BP-Medication Use Improves With Low-Cost Community Initiative in China and India

November 18, 2014

CHICAGO, IL — The use of a simplified electronic decision support system on a smartphone or tablet helped community-health workers increase the number of men and women taking antihypertensive medications in rural communities in China and India[1].

The improvement in the proportion of patients taking antihypertensive medications was modest and resulted in a small but statistically significant net reduction in systolic blood pressure.

The study, known SIMCARD, was presented today by Dr Maoyi Tian (George Institute for Global Health, Beijing, China) at the American Heart Association (AHA) 2014 Scientific Sessions. Speaking during a special-report session, Tian said that India and China are the two largest developing countries in the world, with both experiencing rapid economic growth in the past decade. Despite their rapid growth, significant disparities in healthcare exist between the rich and poor and between urban and rural communities.

Cardiovascular disease accounts for 38% and 29% of deaths in China and India, respectively, said Tian. High blood pressure, tobacco use, unhealthy diet, and physical inactivity are the most significant risk factors contributing to cardiovascular disease in both countries.

To combat this rising tide of cardiovascular disease in healthcare-constrained rural settings, the investigators attempted to develop and evaluate a simplified, guideline-based, cardiovascular-disease prevention program put into action by community health workers. Specifically, the program was initiated in 47 rural villages in Tibet, China and Haryana, India. The program included 2086 subjects at high risk for cardiovascular disease, including individuals with a history of heart disease, stroke, diabetes, or measured systolic blood pressure >160 mm Hg.

In the community, health workers were trained and assisted with a customized smartphone or tablet to use an electronic decision support program. The program allowed the healthcare workers to follow up with and manage their patients with two lifestyle modifications (smoking cessation and sodium reduction) and two appropriate prescriptions (antihypertensive medication and aspirin). In total, 23 villages were randomized to the intervention arm and 24 served as the control arm.

At baseline, just 4.2% and 2.8% of patients in the intervention and control arms, respectively, were taking antihypertensive medications. After one year, 32.3% patients randomized to the intervention arm were taking an antihypertensive medication, whereas only 8.8% of patients in the control arm were doing the same. This translated into a between-group difference of 22.1% (P=0.01) and a 2.1-mm-Hg improvement in systolic pressure.

Overall, follow-up with the community-health workers had no impact on lifestyle behaviors, such as smoking cessation or awareness about the dangers of high salt intake. Aspirin use did increase significantly in the intervention arm, up from 6.0% at baseline to 18.8% at one year. In the control arm, aspirin use actually declined over the one-year period.

Tian said the strengths of the study include the fact that it was strongly supported by government and the interventions were designed to adopt to local cultures. Dr Valentin Fuster (Icahn School of Medicine at Mount Sinai, New York), who was not affiliated with the trial, praised the study, noting it was adequately powered and simple. However, he said the effect on systolic blood pressure was small and that less than one-third of patients randomized to follow-up with the community-health worker were receiving an antihypertensive medication.

"In spite of the dedicated intervention, diuretic uptake occurred in only 32% of the population and aspirin uptake in only 19%," said Fuster. "Linked with these [outcomes], this pilot study confirms the feasibility of the operation, with the power to detect differences in systolic blood pressure, but there appears to be a missed opportunity to make this study more than a feasibility exercise. Nevertheless, it is a complicated study."

The authors have reported they have no relevant financial relationships.


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