Abstract
INTRODUCTION
Globally, hypertension is responsible for approximately half of all heart disease and stroke deaths. Over 75% of these deaths occur in low- and middle-income countries. However globally, hypertension awareness, treatment, and control remain low (39%, 29%, and 10%, respectively). Reasons for poor control are multifactorial, and include patient-specific factors such as poor adherence, often associated with high pill-burden regimens. Health system factors are also important and may include the use of complex algorithms, leading to clinical inertia amongst healthcare workers. Fixed-dose combination (FDC) medications may be one way of reducing pill burden and simplifying clinical algorithms. To understand the use of multiple drug classes in the management of hypertension we analysed antihypertensive prescribing patterns and blood pressure (BP) control in cohorts from MSF treatment programmes in Jordan and Zimbabwe to determine the proportion of patients who may benefit from a FDC (those currently treated with more than two drug classes) and the potential extent of clinical inertia.
METHODS
We used routine, retrospective data from two cohorts of adult patients with hypertension; one from Jordan, a semi-urban clinic managed by doctors (using data from October 2016 to December 2018) and one from Zimbabwe, a rural setting managed by nurses (data from May 2016 to July 2019). We carried out descriptive analyses of prescribing patterns and their relationship with BP control.
Ethics
This study was approved by the ethics committees of Jordan and Zimbabwe and the MSF Ethics Review Board.
RESULTS
We analysed data from 3305 and 3957 hypertensive patients from Jordan and Zimbabwe respectively; with median ages in Jordan 61 (interquartile range, IQR, 53-69) and in Zimbabwe 63 (IQR 53-70); the majority were female (62.7% and 80.4% respectively). Retention and BP control at 12 months were 95% and 77% (Jordan) and 59% and 42.3% (Zimbabwe). The proportion of patients on two, three, or four-five antihypertensive drug classes at baseline were 42%, 19%, 4% in Jordan and 46%, 7%, <1% in Zimbabwe. At 12 months follow-up, proportions were 40%, 28%, 11% in Jordan and 46%, 17%, 1% in Zimbabwe. Proportions with controlled BP at 12 months on two, three, or four-five drug classes were 71%, 64% and 55% in Jordan, and 40%, 27%, 25% in Zimbabwe. No medication change for uncontrolled BP was made at the next visit for 1,843 (79.3%) of 2,325 visits in Jordan, and 4,763 (63.5%) of 7,497 visits in Zimbabwe. This included 545 (28.6%) and 2,549 (53.5%) visits with uncontrolled stage two or three hypertension respectively.
CONCLUSION
Most patients with hypertension required more than two antihypertensive medications, but a significant proportion persisted with uncontrolled BP. No additional class of antihypertensive was given in the majority of visits by patients with uncontrolled BP, suggesting possible clinical inertia by healthcare workers. Despite recent inclusion of FDC’s in MSF guidelines and WHO’s Essential Medicines List, their lack of inclusion in national guidelines, and procurement challenges, have hindered MSF’s implementation of FDC’s. Demonstrating feasibility of FDC use in MSF pilot projects could play an important role in furthering uptake.
Conflicts of Interest
None declared.
