The India Hypertension Control Initiative–early outcomes in 26 districts across five states of India, 2018–2020

Drug- and dose-specific hypertension treatment protocols

All five states developed and implemented drug- and dose-specific hypertension treatment protocols (Table 1). [11] To develop the treatment protocols, NCD program managers conducted consensus workshops in Phase 1 states. The workshops included health officials from the state health departments, clinicians from the District hospitals, specialists from medical colleges, and external invited experts. All protocols included specific doses of three drugs: the calcium channel blocker amlodipine, the angiotensin receptor blocker telmisartan, and the diuretic chlorthalidone (or hydrochlorothiazide). The six steps in protocol guided the progressive addition of dose/drugs needed to control BP and facilitated a realistic estimation of drug supply requirements and accelerated procurement.

Table 1 Description of progress and challenges related to core implementation strategies of India Hypertension Control Initiative, India, 2018–2020.Ensuring availability of antihypertensive drugs and validated BP monitors

Soon after the program launch, shortages and stockouts of the protocol drugs at service delivery points emerged as significant challenges. In addition to inherent difficulties with public procurement, a lack of experience in handling large-scale public health programs requiring a lifelong supply of medications increased the difficulty in planning and procurement for the state procurement agencies. IHCI’s efforts to ensure accurate supply forecasting, budget allocations, timely procurement, and distribution of drugs gradually improved the availability of medicines in all districts (Table 1). At the district level and in the health facilities, all three protocol drugs were available for more than 30 patient days, ensuring one-month refills continuously for each patient (Fig. 1).

Fig. 1: Availability of antihypertensive drugs in the IHCI project sites, March 2020.figure 1

This chart describes the availability of three types of antihypertensive drugs in patient days (≥90 days is optimal) in five Indian states.

The project initially provided professional, independently-validated digital, automated digital blood pressure monitors meeting WHO-recommended specifications to most facilities to demonstrate the value of good quality measurement devices and encourage task sharing. [12] Based on positive feedback from using these good-quality BP monitors, several states have now initiated steps to procure additional professional validated devices using state resources.

Team-based and patient-centric hypertension care

The project was implemented in 1417 facilities by December 2020, including 63 district/sub-district hospitals, 170 Community Health Centres (CHC), 864 Primary Health Centres (PHC) and 320 Health Wellness Centres (HWC). All five states implemented team-based care involving nurses, doctors and pharmacists to manage hypertension (Table 1). Lack of dedicated nurses and vacancies of doctor posts, especially in Punjab and Madhya Pradesh, limited the increase in patient registrations and follow-up in several health facilities. Opportunistic hypertension screening was implemented with limited success except in Telangana and two districts of Maharashtra, where dedicated NCD nurses at the PHCs enabled daily screening. Many of the patients attending busy health care facilities, particularly hospitals, did not have blood pressure taken, and, when taken, many with elevated readings were not started on treatment. During supportive supervision visits, the project team advised ways to streamline the flow of patients through facilities so that patients first visited the nurse, who measured the blood pressure and updated the medical record before the patient visited the doctor for evaluation and a prescription.

All five states implemented drug dispensing for 30-days across all types of health facilities (Table 1). Patient follow-up was decentralized to 320 HWC based in the patient’s community. In Health Wellness Centres, the Community Health Officer (CHO) measured blood pressure and provided refills.

Information systems and key indicators

Data was collected using paper-based cards in Kerala, Madhya Pradesh, and Telangana. The Simple app, an android based app, was introduced in Punjab and Maharashtra. The transition to this mobile phone-based app reduced paperwork, improved documentation of blood pressures, facilitated a more rapid generation of program monitoring reports, and enabled quick feedback on program performance indicators to facilities and districts via summary dashboards. Using Simple, a health worker completes a new patient registration in <60 s and documents a follow-up visit in <20 s. Existing patient data can be retrieved in <5 s by scanning BP passport cards with unique QR codes and carried by the patient. High-risk patients are automatically prioritized at the top of the list of overdue patients generated by Simple. Nurses call overdue patients through a toll-free, anonymized service with a single click. Automatic reminder messages are sent to patients who miss visits, progress can be monitored in real-time, and performance can be monitored daily or monthly. Reports are generated automatically, saving time spent compiling and verifying paper records.

The project was implemented in a phased manner in 26 districts across five states between January 2018 and 31st December 2019. The project districts are home to an estimated 4.5 million people with hypertension, of whom 570,365 (12.7%) were registered for treatment. Among them, 89% (510,856) were actively under care in public sector health facilities, and the remaining were lost to follow up at least through March of 2020, according to available records. Thus, 11% of all people estimated to have hypertension in the 26 districts were actively under care in IHCI facilities in the program’s first two years.

Clinic-level BP control was 43% across all IHCI districts in the five states during the most recent visit between 1st January and 31st March 2020. BP control was highest in IHCI facilities closer to the patient’s home, such as PHC (46%) and Health and Wellness Centres (42%). District hospitals had the lowest control (35%) (Fig. 2). There was a wide variation of clinic-level BP control across districts, ranging from 22% to 79% during the most recent visit in Jan-March, 2020 (Table 2). Control was above 50% in 10 districts in Telangana (a southern state). Six districts in three states had control of 40%- 50%.

Fig. 2figure 2

Blood pressure control in various types of facilities in Jan-March, 2020 among a cohort of patients under care in 26 districts in India.

Table 2 Patients under the care and proportion of controlled blood pressure (BP), uncontrolled BP, and missed visits among patients on treatment in public sector facilities in 26 districts in India, 2020.

Uncontrolled BP among patients who visited a health facility in Jan-March, 2020 ranged from 6% to 38% (overall 25%) across districts (Table 2). Of the 26 districts, 12 had uncontrolled BP above 20%, including all four in Kerala. The proportion of patients who missed visits in the first quarter of 2020 ranged from 12% to 54% (overall 32%) in various districts (Table 2).

Overall estimated community-level hypertension control based on districts’ estimated number of people living with hypertension increased from 1.4% to 5.0%. We documented improvement in all project districts from Jan- to March 2020 compared to Jan-March 2019 (Fig. 3). Community-level hypertension control reached above 5% in 13 districts, including seven from Telangana, all four from Kerala, and two from Maharashtra.

Fig. 3: Community level blood pressure control in IHCI project districts, India.figure 3

Estimated community-level BP control in 26 districts among patients under care in Jan-March, 2020 compared to Jan-March, 2019, India. (Estimated hypertensives N = 45,41,994, Number with BP control = 2,18,340 in Jan-March 2020, Number with BP control = 64,704 in Jan-March, 2019).

留言 (0)

沒有登入
gif