Hypertension Control, an Annotated Bibliography

March 2018

Hypertension Control, an

Annotated Bibliography

Contents

Section Page

Introduction 1

2. The Burden of Hypertension 2

3. Hypertension Treatment Protocols 3

3.1 An Overview of the Public Health Approach .................................................... 3

3.2 The Importance of Protocols ......................................................................... 4

3.3 Evidence for Developing Protocols ................................................................. 6

3.4 Example Guidelines ..................................................................................... 9

4. Task Sharing 10

5. Medical Supplies 14

6. Patient-Centered Services 16

7. Information Systems 18

Hypertension Control, an Annotated Bibliography

e hypertension bibliography was developed by the U.S. Centers for Disease Control and

Prevention (CDC) and RTI International with the assistance of Resolve to Save Lives and

Johns Hopkins Bloomberg School of Public Health. It is designed to serve as a resource in

the implementation of hypertension prevention and management programs.

Hypertension Control, an Annotated Bibliography

1. Introduction

This bibliography is intended as a resource for the design and implementation of

hypertension programs, and is useful for hypertension treatment protocol development and

adaptation. The aim is to provide a brief overview of the scientific basis of key aspects of

hypertension control for a comprehensive approach to hypertension management. This list

is not representative of all aspects of hypertension management and is largely drawn from

the scientific literature published in English.

The bibliography is organized in the following manner: first, a review of the burden of to

underscore its importance as a non-communicable disease; second, a review of the

evidence for protocol-based treatment; third, a review of the evidence on task sharing;

fourth, a summary of the literature on medical supplies and patient-centered services; and

lastly, a synopsis on information systems.

2. The Burden of Hypertension

The burden of hypertension is significant. The prevalence and the health consequences of

uncontrolled hypertension make it among the world’s most deadly diseases.

Bromfield S, Muntner P. High blood pressure: the leading global burden of

disease risk factor and the need for worldwide prevention programs. Current

hypertension reports. 2013 Jun 1;15(3):134-6.

In 2010, high blood pressure was ranked as the leading single risk factor for global

burden of disease. High blood pressure was one of the five leading risk factors for

global burden in all regions except Oceania, Eastern sub-Saharan Africa, and

Western and sub-Saharan Africa.

Lewington S, Lacey B, Clarke R, Guo Y, Kong XL, Yang L, et al. The Burden of

Hypertension and Associated Risk for Cardiovascular Mortality in China. JAMA

Intern Med. 2016;176(4):524-32.

This prospective cohort study of 500,223 adults in China showed that 32.5% of

participants had hypertension. Among participants with hypertension and prior

cardiovascular disease, only 13.0% had their hypertension controlled. Uncontrolled

hypertension was associated with a 4.1 relative risk for cardiovascular disease

mortality for adults age 35 to 59. Uncontrolled hypertension accounted for around

one-third of deaths due to cardiovascular disease at 35 to 79 years of age in China in

2010.

Prince MJ, Ebrahim S, Acosta D, Ferri CP, Guerra M, Huang Y, et al.

Hypertension prevalence, awareness, treatment and control among older

people in Latin America, India and China: a 10/66 cross-sectional population-

based survey. J Hypertens. 2012;30(1):177-87.

Hypertension Control, an Annotated Bibliography

In cross-sectional surveys of 17,014 people aged 65 years and over in urban and

rural sites in Latin America, India, and China, the prevalence of hypertension ranged

between 52.6% (Peru) and 79.8% (Puerto Rico) in urban sites, and between 42.6%

(Peru) and 56.9% (China) in rural sites. Hypertension control was lowest in rural

China (2%), urban India (12%), and rural India (9%).

Lu J, Lu Y, Wang X, Li X, Linderman GC, Wu C, Cheng X, Mu L, Zhang H, Liu J, Su

M. Prevalence, awareness, treatment, and control of hypertension in China:

data from 1· 7 million adults in a population-based screening study (China

PEACE Million Persons Project). The Lancet. 2017 Dec 9;390(10112):2549-58.

In a sample of 1,738,886 participants in China, 44.7% had hypertension. Of those

with hypertension, only 44.7% were aware of their diagnosis, 30.1% were taking

prescribed antihypertensive medications, and 7.2% had achieved control.

Mills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, Chen J, He J.

Global disparities of hypertension prevalence and control. Circulation. 2016

Aug 9;134(6):441-50.

This meta-analysis of 135 population-based studies spanning 90 countries reported

that 31.1% of the world’s adults had hypertension; 28.5% in high-income countries

and 31.5% in low- and middle-income countries. In 2010, an estimated 349 million

people in high-income countries and 1.04 billion people in low- and middle-income

countries had hypertension.

3. Hypertension Treatment Protocols

The chosen hypertension treatment protocol should be simple yet detailed, and include:

specific medication dosage and a schedule for titration or addition of medications if blood

pressure is not controlled to establish standard treatment of patients.

3.1 An Overview of the Public Health Approach to Hypertension

Treatment

Frieden TR, Bloomberg MR. Saving an additional 100 million lives. The Lancet.

2017 Sep 12.

Insights from the MPOWER technical package that successfully aimed at controlling

tobacco can be applied to the worldwide effort to improve hypertension control.

Ten years ago, Thomas Frieden and Michael Bloomberg suggested a way to prevent 100

million deaths from tobacco that led to the development and well-known success of the

MPOWER technical package. Recently, they launched a new cardiovascular initiative called

RESOLVE aiming to prevent an additional 100 million deaths globally. The RESOLVE

initiative focuses on three specific interventions: artificial trans-fat elimination, dietary

sodium reduction, and effective treatment of hypertension. Five essential components have

been identified for the scalable treatment of hypertension: protocols, task sharing, medical

supplies, patient-centered services, and information systems. RESOLVE builds on the

recently released World Health Organization Global Hearts Initiative and is housed at Vital

Hypertension Control, an Annotated Bibliography

Strategies, a global health non-profit organization. The approach will provide support global

and national efforts to scale up focused and effective interventions targeting cardiovascular

disease.

ord N, Ball A, Baggaley R, Vitoria M, Low-Beer D, Penazzato M, Vojnov L,

Bertagnolio S, Habiyambere V, Doherty M, Hirnschall G. The WHO public health

approach to HIV treatment and care: looking back and looking ahead. The Lancet

Infectious Diseases. 2017 Oct 20.

In the effort to improve hypertension control globally, lessons can be learned from

recent public health approaches to end the AIDS epidemic.

