High-Adherence Hypertension Control Achieved via a Physician-Led Community Model in Rural Thailand: A 7-Year Cohort Study

High-Adherence Hypertension Control Achieved via a Physician-Led Community Model in Rural Thailand: A 7-Year Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article High-Adherence Hypertension Control Achieved via a Physician-Led Community Model in Rural Thailand: A 7-Year Cohort Study Wilai Puavilai, Santi Lapbenjakul, Kasem Phiadsoongnern, Saowalak Hunnangkul, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8568478/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 17 You are reading this latest preprint version Abstract Background: Hypertension (HT) is often asymptomatic, resulting in low awareness and poor blood pressure (BP) control. In Thailand, approximately 20–30% of HT patients achieve BP control. This study assessed the impact of a physician-led community HT model on the rate of BP control, with prevalence and incidence. Methods: This was a voluntary community-based cohort study. From 2012 - 2018, annual home BP screenings were conducted in Lumsone-thi District, for residents aged ≥15 years. Individuals with a BP ≥140/90 mmHg and no prior treatment, were referred to a hypertension team with physician to confirm diagnosis (BP > 140/90), registration, management for new cases. Previously diagnosed HT patients (previous cases) continued their treatment, were registered,enrolled in protocols, with no team physician involvement except giving consultations when requested.BP control (<140/90) was retrospectively audited in late 2019 via the 2018 ESC/ESH Guideline. The audits were disrupted because of the COVID-19 pandemic; however, both fraction groups were sufficient to be representative of their total populations, with p-values > 0.5. Results: Among 809 new cases, 55.4% were men; 66.6% had grade 1 HT; 23.1% had grade 2; 6.8% had grade 3; and 3.5% had BP<140/90 from earlier treatment in that year. The prevalence of HT was 18.3% in those aged ≥40 years; the average annual incidence of HT was 1.023% in those aged ≥40; and the highest was in aged 60-69, men= 1.404%. BP control (<140/90) was greater in the new case fraction group (83.3%) than in the previous ones (77.7%, p = 0.024). There were 27 deaths in the new cases, and 56 in previous cases. Conclusion: A physician-led community model that integrates local health care hospitals and volunteers, achieved high hypertension control rates because of accurate BP measurement of both arms, physician reconfirmation of the diagnosis, leading to increased awareness, acceptance of asymptomatic hypertension and all free of charge management. Hypertension Control Cohort study Prevalence Annual Incidence Figures Figure 1 Background Hypertension (HT) is a major global risk factor for cardiovascular disease, stroke, and chronic kidney disease [ 1 , 2 ]. It is called a “silent killer” because it is frequently asymptomatic [ 3 ], resulting in low awareness and poor HT control until complications develop. Globally, only approximately 20% of patients with HT achieve BP control [ 4 ]. In Thailand, national surveys reported controlled HT in 30% of cases in 2014, which decreased to 22.7% by 2019–2020 [ 5 ]. This decrease has persisted despite the implementation of Universal Health Coverage and Primary Care, in Thailand since 2002 [ 6 ]. Factors contributing to low control rates, particularly in rural areas, include low income, low health awareness, lower educational attainment, male sex, current smoking, and alcohol consumption; some factors are related to issues such as the proper use of antihypertensive medication and comorbid diabetes [ 7 , 8 , 9 ]. This study aimed to improve the BP control rate, and evaluate the prevalence and the incidence of HT in a rural Thai district by using a hypertension team with a physician-integrated community-based model. Methods Study design and setting This study was a voluntary community-based cohort study conducted in Lumsone-thi District, Lopburi Province, Central Thailand, between 1 January 2012 and 30 September 2018. The district is served by seven local health care hospitals (LHCHs) and one 30-bed community hospital. Ethical approval was granted by the Institutional Review Board of Lopburi Province in 2016 (Research Code Number KNH 013/2559). Participants and screening Annual home-based blood pressure (BP) screening was performed for residents aged ≥15 years by trained local health care volunteers (LHCVs), who were women from the same villages. Individuals with a BP of ≥ 140/90 mmHg and no prior antihypertensive treatment were referred to the Hypertension Team with Physician (HTTP). This integrated team was composed of LHCVs, LHCH nurses, two trained registered nurses, and a physician (cardiologist). Diagnosis BP measurements followed a standardized protocol: · Position: Measured in both arms while the patient was in a seated position and with no legs crossed (or lying for bedridden patients). · Preparation: Patients rested quietly for at least five minutes, with an empty bladder. They were instructed to abstain from caffeine, alcohol, and smoking for 30 minutes prior to measurement. · Procedure: At least two readings per arm were taken via validated automatic devices (Omron, Japan), and two BP values usually vary within < 10/5 of each arm; both arms’ BPs were recorded, and the higher arm's average BP was selected for diagnosis. · The criteria for the diagnosis of hypertension followed the JNC7 criteria [10]. Newly diagnosed hypertension (new cases) was registered if the BP was > 140/90 mmHg in either digit. Management Protocol New patients who followed the protocol received the following management steps: 1. Baseline assessment and counselling · Assessment: A protocol-driven history was taken, including body weight (in kilograms, with light clothing, no shoes), height (in meters), waist circumference (measured at the highest edge of the umbilicus (in centimeters), and an electrocardiogram (ECG) test. · Counselling: Patients received detailed counselling on HT complications and lifestyle modifications, with a focus on smoking cessation, reduced alcohol intake, weight loss, salt restriction, exercise, and increased consumption of lean meats, vegetables, and low-sugar fruits. 2. Physician: clinical assessment and management · Clinical assessment: Patients met with the physician in groups (separated by sex) for a brief clinical history of anginal pain and heart failure (HF). The physician interpreted the ECG, performed a basic physical examination, and reconfirmed the HT diagnosis. · Prescription: Medicine was prescribed if indicated to control high BP and prevent serious outcomes such as stroke or myocardial infarction (MI). Amlodipine was the primary antihypertensive medication used, provided that there were no contraindications. · Referral: Complex cases were referred to Lumsone-thi Community Hospital. 3. Follow-up and Team Communication · Scheduled Tests: Routineblood tests and urine examinations were scheduled subsequent to the initial assessment. · Nurse-Led Follow-up: Forfollow-up of new cases, LHCH nurses consulted the Lumsone-thi Hospital physician for judgement on whether to initiate nurse-led follow-up, including prescription refills. Patients were scheduled to see the hospital physician later for review and/or follow-up. · Accessibility: The HT team and LHCH nurses maintained continuous mobile phone contact with the HTT physician / or hospital physician because consultation was convenient. There were 170 newly diagnosed hypertension patients (Pts) who received HT treatment and did not meet the HTTP in that year; these Pts were registered as new cases without a protocol. Previously diagnosed HT patients had ahistory of hypertension treatment > 1 year(s), continued their treatment, no team physician involvement except for providing ECG interpretation or consultation when requested, and these Pts were enrolled in protocols that were registered as previous cases. There were 22 previous cases without a protocol. Case Definitions and Categories All patients were categorized on the basis of diagnosis status and completion of the study protocol: 1. New cases: Newly diagnosed with HT during screening or those who received HT treatment for the first time that year. · With Protocol: Completed the full diagnostic and registration protocol (n=809 pts). · Without Protocol: Newly diagnosed with HT, received treatment, and did not meet HTTP in that year (n=170 Pts). 2. Previous cases: Patients who werepreviously diagnosed with HT with a history of hypertension treatment for > 1 year (one calendar year), were enrolled in the protocols by the HTT; no team physician involvement except ECG interpretation; and consultation when requested. · The following protocol was used: enrolled in the protocols by HTT and whose ECG were interpreted by team physicians (n=801 pts). · Without protocol: incomplete registration, and no ECG test (n=22 Pts). Blood Pressure Control Audit A retrospective audit of BP control was conducted between 1 September and 30 November 2019, using patient records from outpatient department (OPD) folders. The audit included patients who had been on stable medication for at least three months. Definition of Control: BP was defined as < 140/90 mmHg. On the basis of the 2018 ESC/ESH guidelines [11]. The JNC8 guidelines [12] were not used because the revised systolic targets for older adults, compared with JNC7 [10], would have complicated the consistent counting of controlled cases. Sampling and Representation: the subsequent, broader audit of all new and previous cases was disrupted by the COVID-19 pandemic. Consequently, only fractions of the cases were available for analysis. We compared 504 fractional new cases (284 men, 220 women) with 809 total new cases (448 men, 361 women). There was no significant difference in sex distribution between the sample and total population (p =0.73). Similarly, 188 fractional previous cases (57 men, 131 women) were compared with 801 total previous cases (263 men, 538 women), and no significant difference in sex distribution was detected (p=0.507). These results indicate that the fractional groups were representative of their respective total populations. Statistical analysis Demographic and clinical data are presented as frequencies, percentages for categorical variables, and