Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis

Abstract

Background: The prevalence of hypertension is high and is increasing worldwide, whereas the proportion of controlled hypertension is low.

Purpose: To assess the comparative effectiveness of 8 implementation strategies for blood pressure (BP) control in adults with hypertension.

Data sources: Systematic searches of MEDLINE and Embase from inception to September 2017 with no language restrictions, supplemented with manual reference searches.

Study selection: Randomized controlled trials lasting at least 6 months comparing the effect of implementation strategies versus usual care on BP reduction in adults with hypertension.

Data extraction: Two investigators independently extracted data and assessed study quality.

Data synthesis: A total of 121 comparisons from 100 articles with 55 920 hypertensive patients were included. Multilevel, multicomponent strategies were most effective for systolic BP reduction, including team-based care with medication titration by a nonphysician (-7.1 mm Hg [95% CI, -8.9 to -5.2 mm Hg]), team-based care with medication titration by a physician (-6.2 mm Hg [CI, -8.1 to -4.2 mm Hg]), and multilevel strategies without team-based care (-5.0 mm Hg [CI, -8.0 to -2.0 mm Hg]). Patient-level strategies resulted in systolic BP changes of -3.9 mm Hg (CI, -5.4 to -2.3 mm Hg) for health coaching and -2.7 mm Hg (CI, -3.6 to -1.7 mm Hg) for home BP monitoring. Similar trends were seen for diastolic BP reduction.

Limitation: Sparse data from low- and middle-income countries; few trials of some implementation strategies, such as provider training; and possible publication bias.

Conclusion: Multilevel, multicomponent strategies, followed by patient-level strategies, are most effective for BP control in patients with hypertension and should be used to improve hypertension control.

Primary funding source: National Institutes of Health.

Figure 1

Flowchart of Study Selection

Figure 2. Adjusted Mean Net Reduction in Blood Pressure Associated with Implementation Strategies

Mean net reduction in systolic blood pressure (upper panel) and diastolic blood pressure (lower panel). Mean net reductions estimated using generalized estimating equations and adjusted for sex, age, baseline systolic (or diastolic) blood pressure, trial duration, type of control group, and all other intervention strategies. Boxes weighted by sample size.