In 2006, the World Health Organization aimed to develop a public health approach for

delivering antiretroviral therapies in order to end the AIDS epidemic. The resulting approach

has been adopted widely and provided the basis for scaling up treatment to over 19.5

million people. In the effort to end AIDS as a public health threat by 2030, there are

opportunities to better tailor the public health approach to address certain challenges. Some

of these challenges have included the need for expanded testing to identify people with HIV,

further simplified treatment and laboratory monitoring, adapting the approach to areas with

concentrated epidemics, and linking testing, treatment, and care to prevention. Evaluating

the implementation of these principles can lead to key insights on how to scale-up a public

health approach focused on hypertension.

3.2 The Importance of Protocols

Frieden TR, King SM, Wright JS. Protocol-based treatment of hypertension: a

critical step on the pathway to progress. JAMA. 2014;311(1):21-2.

Adopting a standard protocol-based treatment of hypertension is a critical step in

helping clinicians, teams, and patients achieve and maintain healthy blood pressures,

thereby preventing myocardial infarction and stroke. Which protocol is selected is

less important than the decision to select, adopt, implement, and evaluate

implementation of any evidence-based protocol.

There are many major benefits of adoption and use of standardized, evidence-based

protocols. Protocols reduce clinical variability that is outside the bounds of evidence-based

practice. A protocol can better enlist and enable all members of the health care team to

reinforce the importance of blood pressure control and the value of adherence to healthy

habits, medications, and self-monitoring, and to participate in medication titration and

adjustment by following standard protocol-consistent order sets. Such clarity allows

qualified staff to advance patients safely and efficiently along the treatment pathway,

ensures that the supervising clinician is consulted if clinical exceptions occur, and identifies

patients likely to benefit from consultation for resistant hypertension. Algorithms can be

incorporated into electronic health records through clinical decision support tools, registry

functions, and measurement to facilitate quality improvement. A protocol can result in a

more efficient and cost-effective selection of medications and treatment approaches.

Standardized treatment facilitates evaluation of both the quality of care and the impact of

care. Adopting a standardized treatment approach sends a strong signal to clinical staff that

Hypertension Control, an Annotated Bibliography

hypertension control is a priority. Countries should strongly consider adopting a standard

protocol for blood pressure treatment.

Handler J. Commentary in support of a highly effective hypertension treatment

algorithm. JCH. 2013;15(12): 874-7.

Including a hypertension treatment algorithm in a standard protocol is a vital step in

controlling rates of hypertension.

A simple hypertension treatment algorithm has contributed to blood pressure control rates

of greater than 85% in the United States and is a critical step in managing population-level

hypertension. The treatment algorithm in the United States is built on the fixed-dose

combination drug lisinopril/hydrochlorothiazide, which is maximized in three steps before

adding amlodipine.

Campbell NR, Sheldon T. The Canadian effort to prevent and control hypertension:

can other countries adopt Canadian strategies?. Current opinion in cardiology.

2010 Jul 1;25(4):366-72.

The study describes important aspects of Canadian hypertension management programs

and implementation in order to aid other countries in successfully increasing

hypertension control rates.

In 1990s, Canada had a hypertension treatment and control rate of 13%. In 1999, Canada

developed a strategy to control hypertension and formed a coalition of national

organizations and volunteers to develop multiple hypertension programs. The effort was

based on management recommendations, a hypertension knowledge translation program,

and an outcomes assessment program. This resulted in large increases in hypertension

awareness and treatment as well as lower rates of cardiovascular disease. Recent initiatives

to continue to improve hypertension control include an education and a dietary salt

reduction program. In 2007-2009, the treatment and control rate had increased to 66% in

Canada.

ffe MG, Lee GA, Young JD, Sidney S, Go AS. Improved blood pressure control

associated with a large-scale hypertension program. Jama. 2013;310(7):699-705.

While hypertension management for large populations is challenging, the Kaiser

Permanente Northern California hypertension program shows that standardized

guidelines can significantly improve blood pressure control at a population level.

This study evaluates the effect of a large-scale hypertension program, the Kaiser

Permanente Northern California hypertension program, at controlling blood pressure. The

program involves five key components: a health system-wide hypertension registry,

measurement of hypertension control rates, the development of evidence-based practice

guidelines, follow-up measurement with medical assistants, and the promotion of single-pill

combination therapy. Implementation of this large-scale program was associated with a

significantly better blood pressure control than state and national control rates.

Hypertension Control, an Annotated Bibliography

3.3 Evidence for Developing Protocols

urnbull F, Neal B, Ninomiya T, Algert C, Arima H, Barzi F, et al. Effects of different

regimens to lower blood pressure on major cardiovascular events in older and

younger adults: meta-analysis of randomised trials. BMJ (Clin Res Ed).

2008;336(7653):1121-3.

There is no compelling evidence that various drug classes protect older and younger

adults against major cardiovascular events differently.

This meta-analysis aimed to quantify the relative risk reductions achieved with different

regimens to lower blood pressure in younger and older adults. The primary outcome was

total major cardiovascular events, including stroke, coronary heart disease, and heart

failure. Younger adults were defined as less than 65 years old and older adults were defined

as 65 years or older at the time of entry into the study. The seven comparisons of

treatment were angiotensin-converting enzyme (ACE) inhibitor versus placebo, calcium

antagonist versus placebo, more-intensive versus less-intensive regimens to lower blood

pressure, angiotensin-receptor blocker versus control regimen, ACE inhibitor versus

diuretics/β blockers, calcium antagonist versus diuretics/β-blockers, and ACE inhibitor

versus calcium antagonists. Thirty-one trials with 190,606 participants were included. No

clear difference was found between age groups in the effects of different regimens or

medications in lowering blood pressure or decreasing major cardiovascular events.

Oliveria SA, Lapuerta P, McCarthy BD, L'Italien GJ, Berlowitz DR, Asch SM.

Physician-related barriers to the effective management of uncontrolled

hypertension. Archives of internal medicine. 2002;162(4):413-20.

An important reason physicians are not treating hypertension more aggressively is that

they are willing to accept higher levels of blood pressure. Education and guidelines

could help physicians better manage elevated blood pressure.

This study aimed to assess barriers to primary care physician’s willingness to increase the

intensity of hypertension treatment for patients. Physicians in the United States were asked

to complete a survey and submit a copy of office notes after treating a patient with

uncontrolled hypertension. Despite documented hypertension for at least 6 months before

the patient’s visit, pharmacologic therapy was initiated or changed at only 38% of visits.

