Figure 1
PRISMA 2020 flow diagram for new systematic reviews which include searches of databases and registers only.
Table 1
Study characteristics of included studies.
| AUTHORS | FINKELSTEIN ET AL. (39) | GARCIA-PENA ET AL. (35) | GAZIANO ET AL. (36) | POZO-MARTIN ET AL. (40) | RIWU ET AL. (37) | STEPHENS ET AL. (41) | YUSRANSYAH ET AL. (38) |
|---|---|---|---|---|---|---|---|
| Country Group | Lower-Middle Income Countries | Upper-Middle Income Countries | Upper-Middle Income Country | Lower-Middle Income Country | Upper-Middle Income Country | Lower-Income Country | Upper-Middle Income Country |
| Country(ies) | Bangladesh, Pakistan, Sri Lanka | Mexico | South Africa | Ghana | Indonesia | Uganda | Indonesia |
| Publication year | 2021 | 2002 | 2014 | 2021 | 2019 | 2021 | 2022 |
| Study period (Duration) | April 2016–March 2019 (3 years) | Jan 1998–Jun 1999 (1 year) | 1 year modelling | 10 years modelling | Dec 2017–Feb 2018 (3 months) | 2011–2021 (10 years) | Jun–Aug 2019 (3 months) |
| Study design | RCT | RCT | Modelling | Modelling | Observational | Descriptive observational study | Quasi-experimental study |
| Sample size | 2645 | 718 | 525 | 10000 | 100 | 413 | 96 |
| Care provider | Community Health Workers | Nurses | Community Health Workers | Pharmacists & Nurses | Pharmacists | Village Health Workers | Pharmacists |
| Female /Male | NI | 459/259 | NI | NI | 57/43 | NI | 77/19 |
| Population | ≥ 40 years | ≥ 60 years | 25–74 years | 18–79 yeas with hypertension | Hypertensive patients | 30–69 years with hypertension | Adults with hypertension |
| Intervention | Multicompetent interventions (Home health education, training of healthcare providers on diagnosis, treatment, follow-up & referral of hypertension, hypertension triaging, financial compensation for additional services) | Home visits for health & lifestyle advice to participants with hypertension | Home visits & hypertension education | Health Education, screening, diagnosis & management of hypertension among community members & referral of severe cases. Information, communication technology messages on healthy lifestyles, treatment adherence & medication refills | Counselling of patients by pharmacists | Screening, diagnosis & treatment of hypertension including counselling on healthy lifestyles | Counselling by pharmacists |
| Comparator | Usual care which is home visit for maternal & childcare | Controlled group received mailed pamphlet about hypertension | Usual or existing care | Standard care (hypertension management services by Ghana Health Services at the time of the study) | No counselling by pharmacists | None | No counselling by pharmacists |
| Outcomes | The program was cost-effective in all the 3 countries with a cost-effectiveness acceptability curve predicted 79.3% cost-effective in Bangladesh, 85.2% in Pakistan, & 99.8% in Sri Lanka | The reduction in BP was cost-effective | Cost-effective at reducing CVD & number of clinic visits | Not cost-effective because of high overhead & high patient cost. | Cost-effective in BP control & improved quality of life. | Cost-effective with BP control | Cost-effective at optimizing hypertension treatment at the PHCs. |
| Sources of funding | UK department of Health & Social Care, UK department of International Development, the Global Challenge Research Fund, UK Medical Research Council, Wellcome Trust | National Council of Science & Technology Mexico, Mexican Institute of Technology | NI | Novartis Foundation | Research Development of Ministry of Research, Technology and Higher Education Republic of Indonesia | None | Ministry of Research, Technology and Higher Education Republic of Indonesia |
| Conflict of interest declaration | None | NI | None | Some co-authors received grants from Novartis Foundation, while others received funds from Novartis. | None | None | None |
[i] NOTE: RCT- Randomized Controlled Trials, NI – No information, CVD – Cardiovascular Diseases, PHCs – Primary Healthcare Centers. BP – Blood Pressure.
