Enhanced hypertension care through private clinics in Pakistan: a cluster randomized trial

Enhanced hypertension care through private clinics in Pakistan: a cluster randomized trial

This study, funded by Department for International Development (DFID), was done in partnership with; Provincial Program for Prevention and Control of Non-communicable Diseases & Mental Health; Directorate General of Health Services, Punjab; Nuffield Centre for International Health and Development, University of Leeds UK and World Health Organization (WHO).

Background Hypertension in Pakistan affects 33% of people≥45 years, and in urban areas around 70% of basic health care occurs in private facilities.

Aim We assessed whether enhanced care at urban private clinics resulted in better control of hypertension, cardiovascular disease risk factors and treatment adherence.

Design and Setting We conducted a two-arm cluster randomised controlled trial at 26 private clinics (three districts of Punjab)between January 2015 and September 2016.Both arms had enhanced screening and diagnosis of hypertension and related conditions, and patient recording processes. Intervention facilities also had a clinical care guide, additional drugs for hypertension, a patient lifestyle education flipchart, associated training, and mobile phone follow-up.

Methods We randomised clinics in a 1:1 ratio (sealed envelope lottery method) and consecutively recruited 574 intervention and 564 control patients in 13 clusters in each arm (male and female, aged ≥25, systolic blood pressure [SBP] >140 mm Hg and/or diastolic blood pressure >90 mm Hg). Primary outcome = change in SBP from baseline to nine-month follow-up. We did not blind staff or patients, but blinded outcome assessors.

Results Nine-month primary outcomes were available for 522/574 (90.9%) intervention and 484/564 (85.8%) control participants (all clusters). Unadjusted cluster-level analysis results: mean intervention outcome = -25.2 mm Hg (95% CI: -29.9, -20.6), mean control outcome = -9.4 mm Hg (95% CI: 21.2, 2.2), and mean control-intervention difference = 15.8 (95% CI: 3.6, 28.0; P=0.01).

Conclusion The findings and separate process evaluation support the scaling of an integrated CVD-hypertension care intervention in urban private clinics in areas lacking public primary care in Pakistan.

 URL: https://bjgpopen.org/content/early/2019/01/23/bjgpopen18X101617