means + SDs for continuous variables. The chi-square test was used to compare BP control between groups. A P- value < 0.05 was considered statistically significant. All the statistical analyses were performed with IBM SPSS Statistics version 29. Results Population characteristics A total of 1,610 registered patients were enrolled, consisting of 809 new cases (male: female ratio of 1.24:1) and 801 previous cases (male: female ratio of 1:2.05). All patients adhered to the study protocol. The cohort was predominantly Buddhist. The main occupation was outdoor work, primarily farming, with some individuals working their own land and others being hired laborers. Women primarily served as house wives, and were responsible for childcare, parental care, and cooking. The local Thai culinary tradition, which flavours being salted with hot chiles, spicy, some dishes added sour, and sweet, likely contributed to a high-salt diet within the households. No participant under 16 years of age. Table 1 Characteristics of hypertension in new and previous cases registered between 2012 and 2018 Category New Cases (n=809) Previous Cases (n=801) Men (%) 55.4 32.8 Mean age(years) 60.4 + 12.7 64.3 + 11.9 Classification of Hypertension (HT)by Severity(mmHg) (%) Grade1HT (systolic140-159 and/or diastolic 90-99) 66.6 36.8 Grade2HT (systolic 160- 179 and/or diastolic100-109) 23.1 15.6 Grade3HT (systolic > 180 and/or diastolic > 110) 6.8 5.4 Controlled HT (systolic <140 and diastolic 140 and diastolic<90) 54.3 34.1 Isolated Diastolic Hypertension (IDH) (systolic 90) 3.7 3.8 Systo-Diastolic Hypertension (SDH) (systolic > 140and diastolic > 90) 38.6 20.0 *New patients received antihypertensive treatment before registration in that year. In 66.6% (n=539) of the patients, approximately 2/3 of the 809 new cases had grade 1 HT (Table 1). The highest number of new cases was observed in the 50 - 59 years age group (n=226, 27.9%), followed closely by the 40 – 49 years age group (n=222, 27.4%). These two decades included 448 patients, accounting for more than 50% of the total new cases, and 52.4% (n=98 from 187) had grade 2 HT, especially 65.5% (n=36 from 55) with grade 3 HT (Supplemental Appendix Table 1A). These groups need more awareness of antihypertensive treatment to control BP, and prevent serious complications from uncontrolled hypertension. The highest number of previous cases was observed in the 50 – 59 years age group (n= 222, 27.7%) (Supplemental Appendix Table 2A). Isolated systolic hypertension (ISH) was identified in 54.3% (n=439), of the 809 new cases across the entire cohort. In total, 54.3%(n=439) were age 15-29 years to 90-99 years from both genders, and 5.6% (45 cases) had a DBP <70. (Supplemental Appendix Table 3A). Table 2 Some socioeconomic and risk factors for hypertension in new and previous cases. Category New Cases (%) Previous Cases (%) Socioeconomic/Lifestyle (%) Low Income ( < 120,000 baht/year) 86.6 92.8 Low Education ( 25) [13] 43.6 48.4 Positive Family History (direct relatives) of Hypertension 39.4 38.1 direct relatives: male = father, brothers (the same parents), or sons (if his mother has no history of hypertension); female = mother, sisters (the same parents), or daughters (if her father has no history of hypertension); BMI= body mass index; [13] Thai Guideline for Prevention and Treatment of Obesity, 2010 Department of Medical Services, Ministry of Public Health, Thailand. Both the new and previous cases had the same low income, low education and one-third positive direct relatives’ family history of hypertension (Table 2). Previous cases demonstrated the effective counselling for lifestyle modifications which caused a decrease in the consumption of salt, alcohol, and smoking compared with new cases, except for obesity (Table 2). A positive direct relatives’ family history of hypertension was similar between new cases (39.4%) and previous cases (38.1%). Further analysis (Supplemental Appendix Table 4A) revealed that a positive history from female direct relatives was more commonly reported than from male direct relatives across both the new and previous cases (overall average: 23.2% vs. 8.7%). In the cohort, at least one-third of both new and previous cases reported a positive family history of hypertension (with 131 cases having an unknown history) (Supplemental Appendix Table 4A). An analysis of the combination of new and previous cases (n=1,479), revealed a significant difference in the rate of positive direct relatives’ family history between sexes: 34.2% of men (n=678) reported a positive history compared with 42.7 % of women (n=801) (p=0.0009) (Table 3). Table 3 The significance of a positive direct relative family history of hypertension in combination with new and previous cases in Lumsone-thi District. Category Combination of Direct relatives Family history of Hypertension in New and Previous Cases Direct relative family history of Hypertension Result Men (%) Women (%) p-value Negative 446 (65.8) 459 (57.3) 0.0009 Positive 232 (34.2) 342 (42.7) (n=678) (n=801) Direct relatives, Male: father, brothers (same parents) and sons (if his mother had no history of hypertension), Female: mother, sisters (same parents) and daughters (if her father had no history of hypertension). There were 131patients whose family history of hypertension was not known: new patients =15, previous patients =116). Hypertension Prevalence and Incidence Hypertension prevalence There were 1,802 registered hypertension cases between 2012 and 2018 in this cohort; 979 new cases with 809 and 170 cases with and without protocols, respectively; and 823 previous cases with 801 and 22 cases with and without protocols, respectively. (Tables 1A, 2A, 5A and 6A.) Prevalence of hypertension in those aged > 40 years = 18.3%; (in those aged > 30 years =15.4%) The annual incidence of hypertension There were 598 new cases registered in 2013 and 2018 (6 years) with the 510 protocol and 88 cases without the protocol. The annual incidence of hypertension starts in the 15-29 years (y) age group for men (M)=0.161 and women (W)=0.064, (Figure 1) with a higher incidence in men than in women every decade until the 80-89 y age group. The highest annual incidence of hypertension in men was 1.404 in the 60-69 y age group; in women, it was 1.141 in the same age group of men. The average annual incidence of hypertension in those aged > 40 years was 1.023 (and that in those aged > 30 years was 0.877). (Supplemental Appendix Table 5A, and 6A.) Blood pressure control There were 504 newly diagnosed patients and 188 previously diagnosed patients audited from 1 September to 30 November 2019. Both groups were representative of their total populations (p > 0.5). There were 83.3% (81.0% and 86.4% of men and women, respectively) with high blood pressure control (BP< 140/90) in the new case group, which was better than the 77.7% (77.2% and 77.9% of men and women, respectively) in the previous case group (p-value =0.024). Table 4. Comparison of blood pressure treatment results between new cases (new case fraction group) and previous cases (previous case fraction group) in 2019. Comparison of blood pressure treatment results of new and previous cases fraction groups Blood pressure (Grade) new cases (%) previous cases (%) p-value 0.024 Men Women Total Men Women Total Control (<140/90) 230 (81.0) 190 (86.4) 420 (83.3) 44(77.2) 102(77.9) 146 (77.7) Grade1 Hypertension 51(18.0) 30 (13.6) 81(16.1) 12(21.1) 24(18.3) 36 (19.2) Grade2 Hypertension 3 (1.1) 0 3(0.6) 1(1.8) 5(3.8) 6(3.2) Grade3 Hypertension 0 0 0 0 0 0 Total 284 220 504 57 131 188 The baseline blood pressures of both groups are shown in Supplemental Appendix Table 7 A. The results of hypertension treatment for both new and previous case audits were divided into 4 groups (Supplemental Appendix Table 8A). Group 1: Blood pressure in the control group (less than 140/90), with 83.3% in the new cases and 77.7% in the previous cases. Group 2: better, at least one grade of HT severity was lower than the BP at registration but not in the control, with 6.2% in the new cases and 4.3% in the previous cases. Group 3: the same grade as at initial registration, with 9.7% in the new cases and 9.6% in the previous cases. Group 4: worse (treatment failure), at least one grade of HT severity was higher than the BP at registration, with 0.8% (n=4) in the new cases and 8.5% (n=16) in the previous cases. We further analyzed a total of 20 cases (in Group 4), and the finding factors for both the new and the previous case combinations (Supplemental Appendix Table 9A) were as follows: A) Low education level in all 20 patients. B) More than two-thirds of the patients had a low income; and were overweight/obese. C) One-half or more of the patients were in the 30-59 years age group (men=3, women=8) (the remaining patients were in the 60-89 years age group); and had a positive direct relative family history of hypertension. D) More than one-fourth of the patients liked salt taste; and consumed alcohol. Each case had at least two factors, as mentioned above. Mortality (Blood pressure documented from registrations) · New cases (n=27): 6 HT-related deaths [2 IDH strokes, 3 renal failures in Grade 2 HT, and 1 circulatory failure (nonspecific) in Grade 2 HT]. :15 HT-unrelated (9 cancers, 3 sepsis, 1 accident, 1 violence, 1 suicide). : 6 unknown causes; age > 70 years =5, age< 60y =1 · Previous cases (n=56): 3 HT-related deaths [1 HF, 1 circulatory failure (nonspecific) both in Grade 3 HT, 1 renal failure in Grade 2 HT]. :6 HT-unrelated [ 2 accidents, 2 cancers, 1 sepsis, and 1 suicide]. : 47 unknown causes; age > 70y =33, age < 70y =14, Discussion · This 7-year newly diagnosed hypertension (new cases) study demonstrated that a physician-led, integrated community model significantly improved HT control in rural Thailand. The control rates among new cases (83.3%) (Table 4) are dramatically higher than both the reported Thai national average (22.7% in 2019−2020) [5] and the global average (approximately 21%) [14]. Accurate BP measurement of both arms with physician confirmation of HT and structured counselling have led to increased awareness and trust, which is essential in overcoming patient denial of asymptomatic hypertension the "silent killer" [3]. Amlodipine, a calcium channel blocker (CCB), was prescribed if there was no contraindication, because of its