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 populationbased approach

[Figure from Erhardt et al., Vasc Health Risk Manag 2007]

Attributes of populationbased 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, populationbased 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
39 eligible Ontario towns/cities
(population from 10,000 - 60,000)

Baseline data assessed 12 months before CHAP implementation

(assessed rerospectively)

Community cluster randomization stratified by size of population 65+ and geographic location
(7 strata)

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-level primary outcome assessed 12 months post CHAP

(mean change in annual rate of hospital admissions for MI, CHF and stroke)

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-todatabase
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)

3015

2936

2790

3013

091 (086097)
p<001*

AMI

1024

1026

954

1081

087 (079097) p<001

CHF

1119

1111

1051

1222

090 (081099) p=003

Stroke

871

799

786

710

099 (088112) p=089

Composite

*3.02 fewer annual hospital admissions for CVD per 1000 people aged 65+

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 (073101) p=006

All-cause
mortality

35.45

33.13

33.98

34.55

0.98 (0.921.03) p=0.38

Initiation of
HTN therapy

1466

1416

1635

1531

110 (102120) p=002

Mean annual healthcare and interventions costs, by

study arm and study time period (in $)
Resource Item

CHAP
hospitalizations only

PrePrePostCHAP minus Control Cost

Post-Control
CHAP
Control
CHAP
Difference (95% CI);
n= 75 499
(n=67,874) n= 72 768 n= 69 942
p value
282

269

269

303

-39.72 (-77.80, -1.64); 0.041

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

All hospitalizations

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 costeffective 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 populationbased administrative data

More information
www.CHAPprogram.ca
Janusz.kaczorowski@umontreal.ca