In this issue of JAMA, He and colleagues1 report the results of the Hypertension Control Program in Argentina, a community health worker–led, home-based intervention that aimed to lower blood pressure among 1432 low-income adults with uncontrolled hypertension in Argentina. Compared with usual care, the intervention lowered systolic blood pressure by 6.6 mm Hg (95% CI, 4.6-8.6 mm Hg) and diastolic blood pressure by 5.4 mm Hg (95% CI, 4.0-6.8 mm Hg). This program led to a remarkable 21% absolute difference in the proportion of individuals with controlled blood pressure, defined as a systolic and diastolic blood pressure less than 140/90 mm Hg (73% in the intervention group vs 52% in the usual care group). After 18 months, the meanadjusted total cost related to the intervention and to health care was $103 (95% CI, $61-$144) higher per participant in the intervention group than in the control group ($178.6 vs $67.6 in total costs, respectively), which was approximately 5% of Argentina’s annual per capita health spending of $1322 in 2015.2 Task sharing has been widely used for longitudinal management of diseases such as HIV and tuberculosis yet has not garnered as much attention for cardiovascular disease prevention and control until recently. The 2016 World Health Organization–led HEARTS technical package includes task sharing as a key element for reducing the risk of premature mortality from cardiovascular diseases.3 However, this recommendation is based on a limited number of randomized trials with heterogeneous blood pressure effects across countries. The study by He and colleagues addresses the large and growing problem of managing elevated blood pressure. Estimates from the Global Burden of Disease 2015 Study suggest that nearly 1 billion adults 25 years or older have a systolic blood pressure of at least 140 mm Hg, which was associated with an estimated 7.8 million (95% uncertainty interval, 7.0 million to 8.7 million) deaths in 2015.4 Despite this substantial burden of disease, data from 142 042 participants from 17 countries who participated in the Prospective Urban Rural Epidemiology Study (including Argentina, among the 14 lowor middleincome countries) suggest that less than half of individuals who are aware of having a diagnosis of elevated blood pressure receive treatment and among those who do receive treatment, only one-third have their blood pressure controlled.5 Thus, scalable, effective, and multilevel strategies are needed to overcome key patient, clinician, and health system barriers for hypertension treatment and control.6 The research team used a cluster randomized study design to test their intervention across 18 primary health centers that are part of Argentina’s Remediar+Redes (Remedy+Network) Program. This program was started in 2002 to provide free access to essential medicines after Argentina’s economic crisis threatened its most vulnerable citizens’ health and was initially funded by the Inter-American Development Bank (IDB) and Argentinian government.7 The program has expanded over the past 15 years through rigorous supply chain and logistics management, transparency, and efficiency to provide free access to essential medicines to a target population of 17 million Argentines whose incomes are below the poverty line. By testing an intervention within the existing health system infrastructure, including one aligned toward achieving universal health coverage, the research team has wisely positioned this intervention for scaling to other sites within the national primary health center network. The Hypertension Control Program in Argentina consisted of community health worker–led training of participants with hypertension and their families over a 2-day period followed by monthly home visits for 6 months and bimonthly visits for another 12 months. The health workers used these visits, along with text messages, to emphasize health behaviors related to blood pressure, home blood pressure monitoring, medication adherence, and linkage to primary care. The intervention also included face-to-face and online training for physicians about stepped-care blood pressure management. The study was designed and conducted well but has some limitations. First, the intervention group received a higher “dose” of treatment, or engagement, from the health system than the usual care group, which likely drives the observed blood pressure differences. Whether this specific complex intervention—and which component—compared with any intervention that increases engagement with the health system leads to lower blood pressure might be debated. For example, 4 previous trials including 1770 participants demonstrated that home blood pressure monitoring via telemedicine was associated with reduction in systolic blood pressure by 4.3 mm Hg (95% CI, 3.4-5.3 mm Hg) at 9 months compared with usual care.8 Text messaging has been demonstrated to lower systolic blood pressure by 2.2 mm Hg (95% CI, 0.04-4.4 mm Hg) at 12 months in 1 trial of 1256 participants in South Africa. Other interventions might either be more expensive (eg, nurse-led medication therapeutic management9) or be difficult to sustain (eg, unpaid peer support), but some degree of peer support through community or other lay health workers seems to be the key ingredient to reach the “hardly reached.”10 Furthermore, the usual care Related article page 1016 Opinion

