Multifaceted Interventions Delivered by Rural Physicians Significantly Reduce Hypertension Rates in Rural China: CRHCP

Key Points

• Rural areas represent particularly vulnerable areas for the control of cardiovascular disease, due to the lack of data to identify at-risk populations and the logistical challenges associated with delivering sustainable health interventions.
• Rural doctors can implement feasible and scalable interventions to empower patients in rural communities so that they can achieve blood pressure control.
• A randomized trial of almost 35,000 patients living in rural communities in China showed a statistically significant and clinically meaningful reduction in blood pressure, as a result of lifestyle coaching and protocol-based antihypertensive treatment delivered by rural physicians.

Cardiovascular disease represents the leading cause of death globally, taking 18 million lives annually. Notably, 75% of CVD-related deaths occur in low- and middle-income countries, where health systems often lack contemporary data to identify high-risk populations to target with aggressive monitoring and treatment efforts. Rural areas represent particularly vulnerable hotspots, where the epidemiologic transition driven by industrialization, urbanization, and associated lifestyle and demographic changes is generating a disproportionate burden of undiagnosed cardiovascular disease.

In China, where about 30% of the population (292 million people) have hypertension, the rate of blood pressure control in rural areas is alarmingly low at around 5.5%. In this setting, appropriately trained rural doctors may be able to offer a feasible and scalable interventions to improve blood pressure control.

During the 2021 American Heart Association Scientific Sessions, Dr. Jiang He and colleagues presented the results of a randomized controlled trial to test the effectiveness of a multifaceted intervention led by rural doctors (n=17,407 patients) compared to usual care (n=16,588 patients) over an observation period of 18 months. Patients were eligible to enroll if they had hypertension, defined in the China Hypertension Guidelines as SBP>140 or DBP>90 mm Hg, or alternatively SBP>130 or DBP>80 and one or more cardiovascular risk factors. In the intervention arm, rural doctors were trained on standardized BP measurement, protocol-based antihypertensive treatment, and lifestyle coaching – while patients also received discounted or free medications and home BP monitors. On average, patients on both arms had a mean age of 63 years, 60% were female, 55% were already taking blood pressure medications with an average SBP of 155 mm Hg and DBP of 88 mm Hg at enrollment.

At the end of the observation period, 57% of patients in the experimental arm achieved BP control (defined as SBP<130 or DBP<80 mm Hg), a significantly higher proportion compared to 19.9% in the usual care arm (net difference 37%, 95% CI 34.9-39.1, p<0.0001). This was due to statistically significant reductions in SBP by 26 mm Hg and DBP by 15 mm Hg, compared to only 12 mm Hg and 7.5 mm Hg in the control group, respectively.

In conclusion, this proof-of-concept study demonstrates that blood pressure interventions delivered by rural physicians in rural areas can achieve statistically significant and clinically meaningful reductions in blood pressure. This lays the foundation to support larger interventions at-scale, which can empower local health system with the tools to address the rapidly growing epidemic of hypertension and other cardiovascular disease.