Even though in 93% of these visits the systolic BP values were 140 mm Hg or higher—which

is above the cut-off recommended by Sixth Report of the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines—the

most frequently cited reason for not initiating or changing therapy was related to the

physician being satisfied with the current blood pressure level.

Turnbull F, Neal B, Algert C, Chalmers J, Chapman N, Cutler J, et al. Effects of

different blood pressure-lowering regimens on major cardiovascular events in

individuals with and without diabetes mellitus: results of prospectively designed

overviews of randomized trials. Arch Intern Med. 2005;165(12):1410-9.

Hypertension Control, an Annotated Bibliography

There is broadly no difference in the short-to-medium-term effects on major

cardiovascular events of blood pressure lowering regimens between patients with

and without diabetes.

This meta-analysis aimed to compare the effects on cardiovascular events and death of

different blood pressure–lowering regimens in individuals with and without diabetes. The six

primary outcomes were nonfatal stroke or death from cerebrovascular disease, nonfatal

myocardial infarction or death from coronary heart disease, heart failure causing death or

requiring hospitalization, total major cardiovascular events, total cardiovascular deaths, and

total mortality. Twenty-seven randomized trials that included 33,395 individuals with

diabetes and 125,314 without diabetes were included. Regimens based on ACE inhibitors,

calcium antagonists, angiotensin-receptor blockers, and diuretics/ β-blockers reduced major

cardiovascular events to a comparable extent in individuals with and without diabetes.

Law MR, Wald NJ, Morris JK, Jordan RE. Value of low dose combination treatment

with blood pressure lowering drugs: analysis of 354 randomised trials. BMJ (Clin

Res Ed). 2003;326(7404):1427

For blood pressure medication, using a combination of low-dose drug treatments instead

of one drug increases efficacy and reduces adverse events.

This meta-analysis aimed to determine the average reduction in blood pressure, prevalence

of adverse effects, and reduction in risk of stroke and ischaemic heart disease events

produced by the five main categories of blood pressure–lowering drugs according to dose,

singly and in combination. Three-hundred fifty-four randomized double-blind placebo

controlled trials including 40,000 treated patients and 16,000 patients given a placebo were

included. Five categories of drugs—thiazides, β-blockers, ACE inhibitors, angiotensin II

receptor antagonists, and calcium channel blockers in fixed dose—were eligible. All drugs

resulted in similar decreases in blood pressure. The blood pressure–lowering effects of

different categories of drugs were additive. Three drugs at half standard dose were

estimated to lower systolic blood pressure by 20 mm Hg systolic and diastolic by 11 mm Hg

and reduce the risk of stroke by 63% and ischaemic heart disease events by 46%, more so

than one drug taken singly.

Muntner P, Whelton PK. Using predicted cardiovascular disease risk in conjunction

with blood pressure to guide antihypertensive medication treatment. J Am Coll

Cardiol. 2017;69(19):2446-56.

Those with high normal blood pressures (130-139/80-89 mmHg) and cardiovascular

disease risk ≥ 10% may benefit from treatment as well as those with hypertension.

Using cardiovascular disease risk instead of or in addition to blood pressure to guide

antihypertensive treatment is an active area of research. This review provides an overview

of studies that could inform this treatment paradigm. Meta-analyses of randomized trials

demonstrate clear cardiovascular disease risk reduction benefits with treatment of systolic

blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg, but these trials have

generally excluded low-risk individuals. Additionally, there are data supporting

antihypertensive treatment for individuals with lower blood pressure levels, especially

among adults with cardiovascular disease or a high global cardiovascular disease risk.

Hypertension Control, an Annotated Bibliography

Knowing this, one approach might be to treat all adults with systolic blood pressure ≥ 140

mm Hg or diastolic blood pressure ≥ 90 mm Hg, as well as those with systolic blood

pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg and a 10-year

cardiovascular disease risk ≥ 10%.

Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J, Chalmers J,

Rodgers A, Rahimi K. Blood pressure lowering for prevention of cardiovascular

disease and death: a systematic review and meta-analysis. Lancet.

2016;387(10022):957-67.

Blood pressure lowering significantly reduces cardiovascular risk independent of baseline

systolic and diastolic levels and comorbidities, apart from diabetes, chronic kidney

diseases, and other cardiovascular diseases.

The benefits of blood pressure treatment vary depending on baseline blood pressure, the

presence of comorbidities, and drug class. This systematic review and meta-analysis aimed

to clarify how effective hypertension medication is at preventing cardiovascular disease and

death over varying factors. One-hundred and twenty-three studies were included. Every 10

mm Hg reduction in systolic blood pressure significantly reduced the risk of major

cardiovascular disease events, coronary heart disease, stroke, and heart failure though the

effect on renal failure was not significant. Similar proportional risk reductions were found in

trials with higher mean baseline blood pressure compared with trials with lower mean

baseline blood pressure. Except for diabetes and chronic kidney disease, there was no clear

evidence that proportional risk reductions in major cardiovascular disease differed by

comorbidities.

Huang S, Chen Y, Zhou J, Wang J. Use of family member-based supervision in the

management of patients with hypertension in rural China. Patient Prefer.

Adherence. 2014;8:1035-42.

Family member-based supportive therapy for patients with hypertension is an affordable

and feasible way to increase medication adherence and improve blood pressure

control.

Poor medication adherence is a critical problem in the management of hypertension. This

study applied a mixed-methods approach using a qualitative and quantitative study design

to assess the effectiveness of a family member-based supportive therapy at improving

hypertension management in a rural area of China. Over the course of the 6-month trial,

uncontrolled blood pressure decreased from 87.2% to 45.7% in those who partook in the

intervention. In addition, 75% of patients expressed a wish for external reminders, and

93.5% responded that they would accept the family member-based supervision showing

this intervention is feasible for patients with hypertension.

Law M, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention

of cardiovascular disease: meta-analysis of 147 randomised trials in the context of

expectations from prospective epidemiological studies. BMJ. 2009;338:b1665.

Hypertension Control, an Annotated Bibliography

All the classes of blood pressure lowering drugs included had similar protective effects

against coronary heart disease events and stroke. Treating elevated blood pressure

is important regardless of baseline level.

his meta-analysis aimed to determine the efficacy of different classes of hypertension

drugs in preventing coronary heart disease and stroke; 108 trials studying difference in

blood pressure between study groups and placebo were included. Participants were divided

into three mutually exclusive categories: participants with no history of vascular disease, a

history of coronary heart disease, or a history of stroke. In the blood pressure difference

trials β blockers had a short-term special effect after a myocardial infarction over and above

that due to blood pressure reduction in preventing recurrent cardiovascular events in people

with a history of coronary heart disease. Calcium channel blockers had a minor additional

effect in preventing stroke. All the classes of blood pressure lowering drugs otherwise had

similar protective effects regardless of pretreatment blood pressure and presence or

absence of existing cardiovascular disease.