中文翻译：

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与社区卫生工作者一起改善血压控制和卫生系统

在本期 JAMA 中，He 及其同事 1 报告了阿根廷高血压控制计划的结果，该计划是一项由社区卫生工作者主导的基于家庭的干预措施，旨在降低阿根廷 1432 名患有未控制高血压的低收入成年人的血压。与常规护理相比，干预措施使收缩压降低了 6.6 毫米汞柱（95% CI，4.6-8.6 毫米汞柱），舒张压降低了 5.4 毫米汞柱（95% CI，4.0-6.8 毫米汞柱）。该计划导致血压控制（定义为收缩压和舒张压低于 140/90 mmHg）的个体比例出现显着的 21% 绝对差异（干预组为 73%，常规护理组为 52%） ）。18 个月后，与干预和医疗保健相关的平均调整后总成本为 103 美元（95% CI，$61-$144) 干预组的每位参与者比对照组高（总成本分别为 178.6 美元和 67.6 美元），约占阿根廷 2015 年人均医疗支出 1322 美元的 5%。艾滋病和肺结核等疾病的纵向管理直到最近才在心血管疾病的预防和控制方面得到足够的重视。2016 年世界卫生组织牵头的 HEARTS 技术包将任务共享作为降低心血管疾病过早死亡风险的一个关键要素。3 然而，该建议基于数量有限的随机试验，这些试验对不同国家的血压影响不同。He 及其同事的研究解决了管理高血压这一巨大且日益严重的问题。2015 年全球疾病负担研究的估计表明，近 10 亿 25 岁或以上的成年人的收缩压至少为 140 毫米汞柱，估计有 780 万（95% 的不确定区间，700 万至 870 万) 2015 年的死亡人数。4 尽管疾病负担如此沉重，来自 17 个国家的 142 042 名参加前瞻性城乡流行病学研究的参与者（包括阿根廷，在 14 个中低收入国家中）的数据表明，只有不到一半的人知道被诊断为血压升高的人接受治疗，在接受治疗的人中，只有三分之一的人血压得到控制。 5 因此，可扩展，需要有效的多层次策略来克服高血压治疗和控制的关键患者、临床医生和卫生系统障碍。 6 研究团队使用集群随机研究设计来测试他们对阿根廷 Remediar+ 一部分的 18 个初级卫生中心的干预措施Redes（补救+网络）计划。该计划于 2002 年启动，目的是在阿根廷的经济危机威胁到其最弱势公民的健康后免费提供基本药物，最初由美洲开发银行 (IDB) 和阿根廷政府提供资金。 7 该计划在过去得到了扩展15 年通过严格的供应链和物流管理、透明度、和效率，为收入低于贫困线的 1700 万阿根廷目标人口免费提供基本药物。通过在现有卫生系统基础设施内测试干预措施，包括与实现全民健康覆盖相一致的干预措施，研究团队明智地将这种干预措施扩展到国家初级卫生中心网络内的其他站点。阿根廷的高血压控制计划包括由社区卫生工作者主导的对高血压参与者及其家人进行为期 2 天的培训，然后是 6 个月的每月家访和另外 12 个月的双月访问。卫生工作者利用这些访问以及短信来强调与血压、家庭血压监测、药物依从性，以及与初级保健的联系。干预措施还包括为医生提供有关阶梯式血压管理的面对面和在线培训。该研究的设计和进行得很好，但有一些局限性。首先，与常规护理组相比，干预组从卫生系统接受了更高“剂量”的治疗或参与，这可能会导致观察到的血压差异。与任何增加与卫生系统接触的干预措施相比，这种特定的复杂干预措施（以及哪个组成部分）是否会导致血压降低可能存在争议。例如，包括 1770 名参与者在内的 4 项先前试验表明，通过远程医疗进行家庭血压监测与收缩压降低 4.3 毫米汞柱有关（95% CI，3.4-5。9 个月时与常规护理相比降低 3 毫米汞柱。8 在 1256 名南非参与者的一项试验中，短信已被证明可在 12 个月时将收缩压降低 2.2 毫米汞柱（95% CI，0.04-4.4 毫米汞柱） . 其他干预措施可能更昂贵（例如，护士主导的药物治疗管理 9）或难以维持（例如，无偿同伴支持），但通过社区或其他非专业卫生工作者提供的某种程度的同伴支持似乎是关键因素到达“难以到达”。10 此外，平时的护理 相关文章第 1016 页 意见