Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana.
Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana.
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DOI：
10.1371/journal.pmed.1002561
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发表时间：
2018-05
期刊：
影响因子：
15.8
通讯作者：
Cooper R
中科院分区：
文献类型：
--
作者：
Ogedegbe G;Plange-Rhule J;Gyamfi J;Chaplin W;Ntim M;Apusiga K;Iwelunmor J;Awudzi KY;Quakyi KN;Mogaverro J;Khurshid K;Tayo B;Cooper R
在撒哈拉以南非洲，难以获得护理和医生短缺是高血压控制的主要障碍。缺乏针对这些障碍的循证系统一级战略的实施。我们进行了一项研究，以评估在加纳未控制的高血压患者中，单独提供医疗保险(HIC)与护士主导的高血压控制任务转移策略(TASSH)加HIC在降低收缩压(SBP)方面的比较效果。使用实用的整群随机试验，加纳公共医疗系统内的32个社区卫生中心被随机分配到单独的HIC或TASSH+HIC。研究对象为2012年11月28日至2014年6月11日期间的757名未控制高血压患者，并随访至2016年10月7日。两个干预组都得到了医疗保险和预定的护士探视，而TASSH+HIC包括心血管风险评估、生活方式咨询和12个月的抗高血压药物启动/滴定，由医疗系统内训练有素的护士提供。主要结果是SBP从基线变化到12个月。次要结果包括12个月时的生活方式行为和血压控制，以及24个月时SBP下降的可持续性。在757名患者中(HIC组389例，TASSH+HIC组368例)，85%的患者有12个月的数据(60%的女性，平均血压155.9/89.6毫米汞柱)。在分组调整后的意向治疗分析中，TASSH+HIC组的SBP下降(−20.4 mm Hg；95%CI−25.2至−15.6)大于HIC组(−16.8 mm Hg；95%CI−19.2至−15.6)，组间差异有统计学意义(−3.6 mm Hg(95%CI−6.1至−0.5；p=0.021)。两组的血压控制均有显著改善(55.2%，95%可信区间50.0%~60.3%，缺氧组为49.9%，95%可信区间44.9%~54.9%)，组间差异无统计学意义(95%可信区间−为1.8%~12.4%；p=0.29)。生活方式行为在两组中都没有明显改变。报告了21个不良事件(TASSH+HIC组和HIC组分别为9和12)。研究的主要局限是缺乏成本效益分析来确定TASSH+HIC组的额外成本和收益(如果有)。在加纳，在未得到控制的高血压患者中，提供医疗保险加上护士主导的任务轮换战略与提供医疗保险相比，SBP的下降幅度更大。未来在撒哈拉以南非洲扩大这些系统水平的高血压控制战略需要进行成本效益分析。临床试验.gov NCT01802372在一项群组随机试验中，Gbenga Ogedes be和他的同事们检验了由护士领导的任务转移策略在加纳控制高血压的有效性撒哈拉以南非洲地区(SSA)的心血管疾病负担正在增加，原因是无法控制的高血压患病率增加。难以获得医疗保健和医生短缺是SSA控制高血压的主要障碍。缺乏针对这些障碍的循证系统一级战略的实施。在这项对加纳32个社区卫生中心的757名患者进行的整群随机对照试验中，我们研究了在医疗保险覆盖范围内增加由护士领导的高血压控制干预是否比仅提供医疗保险覆盖范围更大地降低了收缩压(BP)。我们发现，在提供医疗保险的基础上增加护士主导的干预措施导致的收缩压(−20.4 mm Hg)比单独提供医疗保险(−16.8 mm Hg)的降幅更大，12个月时的净降幅为3.6 mm Hg(p=0.021)。研究结果为政策制定者建议在SSA高血压管理的医疗保险覆盖范围内增加护士领导的高血压控制任务转移策略提供了证据。未来在SSA中扩大这一由护士主导的战略将需要进行成本效益分析，并制定一项政策，授予护士治疗无并发症高血压患者的处方权，类似于目前治疗艾滋病毒的政策。
Poor access to care and physician shortage are major barriers to hypertension control in sub-Saharan Africa. Implementation of evidence-based systems-level strategies targeted at these barriers are lacking. We conducted a study to evaluate the comparative effectiveness of provision of health insurance coverage (HIC) alone versus a nurse-led task shifting strategy for hypertension control (TASSH) plus HIC on systolic blood pressure (SBP) reduction among patients with uncontrolled hypertension in Ghana. Using a pragmatic cluster randomized trial, 32 community health centers within Ghana’s public healthcare system were randomly assigned to either HIC alone or TASSH + HIC. A total of 757 patients with uncontrolled hypertension were recruited between November 28, 2012, and June 11, 2014, and followed up to October 7, 2016. Both intervention groups received health insurance coverage plus scheduled nurse visits, while TASSH + HIC comprised cardiovascular risk assessment, lifestyle counseling, and initiation/titration of antihypertensive medications for 12 months, delivered by trained nurses within the healthcare system. The primary outcome was change in SBP from baseline to 12 months. Secondary outcomes included lifestyle behaviors and blood pressure control at 12 months and sustainability of SBP reduction at 24 months. Of the 757 patients (389 in the HIC group and 368 in the TASSH + HIC group), 85% had 12-month data available (60% women, mean BP 155.9/89.6 mm Hg). In intention-to-treat analyses adjusted for