3.4 Example Guidelines

Galie N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, et al. Guidelines

for the diagnosis and treatment of pulmonary hypertension: the Task Force for the

Diagnosis and Treatment of Pulmonary Hypertension of the European Society of

Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the

International Society of Heart and Lung Transplantation (ISHLT). Eur. Heart J.

2009;30(20):2493-537.

Krause T, Lovibond K, Caulfield M, McCormack T, Williams B. Management of

hypertension: summary of NICE guidance. BMJ (Clin Res Ed). 2011;343:d4891.

Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. British

Hypertension Society guidelines for hypertension management 2004 (BHS-IV):

summary. BMJ (Clin Res Ed). 2004;328(7440):634-40.

Whitworth JA. 2003 World Health Organization (WHO)/International Society of

Hypertension (ISH) statement on management of hypertension. J Hypertens.

2003;21(11):1983-92.

James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al.

2014 evidence-based guideline for the management of high blood pressure in adults:

report from the panel members appointed to the Eighth Joint National Committee

(JNC 8). JAMA. 2014;311(5):507-20.

Kovell LC, Ahmed HM, Misra S, Whelton SP, Prokopowicz GP, Blumenthal RS, McEvoy

JW. US hypertension management guidelines: a review of the recent past and

recommendations for the future. Journal of the American Heart Association. 2015

Dec 22;4(12):e002315.

Weber MA, Schiffrin EL, White WB, Mann S, Lindholm LH, Kenerson JG, Flack JM, Carter

BL, Materson BJ, Ram CV, Cohen DL. Clinical practice guidelines for the management

Hypertension Control, an Annotated Bibliography

of hypertension in the community. The journal of clinical hypertension. 2014 Jan

1;16(1):14-26.

4. Task Sharing

Legal and operational procedures should be in place to enable community-based care and

task sharing so that health care workers who are accessible to patients can provide and,

following a physician’s instructions and protocols, adjust and intensify medication regimens.

Ogedegbe G, Gyamfi J, Plange-Rhule J, Surkis A, Rosenthal DM, Airhihenbuwa C, et

al. Task shifting interventions for cardiovascular risk reduction in low-income and

middle-income countries: a systematic review of randomised controlled trials. BMJ

Open. 2014;4(10):e005983.

Though sparse, randomized controlled trials that investigate task-shifting strategies,

such as provision of medication prescriptions by nurses and telephone follow-ups

post-hospital discharge, for hypertension reduction in low- and middle-income

countries have been shown to significantly decrease patient mean blood pressure.

This is a systematic review of published randomized controlled trials that evaluate the use of

task-shifting for the management of cardiovascular diseases in low- and middle-income

countries. Studies that used task shifting—defined as non-physician health care workers

(NPHWs) involved in the prescribing of medications, treatment, or medical testing—were

included. Cardiovascular risk factors and diseases included hypertension, diabetes,

hyperlipidaemia, stroke, coronary artery disease, or heart failure. Only three trials met the

predefined criteria, two involving hypertension reduction. Both hypertension studies

reported a significant mean blood pressure reduction (2/1 mm Hg and 30/15 mm Hg).

Clark CE, Smith LF, Taylor RS, Campbell JL. Nurse led interventions to improve

control of blood pressure in people with hypertension: systematic review and

meta-analysis. BMJ. 2010;341:c3995

Nurse-led interventions that involve a treatment algorithm for hypertension

management can play a significant role in controlling blood pressure.

This systematic review and meta-analysis reviewed the effectiveness of nurse-led

interventions for adult hypertension in primary care settings. Randomized controlled trials

were included. Because most patients require a combination of antihypertensive drugs to

reach target blood pressure, interventions that included a treatment algorithm for clinicians

to follow were of interest. Interventions that included a stepped treatment algorithm

showed greater reductions in systolic blood pressure than usual care did. Nurse-prescribing

medication, telephone monitoring, and community monitoring also showed greater

reductions in blood pressure and higher achievement of blood pressure targets.

Carter BL, Bosworth HB, Green BB. The hypertension team: the role of the

pharmacist, nurse, and teamwork in hypertension therapy. The Journal of Clinical

Hypertension. 2012 Jan 1;14(1):51-65.

Hypertension Control, an Annotated Bibliography

Team-based care involving pharmacists and/or nurses has consistently been shown to

be a cost-effective strategy that effectively increases blood pressure control

compared to usual care.

This study discusses how team-based care is critical in hypertension therapy. Research has

shown that teams involving pharmacists or nurses in patient management consistently

result in increased blood pressure control. Meta-analyses and systematic reviews have

reported that team-based care can reduce systolic blood pressure by as much as 4–10 mm

Hg compared to usual care. Newer strategies involving telephone or web-based

management that allow pharmacists or nurses to more easily communicate with their

patients are also showing promise.

antschi V, Chiolero A, Colosimo AL, Platt RW, Taffé P, Burnier M, Burnand B,

Paradis G. Improving blood pressure control through pharmacist interventions: a

meta-analysis of randomized controlled trials. Journal of the American Heart

Association. 2014 Apr 22;3(2):e000718.

Pharmacist interventions have routinely been shown to significantly reduce systolic and

diastolic blood pressure compared to usual care. Different pharmacist interventions

should be assessed for their effectiveness, cost-effectiveness, and time-

effectiveness.

This study updated and combined previous systematic reviews to assess the effect of

pharmacist interventions on blood pressure. Thirty-nine randomized controlled trials of over

14,224 patients were included. Pharmacist interventions, mainly including patient education,

feedback to physician, and medication management, showed significantly greater reduction

in systolic blood pressure (7.6 mm Hg) and diastolic blood pressure (3.9 mm Hg) compared

to usual care. The effect tended to be larger if the intervention was led by a pharmacist and

occurred at least monthly.

Labhardt ND, Balo JR, Ndam M, Grimm JJ, Manga E. Task shifting to non-physician

clinicians for integrated management of hypertension and diabetes in rural

Cameroon: a programme assessment at two years. BMC Health Serv Res.

