.

Standardized treatment protocols for hypertension: global availability, characteristics, and alignment with the hypertension guideline recommendations

“…Further, a recent trial by Jiang et al [25] demonstrated the superiority of STPs over usual care in intensive BP reduction as well as reducing cardiovascular disease risk and deaths. The 2023 study by Rosende et al [14], which conducted a similar appraisal of 18 STPs from 16 Latin-American countries (first cohort of 11 countries and a second cohort of 7 additional countries) using the HEARTS checklist, also included a quality improvement intervention that involved expert discussions to solve discrepancies and proposal of a novel clinical pathway to be adopted by the countries. STPs included in this appraisal reported a baseline performance of 65%, which is slightly lower than the observed performance of 68% in our study.…”

“…It defined the attributes and components of a preferred STPs and developed the ‘HEARTS in the Americas appraisal checklist and its Clinical Pathway’ (HEARTS in the Americas Checklist) [13]. This checklist has been used previously to appraise hypertension treatment STPs from 16 countries in the PAHO region [14]. Outside the PAHO, there has been no review of the availability and quality of the hypertension STPs (hereafter referred to as STPs).…”

Can the HEARTS initiative reduce the burden of cardiovascular disease?

“…When being explicit about all the necessary conditions for effectiveness, it becomes clear that there are significant challenges to translating HEARTS’ theoretical potential into real-world impact. Some of these challenges, for example, are the lack of long-acting hypertensives and drug combinations in one pill, and non-physician healthcare team members not being able to intensify treatments or difficulties in implementing CVD risk reduction, for example, using high-dose statins, suggest system barriers to achieve the full potential of the strategy 7. Cost might be a significant barrier with estimates of US$9–US$44 per person treated per year, and antihypertensive drugs need to be priced low enough to reach <$5 per patient per year to provide medications alone in the public sector but still can significantly impact national budgets when scaled up 8.…”