Transforming Hypertension Treatment in BarbadosPosted on by
While being a physician is certainly important to me, first and foremost I consider myself a native of Barbados. The people of Barbados are unique, but they share a commonality with citizens of many other countries: they struggle with a high burden of hypertension, also known as high blood pressure, and other risk factors for cardiovascular disease. That is why I was excited about the opportunity to be a Principal Investigator (PI) on a pilot project to improve hypertension control in patients at two local polyclinics in Barbados. You may have read about this project last year in a blog written by my colleagues Pragna Patel, MD, MPH and Barbara Bowman, PhD.
A daunting challenge
Many people don’t realize that hypertension is the leading risk factor for heart disease and stroke, and is responsible for 9.4 million largely preventable deaths worldwide – more than tobacco. Thirty three percent of adults in Barbados have high blood pressure, and they develop it for largely the same reasons as people in other developing countries: not getting enough exercise and eating an unhealthy diet.
To tackle the problem, we brought together a diverse group of stakeholders that included the Ministry of Health (MOH), civil society organizations (especially the Healthy Caribbean Coalition), universities, professional organizations, and polyclinics. In Barbados, polyclinics refer to clinics that treat various types of diseases and injuries. Our stakeholders chose two MOH polyclinics to pilot the Standardized Hypertension Treatment and Prevention Project (SHTP).
We set lofty goals for this project. We wanted to:
- Improve high blood pressure control among patients
- Increase the number of patients receiving treatment based on standardized protocols and core medications, and
- Implement Barbados’s first electronic registry for tracking patients.
In order to meet these goals, we needed to educate the physicians, nurses, and pharmacists who are responsible for patient care. We held trainings to teach clinic staff how to work in teams and coordinate patient care. I remember that a colleague of mine attended one class, and she was initially very defensive about how she treated her patients. She told me that the doctors already know what they’re doing, and asked me if our project was really going to work. Two years later, her whole thought process is completely different, and she is one of this project’s most vocal champions. Her transformation really showed me that the treatment model we developed can be sustainable.
Beating high blood pressure
Our main activities in the two clinics were:
1) Train the staff to use standardized protocols for treating patients,
2) Use automated blood pressure measurement devices, and
3) Create an electronic registry of hypertensive patients.
The creation of the electronic registry was particularly challenging because Barbados was just beginning to switch from paper-based patient records to electronic medical records (EMR). We received a lot of helpful feedback from our stakeholders while developing the electronic patient registry, and I think that our experience will inform the future as all clinics in Barbados move toward EMR. For example, we learned that the paper-based systems should not be abruptly discontinued when EMRs are introduced. Some overlap between the systems gives staff time to become more comfortable with using the computer systems.
Implementing electronic records was only one of many challenges we faced while working on this project. It was very important to make sure all of our stakeholders stayed involved throughout the course of the project. During implementation, public health organizations had to deal with Ebola and Zika outbreaks. While hypertension affects more people, it is sometimes easy for attention to shift from hypertension treatment to emerging infectious disease.
Another huge challenge was changing the behavior of healthcare providers (HCPs). This project required behavior change among HCPs more so than the patients themselves! It is hard to tell a senior doctor that they haven’t been using the best drug or treatment algorithm. These changes occurred slowly, but we saw them take hold in the clinics, and hopefully doctors will continue to treat hypertension this way.
The beat goes on
Despite these and other challenges, between June 2014 and December 2015 we screened more than 30,000 people at the two polyclinics. After the project ended, high blood pressure control rates improved by 14.5%. To put this number in perspective, a pioneering program in the United States noted that hypertension control improved by 7% in one year, so a 14% improvement is really remarkable.
It was incredibly rewarding for the whole team to see how much high blood pressure rates improved over the course of the project. Beyond the individual impact, it was great to see the cultural and behavioral changes in the clinics. Doctors are much more comfortable now making referrals to tertiary care. This project brought different members of the healthcare team together to coordinate patient care and work toward a common goal. As a hypertension specialist who sees difficult-to-treat cases, I can tell who is coming from an SHTP clinic.
While the pilot project is over, Barbados is just getting started. The SHTP project will continue as part of the Global Hearts Initiative, a larger initiative by the World Health Organization, US CDC, and other partners to improve all aspects of cardiovascular health. I am pleased that SHTP will be a part of the Global Hearts Initiative, and become a legacy that will continue to benefit patients.
A personal challenge for me was seeing how patients at the other six polyclinics in Barbados could not participate in this program, so I’m looking forward to the expansion. I think that Global Hearts can even move beyond Barbados and impact the whole Caribbean region, and become a model for the entire world.