potent, long-acting 24 hours, wide therapeutic range, less adverse drug reaction and low cost. This approach, alongside intensive lifestyle modifications, yielded high control, particularly in Grade 1 HT, which comprised two-thirds of the new cases. Enalapril, an angiotensin converting enzyme inhibitor (ACEI), would be added if BP was not controlled or substituted in those with comorbid diabetes; thiazide diuretics, atenolol and prazosin were used in complex cases, resulting in no grade 3 HT patients being detected from the audit. LHCVs, who lived in the same village of Pts, check the BP of Pts as scheduled and recorded, bringing nurse-led medications from LHCH to their homes, hanging at the fence doors of Pts who had mobility problems, and working outside their villages. All Thai Pts got free management from Universal health coverage and primary care, Thailand [6]. These works achieved high hypertension control rates, resulting in fewer strokes, fewer heart attacks, and longer healthier lives [14]. · Previously diagnosed hypertension patients (previous cases) achieved a 77.7% BP control rate, which was higher than their control status at registration (42.2%) and superior to the 64.1% adherence rate reported in a 2021 clinical audit of Thai hospitals [15]. This improvement suggests that these previous cases received the same management as new cases from LHCH nurses, who could consult HTT physician for their complex cases; however, these Pts still had lower control rates than new cases did (77.7% vs. 83.3%), reflecting therapeutic inertia and long-term adherence challenges (Supplemental Appendix Table 10A). · Worsening in blood pressure control (treatment failure) means that at least one grade of HT severity is higher than the BP at registration. There were 20 cases (4 from new cases and 16 from previous cases) included in this audit. The risk factors were low education in all 20 cases; more than two-thirds from low income, overweight/obese; one-half or more from the 30-59 years age group, (men=3; women=8), positive direct relatives’ family history of hypertension; and more than one-fourth from liking salt taste, alcohol consumption (Supplemental Appendix Tables 8A and 9A). These findings are the same as those of other reports of uncontrolled HT [7,8,9]. We offer ways to solve these complex problems: counselling more health education, especially with less salt intake, quitting alcohol consumption to save money, and basic exercise with symptoms limited (e.g., walking)150 minutes/week to lose weight [16] and being strong enough for a greater workload. Patients in the 30-59-year-old age group (4 from new cases) with limited income often experience stress, are anxious from more respondents, have more children and hormone changes. · Isolated systolic hypertension (ISH) isfound in more than half of new cases, which is consistent with age-related vascular changes [9, 17]. A subgroup (5.6%) had ISH with a DBP <70, complicating BP control efforts and requiring careful management to avoid adverse effects from further lowering the initial DBP<70 [18]. Grade 1 HT in young adults ( < 40 years) had an ISH rate of 44.3%; this may represent early-stage HT. These patients are considered to have lower rates of atherosclerosis and CVD events than patients with systo-diastolic HT and IDH[17]. · Isolated diastolic hypertension (IDH) , although rare (3.7%), is clinically significant, with two stroke-related deaths, which is consistent with previous evidence linking IDH to cardiovascular risk [11, 17]. · The prevalence of hypertension in thoseaged > 40 years was 18.3% in a real rural, is lower than the Thai national average of 25.7% in 2019-2020 with the inclusion of urban areas (34.1%); a multistage sampling design [5]; and other variance likely attributed to the voluntary home screening methodology used in this study. · The annual average (from 2013-2018) incidence of hypertension was 1.023% in those aged > 40 years; it increased with age, and was highest in those aged 60-69 years in both sexes, (men = 1.404, women =1.141), and then gradually decreased until the 80-89 years were reached (Figure 1) (Supplemental Appendix Table 6A); these numbers might be lower than the real incidence because of voluntary population screening compared with the whole district population. This is likely the first hypertension incidence report in rural areas from the English literature. · This program highlights the feasibility of integrating LHCVs, LHCH nurses, and the physician into a community-based HT model. Once patients achieve BP control, nurse-led follow-up with longer durations and prescription refills minimizes physician, LHCH and even LHCV workloads, while maintaining safety. Conclusion Physician-led community screening and management improved hypertension control to levels above national and global averages. Accurate BP measurements of both arms were performed, and the physician confirmed high blood pressure to increase awareness and acceptance of hypertension with free of charge management, even in asymptomatic patients. Patient life-style modification counselling and timely treatment initiation are crucial to prevent complications. This model may be adapted to other rural settings in low- and middle-income countries. Limitations · This research was performed in voluntary populations; the authors could not collect all HT cases in the district. · This study was conducted in Lumsone-thi District, with LHC providers performing better in life-style counselling for DM, and HT in Lopburi Province; the results may not be generalizable to all rural Thai settings. · BP control assessment in 2019 excluded patients with medication changes in the prior three months to avoid widely BP variation. · The spread of COVID-19 led to a heavy workload for local health care personnel, and local health care volunteers were associated with unfinished audits. · Some causes of mortality in previous cases are unknown, aging. Abbreviations ACEI Angiotensin converting enzyme inhibitor BP Blood pressure CCB Calcium channel blocker DBP Diastolic blood pressure DM Diabetes mellitus ECG Electrocardiogram ESH European Society of Hypertension Gr Grade HF Heart failure HTTP Hypertension team with a physician HT Hypertension IDH Isolated diastolic hypertension ISH Isolated systolic hypertension JNC 7 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and. Treatment of high blood pressure LHCH Local health care hospital LHCV Local health care volunteer M Men MI Myocardial infarction Pt Patient SBP Systolic blood pressure W Women Declarations Supplementary Information In Supplemental Appendix. Acknowledgements We thank the Thai Hypertension Society for funding support, the Local Health Care Provider staff, including the volunteer staff of Lumsone-thi Health Care District, the director of Lumsone-thi Hospital and staff, and all the community participants. Author contributions All authors read, discussed and approved the final manuscript. Funding The Thai Hypertension Society. Data availability There are 7 raw datasets are available in Supplemental File; and for reasonable request to the corresponding author; and 10 Supplemental Tables in the Supplemental Appendix. Ethic Ethical approval was granted by the Institutional Review Board of Lopburi Province in 2016 (Research Code Number KNH 013/2559). No participant under 16 years of age. No consent to participate obtained. The study was conducted from 1 January 2012 to 30 September 2018, and was funded by the Thai Hypertension Society with ethical approval in 2016 (Code: KNH 013/2559). As a non-invasive, minimal-risk study-with risks no greater than those of daily life. The participant consent was unnecessary under national regulation at that time. The consent for participants was waived. 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Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. J hypertens 2018; 36:1954-2041 and Eur Heart J 2018; 39:3021-3104. James P, Oparil S, Carter B, Cushman W, Dennison-Himmelfarb C, Handler J, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Report from the Panel Members Appointed to the Eight Joint National Committee (JNC 8). JAMA.doi:10.100/jama2013.284427 Thai Guideline for Prevention and Treatment of Obesity,2010 Department of Medical Services, Ministry of Public Health, Thailand WHO. Global report on hypertension: the race against a silent killer. Geneva, Switzerland: World Health Organization; 2023, p1-276 Angkurawaranon C, Pinyopornpanish K, Srivanichakorn S, Sanchaisuriya P, Thepthien B, Tooprakai D, et al. Clinical audit of adherence to hypertension treatment guideline and control rate in hospitals of different sizes in Thailand. J.Clin Hypertens 2021; (4):702 -12 Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEnglJMed 2002; 346:393-403. McEvoy J, McCarthy C, Bruno R, Brouwers S, Canavan M, Ceconi C, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J . 2024; 45:3912-4108. Mancia G, Kreutz R, Brunstrom M, Burnier M, Grassi G, Januszewicz A, et al.2023 ESH Guidelines for the management of arterial hypertension. J. Hypertens ():10.1097/HJH.0000000000003480, June 21,2023. Additional Declarations No competing interests reported. Supplementary Files Lumsonthiregistry2012WilaiRawDataforBMC1.xls DataLamsonthi2013registryRawDataforBMC.xls DataLamsonthi2014RawDataforBMC.xls Lumsonreg2015RawDataforBMC.xls dataLumson20164RawDataforBMC.xls Lumsonthi2017RawDataforBMC.xls LumsonRegis20185RawDataforBMC.xlsx SUPPLEMENTALAPPENDIX.