Abstract
Background: In rural Bangladesh, there are several challenges to improving hypertension treatment coverage and control, particularly the scarcity of physicians and centralized delivery of hypertension care, which requires patients to travel a long distance to healthcare facilities (Upazila Health Complexes [UHC]). Aim: To assess the feasibility of implementing a community-based (CB) WHO HEARTS package involving non-physician health workers (Community Healthcare Providers [CHCP]) to diagnose and treat patients with hypertension in Community Clinics (CC) under telemedicine supervision and guidance of a UHC physician. Methods: This single-arm pilot study was conducted in four CCs in rural Bangladesh among adults with untreated hypertension [blood pressure (BP) 140-180/90-110 mmHg]. The CB-HEARTS package intervention components were 1) simplified treatment protocol, 2) reliable medication supply, 3) team-based care, 4) standardized follow-up, and 5) an information system to track patients’ BP control. Through teleconsultancy, CHCPs communicated with designated UHC physicians to confirm the diagnosis of hypertension and initiate treatment with amlodipine 5 or 10 mg/day in the CC. Patients with controlled BP (<140/90 mmHg) during follow-up were provided a 3-month medication refill. Patients with complications or uncontrolled BP after medication titration according to the treatment protocol were referred to the UHC. Enrollment and retention rates were primary outcomes, and BP change and hypertension control were secondary. Results: Of 244 who were eligible, 220 (90.2%) individuals with hypertension were enrolled (mean age 56±13.8 years, 76% female). Overall, 97% of enrolled participants started medication treatment. Retention rates at the CC were 88%, 88%, and 85% at 3, 6-12, and 12-18 months, respectively ( Table ). Mean systolic/diastolic BP was 153/92 mmHg at enrollment. BP was lowered by ~35 mmHg systolic and ~18 mmHg diastolic ( Figure ) over 18 months of follow-up. The hypertension control rate was ~98% during the follow-up among patients retained in the program. Conclusions: This pilot study indicates decentralized hypertension care delivered by non-physician health workers through remote supervision of physicians is feasible to implement and may considerably improve hypertension control in rural Bangladesh. A randomized trial to test the safety, effectiveness, and acceptability is warranted.