Background The prevalence of hypertension is high and increasing worldwide while the proportion of controlled hypertension is low. Purpose To assess the comparative effectiveness of 8 implementation strategies for blood pressure (BP) control in adults with hypertension. Data Sources Systematic searches of MEDLINE and Embase from inception to September 2017 with no language restriction supplemented with manual reference searches. Study Selection Randomized controlled trials lasting at least 6 months comparing implementation strategies versus usual care on BP reduction in adults with hypertension. Data Extraction Two investigators independently extracted trial data. Trials were grouped by implementation strategy, and BP reduction effects were compared using multivariate-adjusted generalized estimating equations. A modified Cochrane Risk of Bias tool was used for trial quality assessment. Data Synthesis A total of 121 comparisons from 100 articles with 55,920 hypertensive patients were included. Multilevel, multicomponent strategies, such as team-based care with medication titration by non-physician [−7.1 mmHg (95% CI: −8.9, −5.2)], team-based care with medication titration by physician [−6.2 mmHg (−8.1, −4.2)], and multilevel strategies without team-based care [−5.0 mmHg (−8.0, −2.0)] were most effective for systolic BP reduction. Patient-level strategies also resulted in significant systolic BP reductions of −3.9 mmHg (−5.4, −2.3) for health coaching and −2.7 mmHg (−3.6, −1.7) for home BP monitoring. Similar trends were observed for diastolic BP reduction. Provider training was tested in few trials and resulted in non-significant BP reduction. Limitations Sparse data from low- and middle-income countries, few trials of some implementation strategies, and possible publication bias. Conclusions Multilevel, multicomponent strategies, followed by patient-level strategies, are most effective for BP control in patients with hypertension and ought to be used to improve hypertension control. Primary Funding Source US National Institutes of Health

No abstract

No abstract

Background and objectivesEndothelial dysfunction is common among patients with CKD. We tested the efficacy and safety of combination treatment with sodium nitrite and isoquercetin on biomarkers of endothelial dysfunction in patients with CKD.Design, setting, participants, & measurementsThis randomized, double-blind, placebo-controlled phase 2 pilot trial enrolled 70 patients with predialysis CKD. Thirty-five were randomly assigned to combination treatment with sodium nitrite (40 mg twice daily) and isoquercetin (225 mg once daily) for 12 weeks, and 35 were randomly assigned to placebo. The primary outcome was mean change in flow-mediated vasodilation over the 12-week intervention. Secondary and safety outcomes included biomarkers of endothelial dysfunction, inflammation, and oxidative stress as well as kidney function, methemoglobin, and adverse events. Intention-to-treat analysis was conducted.ResultsBaseline characteristics, including age, sex, race, cigarette smoking, history of hypertension and diabetes, use of renin-angiotensin system blockers, BP, fasting glucose, lipid profile, kidney function, urine albumin-creatinine ratio, and endothelial biomarkers, were comparable between groups. Over the 12-week intervention, flow-mediated vasodilation increased 1.1% (95% confidence interval, −0.1 to 2.3) in the treatment group and 0.3% (95% confidence interval, −0.9 to 1.5) in the placebo group, and net change was 0.8% (95% confidence interval, −0.9 to 2.5). In addition, changes in biomarkers of endothelial dysfunction (vascular adhesion molecule-1, intercellular adhesion molecule-1, E-selectin, vWf, endostatin, and asymmetric dimethylarginine), inflammation (TNF-α, IL-6, C-reactive protein, IL-1 receptor antagonist, and monocyte chemoattractant protein-1), and oxidative stress (oxidized LDL and nitrotyrosines) were not significantly different between the two groups. Furthermore, changes in eGFR, urine albumin-creatinine ratio, methemoglobin, and adverse events were not significantly different between groups.ConclusionsThis randomized phase 2 pilot trial suggests that combination treatment with sodium nitrite and isoquercetin did not significantly improve flow-mediated vasodilation or other endothelial function biomarkers but also did not increase adverse events compared with placebo among patients with CKD.Clinical Trial registry name and registration number:Nitrite, Isoquercetin, and Endothelial Dysfunction (NICE), NCT02552888

Introduction: Globally, only 13.8% of adults with hypertension have controlled blood pressure (BP). Effective strategies are needed to overcome barriers to BP control. The overall objective is to determine the comparative-effectiveness of implementation strategies to reduce BP in adults with hypertension. Methods: We searched Medline and Embase (through November 2015) for randomized controlled trials of implementation strategies targeting barriers to hypertension control compared to usual care. One hundred trials with 48,070 hypertensive participants met our eligibility criteria and were included in this analysis. These trials were grouped by intervention strategy, and the effects of the intervention on BP change were combined using random effects models. Results: Multi-component team-based care with and without non-physician providers titrating medications had the greatest reduction in systolic and diastolic BP. Health coaching, home BP monitoring, and a combination of the two also resulted in significant reductions in BP. Few studies of BP audit and feedback and clinical decision support systems were available, and they did not result in significant reductions in systolic BP. Provider training did not significantly reduce BP. Conclusions: Team-based collaborative care is the most effective strategy for BP control among patients with hypertension. In addition, health coaching and home BP monitoring are useful patient-level strategies for hypertension control. These strategies should be prioritized in future BP control efforts.

No abstract

Introduction: Globally, only 13.8% of hypertensive patients have their blood pressure (BP) controlled. Trials testing implementation strategies to overcome barriers to BP control have produced mixed results. Providers who deliver the intervention may play an important role in implementation strategy success. This meta-analysis aimed to determine which provider-led interventions are most effective for BP reduction. Methods: We searched Medline and Embase (through September 2017) for randomized controlled trials of various provider-led implementation strategies targeting barriers to hypertension control in hypertensive patients. Seventy-four trials with 22,180 hypertensive participants met our eligibility criteria and were included in this analysis. These trials were grouped by intervention provider, and the effects of the intervention on BP change were combined using random effects models. Results: Pharmacist-led health coaching and team-based care had the greatest reduction in systolic and diastolic BP. Nurse- and community health worker-led interventions also resulted in significant reductions in BP. Interventions led by multiple providers were less effective for BP reduction. Research staff-led interventions were also effective at reducing BP but questions of sustainability persist. Conclusions: Pharmacists are most effective for the delivery of implementation strategies for BP control among patients with hypertension. Nurse- and community health worker-led interventions were also effective for BP reduction. Pharmacist-, nurse- and community health worker-led interventions should be prioritized in future BP control efforts.