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BJGP Open. 2019 Jan 23;3(1):bjgpopen18X101617. doi: 10.3399/bjgpopen18X101617. eCollection 2019 Apr.

Enhanced hypertension care through private clinics in Pakistan: a cluster randomised trial.

Author information

1
Chief Coordinating Professional, Association for Social Development, Islamabad, Pakistan.
2
Project Coordinator, Association for Social Development, Islamabad, Pakistan.
3
Professor of International Public Health, Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
4
Assistant Professor, Humanities and Social Sciences Department, Bahria University, Islamabad, Pakistan.
5
Senior Medical Statistician, Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, Leeds, UK.
6
Research Coordinator, Association for Social Development, Islamabad, Pakistan.
7
Research Assistant, Association for Social Development, Islamabad, Pakistan.
8
Senior Professional, Association for Social Development, Islamabad, Pakistan.
9
Director, NCD & Mental Health, Directorate General of Health Services, Lahore, Pakistan.
10
General Coordinator and Strategic Advisor, Operational Research, Médecins Sans Frontières, Brussels, Belgium.

Abstract

Background:

Hypertension in Pakistan affects 33% of people aged ≥45 years, and in urban areas around 70% of basic health care occurs in private facilities.

Aim:

To assess whether enhanced care at urban private clinics resulted in better control of hypertension, cardiovascular disease (CVD) risk factors, and treatment adherence.

Design & setting:

A two-arm cluster randomised controlled trial was conducted at 26 private clinics (in three districts of Punjab) between January 2015-September 2016. Both arms had enhanced screening and diagnosis of hypertension and related conditions, and patient recording processes. Intervention facilities also had a clinical care guide, additional drugs for hypertension, a patient lifestyle education flipchart, associated training, and mobile phone follow-up.

Method:

Clinics were randomised in a 1:1 ratio (sealed envelope lottery method). A total of 574 intervention and 564 control patients in 13 clusters in each arm were recruited (male and female, aged ≥25 years, systolic blood pressure [SBP] >140 mmHg, and/or diastolic blood pressure [DBP] >90 mmHg). The primary outcome was change in SBP from baseline to 9-month follow-up.Staff and patients were not blinded, but outcome assessors were blinded.

Results:

Nine-month primary outcomes were available for 522/574 (90.9%) intervention and 484/564 (85.8%) control participants (all clusters). The unadjusted cluster-level analysis results were as follows: mean intervention outcome was -25.2 mmHg (95% confidence intervals [CI] = -29.9 to-20.6); mean control outcome was -9.4 mmHg (95% CI = 21.2 to 2.2); and mean control-intervention difference was 15.8 (95% CI = 3.6 to 28.0; P = 0.01).

Conclusion:

The findings and separate process evaluation support the scaling of an integrated CVD-hypertension care intervention in urban private clinics in areas lacking public primary care in Pakistan.

KEYWORDS:

Cluster randomised controlled trial; contextualised care package; general practice; hypertension; primary care; primary private clinics

Conflict of interest statement

The authors declare that no competing interests exist.

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