Data from: Health insurance coverage with or without a nurse-led task shifting strategy for hypertension control: a pragmatic cluster randomized trial in Ghana

Rationale: Poor access to care and physician shortage are major barriers
to hypertension control in sub-Saharan Africa. Implementation of
evidence-based systems-level strategies targeted at these barriers are
lacking. Objective: To evaluate the comparative effectiveness of provision
of health insurance coverage (HIC) alone versus a nurse-led task-shifting
strategy for hypertension control (TASSH) plus HIC on systolic BP
reduction among patients with uncontrolled hypertension in Ghana. Methods
and Findings: Using a pragmatic cluster-randomized trial, 32 community
health centers within Ghana's public healthcare system were randomly
assigned to either HIC alone or TASSH+HIC. A total of 757 patients with
uncontrolled hypertension were recruited between November 28 2012 and June
11 2014 and followed up to October 7 2016. Both intervention groups
received health insurance coverage plus scheduled nurse visits while
TASSH+HIC comprised cardiovascular risk assessment; lifestyle counseling,
and initiation/titration of antihypertensive medications for 12 months
delivered by trained nurses within the healthcare system. The primary
outcome was change in systolic BP from baseline to 12 months. Secondary
outcomes included lifestyle behaviors and BP control at 12 months; and
sustainability of systolic BP reduction at 24 months. Of the 757 patients
(389 in HIC and 368 in TASH+HIC groups), 85% had 12 month data available
[60% women, mean BP 155.9/89.6]. In intention-to-treat analyses adjusted
for clustering, the TASSH+HIC group had a greater SBP reduction (20.4
mmHg; 95% CI -25.2 to -15.6) than the HIC group (16.8 mmHg; 95% CI -19.2
to -15.6) with a statistically significant between-group difference of 3.6
mmHg [95% CI -6.1 to -0.5; p = 0.021]. Blood pressure control improved
significantly in both groups (55.2%; 95% CI 50.0 to 60.3 for the TASSH+HIC
group versus 49·9; 95% CI 44.9 to 54.9 for the HIC group) with a
non-significant between-group difference 5.2% ( 95% CI =-1.8 to 12.4;
p=0.29). Similarly, lifestyle behaviors did not change appreciably for
both groups. Twenty-one adverse events were reported (9 and 12 in the
TASSH+HIC and HIC group respectively). The main study limitation is the
lack of cost-effectiveness analysis to determine the additional
cost-benefit, if any, of the TASSH+HIC group. Conclusions: Provision of
health insurance coverage plus a nurse-led task-shifting strategy was
associated with a greater reduction in systolic BP than provision of
health insurance coverage alone, among patients with uncontrolled
hypertension in Ghana. Future scale up of these systems-level strategies
for hypertension control in sub-Saharan Africa requires a cost-benefit
analysis.