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 03 May, 2026 Reviews received at journal 03 May, 2026 Reviews received at journal 02 May, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviews received at journal 23 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviews received at journal 22 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviews received at journal 16 Apr, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor assigned by journal 11 Feb, 2026 Editor invited by journal 11 Feb, 2026 Submission checks completed at journal 05 Feb, 2026 First submitted to journal 05 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Puavilai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYDACZuYGhgQ4owLKwK+FEaYFxDgDZeAHcAVABmMbigh2YHCcsfHDwx2H5SGMebXR/O1ALT8qtuHWcpixWSLxzGHDDWDGtuO5Mw4zNjD2nLmNU4sZUIFEYtthxpnNIMa2Y7kNQBFmxja8Wpp/ALXYA7UAGXOO5c4nQksbyJbEfmYQo6EmdwMhLfZALRaJZ9KTQVosEo4dyN0I1HIQn18k+w8fvvlzh7VtGz+Q8aOmLnfe+cMHH/yowK0FDJAi4jCYPIBfPaqWOoKKR8EoGAWjYOQBAGYJYZm9CfqDAAAAAElFTkSuQmCC","orcid":"","institution":"Rajavithi Hospital","correspondingAuthor":true,"prefix":"","firstName":"Wilai","middleName":"","lastName":"Puavilai","suffix":""},{"id":628048155,"identity":"cc56994b-9690-4846-b5ac-45748dba8735","order_by":1,"name":"Santi Lapbenjakul","email":"","orcid":"","institution":"Tarwoong Hospital","correspondingAuthor":false,"prefix":"","firstName":"Santi","middleName":"","lastName":"Lapbenjakul","suffix":""},{"id":628048160,"identity":"4396133e-85af-4a2e-8200-89931ff10e35","order_by":2,"name":"Kasem 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incidence of hypertension by age and sex (2013-2018) from Lumsone-thi District. \u003c/strong\u003e(M=Men, W=Women)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8568478/v1/579a06f86ced1d3e99788c97.png"},{"id":107709441,"identity":"6ee03c96-949e-4d3a-9400-df08c28c7391","added_by":"auto","created_at":"2026-04-24 09:35:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":469482,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8568478/v1/bd65748e-291a-46fb-b251-0924d730c31c.pdf"},{"id":107706269,"identity":"6510ba02-ffbe-4990-a613-2d8743a2ddd0","added_by":"auto","created_at":"2026-04-24 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09:17:52","extension":"xls","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":103936,"visible":true,"origin":"","legend":"","description":"","filename":"DataLamsonthi2014RawDataforBMC.xls","url":"https://assets-eu.researchsquare.com/files/rs-8568478/v1/e65c20eacab4d344ee3e592b.xls"},{"id":107707212,"identity":"02d0c03b-6201-464f-9a4d-c11a417b3758","added_by":"auto","created_at":"2026-04-24 09:19:49","extension":"xls","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":109568,"visible":true,"origin":"","legend":"","description":"","filename":"Lumsonreg2015RawDataforBMC.xls","url":"https://assets-eu.researchsquare.com/files/rs-8568478/v1/3b34a95db83a1829bef69e49.xls"},{"id":107706996,"identity":"da5de652-79a3-486f-ae6e-a225e3d87a97","added_by":"auto","created_at":"2026-04-24 09:19:13","extension":"xls","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":62976,"visible":true,"origin":"","legend":"","description":"","filename":"dataLumson20164RawDataforBMC.xls","url":"https://assets-eu.researchsquare.com/files/rs-8568478/v1/e892194b035a7947d60b79c2.xls"},{"id":107634617,"identity":"da724d11-d377-4168-9b55-cc67ab435e89","added_by":"auto","created_at":"2026-04-23 12:22:42","extension":"xls","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":147968,"visible":true,"origin":"","legend":"","description":"","filename":"Lumsonthi2017RawDataforBMC.xls","url":"https://assets-eu.researchsquare.com/files/rs-8568478/v1/a1a8aaf9ce128cbe5cca5945.xls"},{"id":107707654,"identity":"00a4ad09-0579-41b8-a415-19ad81c72b39","added_by":"auto","created_at":"2026-04-24 09:20:50","extension":"xlsx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":60547,"visible":true,"origin":"","legend":"","description":"","filename":"LumsonRegis20185RawDataforBMC.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-8568478/v1/f2e23431f06f5e01b246a399.xlsx"},{"id":107634619,"identity":"1f22a8a8-8580-4deb-8e54-acce1d67fcb8","added_by":"auto","created_at":"2026-04-23 12:22:43","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":44321,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTALAPPENDIX.docx","url":"https://assets-eu.researchsquare.com/files/rs-8568478/v1/203e4b9d7c7d51826f24ed23.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eHigh-Adherence Hypertension Control Achieved via a Physician-Led Community Model in Rural Thailand: A 7-Year Cohort Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eHypertension (HT) is a major global risk factor for cardiovascular disease, stroke, and chronic kidney disease [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is called a \u0026ldquo;silent killer\u0026rdquo; because it is frequently asymptomatic [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], resulting in low awareness and poor HT control until complications develop. Globally, only approximately 20% of patients with HT achieve BP control [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Thailand, national surveys reported controlled HT in 30% of cases in 2014, which decreased to 22.7% by 2019\u0026ndash;2020 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This decrease has persisted despite the implementation of Universal Health Coverage and Primary Care, in Thailand since 2002 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Factors contributing to low control rates, particularly in rural areas, include low income, low health awareness, lower educational attainment, male sex, current smoking, and alcohol consumption; some factors are related to issues such as the proper use of antihypertensive medication and comorbid diabetes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This study aimed to improve the BP control rate, and evaluate the prevalence and the incidence of HT in a rural Thai district by using a hypertension team with a physician-integrated community-based model.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was a voluntary community-based cohort study conducted in Lumsone-thi District, Lopburi Province, Central Thailand, between 1 January 2012 and 30 September 2018. The district is served by seven local health care hospitals (LHCHs) and one 30-bed community hospital. Ethical approval was granted by the Institutional Review Board of Lopburi Province in 2016 (Research Code Number KNH 013/2559).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and screening \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnnual home-based blood pressure (BP) screening was performed for residents aged ≥15 years by trained local health care volunteers (LHCVs), who were women from the same villages. Individuals with a BP of ≥ 140/90 mmHg and no prior antihypertensive treatment were referred to the Hypertension Team with Physician (HTTP). This integrated team was composed of LHCVs, LHCH nurses, two trained registered nurses, and a physician (cardiologist).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBP measurements followed a standardized protocol:\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003ePosition:\u003c/strong\u003e Measured in both arms while the patient was in a seated position and with no legs crossed (or lying for bedridden patients).\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003ePreparation:\u003c/strong\u003e Patients rested quietly for at least five minutes, with an empty bladder. They were instructed to abstain from caffeine, alcohol, and smoking for 30 minutes prior to measurement.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eProcedure:\u003c/strong\u003e At least two readings per arm were taken via validated automatic devices (Omron, Japan), and two BP values usually vary within \u003cu\u003e\u0026lt;\u003c/u\u003e 10/5 of each arm; both arms’ BPs were recorded, and the higher arm's average BP was selected for diagnosis.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eThe criteria for the diagnosis of hypertension\u003c/strong\u003e followed the JNC7 criteria [10]. Newly diagnosed hypertension (new cases) was registered if the BP was \u003cu\u003e\u0026gt;\u003c/u\u003e 140/90 mmHg in either digit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManagement Protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNew patients who followed the protocol received the following management steps:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eBaseline assessment and counselling\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eAssessment:\u0026nbsp;\u003c/strong\u003eA protocol-driven history was taken, including body weight (in kilograms, with light clothing, no shoes), height (in meters), waist circumference (measured at the highest edge of the umbilicus (in centimeters), and an electrocardiogram (ECG) test.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eCounselling:\u0026nbsp;\u003c/strong\u003ePatients received detailed counselling on HT complications and lifestyle modifications, with a focus on smoking cessation, reduced alcohol intake, weight loss, salt restriction, exercise, and increased consumption of lean meats, vegetables, and low-sugar fruits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePhysician: clinical assessment and management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eClinical assessment:\u003c/strong\u003e Patients met with the physician in groups (separated by sex) for a brief clinical history of anginal pain and heart failure (HF). The physician interpreted the ECG, performed a basic physical examination, and reconfirmed the HT diagnosis.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003ePrescription:\u003c/strong\u003e Medicine was prescribed if indicated to control high BP and prevent serious outcomes such as stroke or myocardial infarction (MI). Amlodipine was the primary antihypertensive medication used, provided that there were no contraindications.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eReferral:\u003c/strong\u003e Complex cases were referred to Lumsone-thi Community Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFollow-up and Team Communication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eScheduled Tests:\u0026nbsp;\u003c/strong\u003eRoutineblood tests and urine examinations were scheduled subsequent to the initial assessment.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eNurse-Led Follow-up:\u0026nbsp;\u003c/strong\u003eForfollow-up of new cases, LHCH nurses consulted the Lumsone-thi Hospital physician for judgement on whether to initiate nurse-led follow-up, including prescription refills. Patients were scheduled to see the hospital physician later for review and/or follow-up.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eAccessibility:\u0026nbsp;\u003c/strong\u003eThe HT team and LHCH nurses maintained continuous mobile phone contact with the HTT physician / or hospital physician because consultation was convenient.