Is a multicomponent hypertension management program implemented in the public primary care setting associated with fewer patient complications and mortality?

By Pooja Toshniwal PahariaMay 26 2023Reviewed by Danielle Ellis, B.Sc.

In a recent study published in JAMA Network Open, researchers compared hypertension-associated complications and the use of healthcare services at five years among hypertensive individuals managed using the Risk Assessment and Management Program for Hypertension (RAMP-HT) versus regular care.

Background

Hypertension remains a major global risk factor for morbidity and mortality from coronary heart disease (CHD), end-stage kidney disease (ESKD), and cardiovascular stroke. Team-based care, standardized treatment protocols, professional training, and empowering patients have demonstrated efficacy in lowering blood pressure (BP), with multilevel, multifaceted approaches being the most successful for lowering systolic blood pressure (SBP).

However, the impact of employing these methods on the population is not well-characterized, and data on their long-term effects on cardiovascular health, death, or healthcare utilization are limited. The Hospital Authority of Hong Kong launched the territory-wide RAMP-HT in 2011 to enhance the standard of hypertension care. RAMP-HT is a multicomponent, multilevel, collaborative strategy that aims to control overall CVD risk in patients receiving primary care with uncomplicated hypertension.

About the study

In the present prospective cohort study, researchers investigated whether a collaborative, protocol-driven and multicomponent hypertension management program implemented in primary healthcare settings was related to fewer complications and lower mortality among hypertensive patients.

The study comprised 212,707 adult individuals with uncomplicated hypertension treated at either of the 73 publicly accessible outpatient-type clinics in Hong Kong from 1 October 2011 to 30 September 2013. Usual care recipients were individuals who had attended GOPCs ≥1.0 times for hypertension care during the period but did not participate in RAMP-HT until 30 September 2017.

Follow-up was performed until the occurrence of a study outcome, death due to any cause, or the final follow-up prior to October 2017, which occurred first. The RAMP-HT group individuals and the hypertensive regular care recipients were matched by propensity score matching (PSM), and data were analyzed between January 2019 and March 2023.

The study interventions included nurse-performed risk estimations in linkage with electronic reminder systems, nurse interventions, and specialist consultations, apart from the regular scare. Risk assessments were performed 12.0 to 30.0 months apart using the Joint British Societies’ (JBS2) calculator, whereas specialist consultations and nurse interventions were performed when necessary.

Patients with persistent hypertension were directed to health experts, whereas those with compliance difficulties or particular risk factors were provided health interventions by nurses. All study participants received regular care at an eight-to-16-week interval at general outpatient clinics (GOPCs). The outcomes of the study were hypertension-associated complications [EKSD and cardiovascular disease (CVD)], death due to any cause, and use of population health services (overnight hospital admission and visits to the emergency department, GOPCs, and specialist clinics).

Only individuals diagnosed with hypertension using the International Classification of Primary Care, second edition (ICPC-2) codes; individuals with no history of diabetes, EKSD, or CVD; and those receiving GOPC care for hypertension were analyzed.

The team performed Cox proportional hazards regression modeling and binomial regression modeling to calculate the hazard ratios (HRs) and incidence rate ratios (IRRs), respectively, adjusting for covariates such as age, sex, smoking status, height, weight, blood pressure, fasting blood glucose, estimated glomerular filtration rate (eGFR), and lipid profile.

Results

The study included 104,662 regular care recipients and 108,045 individuals in the RAMP-HT group, among whom the mean age was 66 years, and 58% were female. After a five-year follow-up, the absolute risk reductions for CVD, EKSD, and death due to any cause among RAMP-HT group individuals were eight percent, two percent, and 10%, respectively.

Compared to regular care recipients, after covariate adjustment, RAMP-HT participants demonstrated lowered risks of CVD, EKSD, and death due to any cause, with HR values of 0.6, 0.5, and 0.5, respectively.

The numbers needed to treat (NNT) values for preventing a single CVD event, EKSD, and death due to any cause were 16.0, 106.0, and 17.0, respectively. Further, the RAMP-HT group had lower use of hospital-based services (IRRs ranging between 0.6 and 0.9) but higher attendance at public outpatient clinics (IRR 1.1) than regular care recipients.

Conclusion

Overall, the study findings showed that RAMP-HT participation significantly lowered the incidence rates of hypertension-associated complications, death due to any cause, and the use of hospital-based healthcare services after five years. Therefore, a collaborative and protocol-driven program for managing hypertension implemented in publicly accessible primary healthcare settings could be a feasible approach to lower the burden of hypertension on healthcare systems.