HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings
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2023
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Background: HEARTS 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.
Methods: The 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.
Results: Among 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). Conclusion: This 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