clustering, the TASSH + HIC group had a greater SBP reduction (−20.4 mm Hg; 95% CI −25.2 to −15.6) than the HIC group (−16.8 mm Hg; 95% CI −19.2 to −15.6), with a statistically significant between-group difference of −3.6 mm Hg (95% CI −6.1 to −0.5; p = 0.021). Blood pressure control improved significantly in both groups (55.2%, 95% CI 50.0% to 60.3%, for the TASSH + HIC group versus 49.9%, 95% CI 44.9% to 54.9%, for the HIC group), with a non-significant between-group difference of 5.2% (95% CI −1.8% to 12.4%; p = 0.29). Lifestyle behaviors did not change appreciably in either group. Twenty-one adverse events were reported (9 and 12 in the TASSH + HIC and HIC groups, respectively). The main study limitation is the lack of cost-effectiveness analysis to determine the additional costs and benefits, if any, of the TASSH + HIC group. Provision of health insurance coverage plus a nurse-led task shifting strategy was associated with a greater reduction in SBP than provision of health insurance coverage alone, among patients with uncontrolled hypertension in Ghana. Future scale-up of these systems-level strategies for hypertension control in sub-Saharan Africa requires a cost–benefit analysis. ClinicalTrials.gov NCT01802372 In a cluster randomized trial, Gbenga Ogedegbe and colleageues examine the effectiveness of a nurse-led task shifting strategy for hypertension control in Ghana The burden of cardiovascular diseases in sub-Saharan Africa (SSA) is growing due to an increased prevalence of uncontrolled hypertension. Poor access to healthcare and physician shortage are major barriers to hypertension control in SSA. Implementation of evidence-based systems-level strategies targeted at these barriers are lacking. In this cluster randomized controlled trial conducted among 757 patients across 32 community health centers in Ghana, we examined whether the addition of a nurse-led intervention for hypertension control to health insurance coverage led to a greater reduction in systolic blood pressure (BP) than provision of health insurance coverage alone. We found that the addition of a nurse-led intervention to provision of health insurance coverage led to a greater reduction in systolic BP (−20.4 mm Hg) than health insurance coverage alone (−16.8 mm Hg), with a net difference in reduction of 3.6 mm Hg (p = 0.021) at 12 months. The study findings provide evidence for policy makers to recommend addition of a nurse-led task shifting strategy for hypertension control to health insurance coverage for management of hypertension in SSA. Future scale-up of this nurse-led strategy in SSA would require a cost–benefit analysis and establishment of a policy that grants nurses prescribing power to treat patients with uncomplicated hypertension, similar to current policy for treatment of HIV.
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影响因子：
4.5
作者：
Callaghan M;Ford N;Schneider H
通讯作者：
Schneider H
DOI：
10.2471/blt.06.032177
发表时间：
2007-06-01
期刊：
Bulletin of the World Health Organization: International Journal of Public Health
影响因子：
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影响因子：
4.5
作者：
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通讯作者：
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影响因子：
3.3
作者：
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通讯作者：
Wagner, Anita K.
影响因子：
4.9
作者：
Mendis, S;Abegunde, D;Nordet, P
通讯作者：
Nordet, P