Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients

Abstract

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

Implementation of a community‐based hypertension control program in Matanzas, Cuba

“…In Canada, a hypertension control program focused on highly standardized and simplified education to primary care was associated with an increase in hypertension control from approximately 13% to 66% over about 6 years . However, there are few successful hypertension control programs in LMIC . In Yaroslavl, Russia (middle‐income country), a focused hypertension control program increased hypertension control from 17% to 33% over 4 years .…”

“…This case study is, in part, relevant because even in the context of a highly accessible and well‐organized health system, significant improvement can occur if a systematic and standardized approach for hypertension control is applied. In research settings, various aspects of the HEARTS recommended intervention have been successfully tested in LMIC . The Cuban experience had many learnings that may help other countries adopt the HEARTS interventions.…”

“…Raised blood pressure is one of the top global risks for death and disability estimated to have caused over 10 million deaths (~18% of all deaths) and over 200 million years of disability‐adjusted life years (DALYs, ~9% of total DALYs) in 2017 . There is a disproportionate burden of disease from hypertension in low‐ to middle‐income countries (LMICs); however, there are few models in LMIC of how to enhance hypertension control at a population level . Improving the control of hypertension is a major global health care goal, especially in LMICs .…”

“…1 There is a disproportionate burden of disease from hypertension in low-to middle-income countries (LMICs) 1,2 ; however, there are few models in LMIC of how to enhance hypertension control at a population level. 2,3 Improving the control of hypertension is a major global health care goal, especially in LMICs. 4,5 Thus, a greater effort, including the inclusion of implementation science, is required to examine how to best improve population blood pressure control.…”

The Imperative for Patient-Centered Clinical Decision Support

“…The PCCDS can be used to notify the provider about any out-of-range value(s) and provide support for further action and discussion by the patient and provider about the readings and associated treatment(s). In this way, the PCCDS intervention can facilitate patient-led self-management as well [25]. For hypertension, medication adherence is crucial and “patient empowerment can promote medication adherence, but it requires a co-constructed sense of control in the doctor-patient dyad” [26].…”