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HOPE 4: Community intervention cut CVD risk by more than 40%
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PARIS — A comprehensive care model that integrates nonphysician health workers, primary care physicians and family members, and provides free medications, contributed to a more than 40% reduction in CVD risk and increased BP control by twofold, according to new data from the HOPE 4 trial.
“The HOPE 4 nonphysician health worker-led strategy was successful for multiple reasons,” Jon-David Schwalm, MD, MSc, FRCPC, associate professor in the division of cardiology at McMaster University in Hamilton, Ontario, principal investigator of the Knowledge Translation Program at the Population Health Research Institute and interventional cardiologist at Hamilton Health Sciences, said at the European Society of Cardiology Congress. “First, the intervention simultaneously addressed multiple barriers to care. Second, it was a community-based intervention that was carefully adapted to local context. Third, family and friends were involved in the HOPE 4 intervention to help reinforce adherence to medication and healthy behaviors. Finally, this comprehensive intervention using computer-based simplified algorithms not only reduced risk factors in the community, but also identified those who were undiagnosed or poorly managed with respect to hypertension and cardiovascular risk.”
Community-based intervention
HOPE 4 included 1,371 patients with new or poorly controlled hypertension living in 30 urban and rural townships in Malaysia and Colombia. Fourteen communities were assigned to a care model of CV risk detection and management (n = 644 participants; mean age, 65 years; 58% women) and 16 communities were assigned to a care model involving usual care (n = 727 patients; mean age, 66 years; 54% women) for 12 months.
The multifaceted intervention, facilitated by nonphysician health care workers, was comprised of three core elements: community screening, detection, and treatment and control of CVD risk factors. Nonphysician health workers were guided by table-based management algorithms, counseling programs and decision support. Participants were provided with combination antihypertensive medications and a statin at reduced cost, while supervised by local primary care physicians. A participant-nominated treatment supporter — such as a friend or family member — helped participants improve medication adherence and health behaviors.
The control group, assigned to receive usual care, was distributed CV health literature along with recommendations to visit a local health care provider.
Nonphysician health care workers visited participants in both groups at a local clinic or in their home, with visits repeated at 6 months and 12 months to assess components of the Framingham Risk Score. Blood samples were collected at baseline and 12 months to analyze LDL, HDL, total cholesterol, triglycerides and glucose. Participants in the intervention group had additional visits at baseline, 1 month and 3 months. Phone calls were made to all participants at 10 months or 11 months to confirm their availability for the 12-month visit.
Outcomes improved
The primary outcome was mean difference in the Framingham Risk score 10-year CVD risk estimate change from baseline to 12 months.
All communities included in the trial completed follow-up throughout 12 months, which produced data from 97% of living patients.
Reduction in 10-year CVD risk based on the Framingham Risk Score was –6.4% in those assigned the control vs. –11.17% in those assigned in the intervention (difference of change, –4.78; 95% CI, –7.11 to –2.44; P < .0001).
“This is consistent with a more than 40% greater reduction in those receiving intervention,” Schwalm said during the press conference.
Patients in the intervention group had an absolute 11.45-mm Hg greater reduction in systolic BP and a 0.41 mmol/L absolute greater reduction in LDL compared with those in the control group (P < .001 for both). More patients in the intervention group achieved BP control of less than 140 mm Hg compared with the control group (69% vs. 30%; P < .0001). No safety concerns were observed with the intervention.
“Adaptation of the HOPE 4 strategy ... [and] widespread implementation including community screening can help achieve the United Nations General Assembly Action Plan for a one-third reduction in premature mortality in cardiovascular disease,” Schwalm said during the press conference. – by Darlene Dobkowski
The HOPE 4 data were published simultaneously in The Lancet.
Reference s :
Schwalm J-D. Hot Line Session 4. Presented at: European Society of Cardiology Congress; Aug. 31-Sept. 4, 2019; Paris.
Schwalm J-D, et al. Lancet. 2019;doi:10.1016/S0140-6736(19)31949-X.
Disclosure s : Schwalm reports his institution received grants from Boehringer Ingelheim, the Canadian Institutes of Health Research, the Department of Management of Non-Communicable Disease and the Ontario Ministry of Health and Long-Term Care. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Natasja M.S. de Groot, MD, PhD
The most simple things like reducing your salt intake, lowering your BP and taking care of your cholesterol can be done in many ways not only by drugs, but also by simple interventions like taking care of your diet and doing a lot of exercise. That has such a major impact on the reduction of CV diseases. It’s very interesting.
It may be difficult to predict the impact of these interventions in other countries with different people with different genetic backgrounds and different risk factors. The major thing is to create awareness by all the people from different countries. There are so many people from other countries realizing that this is such a simple way to prevent CVD, then they can come back to their own country and think about how can they can do this same study in their own country and see what the benefits will be.
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