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Community-Based Intervention to Reduce CVD Risk in Hypertension (HOPE 4)
Study Questions:
Can a model of care involving nonphysician health workers (NPHWs), primary care physicians, family, and the provision of effective medications substantially reduce cardiovascular disease (CVD) risk?
Methods:
HOPE 4 was an open, community-based, cluster-randomized controlled trial involving 1,371 individuals with new or poorly controlled hypertension from 30 communities (defined as townships) in Colombia and Malaysia. A total of 16 communities were randomly assigned to control (usual care, n = 727), and 14 (n = 644) to the intervention. After community screening, the intervention included treatment of CVD risk factors by NPHWs using tablet computer-based simplified management algorithms and counseling programs; free antihypertensive (community available combination pill) and statin medications (10 mg rosuvastatin or 20 mg atorvastatin) recommended by NPHWs but supervised by physicians; and support from a family member or friend (treatment supporter) to improve adherence to medications and healthy behaviors. The primary outcome was the change in Framingham Risk Score (FRS) 10-year CVD risk estimate at 12 months between intervention and control participants.
Results:
Mean age was 66 years with >50% female, and 30% had at least a secondary education. All communities completed 12-month follow-up (data on 97%, n = 1,299). Mean 10-year FRS CVD estimate was 34%. The reduction in FRS for 10-year CVD risk was –6.40% in the control group and –11.17% in the intervention group, with a difference of change of –4.78% (95% confidence interval [CI], –7.11 to –2.4; p < 0.0001). There was an absolute 11.45 mm Hg (95% CI, –14.94 to –7.97) greater reduction in systolic blood pressure, and 16 mg/dl (95% CI, –23 to –8.8 mg/dl) reduction in low-density lipoprotein cholesterol with the intervention group (both p < 0.0001). Change in blood pressure control status (<140 mm Hg) was 69% in the intervention group versus 30% in the control group (p < 0.0001). There were no safety concerns with the intervention.
Conclusions:
A comprehensive model of care led by NPHWs, involving primary care physicians and family that was informed by local context, substantially improved blood pressure control and CVD risk. This strategy is effective, pragmatic, and has the potential to substantially reduce CVD compared with current strategies that are typically physician based.
Perspective:
Atherosclerotic CVD is the leading cause of death and disability in the United States and throughout the developed world. The cost of prevention can be relatively inexpensive if provided through novel approaches as in HOPE 4, which can be replicated in communities of the poorly educated and with low socioeconomic levels. There are community-based nonprofit organizations ready to work in consort with health care systems burdened with the uninsured or underinsured, and responsible for treating what were preventable strokes, myocardial infarction, heart failure, and chronic kidney disease. Identifying and treating young and middle-aged persons at risk would identify families at risk and impact the future health of the children.
Clinical Topics: Cardiovascular Care Team, Dyslipidemia, Prevention, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Hypertension
Keywords: Atherosclerosis, Antihypertensive Agents, Blood Pressure, Blood Pressure Determination, Cardiovascular Diseases, Cholesterol, LDL, Computers, Handheld, Counseling, Health Behavior, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Medication Adherence, Physicians, Primary Care, Primary Prevention, Risk Factors
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