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Canadian Hypertension Initiative:
Cardiovascular Health Awareness Program
(CHAP)
10th Asian-Pacific Congress of Hypertension
Cebu, Philippines
Janusz Kaczorowski PhD
Dr. Sadok Besrour Chair in Family Medicine
GSK-CIHR Chair in in Optimal Management of Chronic Disease
Professor & Research Director
Department of Family and Emergency Medicine
Universit de Montral and CRCHUM
Disclosure statement
I have not had an affiliation (financial or
otherwise) with a commercial organization that
may have a direct or indirect connection to the
content of my presentation.
Collaborating organizations
Global burden of
hypertension
High blood pressure is the leading risk factor for death today responsible for 9.4 million deaths and 7% of disability worldwide (Lim et
al, Lancet, 2013)
54% of stroke, 47% of ischemic heart disease, and 13.5% of all deaths are
attributable to high blood pressure (Lawes et
al, Lancet, 2008)
Global burden of
hypertension 26% of the world adult population was
estimated to have hypertension in 2000
29% projected to have hypertension by 2025 Number of adults with hypertension in 2000
was 972 million (333 million in developed
countries and 639 million in developing
countries)
Projected to increase to 1.56 billion by 2025 (60% increase)
Kearney et al. Lancet, 2005.
Economic cost of
hypertension The global cost attributed to suboptimal
blood pressure was estimated at $372
billion in 2001 (~ 10% of the world's
overall healthcare expenditures)
Complete control of elevated blood pressure over a 10-year period was
estimated to save nearly $1 trillion
worldwide (Gaziano et al, J Hypertens,
2009)
Prevalence and incidence
of hypertension Widespread and growing epidemics of obesity,
hypertension, diabetes, heart disease and stroke
(Lopez et al, Lancet, 2006)
The incidence and the prevalence of hypertension increases with age
The lifetime residual risk of developing hypertension for a middle-aged person with
normal blood pressure is 90% (Vasan et al,
JAMA, 2002)
Risk reduction Effective strategies to prevent or delay
onset of vascular disease involve factors
at the individual, health care provider,
community and system level
Comprehensive risk management requires combining approaches that seek
to reduce the risks throughout the entire
population with strategies that target
individuals at high risk or with
established disease
Rationale for population-
based approach
[Figure from Erhardt et al., Vasc Health Risk Manag 2007]
Attributes of population-
based strategies Fight root causes of disease and prevent
occurrence of new cases
Synergistic effect on the prevention of numerous diseases with common risk factors
Educational opportunities to reach marginalized populations
Potential to enhance capacity at the community level (organization and activation principles)
Theoretically low cost-effectiveness ratios (use of mass media and new IT)
What community program could be
put in place to improve cardiovascular
health?
How to shift the distribution of risk at the population level?
How to combine individual and population strategies?
Program must be inexpensive, quick & easy to implement in any community
Program must overcome poor/selective uptake & improved follow-up (closing the loop)
Program must be rigorously evaluated
Cardiovascular Health Awareness Program
(CHAP)
CHAP development
Proof of concept pilot with one family practice-- Dundas Proof of concept pilot with a pharmacy -- Ottawa Randomized Trial of 28 family practices in Hamilton and
Ottawa
Community-wide demonstration projects: Grimsby & Brockville, ON Airdrie, AB
CHAP intervention Community-wide promotion of CHAP sessions (letters from GPs,
referrals and local media campaigns)
Trained peer volunteers help participants to measure and record BP with accurate, automated device (BPTru) and fill out standardized CVD and stroke risk profile
BP and risk factor information captured via fax-to-database technology and shared with family physicians, pharmacists and
participants
Participants receive education materials and links to local/provincial/national resources targeted to specific modifiable
risk factors
Community health nurse and pharmacist available to assess participants with high BP
C-CHAP trial objective To evaluate the effectiveness of CHAP in
reducing stroke/CVD morbidity at the
community level:
Primary outcome measure: hospital admissions for acute myocardial infarction,
congestive heart failure, and stroke
(composite end-point) among residents aged
65 years
Design: community cluster RCT Data sources: routinely-collected, population-
based administrative health data (ICES) Kaczorowski et al, Prev Med 2008
Inclusion/exclusion criteria Inclusion criteria:
Community size: 10,000 60,000
Number of family physicians: 5+
Number of pharmacies: 2+
Total community-dwelling population: 65+
Exclusion criteria: Immediately adjacent to metro area (e.g. Dundas)
Rural /dispersed (e.g. townships & native reserves)
Participated in CHAP demonstration project (e.g.