Table 2
Costs of hypertension treatment.
| AUTHORS | FINKELSTEIN ET AL. | GARCIA-PENA ET AL. | GAZIANO ET AL. | POZO-MARTIN ET AL. | RIWU ET AL. | STEPHENS ET AL. | YUSRANSYAH ET AL. |
|---|---|---|---|---|---|---|---|
| Country(ies) | Bangladesh, Pakistan, Sri Lanka | Mexico | South Africa | Ghana | Indonesia | Uganda | Indonesia |
| Cost items | Labor, rentals, materials & supplies, contracted services | Training nurses, equipment, office space, supplies, & time spent travelling & attending to patient | Salaries of community health workers & program coordinators, training (per diem for trainers, trainees, room rentals, chairs, desks, laptop computers, projector, projector screen, notebook, pencil), home visits & follow-up (cell phones & minutes, BP apparatus, recording sheets, educational pamphlets) | Training, screening, administrative support, equipment, investigations, treatments, follow-up, electronic health records | Costs of managing hypertension including counselling | Hypertension screening, diagnosis, treatments & stipends to village health workers | Antihypertensive medication, capitations rate by social health insurance administrative body |
| Perspective(s) | Payer (Health Ministry) | Payer (Health service) & patient | Healthcare Worker | Societal | Payer (Health insurance organization) | NI | Payer & patient |
| Year of costing in USD | 2019 | 1998 | 2012 | 2017 | 2017 | NI | NI |
| Cost of 1 mmHg reduction in SBP | NI | $1.14 ($INT2.25) | NI | NI | NI | NI | NI |
| Cost of 1 mmHg reduction in DBP | NI | $1.03 ($INT 2.03) | NI | NI | NI | NI | NI |
| Cost of controlling Hypertension per person | NI | NI | NI | NI | IDR 6387 ($INT 1.48) | NI | NI |
| Annual Cost of treating 1 person | Bangladesh $10.65 ($INT 12.70), Pakistan $10.25, ($INT 11.54), Sri Lanka $6.42 ($INT 6.93) | $ 7.56 ($INT 14.50) | $8 ($INT 10.28) | $197.20 ($INT 232.31) Current CommHIP, $152.10 ($INT 179.25) GHS-LCS CommHIP | No information | $0.20 ($INT 0.22) | IDR 17,923/patient/counselling for government salary (Annual costs IDR 215,076) ($INT 46.92) |
| Cost per averted DALY | $3430 ($INT 3959.60) in Bangladesh, $2270 ($INT 2620.49) in Pakistan, & $4080 ($INT 4709.96) in Sri Lanka | NI | $320 ($INT 411.39) | $645 ($INT 770.08) | NI | NI | NI |
| Cost per gained QALY | NI | NI | NI | NI | 4490 IDR ($INT 1.04) | NI | IDR 850185 ($INT 172.88) (payers’ perspective), IDR 65394.15 ($INT 13.30) (patient’s perspective) |
| ICER | NI | NI | $335 ($INT 430.48) | $12189 ($INT 14373.97) Current CommHIP, $6530 ($INT 7700.55) GHS-LCS CommHIP | IDR 2296 ($INT 0.53) | NI | IDR 2000–28307 ($INT 0.41 –5.76) |
| GDP | Bangladesh $2,688*, Pakistan $1,597* Sri Lanka $3,408* | $11,091* | $12,855.82 | $2,388 | $4,788* | $964* | $4,788* |
| Absolute Cost-effectiveness†† | Bangladesh $3430 ($INT 3959.60)/ DALY averted Pakistan {$2270 ($INT 2620.49)/ DALY averted} Sri Lanka {$4080 ($INT 4709.96)/ DALY averted} | $1.14/ 1mmHg SBP reductions | $335 ($INT430.48)/ DALY averted | $12189 ($INT14373.97)/ DALY averted | $728.5 / DALY averted | $0.20/ person/ year | $57.26/ QALY gained |
| Relative Cost-effectivenessǂǂ(% of GDP per capita) | Bangladesh 128% (cost-effective) Pakistan 142% (cost-effective) Sri Lanka 120% (cost-effective) | 0.01% (very cost-effective) | 2.71% (very cost-effective) | 504.00% (not cost-effective) | 15.22% (very cost-effective) | 0.02% (very cost-effective) | 1.20% (very cost-effective) |
[i] NOTE: Costs in brackets are converted to 2022 $INT using the World Bank Group Purchasing PowerSS Parity conversion factor (30).
NI: No Information given. GDP: gross domestic product in 2022. ICER: incremental cost-effectiveness ratio. $INT: international Dollar. QALY: quality-adjusted life year. DALY: disability-adjusted life year. mmHg: millimeters mercury. SBP: systolic blood pressure. DBP: diastolic blood pressure. IDR: Indonesian Rupiah.
