Katherine T. Mills, PhD; Katherine M. Obst, MS; Wei Shen, MS; Sandra Molina, MPH; Hui-Jie Zhang, MD, PhD; Hua He, PhD; Lisa A. Cooper, MD, MPH; Jiang He, MD, PhD
Acknowledgment: The authors thank Dr. Lawrence J. Fine for critically reviewing the manuscript and providing insightful comments for improving this work, Dr. Barry Carter for providing additional information for this publication, Dr. Max Gordon for his help with R programming, and Ruisi Zhang for her help with data abstraction. They also thank Alan Clerk, Yoriko Heianza, Arthur Fernandes, and Ayako Suzuki for translation assistance.
Financial Support: By award P20GM109036 from the National Institute of General Medical Sciences and award U01HL114197 from the National Heart, Lung, and Blood Institute.
Disclosures: Dr. Cooper reports grants from the National Heart, Lung, and Blood Institute during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-1805.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol and statistical code: See Supplement. Data set: Available from Jiang He (e-mail, email@example.com).
Requests for Single Reprints: Jiang He, MD, PhD, Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2042, New Orleans, LA 20112; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Mills, Dr. H. He, and Ms. Obst: Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2000, New Orleans, LA 70112.
Ms. Shen: School of Public Health, Nanjing Medical University, 818 East Tianyuan Road, Jiangning District, Nanjing 211166, China.
Ms. Molina: Georgia Department of Public Health, 1916 Northleg Road, Augusta, GA 30909.
Dr. Zhang: The First Affiliated Hospital of Xiamen University, 55 Zhenhai Road, Xiamen 361003, China.
Dr. Cooper: Department of Medicine and Department of Health Behavior and Society, Johns Hopkins University School of Medicine and Bloomberg School of Public Health, 2024 East Monument Street, Suite 2-500, Baltimore, MD 21205.
Dr. J. He: Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2042, New Orleans, LA 70112.
Author Contributions: Conception and design: K.T. Mills, L.A. Cooper, J. He.
Analysis and interpretation of the data: K.T. Mills, K.M. Obst, W. Shen, H.J. Zhang, H. He, L.A. Cooper, J. He.
Drafting of the article: K.T. Mills, J. He.
Critical revision of the article for important intellectual content: L.A. Cooper, J. He.
Final approval of the article: K.T. Mills, K.M. Obst, W. Shen, S. Molina, H.J. Zhang, H. He, L.A. Cooper, J. He.
Provision of study materials or patients: H.J. Zhang,
Statistical expertise: H. He, J. He.
Obtaining of funding: J. He.
Administrative, technical, or logistic support: K.T. Mills, K.M. Obst, J. He.
Collection and assembly of data: K.T. Mills, K.M. Obst, W. Shen, S. Molina, H.J. Zhang.
The prevalence of hypertension is high and is increasing worldwide, whereas the proportion of controlled hypertension is low.
To assess the comparative effectiveness of 8 implementation strategies for blood pressure (BP) control in adults with hypertension.
Systematic searches of MEDLINE and Embase from inception to September 2017 with no language restrictions, supplemented with manual reference searches.
Randomized controlled trials lasting at least 6 months comparing the effect of implementation strategies versus usual care on BP reduction in adults with hypertension.
Two investigators independently extracted data and assessed study quality.
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.
Sparse data from low- and middle-income countries; few trials of some implementation strategies, such as provider training; and possible publication bias.
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.
National Institutes of Health.
Mills KT, Obst KM, Shen W, Molina S, Zhang H, He H, et al. Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis. Ann Intern Med. 2018;168:110–120. doi: 10.7326/M17-1805
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Published: Ann Intern Med. 2018;168(2):110-120.
Published at www.annals.org on 26 December 2017
Cardiology, Coronary Risk Factors, High Value Care, Hypertension, Nephrology.
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