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;There were 170 newly diagnosed hypertension patients (Pts) who received HT treatment and did not meet the HTTP in that year; these Pts were registered as new cases without a protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreviously diagnosed HT patients\u0026nbsp;\u003c/strong\u003ehad ahistory of hypertension treatment \u003cu\u003e\u0026gt;\u003c/u\u003e 1 year(s), continued their treatment, no team physician involvement except for providing ECG interpretation or consultation when requested, and these Pts were enrolled in protocols that were registered as previous cases. There were 22 previous cases without a protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Definitions and Categories\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were categorized on the basis of diagnosis status and completion of the study protocol:\u003c/p\u003e\n\u003cp\u003e1. \u003cstrong\u003eNew cases:\u0026nbsp;\u003c/strong\u003eNewly diagnosed with HT during screening or those who received HT treatment for the first time that year.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eWith Protocol:\u0026nbsp;\u003c/strong\u003eCompleted the full diagnostic and registration protocol (n=809 pts).\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eWithout Protocol:\u0026nbsp;\u003c/strong\u003eNewly diagnosed with HT, received treatment, and did not meet HTTP in that year (n=170 Pts).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePrevious cases:\u0026nbsp;\u003c/strong\u003ePatients who werepreviously diagnosed with HT with a history of hypertension treatment for \u003cu\u003e\u0026gt;\u003c/u\u003e 1 year (one calendar year), were enrolled in the protocols by the HTT; no team physician involvement except ECG interpretation; and consultation when requested.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eThe following protocol was used:\u0026nbsp;\u003c/strong\u003eenrolled in the protocols by HTT and whose ECG were interpreted by team physicians (n=801 pts).\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eWithout protocol:\u0026nbsp;\u003c/strong\u003eincomplete registration, and no ECG test (n=22 Pts).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBlood Pressure Control Audit\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective audit of BP control was conducted between 1 September and 30 November 2019, using patient records from outpatient department (OPD) folders. The audit included patients who had been on stable medication for at least three months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDefinition of Control:\u0026nbsp;\u003c/strong\u003eBP was defined as \u0026lt; 140/90 mmHg. On the basis of the 2018 ESC/ESH guidelines [11]. The JNC8 guidelines [12] were not used because the revised systolic targets for older adults, compared with JNC7 [10], would have complicated the consistent counting of controlled cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and Representation:\u003c/strong\u003e the subsequent, broader audit of all new and previous cases was disrupted by the COVID-19 pandemic. Consequently, only fractions of the cases were available for analysis. We compared 504 fractional new cases (284 men, 220 women) with 809 total new cases (448 men, 361 women). There was no significant difference in sex distribution between the sample and total population (p =0.73). Similarly, 188 fractional previous cases (57 men, 131 women) were compared with 801 total previous cases (263 men, 538 women), and no significant difference in sex distribution was detected (p=0.507). These results indicate that the fractional groups were representative of their respective total populations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic and clinical data are presented as frequencies, percentages for categorical variables, and means \u003cu\u003e+\u003c/u\u003e SDs for continuous variables. The chi-square test was used to compare BP control between groups. A P- value \u0026lt; 0.05 was considered statistically significant. All the statistical analyses were performed with IBM SPSS Statistics version 29.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePopulation characteristics \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 1,610 registered patients were enrolled, consisting of 809 new cases (male: female ratio of 1.24:1) and 801 previous cases (male: female ratio of 1:2.05). All patients adhered to the study protocol. The cohort was predominantly Buddhist. The main occupation was outdoor work, primarily farming, with some individuals working their own land and others being hired laborers. Women primarily served as house wives, and were responsible for childcare, parental care, and cooking. The local Thai culinary tradition, which flavours being salted with hot chiles, spicy, some dishes added sour, and sweet, likely contributed to a high-salt diet within the households. No participant under 16 years of age.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 Characteristics of hypertension in new and previous cases registered between 2012 and 2018\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNew Cases\u003c/strong\u003e (n=809)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious Cases\u003c/strong\u003e (n=801)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMen (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e55.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e32.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eMean age(years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e60.4 \u003cu\u003e+\u003c/u\u003e 12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e64.3 \u003cu\u003e+\u003c/u\u003e 11.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClassification of Hypertension (HT)by Severity(mmHg) (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eGrade1HT (systolic140-159 and/or diastolic 90-99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e66.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e36.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eGrade2HT (systolic 160- 179 and/or diastolic100-109)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e23.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e15.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eGrade3HT (systolic \u003cu\u003e\u0026gt;\u003c/u\u003e 180 and/or diastolic \u003cu\u003e\u0026gt;\u003c/u\u003e 110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eControlled HT (systolic \u0026lt;140 and diastolic \u0026lt;90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.5*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e42.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTypes of Hypertensions (mmHg) (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eIsolated Systolic Hypertension (ISH) (systolic \u003cu\u003e\u0026gt;\u003c/u\u003e 140 and diastolic\u0026lt;90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e54.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e34.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eIsolated Diastolic Hypertension (IDH) (systolic\u0026lt;140and diastolic \u003cu\u003e\u0026gt;\u003c/u\u003e90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eSysto-Diastolic Hypertension (SDH) (systolic \u003cu\u003e\u0026gt;\u003c/u\u003e140and diastolic\u003cu\u003e\u0026gt;\u003c/u\u003e 90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e38.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*New patients received antihypertensive treatment before registration in that year.\u003c/p\u003e\n\u003cp\u003eIn 66.6% (n=539) of the patients, approximately 2/3 of the 809 new cases had grade 1 HT (Table 1). The highest number of new cases was observed in the 50 - 59 years age group (n=226, 27.9%), followed closely by the 40 \u0026ndash; 49 years age group (n=222, 27.4%). These two decades included 448 patients, accounting for more than 50% of the total new cases, and 52.4% (n=98 from 187) had grade 2 HT, especially 65.5% (n=36 from 55) with grade 3 HT (Supplemental Appendix Table 1A). These groups need more awareness of antihypertensive treatment to control BP, and prevent serious complications from uncontrolled hypertension. The highest number of previous cases was observed in the 50 \u0026ndash; 59 years age group (n= 222, 27.7%) (Supplemental Appendix Table 2A).\u003c/p\u003e\n\u003cp\u003eIsolated systolic hypertension (ISH)\u0026nbsp;was identified in 54.3% (n=439), of the 809 new cases across the entire cohort. In total, 54.3%(n=439) were age 15-29 years to 90-99 years from both genders, and 5.6% (45 cases) had a DBP \u0026lt;70. (Supplemental Appendix Table 3A).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Some socioeconomic and risk factors for hypertension in new and previous cases.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNew Cases (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious Cases (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocioeconomic/Lifestyle (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eLow Income (\u003cu\u003e\u0026lt;\u003c/u\u003e 120,000 baht/year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e86.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e92.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eLow Education (\u003cu\u003e\u0026lt;\u003c/u\u003e grade 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e90.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e94.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eHigh Salt Taste\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e58.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e39.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eCurrent Alcohol Use (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e53.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e18.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eCurrent Smoker (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e32.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk Factors (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eObesity (BMI \u003cu\u003e\u0026gt;\u003c/u\u003e 25) [13]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e43.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e48.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePositive Family History (direct relatives) of Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e39.4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e38.