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Citation Information

Type Working Paper - medRxiv
Title Health systems performance for hypertension control using a cascade of care approach in South Africa, 2008-2017
Publication (Day/Month/Year) 2021
URL https://www.medrxiv.org/content/early/2021/09/16/2021.09.13.21251870
Abstract
Background Hypertension is a major contributor to global morbidity and mortality. In South Africa, the government has employed a whole systems approach to address the growing burden of non-communicable diseases. We used a novel incident care cascade approach to measure changes in the South African health system{\textquoteright}s ability to manage hypertension between 2008 and 2017.Methods We used data from Waves 1-5 of the National Income Dynamics Study (NIDS) to estimate trends in the hypertension care cascade and unmet treatment need across four successive cohorts with incident hypertension. We used a negative binomial regression to identify factors that may predict higher rates of hypertension control, controlling for socio-demographic and healthcare factors. The largest cascade attrition occurred prior to diagnosis.Results In 2011, 19{\textperiodcentered}6\% (95\%CI 14{\textperiodcentered}2, 26{\textperiodcentered}2) of individuals with incident hypertension were diagnosed, 15{\textperiodcentered}4\% (95\%CI 10{\textperiodcentered}8, 21{\textperiodcentered}4) were on treatment and 7.1\% had controlled blood pressure. By 2017, the proportion of individuals with diagnosed incident hypertension had increased to 24{\textperiodcentered}4\% (95\%CI 15{\textperiodcentered}9, 35{\textperiodcentered}4) with increases in treatment (23{\textperiodcentered}3\%, 95\%CI 15{\textperiodcentered}0, 34{\textperiodcentered}3) and control (22{\textperiodcentered}1\%, 95\%CI 14{\textperiodcentered}1, 33{\textperiodcentered}.0) were also observed, translating to a decrease in unmet need from 92{\textperiodcentered}9\% in 2011 to 77{\textperiodcentered}9\% in 2017. Multivariable regression showed that participants with incident hypertension in 2017 were 3{\textperiodcentered}01 (95\%CI 1{\textperiodcentered}77, 5{\textperiodcentered}13) times more likely to have a controlled blood pressure compared to those in 2011.Conclusions The proportion of people with incident hypertension who successfully progressed to controlled blood pressure tripled between 2011 and 2017 in South Africa. Despite these improvements, a low absolute proportion of the population were able to control their blood pressure and a high burden of unmet need remains.What is already knownPrevalent cascades provide insight to where losses in care cascades occur.While mostly used in the management of HIV, recently they have also been adopted in studying the management of non-communicable diseases on a population level.Prevalent hypertension cascades in South Africa showed a high burden of unmet need, with the biggest losses where lost between disease development and diagnosis.What are the new findingsIncident hypertension cascades improved from 2008 to 2017 in South Africa.What do the new findings implyIncident cascades provide an improved means to measure changes in management cascades as this allows us to distinguish between historical and current health system performance.Our data show that while substantial improvements in the care cascade occurred between 2008 and 2017, a large burden of unmet need remains.Competing Interest StatementThe authors have declared no competing interest.Funding StatementNo external funding was received for the present study.Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Boston University Medical Campus IRB. The IRB reviewed the research and made the determination that it was not human subjects research and therefore had no requirement to obtain consent.All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesThis study uses data from the first through the fifth waves of the National Income Dynamics Study (NIDS). NIDS is a nationally representative panel survey that was implemented by the South African Labour and Development Research Unit at the University of Cape Town. The data used in the present study are publicly available and can be accessed at the following link: http://www.nids.uct.ac.za/ Data for all 5 waves of the NIDS were accessed using the DataFirst portal following registration. Ethics approval for NIDS data collection for Waves 1 to 5 were granted by University of Cape Town{\textquoteright}s Commerce Faculty Ethics in Research Committee. For Wave 5 additional ethics approval was granted by University of Cape Town{\textquoteright}s Faculty of Health Sciences Human Research Committee.

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