Multifaceted Strategies for Hypertension Control in Low-Income Patients
Clinical Snapshot
PICO Framework
| P — Population | Low-income patients aged ≥40 years with uncontrolled hypertension attending federally qualified health centers in Louisiana and Mississippi (n=1272, mean age 58.8 years, 56.7% women, 63.4% Black, 75.9% unemployed, 73.4% with family income <$25,000/year) |
| I — Intervention | Multifaceted implementation strategy including team-based care, protocol-based intensive blood pressure management, audit and feedback, health coaching for lifestyle changes and medication adherence, and home blood pressure monitoring |
| C — Comparator | Enhanced usual care involving physician education about clinical guidelines for hypertension |
| O — Outcomes | Primary effectiveness: mean change in systolic blood pressure from baseline to 18 months. Primary implementation: adherence summary score (0-4 scale). Safety: serious adverse events |
Bottom Line
This large cluster randomised trial demonstrates that a comprehensive, multifaceted intervention significantly improves blood pressure control in low-income patients with uncontrolled hypertension. The 6.4 mm Hg additional reduction in systolic blood pressure achieved through team-based care, intensive protocols, health coaching, and home monitoring represents a clinically meaningful improvement that could translate to substantial cardiovascular risk reduction at the population level. The intervention's effectiveness in a vulnerable population with multiple social determinants of health challenges makes these findings particularly valuable for addressing health equity. However, implementation requires substantial healthcare system investment and reorganisation. The similar adverse event rates between groups provide reassurance about safety. While the study's design prevents blinding, the robust effect size and narrow confidence intervals support the intervention's effectiveness. Australian healthcare systems, particularly those serving disadvantaged populations, should consider adapting these strategies within existing team-based care frameworks and Primary Health Network initiatives.
Key Findings
P Value: P<0.001
Effect Size: Between-group difference of -6.4 mm Hg favouring intervention
Primary Outcome: Mean change in systolic blood pressure from baseline to 18 months: -15.5 mm Hg (intervention) vs -9.1 mm Hg (control)
Nnt Or Sensitivity: Adherence summary score difference: 0.7 points (95% CI: 0.6 to 0.8) favouring intervention
Confidence Interval: 95% CI: -9.0 to -3.8 mm Hg
Clinical Application
Requires significant healthcare system reorganisation including team-based care models, health coaching resources, and home monitoring equipment. May be challenging to implement in resource-constrained settings Highly relevant to Australian Primary Health Networks and Aboriginal Community Controlled Health Services. Aligns with RACGP guidelines emphasising team-based care. Implementation would require consideration of PBS subsidies for home monitoring devices and practice incentive payments for team-based care models Low-income patients with uncontrolled hypertension in community health settings, particularly relevant for Aboriginal and Torres Strait Islander communities and socioeconomically disadvantaged populations
Abstract
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.).
References
- 1.Mills, K. T., Krousel-Wood, M., Peacock, E. M., Chen, J., Allouch, F., Carreras, A. K., Geng, S., Cyprian, A., Davis, G., Fuqua, S. R., Gilliam, D., Greer, A., Mitchell, T., Gray-Winfrey, W., Williams, S., Wiltz, G. M., Winfrey, K. L., He, H., Whelton, P. K., & He, J. (2026). Multifaceted strategies for hypertension control in low-income patients. *New England Journal of Medicine*. https://doi.org/10.1056/NEJMoa2504068
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