Multilevel, multicomponent strategies provide the greatest reductions in blood pressure (BP) for patients with hypertension, concludes a meta-analysis in Annals of Internal Medicine.
The researchers performed a systematic review and meta-analysis of randomized trials comparing the effectiveness of eight implementation strategies for BP control in adults with hypertension, compared to regular care. There were two patient-level strategies (home coaching and home BP monitoring), three provider-level strategies (provider training, audit and feedback, and electronic decision-support systems), and three multilevel strategies (multilevel strategy without team-based care and team-based care with medication titration by physicians or nonphysicians). The meta-analysis included 121 comparisons from 100 articles including 55,920 patients.
“Multilevel, multicomponent strategies were most effective for systolic BP reduction,” the researchers write.
Mean reductions achieved were 7.1 mm Hg with team-based care with medications titrated by nonphysician providers, 6.6 mm Hg with medications titrated by physicians, and 5.0 mm Hg with multilevel strategies without team-based care.
Analysis of patient-level strategies showed systolic BP reductions of 3.9 mm Hg with health coaching and 2.7 mm Hg with home BP monitoring. On analysis of provider-level strategies, there was a 3.7 mm Hg reduction with electronic decision-support systems, but no significant effect of provider training or audit and feedback. Analysis of diastolic BP noted similar effects.
Various implementation strategies have been shown to improve BP control in patients with hypertension, but there are few data on the comparative effectiveness of these approaches. The new analysis finds that multilevel, multicomponent strategies achieve the largest reductions in BP, followed by patient-level strategies. The authors call for wider dissemination and scale-up of these types of strategies in clinical practice and public health programs [Mills KT, et al. Comparative effectiveness of implementation strategies for blood pressure control in hypertensive patients: a systematic review and meta-analysis. Ann Intern Med 2017; DOI: 10.7326/M17-1805].