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003edirect relatives: male = father, brothers (the same parents), or sons (if his mother has no history of hypertension); female = mother, sisters (the same parents), or daughters (if her father has no history of hypertension); BMI= body mass index; [13] Thai Guideline for Prevention and Treatment of Obesity, 2010 Department of Medical Services, Ministry of Public Health, Thailand.\u003c/p\u003e\n\u003cp\u003eBoth the new and previous cases had the same low income, low education and one-third positive direct relatives\u0026rsquo; family history of hypertension (Table 2).\u0026nbsp;Previous cases demonstrated the effective counselling for lifestyle modifications which caused a decrease in the consumption of salt, alcohol, and smoking compared with new cases, except for obesity (Table 2).\u003c/p\u003e\n\u003cp\u003eA positive direct relatives\u0026rsquo; family history of hypertension was similar between new cases (39.4%) and previous cases (38.1%). Further analysis (Supplemental Appendix Table 4A) revealed that a positive history from\u0026nbsp;female direct relatives\u0026nbsp;was more commonly reported than from male direct relatives across both the new and previous cases (overall average:\u0026nbsp;23.2%\u0026nbsp;vs.\u0026nbsp;8.7%). In the cohort, at least one-third of both new and previous cases reported a positive family history of hypertension (with 131 cases having an unknown history) (Supplemental Appendix Table 4A). An analysis of the combination of new and previous cases (n=1,479), revealed a significant difference in the rate of positive direct relatives\u0026rsquo; family history between sexes: 34.2% of men (n=678) reported a positive history compared with 42.7 % of women (n=801) (p=0.0009) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;The significance of a positive direct relative family history of hypertension in combination with new and previous cases in Lumsone-thi District.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003eCombination of Direct relatives Family history of Hypertension in New and Previous Cases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eDirect relative family history of Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eResult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eMen (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eWomen (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e446 (65.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e459 (57.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.0009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e232 (34.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e342 (42.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e(n=678)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e(n=801)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eDirect relatives, Male: father, brothers (same parents) and sons (if his mother had no history of hypertension), Female: mother, sisters (same parents) and daughters (if her father had no history of hypertension). There were 131patients whose family history of hypertension was not known: new patients =15, previous patients =116). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypertension Prevalence and\u0026nbsp;Incidence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypertension prevalence\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were 1,802 registered hypertension cases between 2012 and 2018 in this cohort; 979 new cases with 809 and 170 cases with and without protocols, respectively; and 823 previous cases with 801 and 22 cases with and without protocols, respectively. (Tables 1A, 2A, 5A and 6A.)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrevalence of hypertension in those aged \u003cu\u003e\u0026gt;\u003c/u\u003e 40 years = 18.3%; (in those aged \u003cu\u003e\u0026gt;\u003c/u\u003e 30 years =15.4%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; The annual incidence of hypertension\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were 598 new cases registered in 2013 and 2018 (6 years) with the 510 protocol and 88 cases without the protocol. The annual incidence of hypertension starts in the 15-29 years (y) age group for men (M)=0.161 and women (W)=0.064, (Figure 1) with a higher incidence in men than in women every decade until the 80-89 y age group. The highest annual incidence of hypertension in men was 1.404 in the 60-69 y age group; in women, it was 1.141 in the same age group of men. The average annual incidence of hypertension in those aged \u003cu\u003e\u0026gt;\u003c/u\u003e 40 years was 1.023 (and that in those aged \u003cu\u003e\u0026gt;\u003c/u\u003e 30 years was 0.877). (Supplemental Appendix Table 5A, and 6A.)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBlood pressure control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;There were 504 newly diagnosed patients and 188 previously diagnosed patients audited from 1 September to 30 November 2019. Both groups were representative of their total populations (p \u0026gt; 0.5).\u003c/p\u003e\n\u003cp\u003eThere were 83.3% (81.0% and 86.4% of men and women, respectively) with high blood pressure control (BP\u0026lt; 140/90) in the new case group, which was better than the 77.7% (77.2% and 77.9% of men and women, respectively) in the previous case group (p-value =0.024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e \u003cstrong\u003eComparison of blood pressure treatment results between new cases (new case fraction group) and previous cases (previous case fraction group) in 2019.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"105%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Comparison of blood pressure treatment results of new and previous cases fraction groups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eBlood pressure (Grade)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; new cases (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; previous cases (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003ep-value\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e0.024\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eControl (\u0026lt;140/90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e230 (81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e190 (86.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e420 (83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e44(77.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e102(77.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e146 (77.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eGrade1 Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e51(18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e30 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e81(16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e12(21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e24(18.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e36 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eGrade2 Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e3 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e3(0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1(1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e5(3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e6(3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eGrade3 Hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e504\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e188\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe baseline blood pressures of both groups are shown in Supplemental Appendix Table 7 A.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe results of hypertension treatment for both new and previous case audits\u0026nbsp;\u003c/strong\u003ewere divided into 4 groups (Supplemental Appendix Table 8A).\u003c/p\u003e\n\u003cp\u003eGroup 1: Blood pressure in the control group (less than 140/90), with 83.3% in the new cases and 77.7% in the previous cases.\u003c/p\u003e\n\u003cp\u003eGroup 2: better, at least one grade of HT severity was lower than the BP at registration but not in the control, with 6.2% in the new cases and 4.3% in the previous cases.\u003c/p\u003e\n\u003cp\u003eGroup 3: the same grade as at initial registration, with 9.7% in the new cases and 9.6% in the previous cases.\u003c/p\u003e\n\u003cp\u003eGroup 4: worse (treatment failure), at least one grade of HT severity was higher than the BP at registration, with 0.8% (n=4) in the new cases and 8.5% (n=16) in the previous cases.\u003c/p\u003e\n\u003cp\u003eWe further analyzed a total of 20 cases (in Group 4), and the finding factors for both the new and the previous case combinations (Supplemental Appendix Table 9A) were as follows:\u003c/p\u003e\n\u003cp\u003eA) Low education level in all 20 patients.\u003c/p\u003e\n\u003cp\u003eB) More than two-thirds of the patients had a low income; and were overweight/obese.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eC) One-half or more of the patients were in the 30-59 years age group (men=3, women=8) (the remaining patients were in the 60-89 years age group); and had a positive direct relative family history of hypertension.\u003c/p\u003e\n\u003cp\u003eD) More than one-fourth of the patients liked salt taste; and consumed alcohol.\u003c/p\u003e\n\u003cp\u003eEach case had at least two factors, as mentioned above.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMortality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(Blood pressure documented from registrations)\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003eNew cases (n=27): 6 HT-related deaths\u0026nbsp;\u003c/strong\u003e[2 IDH strokes, 3 renal failures in Grade 2 HT, and 1 circulatory failure (nonspecific) in Grade 2 HT].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;:15 HT-unrelated\u0026nbsp;\u003c/strong\u003e(9 cancers, 3 sepsis, 1 accident, 1 violence, 1 suicide).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;: 6 unknown causes;\u0026nbsp;\u003c/strong\u003eage\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e 70 years =5, age\u0026lt; 60y =1\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u003cstrong\u003ePrevious cases (n=56): 3 HT-related deaths\u0026nbsp;\u003c/strong\u003e[1 HF, 1 circulatory failure (nonspecific) both in Grade 3 HT, 1 renal failure in Grade 2 HT].