2010;10:339.

Integrating hypertension into primary health care in non-physician clinician (NPC)

facilities resulted in greater staff knowledge on hypertension management and

increased hypertension equipment available. While blood pressure significantly

decreased in patients who returned to the NPC for care, high attrition of patients

remained a challenge.

Non-communicable chronic diseases, such as hypertension and diabetes, are an increasing

health burden in sub-Saharan Africa. Most of the rural population still does not have access

to adequate health care. This study investigates the effectiveness of task shifting

hypertension and type 2 diabetes care to NPC facilities in rural health districts of Cameroon.

Of the NPC facilities included, 87% received basic equipment and training on hypertension

and diabetes care. After 2 years, there was a significant decrease in blood pressure among

hypertensive patients with two or more facility visits. NPCs’ knowledge of hypertension

Hypertension Control, an Annotated Bibliography

treatment and possession of hypertension equipment (sphygmomanometer, stethoscope,

antihypertensive drugs, functional glucose meter, and oral anti-diabetics) also increased.

Abegunde DO, Shengelia B, Luyten A, Cameron A, Celletti F, Nishtar S, Pandurangi

V, Mendis S. Can non-physician health-care workers assess and manage

cardiovascular risk in primary care? Bulletin of the World Health Organization.

2007 Jun;85(6):432-40.

Non-physician health care workers can reliably and effectively assess and manage

cardiovascular risks in primary health care settings where there is no expert

physician.

The objective of this study was to determine the reliability of implementing the WHO

Cardiovascular Risk Management Package to NPHWs in primary health care settings. The

results of 649 paired applications of the protocol showed over 80% agreement between

expert physicians and NPHWs. This shows that NPHWs can effectively be trained to manage

hypertension in settings where there are no attending physicians. Packages like the WHO

Cardiovascular Risk Management Package could be a useful tool in the scaling-up of

hypertension management in primary care settings.

He J, Irazola V, Mills KT, Poggio R, Beratarrechea A, Dolan J, et al. Effect of a

community health worker-led multicomponent intervention on blood pressure

control in low-income patients in Argentina: a randomized clinical trial. JAMA.

2017;318(11):1016-25.

A multicomponent community health worker–led intervention showed significant

reductions in systolic and diastolic blood pressure and increases in the percentage of

patients with controlled hypertension. Involving community health workers could be

a feasible and cost-effective way of managing hypertension in the primary health

care setting.

The goal of this study was to test whether a community health worker–led intervention

could improve blood pressure management in low-income patients. Eighteen centers for

primary health care within the national public system in Argentina participated in this cluster

randomized controlled trial. Half of the centers were randomized to a multi-component

intervention for 18 months, which included: a community health worker–led home

intervention involving health coaching, home blood pressure monitoring, and blood pressure

audit and feedback; a physician intervention; and a text-messaging intervention. A total of

1432 adult patients with uncontrolled hypertension were included. Systolic and diastolic

blood pressure decreased significantly more in the intervention group than in the control

group. In addition, the proportion of patients with controlled hypertension significantly

increased in the intervention group.

Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication

adherence and persistence, blood pressure, and low-density lipoprotein

cholesterol: a randomized controlled trial. JAMA. 2006;296(21):2563-71.

Long-term pharmacist interventions can play a key role in decreasing hypertension

patient blood pressure and increasing medication adherence and persistence.

Hypertension Control, an Annotated Bibliography

Nonadherence to hypertension medication diminishes the benefits of pharmacotherapies and

can be particularly challenging in older adults. This study aimed to evaluate the

effectiveness of a pharmacy care program to improve medication adherence and its

associated effects on blood pressure. Patients aged 65 years or older taking at least four

chronic medications were included in this study. The pharmacy care program included three

elements: individualized medication education, medications dispensed using an adherence

aid, and regular follow-up with clinical pharmacists every two months. After six months of

intervention for all patients, medication adherence and systolic blood pressure significantly

improved. Patients were then randomized to continue the intervention or return to usual

care for another six months. Those who continued the intervention for the next six months

maintained blood pressure and adherence rates, while those in the usual care had

decreased adherence and increases in blood pressure.

Marra C, Johnston K, Santschi V, Tsuyuki RT. Cost-effectiveness of pharmacist care

for managing hypertension in Canada. Canadian Pharmacists Journal/Revue des

Pharmaciens du Canada. 2017;150(3):184-97.

Interventions involving pharmacist management of hypertension are cost-effective and

predicted to save money and improve long-term health outcomes.

This study used a Markov cost-effectiveness model to determine the effect of pharmacists

providing advanced scope of practice for management (prescription, education,

consultation) of hypertension compared with usual care on long-term cardiovascular and

renal disease health outcomes. To determine cost-effectiveness, the model included health

outcomes, costs, and quality of life. The results suggest that a systolic blood pressure

reduction of 18.3 mmHg results in an estimated 0.21 fewer cardiovascular events per a

person, 0.3 additional life-years, 0.4 additional quality-adjusted life-years, and $6364

Canadian dollar cost savings over a lifetime, thereby showing pharmacist interventions to

provide good value for money.

Tsuyuki RT, Houle SK, Charrois T, Kolber M, Rosenthal MM, Lewanczuk RZ, Cooney

D, McAlister FA. A randomized trial of the effect of pharmacist prescribing on

improving blood pressure in the community: the Alberta clinical trial in optimizing

hypertension (RxACTION). Canadian Journal of Cardiology. 2014;30(10):S125-6.

Interventions involving pharmacist-led assessments, prescriptions, education, follow-up

and monitoring are shown to have a significant positive impact on patient blood

pressure management.

This randomized controlled trial enrolled adult patients with above-target blood pressure

from 23 communities in Alberta, Canada. The intervention group received a blood pressure

and cardiovascular risk assessment, hypertension education, antihypertensive medication

prescriptions, laboratory monitoring, and monthly follow-up visits all by their pharmacist for

six months. The control group received written hypertension information, a card for blood

pressure recording, and usual care from their pharmacist or physician. After six months, the

intervention group participants had a significantly larger average decrease in blood pressure

and were 2.32 times more likely to achieve blood pressure target levels compared to the

control group.

Hypertension Control, an Annotated Bibliography

Tsuyuki RT, Al Hamarneh YN, Jones CA, Hemmelgarn BR. The effectiveness of

pharmacist interventions on cardiovascular risk: the multicenter randomized

controlled RxEACH trial. Journal of the American College of Cardiology. 2016 Jun

21;67(24):2846-54.

