Team-based intervention reduces risk for hypertension complications

Key takeaways:

• Patients who underwent a multiteam intervention saw risk reductions for CVD and mortality.
• Nurse-led risk assessments also empowered patients to self-monitor BP and quit smoking.

A team-based, multicomponent program was linked to risk reductions for several CVD and health outcomes in patients with hypertension when compared with usual care, according to researchers.

“Team-based care, standardized management protocols, clinician training, and patient empowerment have shown effectiveness for BP reduction, whereas multilevel, multicomponent interventions have been most effective for lowering systolic BP,” Esther Y. T. Yu, MBBS, a clinical assistant professor in the department of family medicine and primary care at the University of Hong Kong, and colleagues wrote in JAMA Network Open.

However, “the effect of implementing these strategies on the population level is unclear, and evidence for longer-term effects (> 24 months) on cardiovascular outcomes, mortality, or health service use remains sparse,” they wrote.

The researchers conducted a population-based prospective matched cohort study to compare usual care with the Risk Assessment and Management Program for Hypertension — or RAMP-HT — an intervention that combined treatment and evaluation from multiple specialties.

Beginning in 2011, participants who underwent RAMP-HT received three services to augment usual care: nurse-led risk assessments every 12 to 30 months, a nurse intervention and a specialist consultation when necessary. After risk assessments, the care-manager nurse organized a care plan and coordinated follow-up interventions, according to the researchers. The care plan was logged in the patients’ electronic health record “with an action reminder system accessible at any public primary care clinic (ie, general outpatient clinic [GOPC]) to support team members’ clinical decision-making, including GOPC physicians providing usual care,” Yu and colleagues wrote.

“Participants with adherence issues or specific risk factors were referred for nurse interventions, while patients with resistant hypertension were referred for additional specialist consultations,” they added.

Participants receiving usual care, meanwhile, received physician-led care every 8 to 16 weeks.

Overall, 108,045 participants were assigned to the RAMP-HT group and 104,662 were assigned to usual care. The participants received care at 73 outpatient clinics in Hong Kong. Their mean age of 66 years and all had uncomplicated hypertension.

After 5 years, RAMP-HT participants had an 8% absolute risk reduction for CVD, 1.6% absolute risk reduction for end-stage kidney disease and a 10% absolute risk reduction for all-cause mortality.

Additionally, after the researchers adjusted for baseline covariates, RAMP-HT participants had a:

• 42% lower risk for any CVD event (HR = 0.58; 95% CI, 0.57-0.59);
• 38% lower risk for CVD (HR = 0.62; 95% CI, 0.61-0.64);
• 46% lower risk for end-stage kidney disease (HR = 0.54; 95% CI, 0.5-0.59);
• 17% lower risk for diabetes (HR = 0.83; 95% CI, 0.8-0.85); and a
• 48% lower risk for all-cause mortality (HR = 0.52; 95% CI, 0.5-0.54) compared with usual care.

Yu and colleagues noted that the risk reductions in mortality and CVD may be attributable to the combined effects of BP and LDL-C control.

“RAMP-HT participants had a higher likelihood of achieving BP and LDL-C control compared with usual care patients after 5 years, where a greater proportion of RAMP-HT participants were prescribed statins,” they wrote.

The researchers added that the nurse-led risk assessments and interventions further helped grow patient empowerment in self-care, “including self-BP monitoring, smoking cessation, dietary modifications, physical activity, medication adherence and help-seeking behavior.”

Ultimately, the risk reductions in CVD and mortality “might represent a function of change in practices on multiple levels beyond disease parameter control,” Yu and colleagues wrote.

“In addition to overcoming clinicians’ treatment inertia through clinician training and use of action reminder prompts, and empowering patients’ self-care capacity through extra contact time with nurses and the allied health care team, task-shifting also allowed more time for physicians to promptly recognize and manage other complex or urgent issues during the time-constrained consultation, which might contribute to the lower incidence of non-CVD mortality in RAMP-HT participants,” they wrote.