April 8, 2026New England Journal of Medicine
Multifaceted Strategies for Hypertension Control in Low-Income Patients
Key result
Multifaceted team-based strategy reduces SBP vs enhanced usual care in low-income hypertensive patients.
- MD -6.4
- 95% CI -9.0 to -3.8
- P<0.001
- n=1,272
Figures
Why the study?
Does a multifaceted, team-based implementation strategy reduce systolic blood pressure in low-income patients with uncontrolled hypertension?
Key Points
- To evaluate the effectiveness and implementation outcomes of a multifaceted, team-based intervention compared with enhanced usual care for hypertension control in low-income clinical settings.
- Randomized trial across 36 federally qualified health center clinics in Louisiana and Mississippi (IMPACTS-BP; NCT03483662) enrolling 1,272 patients 40 years of age or older with uncontrolled hypertension (642 intervention, 630 control).
- Intervention clinics received team-based care, protocol-driven intensive blood pressure management, audit and feedback, health coaching, and home blood-pressure monitoring, whereas control clinics received enhanced usual care with physician guideline education over 18 months.
- Systolic blood pressure decreased by a mean of -15.5 mm Hg (95% CI, -17.4 to -13.6) in the intervention arm compared to -9.1 mm Hg (95% CI, -11.0 to -7.2) in the control arm (between-group difference, -6.4 mm Hg; 95% CI, -9.0 to -3.8; P<0.001).
- The mean adherence summary score was 2.8 (95% CI, 2.7 to 2.9) in the intervention group versus 2.1 (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).
- Serious adverse events occurred in 20.9% of intervention participants and 21.7% of control participants.
Study Design
Type
RCT (n=1,272)
Multicenter
Yes
Structured PICO
Does a multifaceted, team-based implementation strategy reduce systolic blood pressure in low-income patients with uncontrolled hypertension?
P
Population
1,272 low-income patients aged ≥40 years with uncontrolled hypertension, followed for 18 months.
I
Intervention
Multifaceted implementation strategy including team-based care, protocol-based intensive blood-pressure management, blood-pressure audit and feedback, health coaching on lifestyle changes and medication adherence, and home blood-pressure monitoring.
C
Comparator
Enhanced usual care involving educating physicians about clinical guidelines for hypertension.
O
Outcome
Mean change in systolic blood pressure from baseline to 18 months.surrogate
Main Result
Mean Difference: -6.4 (95% CI -9–-3.8)
Absolute Event Rate: -15.5% vs -9.1%
p-value: p=<0.001
A multifaceted, team-based implementation strategy significantly improved systolic blood pressure reduction compared to enhanced usual care in low-income patients with uncontrolled hypertension.
Discussion
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Hypertension is a major public health priority due to its high prevalence and associated morbidity and mortality. Low-income populations experience higher prevalence and lower control rates, which [contribute] to health disparities.”
“This study is really an important advance in terms of showing that intensive blood pressure, treatment as introduced by the SPRINT trial, can be feasibly implemented in usual primary care, including some of the most challenging primary-care settings to deliver care in. It's really encouraging evidence.”
“This study shows that multi-level intervention is necessary to get blood pressure under control in low-income populations. One doctor alone is not enough. It requires teamwork.”
Implication
Warrants team-based hypertension programs in low-income patients; extends RCT evidence to safety-net primary care settings.
Abstract
BACKGROUND: Uncontrolled hypertension disproportionately affects populations that have substantial health disparities. Data regarding the effectiveness and implementation of multifaceted, team-based strategies for hypertension control among low-income patients are lacking. METHODS: We randomly assigned federally qualified health center clinics in Louisiana and Mississippi to use either a multifaceted implementation strategy (intervention group) or enhanced usual care (control group) for hypertension control. The intervention included team-based care, protocol-based intensive blood-pressure management, blood-pressure audit and feedback, health coaching on lifestyle changes and medication adherence, and home blood-pressure monitoring. Enhanced usual care involved educating physicians about clinical guidelines for hypertension. The primary effectiveness outcome was the mean change in systolic blood pressure from baseline to 18 months. The primary implementation outcome was the adherence summary score (on a scale of 0 to 4, with higher scores indicating better adherence to blood-pressure management). RESULTS: A total of 36 clinics underwent randomization. Among these clinics, we enrolled 1272 patients with uncontrolled hypertension who were 40 years of age or older; 642 were in the intervention group and 630 were in the control group. The mean age of the patients was 58.8 years, 56.7% were women, 63.4% were Black, 75.9% were unemployed, and 73.4% had a family income of less than $25,000 per year. At 18 months, the mean change from baseline in the systolic blood pressure was -15.5 mm Hg (95% confidence interval [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 mm Hg; 95% CI, -9.0 to -3.8; P<0.001). The mean adherence summary score over the 18-month follow-up period was 2.8 (95% CI, 2.7 to 2.9) in the intervention group and 2.1 (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). Serious adverse events occurred in 20.9% of the patients in the intervention group and in 21.7% of those in the control group. CONCLUSIONS: Among low-income patients with hypertension, a multifaceted, team-based implementation strategy resulted in a significantly greater reduction in systolic blood pressure than enhanced usual care. (Funded by the National Heart, Lung, and Blood Institute and others; IMPACTS-BP ClinicalTrials.gov number, NCT03483662.).
Cite This Study
Mills et al. (2026) conducted an RCT in uncontrolled hypertension (n=1,272). Multifaceted implementation strategy vs. Enhanced usual care was evaluated on mean change in systolic blood pressure from baseline to 18 months (MD -6.4, 95% CI -9.0 to -3.8, p=<0.001). A multifaceted, team-based implementation strategy reduced systolic blood pressure more than enhanced usual care among low-income patients (mean difference -6.4 mm Hg; 95% CI -9.0 to -3.8; P<0.001).