Incorporating pharmacists in cardiovascular risk management results in greater

reduction of risk for cardiovascular disease events.

This study aimed to evaluate the effectiveness of a community pharmacy-based intervention

on cardiovascular risk in participants at high risk for cardiovascular disease. This

randomized controlled trial was conducted in 56 community pharmacies in Alberta, Canada.

The intervention group received a Medication Therapy Management review from their

pharmacist and cardiovascular disease risk assessment and education. The control group

received usual pharmacist care. After three months, there was a 21% difference in change

in risk for cardiovascular disease events between the intervention and usual care group. The

intervention group had greater improvement in risk for cardiovascular disease events, low-

density lipoprotein cholesterol, systolic blood pressure, glycosylated hemoglobin, and

smoking cessation.

5. Medical Supplies

Regular and uninterrupted supply of quality-assured medications and equipment for

accurate measurement of blood pressure should be established.

Khatib R, McKee M, Shannon H, Chow C, Rangarajan S, Teo K, et al. Availability and

affordability of cardiovascular disease medicines and their effect on use in high-

income, middle-income, and low-income countries: an analysis of the PURE study

data. Lancet (London, England). 2016;387(10013):61-9.

Cardiovascular prevention medications are both unavailable and unaffordable for a

substantial proportion of communities in upper middle–income, lower middle–

income, and low-income countries. Increasing access and reducing cost will be vital

to reducing the burden of cardiovascular disease.

Medicines to prevent recurrent cardiovascular disease are becoming more widely available.

This study aimed to determine whether low use of these medications was due to lack of

access or affordability. The authors analyzed data regarding availability and costs of aspirin,

β-blockers, angiotensin-converting enzyme inhibitors, and statins in pharmacies from 596

communities in 18 countries. The authors compared results from high-income, upper

middle–income, lower middle–income, and low-income countries. All four cardiovascular

disease medicines were available in 95% of urban and 90% of rural communities in high-

income countries, 80% of urban and 73% of rural communities in upper middle–income

countries, 62% of urban and 37% of rural communities in lower middle–income countries,

25% of urban and 3% of rural communities in low-income countries (excluding India). The

four cardiovascular disease medicines were potentially unaffordable for 0.14% of

households in high-income countries, 25% of upper middle–income countries, 33% of lower

middle–income, 60% of low-income countries (excluding India), and 59% of households in

India.

Hypertension Control, an Annotated Bibliography

Tran DN, Njuguna B, Mercer T, Manji I, Fischer L, Lieberman M, et al. Ensuring

patient-centered access to cardiovascular disease medicines in low-income and

middle-income countries through health-system strengthening. Cardiol Clin.

2017;35(1):125-34.

Significant challenges with distributing cardiovascular disease medications relate to on-

the-ground problems. Countries should address availability, accountability in the

supply chain, and medication adherence when improving access to and uptake of

cardiovascular medications.

Up to 80% of cardiovascular deaths occur in low- and middle-income countries. Translating

cardiovascular disease treatment guidelines into practice is hindered in these countries due

to inadequate health care systems that are unable to provide sufficient access to lifesaving

medications. This review identifies three challenges to patient-centered access to

hypertension drugs: lack of availability of medicines, lack of accountability in the supply

chain, and poor medication adherence. Pilot programs have shown that access to

cardiovascular medication can be improved by standardizing supply chain management,

improving human resource efficiency, and extending supply chain considerations, which

results in improved patient adherence.

Mendis S, Fukino K, Cameron A, Laing R, Filipe A, Khatib O, Leowski J, Ewen M. The

availability and affordability of selected essential medicines for chronic diseases in

six low- and middle-income countries. Bulletin World Health Organization. 2007;

85(4): 279–288

ountry-specific policies are needed to improve access to essential cardiovascular

medicines. Medication affordability should be controlled through creating policies and

incentives for generics, introducing market competition, regulating prices through

taxes, and controlling mark-ups. Availability may be improved by increasing

governance, management efficiency, and local supply options.

This study aimed to assess the availability and affordability of 32 cardiovascular disease,

diabetes, chronic respiratory disease, glaucoma, and palliative cancer care medications in

public and private medicine outlets in six low- and middle-income countries (Bangladesh,

Brazil, Malawi, Nepal, Pakistan and Sri Lanka). In all countries ≤ 7.5% of these 32

medicines were available in the public sector, except in Brazil (30%) and Sri Lanka (28%).

Median price ratios varied substantially. In the private sector of some countries, the cost of

innovator products was three times more than generic medicines. One month’s supply of

combination treatment for coronary heart disease costs 18.4 days’ wages in Malawi, 6.1

days’ wages in Nepal, 5.4 in Pakistan, 5.1 in Brazil, 1.6 days’ wages in Bangladesh, and 1.5

days’ wages in Sri Lanka.

Chen CC, Blank RH, Cheng SH. Medication supply, healthcare outcomes and

healthcare expenses: longitudinal analyses of patients with type 2 diabetes and

hypertension. Health Policy. 2014;117(3):374-81

Improving appropriate medication supplies for patients results in better health care

outcomes than oversupply or undersupply and lower health care costs than

oversupply.

Hypertension Control, an Annotated Bibliography

This study aimed to examine the effect of whether the appropriateness of the quantity of

drug obtained is correlated with better health care outcomes and lower health care costs.

Over 7 years, adult patients newly diagnosed with type 2 diabetes or hypertension in

Taiwan were followed. Patients who were undersupplied or oversupplied with medications

tended to have worse health care outcomes than those with an appropriate medication

supply. Oversupply of medication was also associated with higher health care costs.

6. Patient-Centered Services

Treatment services should reduce the barriers to adherence, including reduction (preferably

elimination) of costs for medications and medical visits, increasing patient convenience of

medical visits and medication refills (e.g., every three months for stable patients), use of

once-daily treatment regimens, use of fewer tablets (e.g., through combination

medications), improving access to free blood pressure monitoring (e.g., in public places, at

home), and public education to increase awareness of the importance of blood pressure

control .

Labhardt ND, Balo JR, Ndam M, Manga E, Stoll B. Improved retention rates with

low-cost interventions in hypertension and diabetes management in a rural

African environment of nurse-led care: a cluster-randomised trial. Tropical

medicine & international health: TM & IH. 2011;16(10):1276-84.

Low-cost interventions, like sending reminder letters or incentivizing patient visits, can

significantly improve retention of patients undergoing hypertension and diabetes

management in nurse-led facilities.

