Implementing and Scaling Up a Team-based Care Strategy for Hypertension Control in Colombia and Jamaica

项目摘要/摘要 高血压不成比例地影响低收入和中等收入国家的人口，特别是在 拉丁美洲和加勒比(LAC)，流行率高，控制率低，导致过量 心血管疾病负担(CVD)。尽管可以广泛获得循证干预措施，但只有7.7%的人 2010年，LMICs的患者接受了血压(BP)控制。弥合知识与实践之间的差距 来自哥伦比亚、牙买加和美国的多学科研究小组将在LAC中控制高血压 与国家和地方政府机构和卫生系统合作，测试实施情况和 在哥伦比亚实施和扩大基于团队的BP控制护理战略的有效性结果 还有牙买加。REACH有效性采用实施维护(RE-AIM)框架正在进行中 用于指导实施战略的制定和评估。医生-护士(或 药剂师)-社区卫生工作者(CHW)团队将与患者协作，实现共享 治疗目标。护士或药剂师将在内科医生的指导下使用简单的规程滴定药物 监督，CHWS将就改变生活方式和服药依从性进行健康指导，以及患者 将积极从事自我管理(包括家庭血压监测)。特定目标1将测试覆盖范围， 实施团队的有效性、采用率、实施(保真度)和维护(可持续性)- 基于护理策略的整群随机试验。共有40家初级保健诊所(20家来自哥伦比亚，20家来自哥伦比亚 来自牙买加；每个诊所32名患者，总共1280名)将被随机分配到以团队为基础的护理 战略或加强12个月的日常护理，以测试实施情况和效果结果。为期6个月的 将进行试验后的后续研究，以评估可持续性。这项试验有90%的统计权力 使用双侧显著性检验高血压控制(BP&lt；140/90 mm Hg)中15%的绝对差异 0.05的水平。具体目标2将评估扩大以团队为基础的 观察性研究中的CARE策略。将提供培训，以扩大所有剩余人员的基于团队的护理 141个初级保健诊所(78个来自哥伦比亚，63个来自牙买加)。然而，扩容 活动将不会得到外部资金的支持。将收集障碍和实施结果 使用初级保健诊所和提供者团队级别的访谈、调查和管理数据。此外，我们 将能够比较3组之间的实施结果--外部资金的干预(诊所 试验干预组)，无外部资助的干预(观察性研究中的诊所)，以及 常规护理(试验对照组诊所)。我们会进行调解分析，以了解 团队护理对血压控制的作用机制及成本-效果分析 成本。这项拟议的研究将确定有效、公平和可持续的策略来实现高血压 在常规临床环境中进行控制，降低LAC和其他LMICs普通人群的心血管疾病风险。

Project Summary/Abstract Hypertension disproportionally affects populations in low- and middle-income countries (LMICs), especially in Latin America and the Caribbean (LAC), with a high prevalence and low control rate, resulting in an excess burden of cardiovascular disease (CVD). Despite widely available evidence-based interventions, only 7.7% of patients in LMICs had their blood pressure (BP) controlled in 2010. To close the knowledge-practice gap for hypertension control in LAC, a multidisciplinary team of investigators from Colombia, Jamaica, and the US will work with national and local government agencies and health systems to test the implementation and effectiveness outcomes of implementing and scaling up a team-based care strategy for BP control in Colombia and Jamaica. The RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework is being used to guide the development and evaluation of the implementation strategies. Physician-nurse (or pharmacist)-community health worker (CHW) teams will work collaboratively with patients to achieve shared treatment goals. Nurses or pharmacists will titrate medications using a simple protocol under physician supervision, CHWs will conduct health coaching on lifestyle change and medication adherence, and patients will actively engage in self-management (including home BP monitoring). Specific Aim 1 will test the reach, effectiveness, adoption, implementation (fidelity), and maintenance (sustainability) of implementing a team- based care strategy in a cluster randomized trial. A total of 40 primary care clinics (20 from Colombia and 20 from Jamaica; 32 patients per clinic and 1,280 in total) will be randomly assigned to a team-based care strategy or enhanced usual care for 12 months to test implementation and effectiveness outcomes. A 6-month post-trial follow-up study will be conducted to assess sustainability. This trial has 90% statistical power to detect an absolute difference of 15% in hypertension control (BP<140/90 mm Hg) using a 2-sided significance level of 0.05. Specific Aim 2 will assess barriers and implementation outcomes of scaling up a team-based care strategy in an observational study. Training will be provided to scale up team-based care in all remaining 141 primary care clinics (78 from Colombia and 63 from Jamaica) after the cluster trial. However, scale-up activities will not be supported by external funding. Barriers and implementation outcomes will be collected using interview, survey, and administrative data at primary care clinic and provider team levels. In addition, we will be able to compare implementation outcomes among 3 groups — intervention with external funding (clinics in the trial intervention group), intervention without external funding (clinics in the observational study), and usual care (clinics in the trial control group). We will conduct mediation analyses to understand the mechanisms of team-based care on BP control and a cost-effectiveness analysis to estimate implementation costs. The proposed study will identify effective, equitable, and sustainable strategies to achieve hypertension control in routine clinical settings and reduce CVD risk in the general population of LAC and other LMICs.