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

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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.

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