Community Practitioner–Led Hypertension Program Yields Strong Results

A multifaceted approach to hypertension intervention is safe and effective even when delivered by nonphysicians, according to a study of more than 30,000 people with hypertension.

The study, which was based on a rural Chinese population, highlights the potential of community-based interventions, especially in underresourced regions. It also shows that the strategy is effective both in younger and older patients. The study was published online today in JAMA Cardiology.¹

About one-third of adults worldwide who are aged 30 to 79 years have hypertension, and the majority of people with hypertension live in low- and middle-income countries, noted the study authors.

An accompanying editorial to this study notes the authors' approach to hypertension management could be successful in both low- and high-resource settings | Image Credit: naowarat-stock.adobe.com

In China, which has the world’s largest population of older people, hypertension is often left untreated and uncontrolled, the authors said, especially in low-resource areas. That led them to launch the China Rural Hypertension Control Project (CRHCP), a trial designed to utilize nonphysician community health practitioners to act as the lead agents tasked with tracking patients with hypertension and implementing interventions as needed. In the trial, nonphysicians were typically local primary care providers known as village doctors. Despite the “doctor” label, the authors said these practitioners typically have about 3 years of vocational or junior medical training, The trial was originally designed to have an 18-month phase and a 36-month phase; however, the investigators eventually decided to extend the trial to 48 months to get a more accurate understanding of the intervention’s long-term impact on cardiovascular disease (CVD).

The study compared outcomes for a usual-care control group and an intervention group. For patients in the intervention group, village doctors were asked to implement a stepped-care protocol for hypertension management based on a blood pressure (BP) treatment goal of below 130/80 mm Hg.¹ The practitioners were given initial training and certification in multifaceted BP management, and then given periodic follow-up training. They were provided with research funding as part of their salaries, along with a performance-based incentive. Patients were given access to discounted or free antihypertensive medication, plus free at-home BP monitoring tools. The work of the practitioners was audited by physicians at local hospitals, the authors explained.

Overall, 22,386 people aged 60 and older were included in the analysis, along with 11,609 people younger than age 60. Most of the patients were female (61.3%). After 4 years, the authors found people in the intervention group had a significantly lower rate of CVD (2.7% vs 3.5% per year; HR, 0.75; 95% CI, 0.69-0.81; P < .001). The intervention also led to a 10% drop in all-cause mortality risk (2.5% vs 2.8% per year; HR, 0.90; 95% CI, 0.83-0.98; P = .01). In younger patients specifically, the authors found reductions in total CVD, stroke, heart failure, and CV death.

The study authors said these results demonstrate that their “effective, feasible, and sustainable strategy should be integrated into hypertension control programs in low-resource settings in China and worldwide.”

In an accompanying editorial, Daniel W. Jones, MD, of the University of Mississippi Medical Center, agreed.² He noted that in the US, hypertension control rates were below 50% in the years before the COVID-19 pandemic, even though at that time the target BP goal was a less aggressive 140/90 mm Hg.³ Less than a quarter of Americans with hypertension were meeting the new goal of 130/80 mm Hg, he said.

Jones argues, however, that the efficacy of the CRHCP approach might not be limited to low-resource settings. He said it might also work in high-resource settings like the US, but only if the health care community embraces such a model.

“In a health care system designed to reward innovation and expensive and invasive treatment mortalities at the end stage of CVD, can something so simple be adopted?” he wrote. He said one change that would need to happen is for American physicians to embrace a broader scope of practice for other health care workers, such as registered nurses. He said research nurses have played roles like that of the CRHCP’s village doctors in American hypertension trials.

“If a regulatory pathway exists to allow for this management approach in clinical trials, can we not extend this ‘safe, effective, and feasible’ model to improve BP control in patients?” he wrote.

Jones said the new study shows that in addition to safe and effective medicines, collective wealth, and overwhelming evidence of the benefits of hypertension control, patients in the US can also benefit from a relatively easy-to-implement management strategy. After trying “everything else,” he concluded, it is time to follow the evidence and implement the new approach.

References

1. Guo X, Ouyang N, Sun G, et al. Multifaceted intensive blood pressure control model in older and younger individuals with hypertension: a randomized clinical trial. JAMA Cardiol. Published online June 18, 2024. doi:10.1001/jamacardio.2024.1449

2. Jones DW. A pathway to better blood pressure control. JAMA Cardiol. Published online June 18, 2024. doi:10.1001/jamacardio.2024.1463

3. Muntner P, Hardy ST, Fine LJ, et al. Trends in blood pressure control among US adults with hypertension, 1999-2000 to 2017-2018. JAMA. 2020;324(12):1190-1200. doi:10.1001/jama.2020.14545