Enhanced hypertension care through private clinics in Pakistan: a cluster randomised trial

• Published in: BJGP open Vol. 3; no. 1; p. bjgpopen18X101617
• Main Authors: Khan, Muhammad Amir, Khan, Nida, Walley, John D, Khan, Shaheer Ellahi, Hicks, Joseph, Sheikh, Faisal Imtiaz, Khan, Muhammad Ahmar, Ali, Muhammad, Ahmed, Maqsood, Khan, Haroon Jehangir, Zachariah, Rony
• Format: Journal Article
• Language: English
• Published: England Royal College of General Practitioners 01.04.2019
• Subjects: Cluster randomised controlled trial; contextualised care package; general practice; hypertension; primary care; primary private clinics; contextualised care package; primary care; Cluster randomised controlled trial; hypertension; general practice; primary private clinics
• DOI: 10.3399/bjgpopen18X101617
• ISSN: 2398-3795

Hypertension in Pakistan affects 33% of people aged ≥45 years, and in urban areas around 70% of basic health care occurs in private facilities. To assess whether enhanced care at urban private clinics resulted in better control of hypertension, cardiovascular disease (CVD) risk factors, and treatment adherence. A two-arm cluster randomised controlled trial was conducted at 26 private clinics (in three districts of Punjab) between January 2015-September 2016. Both arms had enhanced screening and diagnosis of hypertension and related conditions, and patient recording processes. Intervention facilities also had a clinical care guide, additional drugs for hypertension, a patient lifestyle education flipchart, associated training, and mobile phone follow-up. Clinics were randomised in a 1:1 ratio (sealed envelope lottery method). A total of 574 intervention and 564 control patients in 13 clusters in each arm were recruited (male and female, aged ≥25 years, systolic blood pressure [SBP] >140 mmHg, and/or diastolic blood pressure [DBP] >90 mmHg). The primary outcome was change in SBP from baseline to 9-month follow-up.Staff and patients were not blinded, but outcome assessors were blinded. Nine-month primary outcomes were available for 522/574 (90.9%) intervention and 484/564 (85.8%) control participants (all clusters). The unadjusted cluster-level analysis results were as follows: mean intervention outcome was -25.2 mmHg (95% confidence intervals [CI] = -29.9 to-20.6); mean control outcome was -9.4 mmHg (95% CI = 21.2 to 2.2); and mean control-intervention difference was 15.8 (95% CI = 3.6 to 28.0; = 0.01). The findings and separate process evaluation support the scaling of an integrated CVD-hypertension care intervention in urban private clinics in areas lacking public primary care in Pakistan.