Low-Income Patients Benefit From Intensive Blood Pressure Management

An intensive hypertension control program could be implemented effectively in federally qualified health centers (FQHCs), the cluster-randomized IMPACTS-BP trial showed.

Geared towards low-income patients with uncontrolled hypertension, a multifaceted, team-based implementation strategy for blood pressure (BP) management led to a mean reduction of 15.5 mm Hg in systolic BP at 18 months compared with a mean reduction of 9.1 mm Hg in the control group (P<0.001).

“The results of this effectiveness-implementation trial show that among populations with substantial health disparities, a multifaceted, team-based strategy effectively reduced blood pressure and improved adherence to hypertension treatment, as compared with enhanced usual care,” wrote Jiang He, MD, PhD, of the University of Texas Southwestern Medical Center in Dallas, and colleagues in the New England Journal of Medicine.

BP control continues to be a major public health challenge in the U.S., where nearly half of adults have hypertension, nearly 80% of whom do not have it under control, despite lifestyle recommendations and the availability of multiple effective, safe, and inexpensive BP-lowering medications.

In 2025, updated guidelines took the position of widening the pool of candidates for BP drug initiation as part of the goal to address individual risks earlier. The guidelines also endorsed team-based care for uncontrolled hypertension, with an emphasis on addressing adverse social determinants of health, patient engagement, and ongoing review of home BP monitoring.

In IMPACTS-BP, the intervention was a FQHC clinic-level package including team-based care, protocol-based intensive BP management, BP audit and feedback, health coaching on lifestyle changes and medication adherence, and home BP monitoring.

The stepped-care protocol for BP management was adapted from SPRINT, with a BP target of <120/80 mm Hg; patients in the intervention group visited the clinics monthly for the first 3 months, then every 3 months thereafter. Those who had in-clinic BP readings above target had their antihypertensive medication dose raised or a new class of drug added. Those with uncontrolled BP attended additional monthly visits until the target was achieved.

For comparison, control clinics provided enhanced usual care, namely education for physicians about hypertension guidelines.

In an accompanying editorial, Sadiya Khan, MD, of Northwestern University Feinberg School of Medicine in Chicago, and Mark Huffman, MD, MPH, of Washington University School of Medicine in St. Louis, noted that “data on the effectiveness and implementation of integrated treatment bundles remain limited, particularly in resource-constrained settings in which low-income patients are treated.”

“The findings in this trial provide much-needed evidence for systems-based strategies that can be successfully applied in FQHCs,” Khan and Huffman wrote. “The trial represents an important step forward in showing effective and safe implementation of the SPRINT protocol among low-income patients, who are often underrepresented in clinical trials. In addition, this trial was conducted during the onset of the COVID-19 pandemic, when health systems were severely stressed.”

In this study, He and colleagues randomized 36 FQHCs in Louisiana and Mississippi to the multifaceted implementation strategy or enhanced usual care for hypertension control from June 2018 through July 2022.

They included 1,272 patients ages 40 and older with uncontrolled hypertension. Mean age was 58.8 years, 56.7% were women, and 63.4% were Black. Roughly three in four were unemployed, and 73.4% had a family income <$25,000 per year.

Use of antihypertensive medications was reported for about 94% of patients at baseline; the median number of BP-lowering medications was two.

An adherence summary score — gauging patient adherence to antihypertensive medications, initiation or intensification of antihypertensive treatment, BP monitoring at home, and receipt of health education over the 18 months — was higher in the intervention group (2.8 vs 2.1 points on a scale of 0 to 4, P<0.001).

Ultimately, at 18 months, a systolic BP <120 mm Hg was achieved by 21.8% and 15.1% of the intervention and control groups, respectively; a systolic BP <130 mm Hg was reported in 47.7% and 36.4%.

“It is possible that providers were reluctant to treat to [<120 mm Hg] because current clinical guidelines recommend a systolic blood-pressure target of less than 130 mm Hg, and FQHCs are evaluated with the benchmark of less than 140/90 mm Hg, set by the Health Resources and Services Administration," He and colleagues wrote. "Recommending lower blood-pressure targets in clinical guidelines and funding policies is essential to institutionalize intensive blood-pressure reduction programs."

As for safety, serious adverse events occurred in 20.9% of patients in the intervention group versus 21.7% in the control group.

He and colleagues cautioned that the trial was unblinded, since trial group concealment was not possible.

“The next logical question is how to adapt, sustain, and scale this multilevel, team-based strategy for hypertension management across the more than 16,000 clinics among at least 1,400 FQHC organizations currently operating in the United States,” Khan and Huffman wrote. “Expansion of this strategy to new sites will require assessing and addressing key barriers, including readiness for change, clinicians’ confidence in achieving lower blood-pressure targets, and implementation costs.”

Additionally, they suggested that single-pill combination therapy, with three or four medications in a single polypill, “may offer an effective, efficient, and scalable strategy that can improve adherence and side-effect profiles.”

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