Health Care Delivery Interventions for Hypertension Management in Underserved Populations in the United States: A Systematic Review

Abstract

The high prevalence of uncontrolled hypertension in underserved populations is a major cause of health disparities in the United States and requires innovative health care delivery interventions. We conducted a systematic review of randomized controlled trials and comparative observational studies examining the effectiveness of contemporary systems change and quality improvement interventions aimed at improving blood pressure (BP) control published from 2010 to 2020. We included studies evaluating multicomponent practice improvement interventions conducted in the United States in community health centers. We identified 26 studies including 48 187 patients with hypertension with a high proportion of racial/ethnic minorities, low socioeconomic status, and a high burden of chronic illness. Multicomponent interventions led to an average reduction of 5 to 10 mm Hg in systolic BP. Four studies demonstrated the effectiveness of integrating pharmacists into community health centers for BP management and reduced cardiovascular disparities for at-risk populations. Five studies demonstrated the effectiveness of integrating community health workers into care workflows leading to reduction in BP and high patient satisfaction. Five studies used the electronic medical record as a tool for population management and showed only modest reduction in BP. One study demonstrated the effectiveness of incentivizing clinics with higher payments for uninsured and Medicaid patients meeting performance criteria. Very few studies evaluated treatment complications or medications side effects. Multicomponent quality improvement interventions instituted in community health centers are effective in lowering BP. Several components of the interventions were identified as being associated with higher efficacy.

Effect of Lifestyle Coaching or Enhanced Pharmacotherapy on Blood Pressure Control Among Black Adults With Persistent Uncontrolled Hypertension

“…Prior studies also supported that an in-person or a video education intervention was more successful than printed educational materials in achieving BP control. 30 Our LC intervention combined motivational interviewing methods with an emphasis on the DASH eating plan with sodium reduction, which was previously shown to lower BP in Black patients with hypertension. 24,25 Regular monitoring during the study was set up to promote adherence to the intervention protocols and the fidelity of the motivational interviewing method.…”

Patient and primary care perspectives on hypertension management: short report of a qualitative study in a tribal health system

“…Within the SCF integrated care teams, for instance, some primary care providers and nurse case managers are ANAI and the majority of certified medical assistants are ANAI. In other settings, health education and visits with nurses or community health workers have improved blood pressure control in diverse and underserved populations [ 35 , 36 ].…”

Community Health Workers as Key Allies in the Global Battle Against Hypertension: Current Roles and Future Possibilities

“…Numerous strategies have been endorsed by the American Heart Association and other organizations to help combat the mounting hypertension pandemic. 2,4 One promising approach, team-based care, incorporates additional providers beyond physicians to enhance the quality and scope of patient care. A key new team member in this model is the community health worker (CHW).…”

“…A key new team member in this model is the community health worker (CHW). 4,5 CHWs can be vital in the effort to improve BP though a variety of actions complimentary to traditional healthcare professionals including culturally sensitive health coaching and education, improving engagement, trust and adherence, as well as addressing social-economic issues. 2,4,5 While their effectiveness has been most well established in recent studies among resource-constrained countries, 5 history shows that CHWs have long been involved in hypertension research in the United States as well.…”

“…Given methodological heterogeneity across studies, no formal meta-analysis has yet been conducted. 4,5…”