HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings

Abstract

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.

Keywords: cardiovascular diseases; clinical protocols; critical pathways; hypertension; implementation science; public health; quality improvement.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

© 2023 Pan American Health Organization.

Figures

Figure 1

HEARTS in the americas hypertension clinical pathway*. *The medications serve as examples and can be replaced with any two medications from any of the three drug classes (ACEis/ARBs, CCBs or thiazide/thiazide-like diuretics). Start with a single-pill combination (fixed-dose combination) or two individual pills if FDC is not available. Figure was prepared by authors. See Ref (11).

Figure 2

HEARTS in the americas. Intervention and evaluation process to move from a standardized hypertension treatment protocol to a CVD risk management clinical pathway.

Figure 3

HEARTS appraisal checklist overall and domain-specific scores obtained before and after the intervention by cohort of countries. (A) Overall score. (B) Implemenation requirements. (C) Blood pressure treatment. (D) CVD risk management. Each dot represents an evaluated protocol. The overimposed boxplots provide information about the central trend and variation before and after the intervention by cohort of countries. Panel A shows overall scores, and panel B, C, and D presents scores for each domain.

Figure 4

HEARTS appraisal check list scores before and after the evaluation and improvement process by county-protocol.