Intensive multifaceted management may improve blood pressure control among low-income patients

1. In this cluster-randomized trial (IMPACTS-BP), patients with longstanding uncontrolled hypertension who underwent multimodal intervention had significantly greater decreases in systolic blood pressure compared to those who received usual care. 

2. Patients receiving team-based care also demonstrated greater medication adherence compared to those receiving standard care. 

Evidence Rating Level: 1 (Excellent)

Study Rundown: Uncontrolled hypertension is a leading preventable risk factor for cardiovascular disease worldwide. Previous studies have demonstrated that multifaceted strategies for controlling hypertension are generally more effective than a single modality, but data from resource-constrained primary care settings are lacking. This study, titled the IMPACTS-BP trial, was designed to assess the effect of a multifaceted, team-based strategy for blood pressure control among low-income patients at federally qualified health centers (FQHCs). Providers in the intervention group were instructed to utilize a step-wise protocol for hypertension treatment, and nurses and medical assistants were trained as health coaches to follow-up with patients on home blood pressure monitoring and medication adherence. At eighteen months, patients in the intervention group had significantly decreased average systolic blood pressure readings compared to patients in the control group. Further, patients in the intervention group had significantly increased medication adherence scores versus those in the control group. The rate of adverse events or emergency room visits was similar between groups. A strength of this study was the inclusion of a broad population representative of real-world conditions. One limitation was the infeasibility of blinding patients and providers to group assignment, although data collection was conducted by unaffiliated staff to mitigate this potential bias. Nonetheless, this study showed that implementation of a multifaceted team-based approach to uncontrolled hypertension was effective for decreasing blood pressure and improving medication adherence in underserved patients. 

Click to read the study in NEJM

Relevant Reading: A Randomized Trial of Intensive versus Standard Blood-Pressure Control

In-Depth [randomized controlled trial]: This cluster-randomized trial, titled IMPACTS-BP, aimed to evaluate the clinical effectiveness and implementation outcomes of a multifaceted, team-based strategy of controlling hypertension in low-income patients in FQHCs. A total of 36 FQHCs were randomized to either the intervention group or the control group. Eligible patients at these centers were older than 40 years and had a systolic blood pressure of at least 130 mm Hg if taking antihypertensive medications or at least 140 mm Hg if not taking medications. The intervention consisted of an algorithm adapted from the Systolic Blood Pressure Intervention Trial (SPRINT) for blood pressure management, along with scheduled follow ups and consultations with health coaches regarding lifestyle changes, medication adherence, and strategies to overcome barriers. The 1272 enrolled patients were demographically reflective of the FQHC patient population with uncontrolled hypertension. At 18 months, the mean change from baseline in systolic blood pressure was -15.5 mm Hg in the intervention group and -9.1 mm Hg in the control group (between-group difference, -6.4 mm Hg; 95% confidence interval [CI], -9.0 to -3.8; p<0.001). This difference remained significant after adjusting for demographic factors and comorbidities. The mean adherence summary score across visits was 2.8 in the intervention group and 2.1 in the control group (between-group difference, 0.7; 95% CI, 0.6 to 0.8; p<0.001). Serious adverse events occurred at the same rate in both groups. The average implementation cost per patient was $762. Overall, the IMPACTS-BP trial demonstrated that a multifaceted intervention was associated with improved blood pressure control and medication adherence among low-income patients receiving care in resource-constrained settings.

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