Multifaceted Strategies for Hypertension Control in Low-Income Patients.

Katherine T Mills, Marie Krousel-Wood, Erin M Peacock, Jing Chen, Farah Allouch, Amy K Carreras, Siyi Geng, Alecia Cyprian, Gerrelda Davis, Sonja R Fuqua, Darie Gilliam, Angelique Greer, Tammy Mitchell, Wylea Gray-Winfrey, Shondra Williams, Gary M Wiltz, Keith L Winfrey, Hua He, Paul K Whelton, Jiang He

Journal: The New England journal of medicine 2026;394(14):1376-1387

PMID: 41950472

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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.).

Address: Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans.; Tulane University Translational Sciences Institute, New Orleans.; Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans.; Tulane University Translational Sciences Institute, New Orleans.; Department of Medicine, Tulane University School of Medicine, New Orleans.; Tulane University Center for Health Outcomes, Implementation, and Community-Engaged Science, New Orleans.; Department of Medicine, Tulane University School of Medicine, New Orleans.; Tulane University Center for Health Outcomes, Implementation, and Community-Engaged Science, New Orleans.; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.; Department of Epidemiology, University of Texas Southwestern Medical Center O'Donnell School of Public Health, Dallas.; Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans.; Department of Epidemiology, University of Texas Southwestern Medical Center O'Donnell School of Public Health, Dallas.; Southeast Community Health Systems, Greensburg, LA.; Louisiana Primary Care Association, Baton Rouge.; Community Health Center Association of Mississippi, Jackson.; RKM Primary Care, Clinton, LA.; Coastal Family Health Center, Biloxi, MS.; SWLA Center for Health Services, Lake Charles, LA.; EXCELth Primary Care, New Orleans.; InclusivCare, Avondale, LA.; Teche Action Clinic, Franklin, LA.; NOELA Community Health Center, New Orleans.; Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans.; Tulane University Translational Sciences Institute, New Orleans.; Department of Medicine, Tulane University School of Medicine, New Orleans.; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.; Department of Epidemiology, University of Texas Southwestern Medical Center O'Donnell School of Public Health, Dallas.; Department of Neurology, University of Texas Southwestern Medical Center, Dallas.; Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas.

DOI: 10.1056/NEJMoa2504068

MeSH Terms: Humans, Hypertension, Female, Male, Middle Aged, Poverty, Antihypertensive Agents, Blood Pressure, Medication Adherence, Adult, Louisiana, Aged, Blood Pressure Monitoring, Ambulatory, Patient Care Team, Mississippi, Life Style, Guideline Adherence