HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings
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...
| Main Authors: | , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
Frontiers Media S.A.
2023-04-01
|
| Series: | Frontiers in Cardiovascular Medicine |
| Subjects: | |
| Online Access: | https://www.frontiersin.org/articles/10.3389/fcvm.2023.1102482/full |
| _version_ | 1797839067756363776 |
|---|---|
| author | Andres Rosende Donald J. DiPette Ramon Martinez Jeffrey W. Brettler Jeffrey W. Brettler Gonzalo Rodriguez Eric Zuniga Pedro Ordunez |
| author_facet | Andres Rosende Donald J. DiPette Ramon Martinez Jeffrey W. Brettler Jeffrey W. Brettler Gonzalo Rodriguez Eric Zuniga Pedro Ordunez |
| author_sort | Andres Rosende |
| collection | DOAJ |
| description | 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. |
| first_indexed | 2024-04-09T15:51:05Z |
| format | Article |
| id | doaj.art-aeb792e33b174d048134d80e55369f87 |
| institution | Directory Open Access Journal |
| issn | 2297-055X |
| language | English |
| last_indexed | 2024-04-09T15:51:05Z |
| publishDate | 2023-04-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Cardiovascular Medicine |
| spelling | doaj.art-aeb792e33b174d048134d80e55369f872023-04-26T06:31:07ZengFrontiers Media S.A.Frontiers in Cardiovascular Medicine2297-055X2023-04-011010.3389/fcvm.2023.11024821102482HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settingsAndres Rosende0Donald J. DiPette1Ramon Martinez2Jeffrey W. Brettler3Jeffrey W. Brettler4Gonzalo Rodriguez5Eric Zuniga6Pedro Ordunez7Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, United StatesSchool of Medicine Columbia, University of South Carolina, Columbia, SC, United StatesDepartment of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, United StatesDepartment of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United StatesSouthern California Permanente Medical Group, Los Angeles, CA, United StatesConsultant for HEARTS in the Americas, PAHO/WHO Office in Argentina, Buenos Aires, ArgentinaAntofagasta Health Service, University of Antofagasta, Antofagasta, ChileDepartment of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, United StatesBackgroundHEARTS 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.https://www.frontiersin.org/articles/10.3389/fcvm.2023.1102482/fullcardiovascular diseaseshypertensionclinical protocolscritical pathwayspublic healthquality improvement |
| spellingShingle | Andres Rosende Donald J. DiPette Ramon Martinez Jeffrey W. Brettler Jeffrey W. Brettler Gonzalo Rodriguez Eric Zuniga Pedro Ordunez HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings Frontiers in Cardiovascular Medicine cardiovascular diseases hypertension clinical protocols critical pathways public health quality improvement |
| title | HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings |
| title_full | HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings |
| title_fullStr | HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings |
| title_full_unstemmed | HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings |
| title_short | HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings |
| title_sort | hearts in the americas clinical pathway strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings |
| topic | cardiovascular diseases hypertension clinical protocols critical pathways public health quality improvement |
| url | https://www.frontiersin.org/articles/10.3389/fcvm.2023.1102482/full |
| work_keys_str_mv | AT andresrosende heartsintheamericasclinicalpathwaystrengtheningthedecisionsupportsystemtoimprovehypertensionandcardiovasculardiseaseriskmanagementinprimarycaresettings AT donaldjdipette heartsintheamericasclinicalpathwaystrengtheningthedecisionsupportsystemtoimprovehypertensionandcardiovasculardiseaseriskmanagementinprimarycaresettings AT ramonmartinez heartsintheamericasclinicalpathwaystrengtheningthedecisionsupportsystemtoimprovehypertensionandcardiovasculardiseaseriskmanagementinprimarycaresettings AT jeffreywbrettler heartsintheamericasclinicalpathwaystrengtheningthedecisionsupportsystemtoimprovehypertensionandcardiovasculardiseaseriskmanagementinprimarycaresettings AT jeffreywbrettler heartsintheamericasclinicalpathwaystrengtheningthedecisionsupportsystemtoimprovehypertensionandcardiovasculardiseaseriskmanagementinprimarycaresettings AT gonzalorodriguez heartsintheamericasclinicalpathwaystrengtheningthedecisionsupportsystemtoimprovehypertensionandcardiovasculardiseaseriskmanagementinprimarycaresettings AT ericzuniga heartsintheamericasclinicalpathwaystrengtheningthedecisionsupportsystemtoimprovehypertensionandcardiovasculardiseaseriskmanagementinprimarycaresettings AT pedroordunez heartsintheamericasclinicalpathwaystrengtheningthedecisionsupportsystemtoimprovehypertensionandcardiovasculardiseaseriskmanagementinprimarycaresettings |