Tailored interventions may improve BP control among patients of low socioeconomic status
Interventions tailored to address specific socioeconomic concerns of patients with hypertension may lead to BP reduction and improved BP control, researchers reported at the virtual American Heart Association Scientific Sessions.
Interventions including group medical visits and monthly microfinance meetings were held in a Kenyan community as part of the BIGPIC trial, and at 1 year, researchers observed noticeable changes in both hypertension status and BP control, particularly among women and individuals of low socioeconomic status. However, these results did not meet statistical significance.
“It is well known that high blood pressure and high fasting plasma glucose are amongst the top risk factors for mortality around the world,” Rajesh Vedanthan, MD, MPH, associate professor and director of the section for global health at NYU Langone Health in New York, said during his presentation. “Very importantly, we increasingly recognize that social determinants of health are incredibly important with respect to shaping and determining behavioral risk factors, as well as physiology, ultimately leading to a manifest disease. In particular, in this trial, we were focused on the socioeconomic environment.
“The way we decided to approach this issue in Western Kenya, a population characterized by significant poverty, was to combine the microfinance groups, allowing patients to be able to address some of their economic concerns, and at the same time incorporate group medical visits into those microfinance groups, ultimately hoping to improve social network characteristics such as trust, cohesion, etc, leading to improvements in intermediate factors and cardiovascular risk reduction.”
The researchers enrolled 2,890 participants (mean age, 61 years; 70% women; 64% not formally employed), all with hypertension or diabetes, and randomly assigned them to receive usual care or attend either microfinance meetings, group medical visits or both. Approximately 54% of participants had a QRISK3 score of less than 10%.
Individuals were excluded if they had any acute illness requiring immediate medical attention, terminal illness, pregnancy, HIV or inability to provide informed consent.
The monthly group medical visits involved a discussion facilitated by a community health care worker among approximately 20 patients, followed by a one-on-one consultation with a clinician to create individualized treatment and/or management plan.
The monthly microfinance meeting incorporated a community savings group where each member contributed to the group’s collection or savings. From this collection, interest-bearing loans were given to the group members to invest in business ventures or to pay commitment expenses.
According to Vedanthan, there were no external funds provided to these groups from either the study or a third party.
The primary outcome was change in systolic BP at 1 year. The secondary outcomes included change in diastolic BP, change in QRISK3 score or BP control at 1 year.
Mean baseline systolic BP was 157.5 mmHg.
BP reductions across each trial group at 1 year were as follows:
- usual care reduced systolic BP by –11.4 mm Hg (95% CI, –12.9 to –10);
- microfinance meeting reduced systolic BP by –14.8 mm Hg (95% CI, –16.4 to –13.3);
- group medical visits reduced systolic BP by –14.7 mm Hg (95% CI, –16.2 to –13.1); and
- combination group medical visits and microfinance meetings reduced systolic BP by –16.4 mm Hg (95% CI, –18 to –14.7).
These reductions did not meet statistical significance.
Compared with usual care, each group experienced improvements in each of the components of the secondary outcome at 1 year, with the strongest association among individuals who attended group medical visits plus microfinance meetings.
Researchers found that women, younger participants and those who were unemployed experienced the greatest benefits from each of the interventions compared with usual care.
“The group medical visit/microfinance arm did have a positive impact on diastolic blood pressure,” Vedanthan said during the presentation. “There was a positive impact on blood pressure control in the group medical visit arm; those who actively participated in the intervention had greater benefits; and there was some signal that women and those with lower socioeconomic status had greater benefits.”
Moreover, compared with the usual care group, BP control was achieved 10.4% better in the microfinance meeting group, 8.9% better in the group medical visit cohort and 6.3% better in the group medical visit plus microfinance meeting cohort.
“Incorporating social determinants of health in care delivery is important,” Vedanthan said in the presentation. “Group medical visits and microfinance might improve systolic blood pressure and tailored interventions for subgroups might be particularly beneficial, especially for women and those with low socioeconomic status.”
Discussant Karen Joynt Maddox, MD, MPH, assistant professor of medicine and co-director of the Center for Health Economics and Policy in the Institute for Public Health at Washington University in St. Louis, said following the presentation that “High touch interventions using either patient navigators, pharmacists or group visits are feasible. We also know that including attention to social determinants is feasible both in terms of the microfinance group, and frankly, in terms of also including patient navigators. The opportunity to get closer to patients, meet them where they are and be within their communities has huge potential implications for being able to increase equity within our health care treatment.
“To be frank, health is complex, and if there were simple solutions, we would have found them by now,” Maddox said. “Rigorous clinical trials with hard outcomes are needed before we can scale and spread these interventions so that we can fine tune our approach and optimize strategies. Ultimately these do need to be scaled and spread. My hope is that this represents the beginning of a large body of work and understanding how to bring care closer to the patient.”
Collapse
Vedanthan R, et al. LBS.09: High tech or high touch: Creative strategies to optimize patient care. Presented at: American Heart Association Scientific Sessions; Nov. 13-17, 2020 (virtual meeting).