Improved blood pressure control via a novel chronic disease management model of care in sub-Saharan Africa: Real-world program implementation results.
Harun A OtienoCharles MiezahGerald YongaFred KuefferMolly GuyChemuttaai Lang'AtDouglas A HettrickRoland Erich SchmiederPublished in: Journal of clinical hypertension (Greenwich, Conn.) (2021)
A chronic disease management model of care (Empower Health) was launched in rural and urban areas of Ghana and Kenya in 2018. The goal was to improve disease awareness, reduce the burden of disease, and improve the clinical effectiveness and efficiency of managing hypertension. Leveraging the model, clinicians provide patients with tailored management plans. Patients accessed regular blood pressure checks at home, at the clinic, or at community-partner locations where they received real-time feedback. On the mobile application, clinicians viewed patient data, provided direct patient feedback, and wrote electronic prescriptions accessible through participating pharmacies. To date, 1266 patients had been enrolled in the "real-world" implementation cohort and followed for an average of 351 ± 133 days across 5 facilities. Average baseline systolic blood pressure (SBP) was 145 ± 21 mmHg in the overall cohort and 159 ± 16 mmHg in the subgroup with uncontrolled hypertension (n = 743) as defined by baseline SBP ≥ 140 mmHg. SBP decreased significantly through 12 months in both the overall cohort (-9.4 mmHg, p < .001) and in the uncontrolled subgroup (-17.6 mmHg, p < .001). The proportion patients with controlled pressure increased from 46% at baseline to 77% at 12 months (p < .001). In summary, a new chronic disease management model of care improved and sustained blood pressure control to 12 months, especially in those with elevated blood pressure at enrollment.
Keyphrases
- blood pressure
- healthcare
- hypertensive patients
- quality improvement
- palliative care
- heart rate
- end stage renal disease
- primary care
- mental health
- ejection fraction
- newly diagnosed
- chronic kidney disease
- heart failure
- peritoneal dialysis
- affordable care act
- public health
- systematic review
- blood glucose
- health insurance
- case report
- type diabetes
- electronic health record
- clinical trial
- big data
- chronic pain
- patient reported outcomes
- social media