BACKGROUND: Uncontrolled hypertension disproportionately affects populations that have substantial health disparities. Data regarding the effectiveness and implementation of multifaceted, team-based strategies for hypertension control among low-income patients are lacking.
METHODS: We randomly assigned federally qualified health center clinics in Louisiana and Mississippi to use either a multifaceted implementation strategy (intervention group) or enhanced usual care (control group) for hypertension control. The intervention included team-based care, protocol-based intensive blood-pressure management, blood-pressure audit and feedback, health coaching on lifestyle changes and medication adherence, and home blood-pressure monitoring. Enhanced usual care involved educating physicians about clinical guidelines for hypertension. The primary effectiveness outcome was the mean change in systolic blood pressure from baseline to 18 months. The primary implementation outcome was the adherence summary score (on a scale of 0 to 4, with higher scores indicating better adherence to blood-pressure management).
RESULTS: A total of 36 clinics underwent randomization. Among these clinics, we enrolled 1272 patients with uncontrolled hypertension who were 40 years of age or older; 642 were in the intervention group and 630 were in the control group. The mean age of the patients was 58.8 years, 56.7% were women, 63.4% were Black, 75.9% were unemployed, and 73.4% had a family income of less than $25,000 per year. At 18 months, the mean change from baseline in the systolic blood pressure was -15.5 mm Hg (95% confidence interval [CI], -17.4 to -13.6) in the intervention group and -9.1 mm Hg (95% CI, -11.0 to -7.2) in the control group (between-group difference, -6.4 mm Hg; 95% CI, -9.0 to -3.8; P<0.001). The mean adherence summary score over the 18-month follow-up period was 2.8 (95% CI, 2.7 to 2.9) in the intervention group and 2.1 (95% CI, 2.0 to 2.2) in the control group (between-group difference, 0.7 points; 95% CI, 0.6 to 0.8; P<0.001). Serious adverse events occurred in 20.9% of the patients in the intervention group and in 21.7% of those in the control group.
CONCLUSIONS: Among low-income patients with hypertension, a multifaceted, team-based implementation strategy resulted in a significantly greater reduction in systolic blood pressure than enhanced usual care. (Funded by the National Heart, Lung, and Blood Institute and others; IMPACTS-BP ClinicalTrials.gov number, NCT03483662.).
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
The multifaceted intervention achieved a clinically meaningful reduction in BP. It is not clear how such an intervention would be implemented and funded outside of a research context.
Physician rater
Nearly 75% of the patients in United States with hypertension are believed to have inadequate control, despite our having the medications to do so. In this study of an underserved population in Mississippi and Louisiana, an intensive process including monthly visits for 3 months followed by continued monthly if goals not achieved, using health coaches and phone calls. The trial achieved a drop of 6 points in systolic blood pressure over the 18 months. Visit attendance was generally below 60%; the trial screened 4300 but only enrolled 1200 and still lost 200 those to follow-up and imputed their data. Cost was $762 per participant. As a healthcare system, we are still designed around the patients coming to us. If we are going to make a difference, we need to go where they are, and ramp up public health measures.
Physician rater
Health disparities are increasingly recognized as important. This intervention showed a way to improve care for disadvantaged populations and should be widely implemented.
, McMaster University