Multifaceted team-based strategy improves blood pressure control in low-income patients

In IMPACT-BS among low-income patients with hypertension, a multifaceted, team-based implementation strategy reduced SBP and improved adherence to hypertension treatment compared with enhanced usual care.

This summary is based on the publication of Mills KT, Krousel-Wood M, Peacock EM, et al. - Multifaceted Strategies for Hypertension Control in Low-Income Patients. N Engl J Med. 2026 Apr 9;394(14):1376-1387. doi: 10.1056/NEJMoa2504068.

Introduction and methods

Background

Multilevel, multicomponent implementation strategies have shown to be more effective for hypertension control than single interventions [1]. However, evidence on how to implement such multifaceted blood-pressure strategies in resource-limited primary care settings—such as federally qualified health centers (FQHCs) serving predominantly low-income populations—remains limited. In the SPRINT (Systolic Blood Pressure Intervention Trial) trial, intensive hypertensive treatment targeting a SBP of less than 120 mmHg resulted in lower rates of cardiovascular events or all-cause mortality than targeting a SBP of less than 140 mmHg [2].

Aim of the study

The aim of the study was to evaluate the effectiveness and implementation outcomes of a multifaceted, team-based strategy for improving blood pressure control adapted from SPRINT in low-income patients.

Methods

IMPACTS-BP (Implementation of Multifaceted Patient-Centered Treatment Strategies for Intensive Blood Pressure Control) was a cluster-randomized trial, in which 36 FQHC clinics in Louisiana and Mississippi were assigned to either a multifaceted, team-based implementation strategy (intervention group) or enhanced usual care (control group) for hypertension control.

The implementation strategy included team-based care, protocol-based intensive blood pressure management, blood-pressure audit and feedback, health coaching, and home blood pressure monitoring. In addition, SPRINT findings were shared with care teams, patients, and administrators. Enhanced usual care included educating physicians about clinical guidelines for hypertension and SPRINT findings.

Patients (≥40 years old) from participating FQHCs were eligible if they had a SBP ≥140 mmHg without antihypertensive treatment, or ≥130 mmHg while on antihypertensive medication. A total of 1272 patients were included.

Outcomes

The primary effectiveness outcome was the mean change in SBP from baseline to 18 months. The primary implementation outcome was the adherence summary score assessed at 6, 12, and 18 months (scores range from 0 to 4, with higher scores indicating better adherence to blood-pressure management).

Main results

• At 18 months, the mean change in SBP was −15.5 mmHg (95%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 mmHg; 95%CI: −9.0 to −3.8; P<0.001).
• At 18 months, SBP of less than 120 mmHg was reported in 21.8% of the patients in the intervention group and in 15.1% of the patients in the control group.
• The mean adherence summary score, averaged over 6, 12, and 18 months, was 2.8 points (95%CI: 2.7 to 2.9) in the intervention group and 2.1 points (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).
• The rates of serious adverse events were similar between the two groups (20.9% in the intervention group vs. 21.7% in the control group).
• Subgroup analyses showed that the reduction in SBP was consistent across subgroups stratified by, among others, age, sex, family income, and history of CVD, CKD, or diabetes.

Conclusion

In IMPACT-BS among low-income patients with hypertension receiving care at FQHCs, a multifaceted, team-based implementation strategy reduced SBP and improved adherence to hypertension treatment compared with enhanced usual care.

Find this article online at N Engl J Med.

References

1. Mills KT, Obst KM, Shen W, 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: 110-20.
2. The SPRINT Research Group. Final report of a trial of intensive versus standard blood-pressure control. N Engl J Med 2021; 384: 1921-30.