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;:6 HT-unrelated\u0026nbsp;\u003c/strong\u003e[ 2 accidents, 2 cancers, 1 sepsis, and 1 suicide].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;: 47 unknown causes;\u0026nbsp;\u003c/strong\u003eage \u003cu\u003e\u0026gt;\u003c/u\u003e 70y =33, age \u003cu\u003e\u0026lt;\u003c/u\u003e 70y =14,\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\n\u003cp\u003e· \u003cstrong\u003eThis 7-year newly diagnosed hypertension (new cases) study\u003c/strong\u003e demonstrated that a physician-led, integrated community model significantly improved HT control in rural Thailand. The control rates among new cases (83.3%) (Table 4) are dramatically higher than both the reported Thai national average (22.7% in 2019−2020) [5] and the global average (approximately 21%) [14]. Accurate BP measurement of both arms with physician confirmation of HT and structured counselling have led to increased awareness and trust, which is essential in overcoming patient denial of asymptomatic hypertension the \"silent killer\" [3]. Amlodipine, a calcium channel blocker (CCB), was prescribed if there was no contraindication, because of its potent, long-acting 24 hours, wide therapeutic range, less adverse drug reaction and low cost. This approach, alongside intensive lifestyle modifications, yielded high control, particularly in Grade 1 HT, which comprised two-thirds of the new cases. Enalapril, an angiotensin converting enzyme inhibitor (ACEI), would be added if BP was not controlled or substituted in those with comorbid diabetes; thiazide diuretics, atenolol and prazosin were used in complex cases, resulting in no grade 3 HT patients being detected from the audit. LHCVs, who lived in the same village of Pts, check the BP of Pts as scheduled and recorded, bringing nurse-led medications from LHCH to their homes, hanging at the fence doors of Pts who had mobility problems, and working outside their villages. All Thai Pts got free management from Universal health coverage and primary care, Thailand [6]. \u0026nbsp;These works achieved high hypertension control rates, resulting in fewer strokes, fewer heart attacks, and longer healthier lives [14].\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003ePreviously diagnosed hypertension patients (previous cases)\u003c/strong\u003e achieved a 77.7% BP control rate, which was higher than their control status at registration (42.2%) and superior to the 64.1% adherence rate reported in a 2021 clinical audit of Thai hospitals [15]. This improvement suggests that these previous cases received the same management as new cases from LHCH nurses, who could consult HTT physician for their complex cases; however, these Pts still had lower control rates than new cases did (77.7% vs. 83.3%), reflecting therapeutic inertia and long-term adherence challenges (Supplemental Appendix Table 10A).\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eWorsening in blood pressure control (treatment failure)\u003c/strong\u003e means\u0026nbsp;that at least one grade of HT severity is higher than the BP at registration. There were 20 cases (4 from new cases and 16 from previous cases) included in this audit. The risk factors were low education in all 20 cases; more than two-thirds from low income, overweight/obese; one-half or more from the 30-59 years age group, (men=3; women=8), positive direct relatives’ family history of hypertension; and more than one-fourth from liking salt taste, alcohol consumption (Supplemental Appendix Tables 8A and 9A). These findings are the same as those of other reports of uncontrolled HT [7,8,9]. We offer ways to solve these complex problems: counselling more health education, especially with less salt intake, quitting alcohol consumption to save money, and basic exercise with symptoms limited (e.g., walking)150 minutes/week to lose weight [16] and being strong enough for a greater workload. Patients in the 30-59-year-old age group (4 from new cases) with limited income often experience stress, are anxious from more respondents, have more children and hormone changes.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eIsolated systolic hypertension (ISH)\u0026nbsp;\u003c/strong\u003eisfound in more than half of new cases, which is consistent with age-related vascular changes [9, 17]. A subgroup (5.6%) had ISH with a DBP \u0026lt;70, complicating BP control efforts and requiring careful management to avoid adverse effects from further lowering the initial DBP\u0026lt;70 [18]. Grade 1 HT in young adults (\u003cu\u003e\u0026lt;\u003c/u\u003e 40 years) had an ISH rate of 44.3%; this may represent early-stage HT. These patients are considered to have lower rates of atherosclerosis and CVD events than patients with systo-diastolic HT and IDH[17].\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eIsolated diastolic hypertension (IDH)\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e although rare (3.7%), is clinically significant, with two stroke-related deaths, which is consistent with previous evidence linking IDH to cardiovascular risk [11, 17].\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eThe prevalence of hypertension\u0026nbsp;\u003c/strong\u003ein thoseaged\u003cu\u003e\u0026gt;\u003c/u\u003e 40 years was 18.3% in a real rural, is lower than the Thai national average of 25.7% in 2019-2020 with the inclusion of urban areas (34.1%); a multistage sampling design [5];\u0026nbsp;and other variance likely attributed to the voluntary home screening methodology used in this study.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eThe annual average (from 2013-2018) incidence of hypertension\u0026nbsp;\u003c/strong\u003ewas 1.023% in those aged \u003cu\u003e\u0026gt;\u003c/u\u003e 40 years; it increased with age, and was highest in those aged 60-69 years in both sexes, (men = 1.404, women =1.141), and then gradually decreased until the 80-89 years were reached (Figure 1) (Supplemental Appendix Table 6A); these numbers might be lower than the real incidence because of voluntary population screening compared with \u0026nbsp; the whole district population. This is likely the first hypertension incidence report in rural areas from the English literature.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eThis program highlights the feasibility of integrating LHCVs, LHCH nurses, and the physician into a community-based HT model.\u003c/strong\u003e Once patients achieve BP control, nurse-led follow-up with longer durations and prescription refills minimizes physician, LHCH and even LHCV workloads, while maintaining safety.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003ePhysician-led community screening and management\u003c/strong\u003e improved hypertension control to levels above national and global averages. Accurate BP measurements of both arms were performed, and the physician confirmed high blood pressure to increase awareness and acceptance of hypertension with free of charge management, even in asymptomatic patients. Patient life-style modification counselling and timely treatment initiation are crucial to prevent complications. This model may be adapted to other rural settings in low- and middle-income countries.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot;\u0026nbsp; \u0026nbsp;\u0026nbsp;This research was performed in voluntary populations; the authors could not collect all HT cases in the district.\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u0026nbsp;This study was conducted in Lumsone-thi District, with LHC providers performing better in life-style counselling for DM, and HT in Lopburi Province; the results may not be generalizable to all rural Thai settings.\u003c/p\u003e\n\u003cp\u003e\u0026middot; BP control assessment in 2019 excluded patients with medication changes in the prior three months to avoid widely BP variation.\u003c/p\u003e\n\u003cp\u003e\u0026middot; The spread of COVID-19 led to a heavy workload for local health care personnel, and local health care volunteers were associated with unfinished audits.\u003c/p\u003e\n\u003cp\u003e\u0026middot; Some causes of mortality in previous cases are unknown, aging.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACEI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAngiotensin converting enzyme inhibitor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBlood pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCCB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCalcium channel blocker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDBP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiastolic blood pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eECG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eElectrocardiogram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEuropean Society of Hypertension\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGr\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGrade\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHeart failure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHTTP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHypertension team with a physician\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIsolated diastolic hypertension\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eISH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIsolated systolic hypertension\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJNC 7\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSeventh Report of the Joint National Committee on Prevention, Detection, Evaluation and. Treatment of high blood pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLHCH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLocal health care hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLHCV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLocal health care volunteer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMyocardial infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePt\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSBP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSystolic blood pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn Supplemental Appendix.