$* Corresponding countries nominal GDP per capita for 2022 from online Worldometers (31). USD: United States Dollar.
GHS-LCS CommHIP: Ghana Health Service-Licensed Chemical Sellers Community-based Hypertension Improvement Project.
††Absolute cost-effectiveness is the total cost in US dollars required to gain one additional unit of health outcomes, such as QALY, DALY averted, 1 mmHg reduction in SBP or DBP and ICER.
ǂǂRelative cost-effectiveness is the ratio of the ICER or DALY averted or QALY gained or 1 mmHg reduction in SBP or DBP to the individual country’s GDP per capita.
Table 3
Specification of Strategies used in task shifting to non-physician healthcare workers and Implementation of Task Shifting by non-physician healthcare workers (65).
| AUTHORS | FINKELSTEIN ET AL. | GARCIA-PENA ET AL. | GAZIANO ET AL. | POZO-MARTIN ET AL. | RIWU ET AL. | STEPHENS ET AL. | YUSRANSYAH ET AL. |
|---|---|---|---|---|---|---|---|
| Name of strategy(ies) | Train, education of stakeholders & utilization of financial strategies | Train & educate stakeholders, engage consumer | Train & educate stakeholders | Train & educate stakeholders, engage consumers & change infrastructures | Engagement of patients through counselling. | Train & educate stakeholders, engage consumes, use financial strategy | Engage consumers |
| Definition/ description of strategy(ies) used in task shifting to non-physician healthcare workers | The training involve education of healthcare workers in the diagnosis and management of hypertension. The financial model used here was to secure additional funding to compensate for up to 20% of healthcare workers’ salaries. | Training nurses about ageing, diagnosis & management of hypertension, how to conduct personal interviews, behavioral change models & ethics of home visits. | Train community health workers on using semi-automated BP measuring apparatus & also on etiology & prevention of hypertension & cardiovascular diseases. Documentation & monitoring of patient’s BP, treatment adherence & health education on healthy lifestyles with referrals where necessary. | Provision of cloud-based health record system linked to Short Message Service (SMS)/voice messaging for treatment adherence, reminder & health messaging. | Training village health workers on diagnosis & treatment of hypertension including healthy lifestyle. Village health workers are paid stipend as incentive per patient recruited or follow-up. | ||
| Definition/ description of strategy(ies) used by non-physician healthcare workers to improve patients’ outcomes | Education on hypertension & risk factors was done to patients by healthcare workers during home visits | During visits, nurses & patients reviewed health records from baseline changes & discussed the possible lifestyle changes. Two to four weekly subsequent visits were discussed & approved at the patient’s’ convenience. | Community education on cardiovascular risk factors & healthy lifestyles, BP screening & monitoring by community pharmacists & cardiovascular diseases nurses, diagnosis, treatment, counselling, follow-up & referrals for severe cases. Information, Communication and Technology (ICT) messages on healthy lifestyles, treatment adherence support & reminders for hypertensive drug refills. | Counselling of patients with hypertension on medications by pharmacist during clinic visits | Village health workers go from house to house twice a year to engage & screen adults 25 years & above for hypertension & monthly follow-up and referral of severe cases to nurses supervising them. | Pharmacists engage patients by counselling to enhance treatment adherence resulting in improvement of blood pressure & quality of life. | |
| Actor: Identify who enacts the strategy | Healthcare Workers | Nurses | Community Health Workers | Licensed Chemical Sellers and Cardiovascular Diseases Nurses | Pharmacists | Village health workers | Pharmacists |
| Action: specify the steps, actions or process to be taken. | Health education, training & management of hypertension | Home visit, blood pressure measurements and healthy lifestyle counselling | Education of patients on risk of hypertension & benefits of lifestyle changes & medication adherence | Community-based education on cardiovascular diseases risk factors & healthy lifestyles, screening, diagnosis, treatment, counselling & referral of severe cases. Information, communication & technology messages for healthy lifestyles, treatment adherence, & medication refill reminders, cloud-based health record system | Counselling on antihypertensive medications | Training, screening, diagnosis, counselling on healthy lifestyle, treatment & follow-up of enrollees with hypertension | Counselling |
| Action Target: Who or where the strategy is directed or targeted to impact | Patients | Patients | Patients | Community members and patients | Patients | Patients | Patients |
| Temporality: When/sequence of use | Pre-implementation & during implementation (training providers, follow-up, treatment, sustained over 2 years | Exploration/ adoption phase to implementation phase | Exploration to implementation phase | Blended community-facility-based model that spans adoption, implementation & sustainment phase | Implementation phase | Exploration/adoption to implementation with community BP care & follow-up | National program sustainment phase |
| Dose: Frequency/intensity/duration of strategy used | 3-monthly home education & BP screening. Each session lasting 30–90 mins | Intervention is 2–4 weekly & lasted for 6 months | 2 times a year | No information | Once during clinic visits lasted 15–30 mins | Twice yearly screening & monthly treatments & follow-up | Monthly education/clinic visits & 3 monthly laboratory tests |
| Implementation outcomes likely to be affected | Reach, adoption, fidelity, costs & effectiveness | Reach, adoption, fidelity, costs & effectiveness | Reach, adoption, fidelity, costs & effectiveness | Reach, adoption, fidelity, costs & effectiveness | Reach, adoption, fidelity, costs & effectiveness | Reach, fidelity, adoption, costs & effectiveness | Reach, adoption, fidelity, costs, & effectiveness |
[i] BP: Blood pressure. SMS: Short Message Service. ICT: Information Communication Technology.
