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

Janusz.kaczorowski@umontreal.ca