Due to the current environment of task-shifting, this study aimed to identify which

interventions would improve patient retention in nurse-led cardiovascular care in rural

African health districts. A randomized trial was completed with three groups: a control

group, a group that received the incentive of one-month free treatment every fourth month

of visits, and a group that received reminder letters in case of a missed follow-up. A total of

33 centers were included. At the end of one year, retention rates in groups two and three

were significantly higher at 60% and 65%, respectively, than 29% in the control group.

Margolis KL, Asche SE, Bergdall AR, Dehmer SP, Groen SE, Kadrmas HM, et al.

Effect of home blood pressure telemonitoring and pharmacist management on

blood pressure control: a cluster randomized clinical trial. Jama. 2013;310(1):46-

56.

Home blood pressure telemonitoring and pharmacist case management is a highly

effective method of controlling blood pressure in patients.

The objective of this study is to determine whether a home blood pressure telemonitoring

and pharmacist case management intervention improves blood pressure control; 452 adults

with uncontrolled hypertension were recruited to this cluster randomized clinical trial. Eight

clinics were randomized to provide usual care, and eight clinics were randomized to provide

the telemonitoring intervention to patients. Patients in the intervention group received home

blood pressure telemonitors and transmitted blood pressure data to pharmacists who were

then able to adjust antihypertensive therapy as needed. Blood pressure was significantly

Hypertension Control, an Annotated Bibliography

better controlled in the intervention group during 12 months of intervention and six months

of post intervention follow-up.

James K, Dolan E, O’Brien E. Making ambulatory blood pressure monitoring

accessible in pharmacies. Blood pressure monitoring. 2014;19(3):134-9.

Ambulatory blood pressure measurement data from pharmacies is similar to those

recorded in primary care practices. Ambulatory blood pressure measurements could

be collected in pharmacies so they are more accessible to a greater number of

hypertension patients.

Ambulatory blood pressure measurements are recommended for the diagnosis and

management of hypertension. This study aimed to compare measurement in a pharmacy

and primary care clinic setting to determine if the technique could be made more accessible

to patients. Ambulatory blood pressure measurement data was compared for 46,978

patients in Ireland. The blood pressure characteristics of patients with ambulatory blood

pressure measurements recorded in pharmacies was similar to those recorded in primary

care practices.

Bobrow K, Farmer AJ, Springer D, Shanyinde M, Yu LM, Brennan T, et al. Mobile

phone text messages to support treatment adherence in adults with high blood

pressure (SMS-Text Adherence Support [StAR]): a single-blind, randomized trial.

Circulation. 2016;133(6):592-600.

A text message intervention that provided hypertension patients with information

resulted in the greatest decrease in blood pressure.

This study aimed to evaluate the effectiveness of mobile phone messages to deliver

automated adherence support for blood pressure medication. The randomized controlled

trial was conducted in South Africa with 1,372 patients randomized to one of three arms:

information-only text messages, interactive text messages, or usual care. At 12 months,

there was a drop in blood pressure and increase in proportion of patients with controlled

blood pressure for those who received educational text messages. There was no evidence

that an interactive intervention increased this effect.

Cooper LA, Roter DL, Carson KA, Bone LR, Larson SM, Miller ER, et al. A

randomized trial to improve patient-centered care and hypertension control in

underserved primary care patients. J Gen Intern Med. 2011;26(11):1297-304.

Interventions that enhance physicians’ communication skills and encourage patients to

play an active role in their care increases communication and engagement in care

and may improve blood pressure control in vulnerable populations.

Vulnerable populations, such as African Americans and persons with lower socioeconomic

status, are disproportionately affected by hypertension yet receive less patient-centered

care. The objective of this study is to compare the effectiveness of patient-centered

interventions for underserved groups. A randomized control trial with 12 months follow-up

was conducted in the United States. In the intervention groups, physicians were trained on

communication skills and patients were coached by a community health worker at varying

intensities. Trained physician visits for the intervention groups had significantly more

Hypertension Control, an Annotated Bibliography

positive communication change, physicians’ participatory decision making, and patient

involvement in care related to doctor facilitation. While improvements in patient adherence

and blood pressure control did not differ significantly between intervention and control

groups, non-significant reductions in blood pressure were observed in the intervention

groups for patients with uncontrolled hypertension at baseline.

Sieverdes J, Gregoski M, Patel S, Williamson D, Brunner-Jackson B, Rundbaken J,

et al. mHealth medication and blood pressure self-management program in

Hispanic hypertensives: a proof of concept trial. Smart Homecare Technology and

TeleHealth. 2013;1:1-10.

Electronic measures, such as wireless-enabled blood pressure monitors, text message

reminders and encouragement, and electronic pill-boxes, increase patient adherence

and allow physicians to better monitor patients’ progress.

This proof of concept randomized trial aimed to investigate how mHealth (i.e., mobile

health) could improve blood pressure self-management in patients with hypertension.

Patients were given a cellular electronic medication tray that provided a reminder signal for

patients when to take their medications. Smartphone messages were also used to remind

patients to take at-home blood pressure measurements using a Bluetooth-enabled monitor

and encourage patients to adhere to the program. Patients in the control group strongly

believed the program helped them remember to take their medication, were more compliant

with blood pressure control instructions, and had greater reductions in blood pressure.

Hareri HA, Abebe M. Assessments of Adherence to Hypertension Medications and

Associated Factors among Patients Attending Tikur Anbessa Specialized Hospital

Renal Unit, Addis Ababa, Ethiopia 2012. IJNS. 2013;3(1):1-6.

Adherence to hypertension medication is low. Health workers should take time to inform

patients of the benefits and risks of medications and be aware of factors that put

patients at a greater risk of non-adherence.

Adherence to hypertension medication is a crucial part of cardiovascular management that

is often overlooked. This study aimed to assess hypertension medication adherence rates

and risk factors for low adherence in Ethiopia. Two-hundred and eighty-six patients were

sampled. The adherence level was generally low at 69.2%. Adherence was better in patients

who had been better informed about their medication, and varied depending on marital

status, work status, health care facility visited, and duration of hypertension and treatment.

7. Information Systems

Information systems should allow real-time feedback on adherence and blood pressure

control of individual patients and assessment of control rates in cohorts of different

treatment systems to facilitate continuous and real-time program improvement.

Letebo M, Shiferaw F. Adapting HIV patient and program monitoring tools for

chronic non-communicable diseases in Ethiopia. Globalization and health.

2016;12(1):26.