Table 4
Assessments of quality of studies on economic evaluation using Drummond checklist.
| QUESTION | FINKELSTEIN ET AL. | GARCIA-PENA ET AL. | GAZIANO ET AL. | POZO-MARTIN ET AL. | RIWU ET AL. | STEPHENS ET AL. | YUSRANSYAH ET AL. |
|---|---|---|---|---|---|---|---|
| 1. Was a well-defined question posed in answerable form? | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
| 2. Was a comprehensive description of the competing alternative given? (i.e. Can you tell who? did what? to whom? where? & how often?) | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
| 3. Was there evidence that the program’s effectiveness had been established? | 1 | 1 | 1 | 1 | 1 | 1 | 1 |
| 4. Were all the important & relevant costs & consequences for each alternative identified? | 1 | 1 | 1 | 1 | 1 | 0 | 1 |
| 5. Were costs & consequences measured accurately in appropriate physician units? (e.g. hours of nursing time, number of physician visits, lost workdays, gain life years) | 1 | 1 | 1 | 1 | 1 | 0 | 1 |
| 6. Were costs & consequences valued credibly? | 1 | 1 | 1 | 1 | 1 | 0 | 1 |
| 7. Were costs & consequences adjusted for differential timing? | 1 | 0 | 0 | 1 | 0 | 0 | 0 |
| 8. Was an incremental analysis of costs & consequences of alternatives performed? | 1 | 1 | 1 | 1 | 1 | 0 | 1 |
| 9. Was uncertainty in the estimates of costs & consequences adequately characterized? | 1 | 1 | 1 | 1 | 0 | 0 | 1 |
| 10. Did the presentation & discussion of study results include all issues of concern to users? | 1 | 1 | 1 | 1 | 0 | 0 | 1 |
| Overall score | 10 | 9 | 9 | 10 | 7 | 3 | 9 |
Table 5
Assessment of risk of bias of included studies using ROBINS-I tool.
| QUESTIONS | FINKELSTEIN ET AL. | GARCIA-PENA ET AL. | GAZIANO ET AL. | POZO-MARTIN ET AL. | RIWU ET AL. | STEPHENS ET AL. | YUSRANSYAH ET AL. |
|---|---|---|---|---|---|---|---|
| D1 (Bias due to confounders) | Low | Low | Moderate | Serious | Moderate | Serious | Low |
| D2 (Bias in selection of study participants) | Low | Low | Moderate | Moderate | Moderate | Low | Moderate |
| D3 (Bias in classification of Interventions) | Low | Low | Low | Low | Low | Low | Low |
| D4 (Bias due to deviations from intended interventions) | Low | Low | Moderate | Moderate | Moderate | Moderate | Low |
| D5 (Bias due to missing data) | Low | Low | Low | Low | Low | Low | Low |
| D6 (Bias in measurements of outcomes) | Low | Low | Moderate | Moderate | Moderate | Moderate | Moderate |
| D7 (Bias in the selection of reported result) | Low | Low | Low | Low | Low | Low | Low |
| Overall assessment | Low | Low | Moderate | Serious | Moderate | Serious | Moderate |