Research Article: Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: A pragmatic cluster randomized trial in Ghana

Date Published: May 1, 2018

Publisher: Public Library of Science

Author(s): Gbenga Ogedegbe, Jacob Plange-Rhule, Joyce Gyamfi, William Chaplin, Michael Ntim, Kingsley Apusiga, Juliet Iwelunmor, Kwasi Yeboah Awudzi, Kofi Nana Quakyi, Jazmin Mogaverro, Kiran Khurshid, Bamidele Tayo, Richard Cooper, Kazem Rahimi

Abstract: BackgroundPoor access to care and physician shortage are major barriers to hypertension control in sub-Saharan Africa. Implementation of evidence-based systems-level strategies targeted at these barriers are lacking. We conducted a study to evaluate the comparative effectiveness of provision of health insurance coverage (HIC) alone versus a nurse-led task shifting strategy for hypertension control (TASSH) plus HIC on systolic blood pressure (SBP) reduction among patients with uncontrolled hypertension in Ghana.Methods and findingsUsing a pragmatic cluster randomized trial, 32 community health centers within Ghana’s public healthcare system were randomly assigned to either HIC alone or TASSH + HIC. A total of 757 patients with uncontrolled hypertension were recruited between November 28, 2012, and June 11, 2014, and followed up to October 7, 2016. Both intervention groups received health insurance coverage plus scheduled nurse visits, while TASSH + HIC comprised cardiovascular risk assessment, lifestyle counseling, and initiation/titration of antihypertensive medications for 12 months, delivered by trained nurses within the healthcare system. The primary outcome was change in SBP from baseline to 12 months. Secondary outcomes included lifestyle behaviors and blood pressure control at 12 months and sustainability of SBP reduction at 24 months. Of the 757 patients (389 in the HIC group and 368 in the TASSH + HIC group), 85% had 12-month data available (60% women, mean BP 155.9/89.6 mm Hg). In intention-to-treat analyses adjusted for clustering, the TASSH + HIC group had a greater SBP reduction (−20.4 mm Hg; 95% CI −25.2 to −15.6) than the HIC group (−16.8 mm Hg; 95% CI −19.2 to −15.6), with a statistically significant between-group difference of −3.6 mm Hg (95% CI −6.1 to −0.5; p = 0.021). Blood pressure control improved significantly in both groups (55.2%, 95% CI 50.0% to 60.3%, for the TASSH + HIC group versus 49.9%, 95% CI 44.9% to 54.9%, for the HIC group), with a non-significant between-group difference of 5.2% (95% CI −1.8% to 12.4%; p = 0.29). Lifestyle behaviors did not change appreciably in either group. Twenty-one adverse events were reported (9 and 12 in the TASSH + HIC and HIC groups, respectively). The main study limitation is the lack of cost-effectiveness analysis to determine the additional costs and benefits, if any, of the TASSH + HIC group.ConclusionsProvision of health insurance coverage plus a nurse-led task shifting strategy was associated with a greater reduction in SBP than provision of health insurance coverage alone, among patients with uncontrolled hypertension in Ghana. Future scale-up of these systems-level strategies for hypertension control in sub-Saharan Africa requires a cost–benefit analysis.Trial NCT01802372

Partial Text: Ghana and other countries in sub-Saharan Africa (SSA) are experiencing a growing burden of cardiovascular diseases (CVDs) propelled by a rapidly increasing prevalence of hypertension [1]. Barriers to hypertension control in SSA include poor access to healthcare due to lack of health insurance coverage, high out-of-pocket costs, and shortage of skilled healthcare providers [2,3]. The World Health Organization (WHO) estimates that 60% of countries worldwide fall below the threshold of what is considered a sufficient level of skilled health professionals, i.e., they have fewer than 59.4 physicians, nurses, or midwives per 10,000 population [4]. Most countries in SSA fall far below this threshold, with a per capita skilled workforce of less than 22.8 per 10,000. Specifically, there are only 2 physicians and 11 nurses per 10,000 people in SSA, compared to 19 physicians and 49 nurses per 10,000 in North America [4]. The healthcare workforce crisis is even more acute in Ghana, which in 2015 had 1 physician and 9 nurses per 10,000 people [4], thus limiting its capacity for hypertension control at the primary care level, where most people receive their care.

As shown in Fig 1, between November 28, 2012, and June 11, 2014, a total of 2,779 patients were screened and 757 enrolled, with an 85% completion rate at 12 months (88% for the TASSH + HIC group and 82% for the HIC group). Patients were followed up until October 7, 2016. The majority of the patients were middle-aged, were women, had elementary or high school education, and were employed. Mean BP, level of physical activity, and BMI were similar for both groups at baseline (see Table 1); the ICCs for systolic and diastolic BP were 0.04 and 0.07, respectively. A total of 64 nurses (2 per CHC) were trained to deliver the interventions [13]. Table 2 provides baseline characteristics for the CHC clusters.

In this pragmatic cluster randomized controlled trial, we evaluated the comparative effectiveness of 2 systems-level strategies for hypertension control among patients with newly diagnosed uncomplicated hypertension in 32 CHCs in Ghana. While both strategies led to significant reduction in SBP at 12 months, the TASSH + HIC group had a greater SBP reduction (−20.4 mm Hg; 95% CI −25.2 to −15.6) than the HIC group (−16.8 mm Hg; 95% CI −19.2 to −15.6), with a between-group difference of −3.6 mm Hg (95% CI −6.1 to −0.5). The SBP reduction for both groups was sustained at 24 months (1 year after completion of the trial), although there was no significant difference in SBP between the 2 groups at 24 months. The rate of BP control was similar for both groups (55.2% in the TASSH + HIC group versus 49.9% in the HIC group, p = 0.29), and there was no difference in lifestyle behaviors at 12 months.



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