Target: BP™: A National Initiative to Improve Blood Pressure Control

Trends in Blood Pressure Control among US Adults With Hypertension, 2013-2014 to 2021-2023

BACKGROUND

Prior studies have reported a decrease in the proportion of US adults with hypertension who had controlled blood pressure (BP).

METHODS

We analyzed data from the National Health and Nutrition Examination Survey (n = 25,128, ≥18 years of age) to determine changes in BP control from 2013-2014 to 2021-2023. Hypertension was defined as systolic BP ≥140 mm Hg, diastolic BP ≥90 mm Hg, or antihypertensive medication use. BP control was defined as systolic BP <140 mm Hg and diastolic BP <90 mm Hg.

RESULTS

The age-adjusted prevalence of hypertension (95% CI) was 32.8% (31.2%-34.4%) in 2013-2014 and 32.0% (30.1%-33.9%) in 2021-2023. Among US adults with hypertension, the age-adjusted proportion (95% CI) with controlled BP was 54.1% (49.1%-59.2%), 48.6% (44.5%-52.7%), and 48.3% (45.8%-50.8%) in 2013-2014, 2015-2016, and 2017-2020, respectively, (P-trend = 0.058), and 51.1% (47.9%-54.3%) in 2021-2023 (P-value = 0.184 comparing 2021-2023 vs. 2017-2020). The proportion (95% CI) of US adults taking antihypertensive medication with controlled BP was 72.0% (68.5%-75.5%), 66.7% (62.9%-70.5%), and 67.8% (65.3%-70.3%) in 2013-2014, 2015-2016, and 2017-2020, respectively, (P-trend = 0.085), and 68.3% (64.8%-71.9%) in 2021-2023 (P-value = 0.654 comparing 2021-2023 vs. 2017-2020). Among non-Hispanic Black adults, BP control increased from 37.4% (95% CI 33.6%-41.1%) to 49.6% (95% CI 42.3%-56.9%) between 2017-2020 and 2021-2023 for those with hypertension (P-value = 0.005), and from 52.6% (95% CI 47.4%-57.8%) to 62.6% (95% CI 55.6%-69.7%) for those taking antihypertensive medication (P-value = 0.033). There was no difference in BP control across race/ethnicity groups in 2021-2023.

CONCLUSIONS

The decline in BP control from 2013-2014 to 2017-2020 did not continue through 2021-2023. An increase in BP control occurred from 2017-2020 and 2021-2023 among non-Hispanic Black adults.

Application of the FRAME-IS to a multifaceted implementation strategy

BACKGROUND

Research demonstrates the importance of documenting adaptations to implementation strategies that support integration of evidence-based interventions into practice. While studies have utilized the FRAME-IS [Framework for Reporting Adaptations and Modifications for Implementation Strategies] to collect structured adaptation data, they are limited by a focus on discrete implementation strategies (e.g., training), which do not reflect the complexity of multifaceted strategies like practice facilitation. In this paper, we apply the FRAME-IS to our trial evaluating the effectiveness of PF on implementation fidelity of an evidence-based technology-facilitated team care model for improved hypertension control within a federally qualified health center (FQHC).

METHODS

Three data sources are used to document adaptations: (1) implementation committee meeting minutes, (2) narrative reports completed by practice facilitators, and (3) structured notes captured on root cause analysis and Plan-Do-Study-Act worksheets. Text was extracted from the data sources according to the FRAME-IS modules and inputted into a master matrix for content analysis by two authors; a third author conducted member checking and code validation.

RESULTS

We modified the FRAME-IS to include part 2 of module 2 (what is modified) to add greater detail of the modified strategy, and a numbering system to track adaptations across the modules. This resulted in identification of 27 adaptations, of which 88.9% focused on supporting practices in identifying eligible patients and referring them to the intervention. About half (52.9%) of the adaptations were made to modify the context of the PF strategy to include a group-based format, add community health workers to the strategy, and to shift the implementation target to nurses. The adaptations were often widespread (83.9%), affecting all practices within the FQHC. While most adaptations were reactive (84.6%), they resulted from a systematic process of reviewing data captured by multiple sources. All adaptations included the FQHC in the decision-making process.

CONCLUSION

With modifications, we demonstrate the ability to document our adaptation data across the FRAME-IS modules, attesting to its applicability and value for a range of implementation strategies. Based on our experiences, we recommend refinement of tracking systems to support more nimble and practical documentation of iterative, ongoing, and multifaceted adaptations.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03713515, Registration date: October 19, 2018.

Application of the FRAME-IS to a Multifaceted Implementation Strategy

Background

Research demonstrates the importance of documenting adaptations to implementation strategies that support integration of evidence-based interventions into practice. While studies have utilized the FRAME-IS [Framework for Reporting Adaptations and Modifications for Implementation Strategies] to collect structured adaptation data, they are limited by a focus on discrete implementation strategies (e.g., training), which do not reflect the complexity of multifaceted strategies like practice facilitation (PF). In this paper, we apply the FRAME-IS to our trial evaluating the effectiveness of PF on implementation fidelity of an evidence-based technology-facilitated team care model for improved hypertension control within a federally qualified health center (FQHC).

Methods

Three data sources are used to document adaptations: (1) implementation committee meeting minutes, (2) narrative reports completed by practice facilitators, and (3) structured notes captured on root cause analysis and Plan-Do-Study-Act worksheets. Text was extracted from the data sources according to the FRAME-IS modules and inputted into a master matrix for content analysis by two authors; a third author conducted member checking and code validation.

Results

We modified the FRAME-IS to include part 2 of module 2 (what is modified) to add greater detail of the modified strategy, and a numbering system to track adaptations across the modules. This resulted in identification of 27 adaptations, of which 88.9% focused on supporting practices in identifying eligible patients and referring them to the intervention. About half (52.9%) of the adaptations were made to modify the context of the PF strategy to include a group-based format, add community health workers to the strategy, and to shift the implementation target to nurses. The adaptations were often widespread (83.9%), affecting all practices within the FQHC. While most adaptations were reactive (84.6%), they resulted from a systematic process of reviewing data captured by multiple sources. All adaptations included the FQHC in the decision-making process.

Conclusion

With modifications, we demonstrate the ability to document our adaptation data across the FRAME-IS modules, attesting to its applicability and value for a range of implementation strategies. Based on our experiences, we recommend refinement of tracking systems to support more nimble and practical documentation of iterative, ongoing, and multifaceted adaptations.

Trial Registration

clinicaltrials.gov NCT03713515, Registration date: October 19, 2018.