Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Lancet. 2019 Aug 24;394(10199):652-662. doi: 10.1016/S0140-6736(19)30955-9. Epub 2019 Jul 18.
Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs-and its variation between countries and population groups-by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage.
In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval.
Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9-74·3) had ever had their blood pressure measured, 39·2% of participants (38·2-40·3) had been diagnosed with hypertension, 29·9% of participants (28·6-31·3) received treatment, and 10·3% of participants (9·6-11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade.
Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage.
Harvard McLennan Family Fund, Alexander von Humboldt Foundation.
在低收入和中等收入国家（LMICs）中，关于高血压患者在连续护理中流失的证据很少来自具有全国代表性的研究。然而，这些信息对于卫生服务部门有效定位干预措施和监测改善高血压护理的进展至关重要。我们旨在确定 44 个 LMICs 中高血压护理的连续护理情况——以及国家和人群之间的差异——通过将从需要护理到成功治疗的护理过程的进展分为离散阶段，并测量每个阶段的损失。
在这项横断面研究中，我们汇总了来自 44 个 LMICs 的个体水平基于人群的数据。我们首先从世卫组织逐步监测方法（STEPS）中寻找具有全国代表性的 2005 年或以后的数据。如果某个 LMIC 没有 STEPS 数据集（或者我们无法访问），我们会进行系统搜索以寻找调查数据集；这些搜索的纳入标准是调查是在 2005 年或以后进行的，至少代表了 15 岁以上的三个 10 岁年龄组，包括测量血压数据，并包含至少两个高血压护理连续护理步骤的数据。高血压定义为收缩压至少 140mmHg，舒张压至少 90mmHg，或报告使用高血压药物。对于患有高血压的患者，我们计算了曾经测量过血压的个体比例；被诊断患有高血压的个体比例；接受过高血压治疗的个体比例；以及高血压得到控制的个体比例。在确定全球和区域层面的高血压护理连续护理情况时，我们按国家人口规模进行加权。我们根据年龄、性别、教育、家庭财富五分位数、体重指数、吸烟状况、国家和地区对高血压护理连续护理进行细分。我们使用线性回归分别预测每个连续护理步骤中每个国家的表现，根据人均国内生产总值（GDP）进行预测，允许我们识别表现超出 95%预测区间的国家。
我们汇总的数据集包括 110 万 507 名参与者，其中 192 万 441 人（17.5%）患有高血压。在患有高血压的患者中，73.6%的患者（95%CI 72.9-74.3）曾经测量过血压，39.2%的患者（38.2-40.3）被诊断患有高血压，29.9%的患者（28.6-31.3）接受了治疗，10.3%的患者（9.6-11.0）实现了高血压的控制。与基于人均 GDP 的预测表现相比，拉丁美洲和加勒比地区的国家总体表现较好，而撒哈拉以南非洲的国家表现最差。孟加拉国、巴西、哥斯达黎加、厄瓜多尔、吉尔吉斯斯坦和秘鲁在所有护理连续护理步骤上的表现均明显好于基于人均 GDP 的预测。女性、年龄较大、受教育程度较高、较富裕、不吸烟均与实现护理连续护理的四个步骤呈正相关。
我们的研究为 LMICs 中高血压的卫生政策和服务干预措施的设计和定位提供了重要证据。我们展示了在我们研究的 44 个国家中的每一个国家中，高血压护理过程在哪些步骤以及哪些人群中存在差距。我们还确定了每个世界区域中表现优于预期的国家，这些国家可以为政策制定者提供重要的政策经验教训。鉴于高血压在 LMICs 中造成的高疾病负担，作为本研究构建的具有全国代表性的高血压护理连续护理情况，是衡量实现全民健康覆盖进展的重要指标。
哈佛麦克伦南家族基金、亚历山大·冯·洪堡基金会。
