Impact of Advanced Practice Nurses on Blood Pressure Control in Hypertension Management: A Scoping Review

doi:10.21203/rs.3.rs-4809148/v1

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Impact of Advanced Practice Nurses on Blood Pressure Control in Hypertension Management: A Scoping Review

https://doi.org/10.21203/rs.3.rs-4809148/v1

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Background: Hypertension is a major public health problem, with serious consequences in terms of morbidity and mortality. Its high prevalence makes it the leading chronic pathology in the world. Since the 1960s, advanced practice nurses have gradually emerged worldwide. With their wide range of skills, they play an increasingly important role in the management of hypertension. This scoping review aimed to map the literature about the impact of an advanced practice nurse intervention on blood pressure control in hypertension management and to identify research gaps.

Methods: A scoping review was carried out using Pubmed, CINHAL, Cairn, Embase, Cochrane and Google scholar databases. The major inclusion criterion was advanced practice nurse interventions including the ability to prescribe antihypertensive treatment (renewal +/- initiation).

Results: A total of 8 studies were included according to our eligibility criteria. All agreed on the significant benefits of an advanced practice nurse intervention on blood pressure control in hypertension management versus usual care or physician care only. The lack of literature and the poor quality of available data were deplored.

Conclusion: All references supported the hypothesis that advanced practice nurses can be a considerable lever to optimize blood pressure control in the overall hypertension management. Nevertheless, research of good methodological quality remains needed to draw any conclusion.

Advanced practice nurse

hypertension

control

scoping review

The International Council of Nurses (ICN) defined in 2008 the APN as a “registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice” (1). The ICN adapted this definition in 2020 and defined an APN as “ a generalist or specialized nurse who has acquired, through additional graduate education (minimum of a master’s degree), the expert knowledge base, complex decision-making skills and clinical competencies for Advanced Nursing Practice, the characteristics of which are shaped by the context in which they are credentialed to practice. The two most commonly identified APN roles are CNS and NP” (2).

The profession first appeared in the United States and has gradually been established in several countries over the years. To date, it is best established in English-speaking countries, but other countries are gradually catching up, with, for example, France who has implemented it since 2018 (second French-speaking country to implement the profession).

Hypertension is defined by a high blood pressure (BP) with a systolic BP (SBP) superior or equal to 140 mmHg and/or a diastolic BP (DBP) superior or equal to 90 mmHg (3). Called the "silent killer" because of its asymptomatic nature, this disease is a major cause of premature deaths worldwide and can lead to a variety of cardiovascular (CV) complications, including stroke, myocardial infarction and renal failure (4).

In March 2023, the World Health Organization estimated that 1.28 billion adults aged 30–79 years worldwide had HTN, most (two-thirds) living in low- and middle-income countries, making it the first chronic disease worldwide (5, 6). Almost half of adults with HTN (46%) were unaware of their condition. Among hypertensive adults, only 42% were diagnosed and treated, and only 21% were controlled. Considering this situation, one of the WHO’s global targets for no communicable diseases is to reduce the prevalence of hypertension by 33% between 2010 and 2030 (5). Literature highlighted some barriers to HTN control: medication adherence barriers, lifestyle-related barriers, barriers related to the affordability and accessibility of care, awareness-related barriers, and, finally, barriers related to prescribed pharmacotherapy (7). The alarming rates of screening, diagnosis and control could be explained by these factors, as well as by therapeutic inertia in the diagnosis and titration of treatment. The lack of medical time may also represent a considerable obstacle to therapeutic education, the keystone in the hypertension management to ensure good therapeutic adherence in this context of asymptomatic disease (8). The implementation of multi-disciplinary management could solve few of these barriers as medication adherence or even accessibility of care.

The role of nurses in the management of hypertension has considerably evolved over the last few decades, particularly with the emergence of the APN profession and its wide range of skills. In 2003, Bengston & al. reviewed studies on nursing in hypertension management over the period 1966–1997 to explore the role and skills of the nurse in hypertension management (9). A review of forty-two articles showed that the role of the nurse was described as a team member, an educator in non-pharmacological treatment and a translator for the physician, with a holistic and psychosocial approach. The involvement of a nurse in hypertension care led to a reduction in BP when patients lost weight, reduced their sodium intake, stopped smoking, increased their physical activity, took their medication more correctly and returned more frequently for follow-up visits. In 2016, Himmelfarb & al. also reviewed the role of nurse to improve hypertension care and control. They highlighted the evolution of nursing skills over the years with increasing independence in practice (10). As nurses' skills evolved through on-the-job training or graduation, their role in hypertension evolved to include physical assessment, medication and lifestyle prescribing, and greater independence in practice. The authors list the different competencies that may be included in the scope of nursing practice: (1) detection, referral and follow-up; (2) diagnosis and medication management; (3) patient education, counselling and skills enhancement; (4) care coordination; (5) clinic or office management; (6) population health management; and (7) performance measurement and quality improvement. This field of expertise may vary depending on the country and, where applicable, the degree. Nurses also play a major role in patient-centered multidisciplinary teams and these models of care have been shown improve care processes and control rates.

