In the Journals

BP best controlled with multilevel strategy

A multilevel, multicomponent approach, including physician and nonphysician-led interventions, was more effective at reducing BP in patients with hypertension, compared with patient-level and provider-level strategies, according to findings published in Annals of Internal Medicine.

“The prevalence of hypertension is high and is increasing worldwide, whereas the proportion of controlled hypertension is low,” Katherine T. Mills, PhD, from Tulane University School of Public Health, and colleagues wrote.

Mills and colleagues conducted a systematic review and meta-analysis to investigate how effective several implementation strategies are in controlling BP in patients with hypertension compared with regular care. The researchers identified 100 randomized controlled trials including 121 comparisons and 55,920 patients with hypertension.

They separated the trials into eight implementation strategy categories based on the descriptions of the interventions. The categories included interventions that focused on health coaching, home BP monitoring, provider training, audit and feedback and electronic decision-support systems, as well as multilevel strategies, such as those without team-based care, team-based care with physicians titrating medications and team-based care with nonphysician providers titrating medications.

Data revealed that multilevel, multicomponent strategies led to the most reductions in systolic BP. Specifically, multilevel strategies that included team-based care with medication titration by a nonphysician reduced systolic BP by 7.1 mm Hg (95% CI, –8.9 to –5.2 mm Hg), team-based care with medication titration by a physician reduced systolic BP by 6.2 mm Hg (95% CI, –8.1 to –4.2 mm Hg) and those without team-based care reduced systolic BP by 5 mm Hg (95% CI, –8 to –2 mm Hg).

Patient level strategies also decreased systolic BP levels, with health coaching reducing systolic BP by 3.9 mm Hg (95% CI, –5.4 to –2.3 mm Hg) and home BP monitoring reducing systolic BP by 2.7 mm Hg (95% CI, –3.6 to –1.7 mm Hg).

The researchers noted that trends for diastolic BP reduction were similar.

“Multilevel, multicomponent implementation strategies with and without team-based care are most effective for BP control among patients with hypertension,” Mills and colleagues concluded. “Health coaching and home BP monitoring that target barriers at the patient level are also effective. These strategies should be disseminated and scaled up in clinical practices and public health programs to improve hypertension control in communities.”

In an accompanying editorial, Liam G. Glynn, MD, from the University of Limerick, Ireland, and Richard J. McManus, PhD, from the University of Oxford, England, wrote that the findings by Mills and colleagues are encouraging for primary care physicians and note that the results highlight the importance of involving nonphysicians in the care of patients with hypertension.

“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,” they wrote. “Only time will tell if we will meet that challenge after 40 years of trying.” – by Alaina Tedesco

Disclosure: Mills and Glynn report no relevant financial disclosures. McManus reports grants and personal fees from Omron. Please see study for all other authors’ relevant financial disclosures.

 

A multilevel, multicomponent approach, including physician and nonphysician-led interventions, was more effective at reducing BP in patients with hypertension, compared with patient-level and provider-level strategies, according to findings published in Annals of Internal Medicine.

“The prevalence of hypertension is high and is increasing worldwide, whereas the proportion of controlled hypertension is low,” Katherine T. Mills, PhD, from Tulane University School of Public Health, and colleagues wrote.

Mills and colleagues conducted a systematic review and meta-analysis to investigate how effective several implementation strategies are in controlling BP in patients with hypertension compared with regular care. The researchers identified 100 randomized controlled trials including 121 comparisons and 55,920 patients with hypertension.

They separated the trials into eight implementation strategy categories based on the descriptions of the interventions. The categories included interventions that focused on health coaching, home BP monitoring, provider training, audit and feedback and electronic decision-support systems, as well as multilevel strategies, such as those without team-based care, team-based care with physicians titrating medications and team-based care with nonphysician providers titrating medications.

Data revealed that multilevel, multicomponent strategies led to the most reductions in systolic BP. Specifically, multilevel strategies that included team-based care with medication titration by a nonphysician reduced systolic BP by 7.1 mm Hg (95% CI, –8.9 to –5.2 mm Hg), team-based care with medication titration by a physician reduced systolic BP by 6.2 mm Hg (95% CI, –8.1 to –4.2 mm Hg) and those without team-based care reduced systolic BP by 5 mm Hg (95% CI, –8 to –2 mm Hg).

Patient level strategies also decreased systolic BP levels, with health coaching reducing systolic BP by 3.9 mm Hg (95% CI, –5.4 to –2.3 mm Hg) and home BP monitoring reducing systolic BP by 2.7 mm Hg (95% CI, –3.6 to –1.7 mm Hg).

The researchers noted that trends for diastolic BP reduction were similar.

“Multilevel, multicomponent implementation strategies with and without team-based care are most effective for BP control among patients with hypertension,” Mills and colleagues concluded. “Health coaching and home BP monitoring that target barriers at the patient level are also effective. These strategies should be disseminated and scaled up in clinical practices and public health programs to improve hypertension control in communities.”

In an accompanying editorial, Liam G. Glynn, MD, from the University of Limerick, Ireland, and Richard J. McManus, PhD, from the University of Oxford, England, wrote that the findings by Mills and colleagues are encouraging for primary care physicians and note that the results highlight the importance of involving nonphysicians in the care of patients with hypertension.

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“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,” they wrote. “Only time will tell if we will meet that challenge after 40 years of trying.” – by Alaina Tedesco

Disclosure: Mills and Glynn report no relevant financial disclosures. McManus reports grants and personal fees from Omron. Please see study for all other authors’ relevant financial disclosures.