Study Shows How We Can Massively Improve Hypertension Treatment

A study conducted in KwaZulu-Natal has been published in the New England Journal of Medicine, the world’s leading medical journal.

• Hypertension is described by the World Health Organisation as a “silent killer” because it’s often undiagnosed, and even once diagnosed, it’s often uncontrolled.
• A study has compared treating hypertension in clinics, the current standard of care, versus letting patients have more autonomy and treating the disease at home.
• The home-based care patients had better outcomes.
• The results of the study were published in the prestigious New England Journal of Medicine this month.

Hypertension kills many South Africans. A new study shows how simply changing where people are treated — at home rather than in a clinic — improves their health and reduces the burden on the public health system.

A clinical trial has found that treating hypertension at home is significantly more effective than treating hypertension in clinics. The Africa Health Research Institute’s (AHRI) IMPACT-BP trial took place in rural KwaZulu-Natal and the results were published in the New England Journal of Medicine.

The trial looked at how patients with hypertension responded to treatment either at home or in clinics. Results showed that home-based hypertension treatment, with the help of community health workers (CHWs), home visits and a mobile app, led to significantly lowered blood pressure at six and 12 months.

The World Health Organisation calls high blood pressure a “silent killer” as it is a condition that often goes untreated, and is one of the world’s leading risk factors for heart disease and premature death. Only about half of people with hypertension are diagnosed and only about one in five have their hypertension under control.

In the clinical trial, about 774 patients with hypertension were split into three groups: one group was assigned home-based care for hypertension from a community health worker, another received enhanced home-based care, and the third received standard care in a clinic.

In the home-based care group, participants received an automated blood-pressure machine to take blood-pressure measurements daily, and were trained by community health workers how to use it.

The blood pressure data was recorded into an app by community health workers on a monthly basis. Nurses reviewed patient data monthly and entered prescription information. Prescriptions were sent to the community health workers who fetched and delivered the medication.

In the enhanced group, the participants received a blood-pressure machine that sent data directly to the app. Community health workers visited participants to ensure their machines were working and to deliver medication.

Results showed that hypertension control rates were 32% in the standard-care group compared to about 60% in the home-based care groups.

Mark Siedner, infectious diseases specialist from AHRI and co-principal investigator of the trial, said that if the reduction in blood pressure seen in the home-based care groups is sustained over time, it will mean a significant reduction in heart attacks or strokes.

Travelling to clinics in rural KwaZulu-Natal is usually a whole-day affair, said Siedner. It’s inconvenient, costs money, and it’s difficult for people who are older and have other illnesses or limited mobility. And when patients get there, they may have to queue for hours at a time, nurses may not have capacity to treat them, or the blood pressure machines may not work.

“I think there are multiple features of hypertension which make it difficult for patients potentially to engage in their care. What we offered them was not to spend four hours in a clinic, but to measure their own blood pressure, to understand their own health, and to be able to receive care especially in the comfort of their own home, where the community health worker would deliver their medicines for them,” he said.

Siedner said they also heard from nurses and managers in the clinic that patient loads had reduced and that pressure was taken off the clinics.

Nsika Sithole, the trial’s project manager from AHRI, said that the study shows that “community-based care is actually feasible” and that the model they used is “scaleable”.

Sithole explained the only thing they brought that was not already established in the health department was the mobile health app. Otherwise, the trial was done in partnership with health department clinics and nurses. The community health workers were from the community. “It’s an easy scaleable model because it’s got a system that is already established within the community,” said Sithole.

Sithole said the biggest challenge was network connections, especially during loadshedding. Internet access was needed for community health workers to input data into the app. To manage this, each staff member had two or three sim cards. If they couldn’t connect to Vodacom, they would switch to MTN, for instance. Otherwise, they would input the data when they were on wifi at the clinics.

Siedner also said that other challenges included loadshedding, drug stockouts, or a case where a clinic they were working at was damaged by weather. “We were pleasantly surprised that it worked despite all of those challenges,” he said.

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