Lay community health worker-led care with mobile decision support for uncontrolled hypertension: a cluster-randomized trial.

Summary

In 103 rural clusters in Lesotho (n=547), lay CHWs using a mobile clinical decision support system independently initiated and titrated a fixed-dose amlodipine/hydrochlorothiazide regimen, achieving higher 12-month BP control versus facility referral with no safety signal. Results support task-shifting first-line hypertension management to CHWs in remote settings.

Key Findings

• BP control at 12 months: 58% (intervention) vs 48% (control); adjusted OR 1.52 (95% CI 1.01–2.29), P=0.046
• No relevant differences in safety outcomes between arms
• CHWs independently prescribed and titrated fixed-dose amlodipine/hydrochlorothiazide guided by mobile CDSS
• Complete-case analysis confirmed primary findings

Clinical Implications

Health systems can safely expand first-line antihypertensive initiation and titration to trained CHWs with mobile CDSS, potentially increasing BP control coverage in remote areas.

Limitations

• Conducted in a single low-resource country, which may limit generalizability
• Borderline statistical significance for the primary outcome and limited to a single fixed-dose regimen

Future Directions

Scale-up studies with cost-effectiveness, medication safety surveillance, and evaluation across diverse geographies and comorbidities; comparative effectiveness versus nurse/physician-led care.