Multifaceted Intervention Controls BP in Low-income Hypertension Patients

A systematic, multipronged intervention can meaningfully reduce systolic blood pressure levels in low-income patients compared with usual care, according to results of the IMPACTS-BP trial.

Using a team-based approach, protocol-based intensive BP management and auditing, health coaching, and home BP monitoring among a population making less than $25,000 a year in Louisiana and Mississippi, researchers showed a -6.4 mm Hg greater drop in systolic BP compared with standard care after 18 months (95% CI -9.0 to -3.8; P < 0.001).

“Hypertension is a major public health priority due to its high prevalence and associated morbidity and mortality,” senior author Jiang He, MD, PhD (University of Texas Southwestern Medical Center O’Donnell School of Public Health, Dallas, TX), told TCTMD in an email. While almost half of US adults have hypertension, upwards of three-quarters do not have their BP under control, he continued. “Low-income populations experience higher prevalence and lower control rates, which [contribute] to health disparities.”

Recent data also show a widening gap between lower- and higher-income countries when it comes to hypertension’s growing burden worldwide.

The 6-mm Hg reduction identified here “has important clinical and public health significance,” He said, adding that such a decrease could translate into lower long-term risks of MACE, coronary heart disease, stroke, heart failure, and death.

“This study is really an important advance in terms of showing that intensive blood pressure, treatment as introduced by the SPRINT trial, can be feasibly implemented in usual primary care, including some of the most challenging primary-care settings to deliver care in,” Andrew E. Moran, MD, MPH (Columbia University Irving Medical Center, New York, NY), who was not involved in the trial, told TCTMD. “It’s really encouraging evidence.”

IMPACTS-BP Results

For the study, published online Wednesday in the New England Journal of Medicine, researchers led by Katherine T. Mills, PhD (Tulane University School of Public Health and Tropical Medicine, New Orleans, LA), enrolled 1,272 adults (mean age 58.8 years; 56.7% women) with uncontrolled hypertension who were being treated at one of 36 federally qualified health centers (FQHCs) in Louisiana and Mississippi between 2018 and 2022. Almost three-quarters (73.4%) of patients had a family annual income of less than $25,000.

In total, 642 were randomized to the intervention and 630 were assigned to usual care based on their clinic. By 18 months, the mean drop from baseline in systolic BP was 15.5 mm Hg in the intervention arm and 9.1 mm Hg among controls. More patients assigned to the intervention achieved a systolic BP of less than 120 mm Hg by 18 months than controls (21.8% vs 15.1%), and the gap widened when that threshold rose to less than 130 mm Hg (47.7% vs 36.4%).

Additionally, the primary implementation outcome of mean adherence summary score—which is scaled from 0 to 4, increasing with better adherence to BP management—was also higher among those treated with the systematic treatment paradigm (2.8 vs 2.1; P < 0.001).

Treatment intensification, home BP monitoring, and health education were more often reported in those randomized to clinics offering the team-based approach versus usual care. However, patient-reported adherence to antihypertensive medications was higher among controls. Satisfaction with antihypertensive medications as well as BP-related care was similar in both groups.

The rates of serious adverse events also were similar among the intervention group (20.9%) and controls (21.7%).

Not the Same as SPRINT

“We are very excited to see that this team-based, multifaceted strategy . . . works well for hypertension control in low-income patients receiving care from FQHCs,” He said, noting that it’s not possible to parse out which components of the intervention drove the most benefit. “This study was designed to test the effectiveness of this multifaceted strategy for hypertension control. Previous studies have shown that single-component strategies are not very effective.”

Another positive is that the approach is “effective, implementable, and scalable within health care systems,” he continued. “The biggest challenges include securing commitment from system leadership to a team-based care model and obtaining reimbursement for health coaching, home blood pressure monitoring, and blood pressure auditing and feedback. It is also critically important to make antihypertensive medications affordable and available.”

Moran noted that while the IMPACTS-BP study didn’t replicate quite the same systolic BP levels as were achieved in SPRINT, this is likely explained by the fact that it was based in clinical practice and not a pragmatic trial.

“The SPRINT trial was a landmark trial and it established using intensive goals of treating blood pressure in high-risk people, and it really at least changed the clinical guidelines, if not the clinical practice,” he said. Even so, there were questions of real-world generalizability, and that’s where a study like IMPACTS-BP provides value.

“The outcomes are really encouraging given all those limitations of the setting and the challenges that they faced,” Moran continued, adding that there are obvious differences between practice settings of the two trials that had nothing to do with patient income, including how systematically BP was measured and tracked, and how many outside distractions there were. Here, “providers were not encumbered by any external pressures or practice patterns. They just were given a protocol to follow and they did it. It’s much more experimental almost.”

Moran agreed that it would be “really hard to disentangle” which components of the intervention worked the best, adding that “it’s good to include as much as you can within what’s possible in a primary-care setting. That’s the point of this study. It shows that even in some of the more challenging environments in the US, [like] busy clinics attended by patients with a lot of social barriers and challenges, that the SPRINT protocol can be physical feasibly implemented.”

Government support is critical for the success of programs like these, he continued. “You have to have a regulatory environment in the state that allows all these different healthcare providers to operate at the top of their license and really extend their license to be able to do more and offload the tasks from the physician. That’s part of why this worked: the team-based care factor.”

Next, Moran would like to see more studies looking at new reimbursement benchmarks for this type of care protocol either through Medicare or the Veterans Administration. Also, he said, “we need more studies of how the home blood pressure monitoring can be used to pursue this intensive goal more efficiently.”

As for He, “I would like to see more research on scaling up effective implementation strategies for hypertension control in large healthcare systems, as well as in low-income populations,” he said.