Long-Term Follow-Up of integrated primary care models for essential hypertension
DOI:
https://doi.org/10.5281/zenodo.22813676Keywords:
hypertension, primary care, integrated care, team-based care, long-term follow-upAbstract
Background: Integrated primary care models combining registry-based recall, pharmacist- or nurse-led titration, and home blood-pressure telemonitoring have produced large early gains in hypertension control, but whether these gains are sustained over a multi-year horizon has been less well characterized.
Objective: This study reports a long-term follow-up of an integrated primary care hypertension program, examining control trajectories, cardiovascular and renal outcomes, and predictors of durable control.
Methods: Adults with essential hypertension enrolled in a multi-site integrated care program were followed for up to five years. Blood-pressure control was assessed annually; cardiovascular and renal outcomes and predictors of sustained control at final follow-up were analyzed with multivariable logistic regression.
Results: Control rose from 46% at enrollment to approximately 90% by year two among telemonitoring-enrolled participants and was largely sustained through year five; sustained early control was associated with fewer composite cardiovascular events over follow-up. Telemonitoring use, pharmacist-visit frequency, and registry-based recall independently predicted durable control, while comorbidity burden and low adherence predicted loss of control.
Conclusions: Blood-pressure control achieved through integrated primary care models can be sustained over the long term and is associated with reduced downstream cardiovascular and renal morbidity, supporting continued investment in multi-component integrated hypertension care.
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