Hypertension Control, an Annotated Bibliography

Countries should develop standardized intake process, enrollment, follow-up, cohort

monitoring, appointment keeping, analysis, and reporting guidelines to monitor

hypertension. Studying existing national guidelines may give insights to how

hypertension information should be managed.

This cross-sectional study assessed existing monitoring and evaluation tools in place for

non-communicable diseases in Ethiopia. Because HIV care and treatment is a current

widespread program in the country, the authors explored the tools being used for HIV and

investigated how they might be applied to other diseases. Interviews with health care

workers from four health centers were conducted. There was an obvious lack of information

systems relating to non-communicable diseases in Ethiopia. Given the huge investment to

set-up standardized guidelines like those for HIV care and treatment, other programs should

adapt and use monitoring tools from existing program to improve information management

for hypertension and other non-communicable diseases.

Aljunid SM, Srithamrongsawat S, Chen W, Bae SJ, Pwu RF, Ikeda S, et al. Health-

care data collecting, sharing, and using in Thailand, China mainland, South Korea,

Taiwan, Japan, and Malaysia. Value in Health: The Journal of the International

Society for Pharmacoeconomics and Outcomes Research. 2012;15(1 Suppl):S132-

Given the importance of health-care data to evaluate the strength of a system, raise

awareness of public health concerns, and make evidence-based decisions, countries

should work to standardize and improve access to cardiovascular and hypertension

data.

This article investigated the health care data situation in six countries from the Asia-Pacific

region. In Thailand, mainland China, Taiwan, and Malaysia, the Ministry of Health is

responsible for collecting and managing the health care data through various agencies both

public and private. In South Korea and Japan, health insurance handles the collection and

storage of health care data. All countries struggled with limited access to data due to

privacy protection, fragmented health care systems, poor quality of routinely collected data,

unclear policies and procedures to access the data, and control on the freedom on

publication.

Campbell N, Ordunez P, Jaffe MG, Orias M, DiPette DJ, Patel P, Khan N, Onuma O,

Lackland DT. Implementing standardized performance indicators to improve

hypertension control at both the population and healthcare organization levels.

The Journal of Clinical Hypertension. 2017 May 1;19(5):456-61.

Widespread adoption of standardized population and clinical hypertension performance

indicators is important in efforts to control hypertension.

The ability to reliably evaluate the impact of interventions and changes in hypertension

control is critical. Previously, a World Hypertension League Expert Committee made

recommendations to standardize the reporting of population blood pressure surveys. This

article adds to the recommendations and provides slight alterations that were discussed at a

Pan American Health Organization expert meeting for “performance indicators”. Core

indicators for population surveys are recommended to include: mean systolic and diastolic

Hypertension Control, an Annotated Bibliography

blood pressure and the prevalence of hypertension, awareness of hypertension, drug-

treated hypertension, and drug-treated and controlled hypertension. Core indicators for

clinical registries are recommended to include: the prevalence of diagnosed hypertension

and the ratio of diagnosed hypertension to that expected by population surveys, and the

prevalence of controlled hypertension, lack of blood pressure measurement within a year in

people diagnosed with hypertension, and missed visits by people with hypertension.

Campbell NR, McAlister FA, Quan H. Hypertension Outcomes Research Task Force.

Monitoring and evaluating efforts to control hypertension in Canada: why, how,

and what it tells us needs to be done about current care gaps. Can J Cardiol.

2013;29(5):564-70.

Evaluation of hypertension programs is critical. Surveillance and monitoring efforts

should include vulnerable populations and be large enough to have adequate power

to measure small effect sizes and analyze subpopulations.

The Hypertension Outcomes Research Task Force is based in Canada and has existed since

2003. Members assist in the development and revision of surveys and conduct analyses that

help guide hypertension programs. Task Force surveillance data indicates that many gaps in

hypertension care remain. Blood pressure surveillance and monitoring is key to developing

effective programs that increase hypertension control. The Task Force noted that many

current surveys do not have adequate statistical power to assess vulnerable populations and

surveys of vulnerable populations do not usually include blood pressure, resulting in the

inability to measure the burden of hypertension in high risk populations.

Khader A, Farajallah L, Shahin Y, Hababeh M, Abu

‐Zayed I, Kochi A, Harries AD,

Zachariah R, Kapur A, Venter W, Seita A. Cohort monitoring of persons with

hypertension: an illustrated example from a primary healthcare clinic for Palestine

refugees in Jordan. Tropical medicine & international health. 2012 Sep

1;17(9):1163-70.

Hypertension programs should incorporate a recording, monitoring, and reporting

system in order to assess the program’s successes and deficiencies and improve the

program’s effectiveness.

Recording and reporting systems borrowed from the DOTS framework for tuberculosis

control can be used to record, monitor and report on other chronic diseases. This descriptive

cohort study used routine program data collected through E-Health to monitor persons with

hypertension in a primary healthcare clinic in Amman, Jordan serving Palestine refugees.

There were 97 newly registered patients in the first quarter of 2012. There was a total of

4,130 patients with hypertension registered from when E-Health started in 2009, 76% were

retained in care and 21% failed to present to a healthcare worker in the last three months.

The E-Health data also indicated deficiencies in several components of clinical performance

related to blood pressure measurements and fasting blood glucose tests to screen

simultaneously for diabetes.

Khader A, Farajallah L, Shahin Y, Hababeh M, Abu

‐Zayed I, Zachariah R, Kochi A,

Kapur A, Harries AD, Shaikh I, Seita A. Hypertension and treatment outcomes in

Palestine refugees in United Nations Relief and Works Agency primary health care

Hypertension Control, an Annotated Bibliography

clinics in Jordan. Tropical medicine & international health. 2014 Oct

1;19(10):1276-83.

E-Health can be used to regularly assess caseload, program outcomes, clinic

performance, blood pressure control, and cumulative prevalence of disease-related

complications regarding hypertension.

This retrospective cohort study occurred in six United Nations Relief and Works Agency

(UNRWA) primary health care clinics in Jordan serving Palestine refugees diagnosed with

hypertension. The objective was to evaluate the benefit of E-Health and determine the

number, characteristics, program outcomes, and measures of disease control for those

registered up to 2013. There were 18,881 patients registered with hypertension. Amongst

those attending a clinic, 92% had their blood pressure measured, of whom 83% had blood

pressure <140/90 mm Hg. Large numbers of Palestine refugees were registered and treated

for hypertension; E-Health was successfully used to monitor hypertension management and

performance.