Design

This scoping review was conducted between May and June 2024 according to the Joanna Briggs Institute (JBI) evidence-implementation approach, as set out by Peters et al (11). Preliminary research showed a wide diversity of practice patterns for APNs on an international scale, resulting in a multitude of scopes of practices and modes of practice. Comparative trials focusing on these professionals therefore proposed a multitude of objectives, interventions, study populations and judgement criteria. In this context, as suggested by Peters et al. in their article published in 2015 to guide authors for conducting systematic scoping reviews, the latter seemed to be the most appropriate way of mapping the state of the literature on our subject because it is particularly useful when a the body of literature has not yet been comprehensively reviewed or exhibits a complex or heterogeneous nature not amenable to a more precise systematic review of the evidence (11).

Aim

This scoping review aimed to map the literature about the impact of an advanced practice nurse intervention on blood pressure control in hypertension management and to identify research gaps.

Search method

Six databases were used for this scoping review: Pubmed, CINHAL, Cairn, Embase, Cochrane and Google scholar. Research was firstly performed to identify the best MeSH terms and keywords to obtain reliable data about our topic. The search terms used included the following MeSH, keywords and Boolean terms: “advanced practice nurse” OR “nurse practitioner” OR “clinical nurse specialist” AND “hypertension” OR “blood pressure”.

Eligibility criteria

Given the heterogeneous nature of the skills of APNs, which can range from therapeutic education to physician referral, it was decided to limit references according to one major inclusion criterion: APN intervention including drug prescription.

Experimental studies were excluded if it was not possible (1) to clearly identify the APN’s intervention in the context of interventions carried out by a team of healthcare givers and/or (2) to evaluate it independently. References were also excluded if (1) nurse intervention was limited to non-pharmacological interventions to focus on those exploiting the widest range of APNs’ skills and/or (2) if the study population was not with hypertension, even if BP was an outcome of the study.

Filters were used according to databases’ options: MeSH terms/keywords included in title/abstract, free full text, English and French languages, adults aged 19 or more.

If any database contained more than 500 references, screening was stopped after a minimum of 50 consecutive irrelevant references.

Data extraction and analysis

A total of 757 references were suggested on the Embase database and 17 500 were suggested on the Google Scholar database. Screening was stopped after 50 consecutive irrelevant references. In the end, 300 references were reviewed in each of these two databases.

A total of 679 references were identified through database screening. Among the 312 references kept after exclusion of duplicates, 244 were excluded on reading the title/abstract by a first reviewer. The 68 last references were independently reviewed by two reviewers. Both came to a consensus on the eight references selected. A PRISMA flow diagram illustrated the systematic study selection process (Fig. 1).

Some references relating to the impact of APN intervention on BP control were not retained because the intervention was focused on cardiovascular prevention in patients with cardiovascular comorbidities but who were not necessarily hypertensive. The three main references will nevertheless be described in the discussion.

Eight references met the eligibility criteria and were finally used to elaborate this review.

A data extraction table was developed to synthetize the main information about these quantitative studies (Additional file 1). The table showed the title, the first author, the year of publication, the type of study and its level of evidence according to Evidence Based Medicine, the objectives, the populations, the interventions, the main results regarding to the aim of our review and the conclusion. In case of systematic reviews and meta-analyses, it also specified the number of studies included and, if necessary, the number of relevant studies regarding to the aim of our review.

This scoping review included two systematic reviews and meta-analyses (12, 13), three randomized controlled trials (RCT) (14–16) and three retrospective cohort studies (17–19). Note that Mundinger and Rudd’s RCTs were included in the Stephen’s systematic review and meta-analysis.

