Improving Blood Pressure Management in Primary Care Patients with Chronic Kidney Disease: a Systematic Review of Interventions and Implementation Strategies



Chronic kidney disease (CKD) is widely prevalent, associated with morbidity and mortality, but may be lessened with timely implementation of evidence-based strategies including blood pressure (BP) control. Nonetheless, an evidence-practice gap persists. We synthesize the evidence for clinician-facing interventions to improve hypertension management in CKD patients in primary care.


Electronic databases and related publications were queried for relevant studies. We used a conceptual model to address heterogeneity of interventions. We conducted a quantitative synthesis of interventions on blood pressure (BP) outcomes and a narrative synthesis of other CKD relevant clinical outcomes. Planned subgroup analyses were performed by (1) study design (randomized controlled trials (RCTs) or nonrandomized studies (NRS)); (2) intervention type (guideline-concordant decision support, shared care, pharmacist-facing); and (3) use of behavioral/implementation theory.


Of 2704 manuscripts screened, 73 underwent full-text review; 22 met inclusion criteria. BP target achievement was reported in 15 and systolic BP reduction in 6 studies. Among RCTs, all interventions had a significant effect on BP control, (pooled OR 1.21; 95% CI 1.07 to 1.38). Subgroup analysis by intervention type showed significant effects for guideline-concordant decision support (pooled OR 1.19; 95% CI 1.12 to 1.27) but not shared care (pooled OR 1.71; 95% CI 0.96 to 3.03) or pharmacist-facing interventions (pooled OR 1.04; 95% CI 0.82 to 1.34). Subgroup analysis finding was replicated with pooling of RCTs and NRS. The five contributing studies showed large and significant reduction in systolic BP (pooled WMD − 3.86; 95% CI − 7.2 to − 0.55). Use of a behavioral/implementation theory had no impact, while RCTs showed smaller effect sizes than NRS.


Process-oriented implementation strategies used with guideline-concordant decision support was a promising implementation approach. Better reporting guidelines on implementation would enable more useful synthesis of the efficacy of CKD clinical interventions integrated into primary care.

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We acknowledge Aaron Leppin MD for the implementation science expertise and advice with the study.

Author information




CCK and BT are the guarantors of this review. CCK conceptualized, designed, and coordinated the study; did the title and abstract and full-text review, data abstraction, data coordination, and clean-up; and drafted the initial and final manuscript. BT designed and coordinated the study; did the title and abstract and full-text review and data abstraction; and helped revise the manuscript. CCD and MAL helped in the design of the study; did the title and abstract and full-text review and data abstraction; and helped revise the manuscript. RGM did full-text review and data abstraction. CCD and RGM also provided substantial input and revisions to later drafts of the manuscript. AP did data abstraction, data coordination, and clean-up. PJE was responsible for the search strategy and literature search. JM did the title and abstract and full-text review and data abstraction. ME and JD did data abstraction. MA and ZW conducted meta-analyses. NDS and HMM provided guidance in conceptualizing the study and provided feedback through the project. HMM also guided strategy for analyses and provided substantial input into revisions to the manuscript. All authors read, added final revisions, and approved the final manuscript.

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Correspondence to Celia C. Kamath PhD.

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Prior Presentations

This research was presented in two poster abstracts at the 11th Annual Conference on the Science of Dissemination & Implementation in Health, Academy Health; December 3–5, 2018, Washington DC.

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Kamath, C.C., Dobler, C.C., McCoy, R.G. et al. Improving Blood Pressure Management in Primary Care Patients with Chronic Kidney Disease: a Systematic Review of Interventions and Implementation Strategies. J GEN INTERN MED 35, 849–869 (2020).

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Key Words

  • chronic kidney disease
  • blood pressure control
  • primary care practitioner interventions
  • systematic review
  • guideline implementation
  • implementation strategies