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e Acknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the Thai Hypertension Society for funding support, the Local Health Care Provider staff, including the volunteer staff of Lumsone-thi Health Care District, the director of Lumsone-thi Hospital and staff, and all the community participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors read, discussed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Thai Hypertension Society.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e Data availability \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are 7 raw datasets are available in Supplemental File; and for reasonable request to the corresponding author; and 10 Supplemental Tables in the Supplemental Appendix.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e Ethic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Institutional Review Board of Lopburi Province in 2016 (Research Code Number KNH 013/2559).\u003c/p\u003e\n\u003cp\u003eNo participant under 16 years of age. No consent to participate obtained. \u003c/p\u003e\n\u003cp\u003eThe study was conducted from 1 January 2012 to 30 September 2018, and was funded by the Thai Hypertension Society with ethical approval in 2016 (Code: KNH 013/2559). As a non-invasive, minimal-risk study-with risks no greater than those of daily life. The participant consent was unnecessary under national regulation at that time.\u003c/p\u003e\n\u003cp\u003eThe consent for participants was waived. Given on 19 January 2026 by Piyadet Valeepitakdet, M.D., Chief of Lopburi Provincial Public Health Office. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMills KT, Bundy JD, Kelly TN, Reed JE, Kearney PM, Reynolds K, et al. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. \u003cem\u003eCirculation\u003c/em\u003e. 2016;134(6):441\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eWhelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Himmelfarb CD, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. \u003cem\u003eHypertension\u003c/em\u003e. 2018;71(6): e13\u0026ndash;115.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO) publication: A Global Brief on Hypertension: silent killer, global public health crisis: World Health Day 2013. World Health Organization (WHO) 2013. WHO/DCO/WHD/2013.2\u003c/li\u003e\n\u003cli\u003eZhou B, Carrillo-Larco RM, Danaei G, Riley LM, Paciorek CJ, Stevens GA, et al. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. \u003cem\u003eLancet\u003c/em\u003e. 2021;398(10304):957\u0026ndash;80.\u003c/li\u003e\n\u003cli\u003eAekplakorn W, Chariyalertsak S, Kessomboon P, Assanangkornchai S, Taneepanichskul S, Goldstein A, et al. Trends in hypertension prevalence, awareness, treatment, and control in the Thai population, 2004 to 2020. \u003cem\u003eBMC Public Health\u003c/em\u003e.2024; 24:3149.\u003c/li\u003e\n\u003cli\u003eSumriddetchkajorn K, Shimazaki K, Ono T, Kusaba T, Sato K, Kobayashi N. (2019) Universal health coverage and primary care, Thailand. \u003cem\u003eBulletin of the World Health Organization. \u003c/em\u003e2019, 97, (\u003cem\u003e6\u003c/em\u003e), 415-422.\u003c/li\u003e\n\u003cli\u003eAttaei MW, Khatib R, McKee M, Lear S, Dagenais G, Igumbor EU, et al. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data. \u003cem\u003eLancet Public Health\u003c/em\u003e. 2017;2(9): e411\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eGeldsetzer P, Manne-Goehler J, Marcus ME, Ebert C, Zhumadilov Z, Wesseh CS, et al. The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1.1 million adults. \u003cem\u003eLancet\u003c/em\u003e. 2019;394(10199):652\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eBeaney T, Schutte AE, Tomaszewski M, Ariti C, Burrell LM, Castillo RR, et al. May Measurement Month 2017: an analysis of blood pressure screening results worldwide. \u003cem\u003eLancet Glob Health\u003c/em\u003e. 2018;6(7): e736\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eChobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. \u003cem\u003eHypertension\u003c/em\u003e. 2003;42(6):1206\u0026ndash;1252.\u003c/li\u003e\n\u003cli\u003eWilliams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. \u003cem\u003eJ hypertens\u003c/em\u003e 2018; 36:1954-2041 and \u003cem\u003eEur Heart J\u003c/em\u003e 2018; 39:3021-3104.\u003c/li\u003e\n\u003cli\u003eJames P, Oparil S, Carter B, Cushman W, Dennison-Himmelfarb C, Handler J, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Report from the Panel Members Appointed to the Eight Joint National Committee (JNC 8). JAMA.doi:10.100/jama2013.284427\u003c/li\u003e\n\u003cli\u003eThai Guideline for Prevention and Treatment of Obesity,2010 Department of Medical Services, Ministry of Public Health, Thailand\u003c/li\u003e\n\u003cli\u003eWHO. Global report on hypertension: the race against a silent killer. Geneva, Switzerland: World Health Organization; 2023, p1-276\u003c/li\u003e\n\u003cli\u003eAngkurawaranon C, Pinyopornpanish K, Srivanichakorn S, Sanchaisuriya P, Thepthien B, Tooprakai D, et al. Clinical audit of adherence to hypertension treatment guideline and control rate in hospitals of different sizes in Thailand. \u003cem\u003eJ.Clin Hypertens\u003c/em\u003e 2021; (4):702 -12\u003c/li\u003e\n\u003cli\u003eDiabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. \u003cem\u003eNEnglJMed\u003c/em\u003e 2002; 346:393-403.\u003c/li\u003e\n\u003cli\u003eMcEvoy J, McCarthy C, Bruno R, Brouwers S, Canavan M, Ceconi C, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. \u003cem\u003eEur Heart J\u003c/em\u003e. 2024; 45:3912-4108.\u003c/li\u003e\n\u003cli\u003eMancia G, Kreutz R, Brunstrom M, Burnier M, Grassi G, Januszewicz A, et al.2023 ESH Guidelines for the management of arterial hypertension.\u003cem\u003e J. Hypertens \u003c/em\u003e():10.1097/HJH.0000000000003480, June 21,2023.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hypertension, Control, Cohort study, Prevalence, Annual Incidence","lastPublishedDoi":"10.21203/rs.3.rs-8568478/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8568478/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Hypertension (HT) is often asymptomatic, resulting in low awareness and poor blood pressure (BP) control. In Thailand, approximately 20–30% of HT patients achieve BP control. This study assessed the impact of a physician-led community HT model on the rate of BP control, with prevalence and incidence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This was a voluntary community-based cohort study. From 2012 - 2018, annual home BP screenings were conducted in Lumsone-thi District, for residents aged ≥15 years. Individuals with a BP ≥140/90 mmHg and no prior treatment, were referred to a hypertension team with physician to confirm diagnosis (BP \u003cu\u003e\u0026gt;\u003c/u\u003e 140/90), registration, management for new cases. Previously diagnosed HT patients (previous cases) continued their treatment, were registered,enrolled in protocols, with no team physician involvement except giving consultations when requested.BP control (\u0026lt;140/90) was retrospectively audited in late 2019 via the 2018 ESC/ESH Guideline. The audits were disrupted because of the COVID-19 pandemic; however, both fraction groups were sufficient to be representative of their total populations, with p-values \u0026gt; 0.5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong 809 new cases, 55.4% were men; 66.6% had grade 1 HT; 23.1% had grade 2; 6.8% had grade 3; and 3.5% had BP\u0026lt;140/90 from earlier treatment in that year. The prevalence of HT was 18.3% in those aged ≥40 years; the average annual incidence of HT was 1.023% in those aged ≥40; and the highest was in aged 60-69, men= 1.404%. BP control (\u0026lt;140/90) was greater in the new case fraction group (83.3%) than in the previous ones (77.7%, p = 0.024). There were 27 deaths in the new cases, and 56 in previous cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eA physician-led community model that integrates local health care hospitals and volunteers, achieved high hypertension control rates because of accurate BP measurement of both arms, physician reconfirmation of the diagnosis, leading to increased awareness, acceptance of asymptomatic hypertension and all free of charge management.\u003c/p\u003e","manuscriptTitle":"High-Adherence Hypertension Control Achieved via a Physician-Led Community Model in Rural Thailand: A 7-Year Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 12:22:37","doi":"10.21203/rs.3.rs-8568478/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-04T01:26:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T13:51:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T16:22:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182621050361085690832889336804934037919","date":"2026-04-24T05:57:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32339679367425476628585596598874643079","date":"2026-04-24T02:55:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T11:44:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85903541487301614806201795079858530577","date":"2026-04-23T11:39:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"238035635803415446100917068716406814420","date":"2026-04-23T01:01:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-22T22:22:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309435480988367737165955954486885759019","date":"2026-04-22T18:58:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-16T07:47:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310841566704300738475468228888934138368","date":"2026-04-16T07:05:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T12:22:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-11T20:56:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-11T12:36:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-05T23:45:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2026-02-05T23:40:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c59ed803-28c6-402d-b639-74599c8c4319","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-04T01:26:04+00:00","index":78,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T13:51:52+00:00","index":77,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T16:22:47+00:00","index":76,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T12:22:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 12:22:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8568478","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8568478","identity":"rs-8568478","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}