Deaver John E, Uchuya Gabriela M, Cohen Wayne R, Foote Janet A
Asociación Siempre Salud, Chincha Alta, Ica, Peru.
College of Medicine, University of Arizona, Tucson, Arizona, United States of America.
PLOS Glob Public Health. 2024 Aug 22;4(8):e0003512. doi: 10.1371/journal.pgph.0003512. eCollection 2024.
Little is known about the effects of the Chronic Care Model (CCM) and community health workers (CHWs) on pharmacotherapy of type 2 diabetes and hypertension in resource-poor settings. This retrospective cohort implementation study evaluated the effects of a community-based program consisting of CCM, CHWs, guidelines-based treatment protocols, and inexpensive freely accessible medications on type 2 diabetes and hypertension pharmacotherapy quality. A door-to-door household survey identified 856 adults 35 years of age and older living in a low-income Peruvian community, of whom 83% participated in screening for diabetes and hypertension. Patients with confirmed type 2 diabetes and/or hypertension participated in the program's weekly to monthly visits for < = 27 months. The program was implemented as two care periods employed sequentially. During home care, CHWs made weekly home visits and a physician made treatment decisions remotely. During subsequent clinic care, a physician attended patients in a centralized clinic. The study compared the effects of program (pre- versus post-) (N = 262 observations), and home versus clinic care periods (N = 211 observations) on standards of treatment with hypoglycemic and antihypertensive agents, angiotensin converting enzyme inhibitors, and low-dose aspirin. During the program, 80% and 50% achieved hypoglycemic and antihypertensive standards, respectively, compared to 35% and 8% prior to the program, RRs 2.29 (1.72-3.04, p <0.001) and 6.64 (3.17-13.9, p<0.001). Achievement of treatment standards was not improved by clinic compared to home care (RRs 1.0 +/- 0.08). In both care periods, longer retention in care (>50% of allowable time) was associated with achievement of all treatment standards. 85% compared to 56% achieved the hypoglycemic treatment standard with longer and shorter retention, respectively, RR 1.52 (1.13-2.06, p<0.001); 56% compared to 27% achieved the antihypertensive standard, RR 2.11 (1.29-3.45, p<0.001). In a dose-dependent manner, the community-based program was associated with improved guidelines-based pharmacotherapy of type 2 diabetes and hypertension.
在资源匮乏地区，关于慢性病护理模式（CCM）和社区卫生工作者（CHW）对2型糖尿病和高血压药物治疗的影响，人们了解甚少。这项回顾性队列实施研究评估了一个基于社区的项目的效果，该项目包括CCM、CHW、基于指南的治疗方案以及价格低廉且可免费获取的药物，对2型糖尿病和高血压药物治疗质量的影响。一项挨家挨户的家庭调查确定了856名年龄在35岁及以上、生活在秘鲁低收入社区的成年人，其中83%参与了糖尿病和高血压筛查。确诊为2型糖尿病和/或高血压的患者参加了该项目每周至每月一次的就诊，为期<=27个月。该项目分两个护理阶段依次实施。在家庭护理期间，社区卫生工作者每周进行家访，医生远程做出治疗决策。在随后的门诊护理期间，医生在集中的诊所接待患者。该研究比较了项目前后（N = 262次观察）以及家庭护理与门诊护理阶段（N = 211次观察）对使用降糖药、抗高血压药、血管紧张素转换酶抑制剂和低剂量阿司匹林的治疗标准的影响。在项目实施期间，分别有80%和50%的患者达到了降糖和抗高血压标准，而在项目实施前这一比例分别为35%和8%，相对危险度分别为2.29（1.72 - 3.04，p<0.001）和6.64（3.17 - 13.9，p<0.001）。与家庭护理相比，门诊护理并未提高治疗标准的达成率（相对危险度为1.0 +/- 0.08）。在两个护理阶段，护理时间更长（>可允许时间的50%）都与所有治疗标准的达成相关。分别有85%和56%的患者在护理时间长和短的情况下达到了降糖治疗标准，相对危险度为1.52（1.13 - 2.06，p<0.001）；56%和27%的患者达到了抗高血压标准，相对危险度为2.11（1.29 -
