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Directing hypertension treatment doesn't have to rest solely in the hands of physicians, authors of a meta-analysis found.

After accounting for various factors, Jiang He, MD, PhD, of Tulane University School of Public Health and Tropical Medicine in New Orleans, Louisiana, and colleagues determined that systolic blood pressure :

• Team-based care with medication titration by a nonphysician (-7.1 mm Hg on average)
• Team-based care with medication titration by a physician (-6.2 mm Hg)
• Multilevel strategies without team-based care (-5.0 mm Hg)
• Patient-level strategy of health coaching (-3.9 mm Hg)
• Patient-level strategy of home blood pressure monitoring (-2.7 mm Hg)

Provider training and audit/feedback strategies, however, were not tied to statistically significant drops in systolic blood pressure, they reported online in the Annals of Internal Medicine. The investigators observed similar trends for diastolic blood pressure reduction.

"Multilevel, multicomponent strategies, followed by patient-level strategies, are most effective for blood pressure control in patients with hypertension and should be used to improve hypertension control," He's group concluded.

"We need to facilitate involvement of our nonphysician colleagues in helping us control our patients' blood pressure, particularly because the most recent guidelines emphasize the importance of a team-based approach to care for all adults with hypertension," commented Liam Glynn, MD, MMSc, of Ireland's University of Limerick, and Richard McManus, PhD, of University of Oxford in England.

"Yet, doing so will require ceding control, training nonphysician staff, and developing clear treatment algorithms," they said in an .

On the home front, they added, technology may play a role in motivating patients to stick with necessary behavior changes to lower their blood pressure.

"When patients disengage from care, mobile platforms mean that the potential for reengagement is only a 'click' or a 'swipe' away. Having quality information at their fingertips offers patients tools to improve their blood pressure control, particularly now that out-of-office blood pressure measurements have been recommended for diagnosis and management in conjunction with telehealth counseling."

Data for the meta-analysis came from 55,920 patients who were enrolled in randomized hypertension trials lasting at least 6 months.

Having sparse data from low-and middle-income countries was one limit to the generalizability of their findings. Another was that few trials existed testing implementation strategies such as provider training, audit and feedback, electronic decision-support systems, and multilevel strategies without team-based care.

Even so, "[t]he message of the current review is similar to that of the seminal Hypertension and Detection Follow-up Program study nearly 40 years ago, where an organized system of regular review and vigorous therapy with antihypertensive drugs was shown to reduce blood pressure as well as all-cause mortality," Glynn and McManus wrote.

"So why has our ability to control blood pressure not improved over the past 40 years? The answer seems to lie in the 'swamp' that is everyday clinical practice, where unreliable blood pressure measurement and polypharmacy with associated patient illness seem to challenge adherence at every turn and can create a complicit therapeutic nihilism between patients and health care providers," the editorialists suggested.