Grimsby & Brockville)
Study Flowchart
Community-level primary outcome assessed 12 months post CHAP
(mean change in annual rate of hospital admissions for MI, CHF and stroke)
Intervention (20 communities)
CHAP sessions in each local pharmacy at least 1 x per week for 10 weeks
Community-level primary outcome assessed 12 months post CHAP
(mean change in annual rate of hospital admissions for MI, CHF and stroke)
Control (19 communities)
CHAP not offered
Community cluster randomization stratified by size of population 65+ and geographic location
(7 strata)
Baseline data assessed 12 months before CHAP implementation
(assessed rerospectively)
39 eligible Ontario towns/cities
(population from 10,000 - 60,000)
CHAP implementation
RFP was publicized in each of the 20 intervention communities in January
2006 to identify a local organization that
would lead CHAP implementation
26 submissions received, 20 selected Hospitals, Senior centeres, YMCA, Meals
on Wheels, Community Care Access
Centeres, VON, District Stroke Centres
Carter et al., Health Promotion International 2009
Standardized implementation Local CHAP Lead Organization in each community Implementation Guide (IG) and DVDs Website with downloads and message board CHAP Connections newsletters Regular teleconferences with Local Coordinators Two Regional Coordinators CHAP Working Group (weekly teleconferences) Volunteer Peer Health Educator training Centralized, web-based data management Pharmacist training, protocol and documentation
Community Profiles Local data on socio
demographic factors
and cardiovascular
health status of each
community,
comprehensive list of
local resources
Completed for all 39 communities
Profiles were translated into French if
communities with 10% francophone population
At CHAP sessions
CHAP implementation All 20 randomly selected communities successfully
launched CHAP
214/341 physicians actively participated 24,196 personalized invitation letters from GPs
mailed
129/145 pharmacies participated 577 volunteers recruited & trained 1,265 sessions held 27,358 assessments (15,889 unique participants) ~25% of older adults in CHAP communities attended
at least one CHAP pharmacy session
Fax-to-
database
risk
profile
form
Aggregate
Physician
Practice
Summary
Comparative
feedback
@ 6 month
Results
Baseline characteristics
Measure Control (n=19) CHAP (n=20)
No. of residents aged 65+ 3 82989 2 17644 3 39370 1 83159
Age (in years) 7479 043 7482 062
% Male 4265 119 4292 216
Rurality Index 2896 1360 3163 1409
% Low income status 1695 855 1857 1133
No. of prescription drugs 725 049 698 054
No. of Comorbidity Groups 731 030 717 050
Charlson Comorbidity Index 057 009 058 011
% with diabetes 2216 234 2120 279
% with history of CHF 1219 191 1245 234
Death rate per 100 345 040 355 057
Kaczorowski et al, BMJ 2011
Hospital admission rates per 1,000
Outcome
Before
CHAP
n=67 874
Before
Control
n=72 768
After
CHAP
n=69 942
After
Control
n=75 499
Rate Ratio
(95% CI)
Composite 3015 2936 2790 3013
091 (086-
097)
p
Secondary outcomes: rates per 1,000
Outcome
Before
CHAP
n=67 874
Before
Control
n=72 768
After
CHAP
n=69 942
After
Control
n=75 499
Rate Ratio
(95% CI)
In-hospital
death
435
446
388
466
086 (073-
101) p=006
All-cause
mortality 35.45 33.13 33.98 34.55
0.98 (0.92-
1.03) p=0.38
Initiation of
HTN therapy 1466 1416 1635 1531
110 (102-
120) p=002
Mean annual healthcare and interventions costs, by
study arm and study time period (in $)
Resource Item
Pre-
CHAP
(n=67,874)
Pre-
Control
n= 72 768
Post-
CHAP
n= 69 942
Post-Control
n= 75 499
CHAP minus Control Cost
Difference (95% CI);
p value
CHAP
hospitalizations only 282 269 269 303 -39.72 (-77.80, -1.64); 0.041
All hospitalizations 2,164 2,110 2,160 2,129 -18.67 (-157.09, 119.76);
0.786
Visits to ER
departments 259 255 265 265 -4.27 (-16.10, 7.57); 0.470
Family physician visits 191 200 174 184 -1.93 (-10.16, 6.31); 0.638
Specialist visits 137 141 141 143 1.45 (-3.62, 6.51); 0.566
Prescription drug
claims 1,382 1,422 1,437 1,474 0.42 (-30.87, 31.70); 0.979
Intervention costs - - 20.202 - 20.203; n/a
Total healthcare &
intervention costs 4,132 4,128 4,198 4,196 -1.69 (-155.76, 152.39); 0.982
Goeree et al, Value in Health 2013
Interpreting RR = 0.91 Extrapolating these results to the population
65+ in Ontario, UK and USA would result in
approximately 5 000, 30 000, and 120 000
fewer annual CVD hospital admissions,
respectively
On par with the benefits of population-wide reductions in dietary salt (2g/day reduction),
tobacco use (elimination of 40% of use of or
exposure to tobacco), or obesity (5% BMI
reduction in obese individuals) on annual
number of CVD events
Factors responsible for success
Organizational support at local community level Guidance and support from CHAP Central team Devolution of responsibility to communities Community mobilization and recruitment of
physicians and pharmacists
Support for volunteer-led activities Protocols for high-risk participants and
availability of health professionals
Accurate tracking of participation and community-level data
Assessment results provided to family physicians and pharmacists for follow-up
Limitations Not possible to know which specific
components of CHAP were responsible for
the observed reductions in CVD hospital
admissions
Our findings may not hold for larger urban centers (including ethno-cultural minorities)
or countries where health care delivery is
organized differently
Requires culture of volunteerism and community engagement
But Two-thirds of adults with hypertension live in
low- and middle-income countries
CHAP has shown to be effective and cost-effective in Canada
CHAP model might be particularly suitable for low-and middle-income countries
CHAP team is currently working with Ateneo de Zamboanga University School of Medicine to
adapt, implement and evaluate CHAP in the
Philippines
Conclusions Effectiveness results: collaborative,
multipronged, community-based health
promotion program targeted at older adults
reduces cardiovascular morbidity in population
CHAP is feasible: successfully implemented in all 20 randomly selected communities
C-CHAP evaluation highlights: a randomized design, peer volunteers to deliver the
intervention, high rate of participation, involved
both health professionals and community
organizations, and, relied upon population-
based administrative data
More information
www.CHAPprogram.ca