NEW ORLEANS, LA—In hypertensive patients, blood pressure (BP) control is best achieved through multilevel, multicomponent strategies that include physician- and nonphysician-led interventions, results of a comparative effectiveness analysis suggest.[1]
Despite strong evidence that antihypertensive drug therapy and lifestyle changes effectively lower high BP and subsequent morbidity and mortality from heart disease, hypertension control rates remain low worldwide, the authors note. Estimates are that BP goals are reached in only 25% to 40% of patients who receive antihypertensive therapy, with little improvement in the past 40 years.
The current analysis clearly demonstrates that “multicomponent strategies at health system, provider, and patient levels are essential for blood pressure control in patients with hypertension,” Dr Jiang He (Tulane University, New Orleans, LA) told theheart.org | Medscape Cardiology.
“Our study findings can be used for developing public health policy and programs for hypertension control,” he added, as well as to change clinical guidelines.
The study was published online December 26, 2017, in Annals of Internal Medicine.
The researchers did a meta-analysis to assess the comparative effectiveness of eight implementation strategies for BP control: health coaching; home BP monitoring; provider training, audit, and feedback; electronic decision-support system; multilevel strategy without team-based care; team-based care with physicians titrating medication; and team-based care with nonphysician providers titrating medication.
They reviewed randomized controlled trials lasting at least 6 months that compared the effect of these strategies vs usual care on BP reduction. They included a total of 121 comparisons from 100 articles with 55,920 hypertensive patients.
Multilevel, multicomponent strategies proved most effective in reducing systolic BP, including team-based care with medication titration by physicians and nonphysicians, and multilevel strategies without team-based care.
The patient-level strategies of health coaching and home BP monitoring were also effective and, when combined, may be a good alternative for BP control in settings where multilevel strategies are not feasible because of limited resources, the researchers say.
The provider-level strategies (training, audit, and feedback; electronic decision support) were the least effective. Trends were similar for diastolic BP reduction.
Table. Adjusted Mean Net Reduction in BP by Implementation Strategy
| Implementation Strategy | Net Change in Systolic BP (95% Confidence Interval) (mm Hg) |
|---|---|
| Team-based care with titration by nonphysician | –7.1 (–8.9 to –5.2) |
| Team-based care with titration by physician | –6.2 (–8.1 to –4.2) |
| Multilevel strategy without team-based care | –5.0 (–8.0 to –2.0) |
| Health coaching | –3.9 (–5.4 to –2.3) |
| Electronic decision-support system | –3.7 (–5.2 to –2.2) |
| Home BP monitoring | –2.7 (–3.6 to –1.7) |
| Provider training | –1.4 (–3.6 to 0.7) |
| Audit and feedback | –0.8 (–2.1 to 0.5) |
Limitations of the analysis include sparse data from low- and middle-income countries and the limited number of trials of some implementation strategies, such as provider training, as well as possible publication bias.
Time to Cede Control to Office Staff?
The coauthors of a linked editorial[2] say the reason BP control has not improved over the past 40 years likely has to do with the “swamp” that is everyday clinical practice, “where unreliable blood pressure measurement and polypharmacy with associated patient illness seem to challenge adherence at every turn and can create a complicit therapeutic nihilism between patients and health care providers.”
This new analysis highlights the superiority of nonphysician-led care, write Dr Liam Glynn (University of Limerick, Ireland) and Dr Richard McManus (University of Oxford, UK).
“We need to facilitate involvement of our nonphysician colleagues in helping us control our patients’ blood pressure, particularly because the most recent guidelines emphasize the importance of a team-based approach to care for all adults with hypertension. Yet, doing so will require ceding control, training nonphysician staff, and developing clear treatment algorithms,” they say.
“In the context of improved diagnosis and self-monitoring, better practice organization, adoption of team-based care as the norm, and technologies to facilitate care, we finally have the tools to rise to the challenge of improved blood pressure control. Only time will tell if we will meet that challenge after 40 years of trying,” they add.
The study was funded by the National Institutes of Health. The authors and editorial writers have disclosed no relevant financial relationships.
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