Nonphysician Community Health Care Provider-Led Intensive BP Intervention

Quick Takes

  • In low-income and middle-income countries, hypertension is prevalent, accounting for 75% of individuals with hypertension, with only 7.7% having their blood pressure (BP) controlled.
  • A nonphysician led community health care provider-led intensive BP intervention was effective in reducing BP.
  • The group of patients that were enrolled in the community program had a reduction in systolic BP -23.1 mm Hg, and diastolic BP -9.9 mm Hg.

Study Questions:

What is the effectiveness of a nonphysician community health care provider-led intensive blood pressure (BP) intervention on cardiovascular disease (CVD)?


Between May 8–November 28, 2018, 33,995 participants were enrolled from 326 villages in rural China. The villages were randomized 1:1 to either the intervention group or usual care. Nonphysician community health care providers in the intervention group were trained in protocol-based antihypertensive treatment and health coaching. A stepped-care protocol for hypertension was implemented, which included treatment algorithm, medication selection, contraindications of medications, and adjustment strategies. The goal was to achieve a systolic BP <130 mm Hg. The primary outcome was BP control at 18 months in phase 1, and CVD events over 36 months in phase 2. Patients in the intervention group received either free or reduced cost in antihypertensive medications and a home BP monitor with instructions to take their BP 2-3 days per week. They received health coaching at individual visits or group sessions monthly for the first 6 months and quarterly thereafter. The patients in the usual care group received care from nonphysician community health care providers or primary care physicians in township hospitals. The researchers conducted intention-to-treat analyses, with study outcomes compared between participants according to their village randomization.


Of the 33,995 participants, 95.3% were followed for clinical outcomes over a 36-month period. Average age was 63.0 years, 20.9% had a history of CVD, and 57.6% were taking antihypertensive medications at baseline. Characteristics between the two groups of nonphysician community health care providers were similar and had equivalent training prior to the study.

The intervention group had a net reduction in systolic BP -23 mm Hg (95% confidence interval [CI], 3.0-3.1) and in diastolic BP -9.9 mm Hg (10.6-9.3; p < 0.0001) with an average of 3.1 antihypertensive medications (95% CI, 3.0-3.1). In the usual care group, the systolic BP decreased from 155.4 mm Hg (standard deviation [SD], 17.3) to 147.6 mm (SD, 18.5) and diastolic BP decreased from 87.2 mm Hg to 82.3 mm Hg and took an average of 1.1 medications. Secondary outcomes were also reduced in the intervention group: myocardial infarction (hazard ratio, 0.77; 95% CI, 0.60–0.98; p = 0.037), stroke (0.66, 0.60–0.73; p < 0.0001), heart failure (0.58, 0.42–0.81; p = 0.0016), CVD death (0.70, 0.58–0.83; p < 0.0001), and all-cause mortality (0.85, 0.76–0.95; p = 0.0037). The risk reduction of the primary outcome was consistent across subgroups of age, sex, education, antihypertensive medication use, and baseline CVD risk. Hypotension was higher in the intervention than in the usual care group (1.75% vs. 0.89%; p < 0.0001).


The nonphysician community health care provider-led intensive BP intervention is effective in reducing CVD and death.


This large community-based study demonstrated the effectiveness of using nonphysician providers to initiate and titrate medications to reduce hypertension and improve overall CV health. This project implemented the use of a stepped-care protocol in conjunction with patient engagement with the use of home BP monitoring and lifestyle modification. Nonphysician community-based providers combined patient education with medication titration to achieve systolic BPs <130 mm Hg. The intervention group did have a higher incidence of hypotension, but <2%. This study demonstrates that the use of stepped-care protocols by nonphysician health care providers can achieve BP goals and improve overall CV outcomes.

Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension

Keywords: Antihypertensive Agents, Blood Pressure, Cardiovascular Diseases, Health Personnel, Heart Failure, Hypertension, Hypotension, Myocardial Infarction, Patient Care Team, Physicians, Primary Care, Secondary Prevention, Stroke

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