Hypertension Control Drivers at Primary Health Care Centers - 2021

Background
Cardiovascular disease continues to be the leading cause of premature morbidity and mortality globally. According to the 2019 Global Burden of Disease Report, systolic blood pressure accounted for 10.8 million deaths in 2019 or 19.2% of total deaths. High systolic blood pressure was the leading attributable risk factor for disability-adjusted life years for people over 50.

Cardiovascular disease is also the leading cause of premature morbidity and mortality in the Americas. In 2016, there were 1.9 million deaths attributable to CVD.
Improvement in blood pressure control has occurred. However, part of the improvement seen in the last two decades has slowed significantly, and in some cases, even reversed. This has been shown clearly in the US, where NHANES data (JAMA. 2020;324(12):1190-1200), and in the WHO Region of the Americas, where 11 countries showed flattening and even an increase in mortality.

Significant improvement in hypertension control has been demonstrated in multiple settings. In both Southern and Northern California Kaiser Permanente regions, blood pressure control improved from approximately 50% to 90% for ten years. Similar improvements have been achieved in the Veterans’ Administration system in the US and nationally in Canada. In Kaiser Southern California, this improvement mirrored a significant decrease in CVD mortality, which outpaced the state of California and the US national rates.

WHO/PAHO RESPONSE
HEARTS IN THE AMERICAS

HEARTS is an initiative spearheaded by the World Health Organization involving various global actors, including the Centers for Disease Control and prevention of the United States (CDC) and the Initiative Resolve to Save Lives, among other global actors. The Department of Noncommunicable Diseases and Mental Health of the Pan American Health Organization (PAHO) leads the implementation of HEARTS in the Region of the Americas, ensuring that implementation actions are aligned with the strategic priorities of the region, particularly with the universal health coverage resolution, strengthening of health systems based on primary care and with the Sustainable Development Goals 2030, specifically those related to the prevention and control of noncommunicable diseases (NCD).

HEARTS in the Americas (https://www.paho.org/en/hearts-americas) is an initiative of the countries, led by the Ministries of Health with the participation of local stakeholders with the technical cooperation of PAHO, which seeks to integrate seamlessly and progressively to already existing health delivery services to promote the adoption of global best practices in the prevention and control of cardiovascular diseases (CVD) and improve the performance of the services through better control of high blood pressure and the promotion of secondary prevention with emphasis on the primary health care.

HEARTS is being implemented and expanded in 16 countries of the Region to include 478 health centers across the Region implementing HEARTS, covering approximately 7.8 million adults in the respective catchment areas.  HEARTS will be the institutionalized model of care for cardiovascular risk management, emphasizing the control of hypertension and secondary prevention in primary health care in the Americas by 2025.

Recognizing that the team-based care approach is not highly applied and that it is poorly implemented in many countries, there is a substantial gap to be filled.  The drivers of hypertension control are solidly embedded within a team-based approach and take advantage of the progress of this Region in implementing the Chronic Care Model. HEARTS in the Americas is focusing on substantially enhancing the team-based care component. This enhancement includes the design of innovative, simple, and functional workflow pathways, led by physicians, nurses or non-physician health workers (NPHW), to increase control of hypertension in PHC centers. HEARTS is enhancing its technical package with an emphasis on its team care approach and aligned with the foundations of the Kaiser care pyramid and the Kaiser Permanente hypertension care model, among other models.

Intended audience
This course is intended for primary care teams, primary care physicians, nurses, nurse assistants, nurse practitioners, allied health professionals, primary care centers administrators, medical, nurses and allied health students. In addition, teachers of health science programs, which include medicine and nursing, are recommended to embed the course, and make it available for their students or to incorporate it into their curriculum.
 
Course format
The course is placed on the platform of the Virtual Campus for Public Health of PAHO/WHO available 24 hours a day, 7 days a week, in a self-administered modality according to the own participant pace, individually or as part of professional programs and /or educational meetings in the workplace.

The course issues a certificate with 16 hours.

Course structure

Introduction/Overview of the Course. Key Hypertension Control Drivers Overview
Objectives

  • To become familiar with the overall course objective, structure and evaluative exercises
  • To become familiar with main successful experiences of hypertension control
  • To identify the major drivers of hypertension control

Module 1: Overview of quality improvement
Objectives

  • To become familiar with basic principles of quality improvement
  • To understand importance of process measures in improving performance of outcome measures
  • To understand basics of quality improvement application to hypertension control

Module 2: Accurate BP Measurement
Objectives

  • To understand importance of accurate BP measurement
  • To learn how to assess BP measurement competency
  • To become familiar with assessment tools including repeat BP and spot audits
  • To become familiar with how to check if a BP monitor is validated

Module 3: Medication Titration
Objectives

  • To understand the importance of using standardized treatment protocols for control of HTN
  • To understand how to measure treatment intensification
  • To become familiar with task shifting strategies to improve BP control
  • To become familiar with guideline-based recommendations to initiate medication within 2-4 weeks of hypertension diagnosis

Module 4: Follow-Up Blood Pressure Check
Objectives

  • To understand the importance of prompt follow-up of elevated blood pressures
  • To learn strategies for improving follow-up, including uncoupling of BP measurement from a physician visit
  • To familiarize yourself with measurement of elevated BP follow-up

Module 5: Utilization of Scorecards for Quality Improvement
Objectives

  • To familiarize yourself with the major process measures in the new HEARTS scorecard
  • To better understand how to use the scorecard as a quality improvement tool in improving BP control

Module 6: Community Outreach
Objectives

  • To understand the importance of screening all patients for hypertension upon clinic entry
  • To review the diagnosis of hypertension using standard criteria
  • To search for undiagnosed hypertensive patients already seen in clinic
  • To familiarize yourself with recommended outreach to inactive hypertensive patients

Module 7: Home Blood Pressure Monitoring
Objectives

  • To understand the importance of home BP monitoring in the diagnosis and management of hypertensive patients
  • To familiarize yourself with the key steps in creating a home BP monitoring program
  • To understand how to incorporate home BP readings into hypertension management

Special module: COVID-19, Hypertension Control and Cardiovascular Disease
Objectives

  • To emphasize the importance of implementing proven strategies to control hypertension as a key role to minimize the risk of complication in patients with COVID-19
  • To understand the inter-relationship between the acute COVID-19 and Chronic Non-communicable Disease (NCD) pandemics
  • To review local data on COVID-19 and hypertension