Our various quantitative studies included populations from the United States, England, New Zealand and China. Among our references: the two meta-analyses analyzed 33 RCTs (i.e. 18481 participants) and 11 RCTs (i.e. 4454 participants) respectively, the three RCTs had a total of 1,860 participants and the three retrospective cohort studies a total of 1062 participants (12–19). All references converged towards a common objective: to assess the impact of nursing intervention in the management of hypertension. This intervention was compared either with usual care (12, 16) or with care provided by physicians (14, 15, 17–19). Note that when “usual care" was described, it mostly consisted in physician’s management. All references assessed BP control using mean of SBP and DBP and/or rate of controlled BP.

The two following references compared an APN intervention group versus a control group with usual patterns of care.

The systematic review and meta-analysis, published by Clarck et al. in 2010, reviewed 33 RCTs that included an intervention delivered by nurses, nurse prescribers, or nurse practitioners designed to improve BP, compared with usual care (12). Depending on trials design, these nurse interventions could include the use of a treatment algorithm, nurse prescribing, telephone monitoring, community monitoring and nurse-led clinics.

In 2004, Rudd & al. published a RCT aimed to test the efficacy of a physician-directed, nurse-managed, home-based system for hypertension management with standardized algorithms to modulate drug therapy (16). This study was the only RCT in our review to compare a usual care + nurse managed care group versus a usual care only group. Nurse care management consisted in basic advice on patients' correct use of the automatic BP monitor, regular feedback of automatically printed BP reports, tips for enhancing drug adherence, and recognition of potential drug side effects. The nurse intervention consisted in a telephone follow-up with contacts after one week and after 1, 2 and 4 months (an average of 10 minutes, a total of 40 minutes). The nurse asked participants about the dosage of each medication and any problems encountered since the previous contact and encouraged them to ask questions or raise concerns. The nurse care manager contacted the doctors for authorization to introduce a new BP medication, but not for changes in medication dosage. In this case, the nurse manager implemented a management algorithm based on patients' current medications, laboratory values and BP measurements.

Both showed a significant benefit of an APN intervention compared to usual care in hypertension management:

- Systematic review and meta-analysis, Clarck et al. (12): greater reductions in SBP with a weighted mean difference of -8.2 mmHg with interventions that included a stepped treatment algorithm showed, greater reductions in both SBP and DBP with a weighted mean difference of -8.9 mmHg, and − 4.0 mmHg respectively with nurse prescribing, higher achievement of BP targets with a relative risk of 1.24 with telephone monitoring, and greater reductions in both SBP and DBP with a weighted mean difference of -4.8 mmHg and − 3.5 mmHg respectively with community monitoring.
- RCT, Rudd et al. (16): significant greater reductions in BP level at 6 months versus usual care with a decrease of SBP level (-14.2 mmHg versus − 5.7 mmHg, P < .01) and a decrease of DBP lever (-6.5 mmHg versus − 3.4 mmHg, P < .05). There was one or more changes in drug therapy in 97% of participants in the intervention group versus 43% in the control group. More patients received two or more drugs in the intervention group (70% versus 46% in the control group). The greater variety of BP drugs, the greater proportion of patients on antihypertensive therapy, and the progressive medication adjustment contributed to the superior outcomes in the intervention group. No significant adverse effects were found in either group. The intervention group showed a greater daily medication adherence was higher in the intervention group (80.5% versus 69.2%, P = 0.03). Pill-taking adherence assessed by the electronic drug event monitor remained high in both groups but reached statistically higher levels in the intervention group. Note that the study sample size of the RCT limited the power of the study. Indeed, out of a total of 1,580 patients, almost half of them (47%) were ineligible because they did not meet the inclusion criteria, 40% could not be contacted or refused to participate after being contacted, and 5% had mean baseline values below the criterion of 150 mmHg for SBP or 95 mmHg for DBP. Finally, study sample was limited to 150 patients, representing 10% of the selected population, for randomization.

These next quantitative studies compared an APN intervention group versus a control group with care provided by physicians.

A systematic review and meta-analysis, published by Stephen et al. in 2022, aimed to assess the impact of general practice nurse-led interventions for BP control and cardiovascular disease risk factor reduction in patients with hypertension (13). General practice nurses' intervention included prevention, diagnosis, therapeutic education, and treatment management with drug prescription and clinical examination.

In 2000, Mundinger & al. published a non-inferiority RCT aimed to compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit (14). According to their allocation, the patients became a part of the nurse practitioner or physician practices' regular patient panel. Intervention included appointments, care, and treatments in both groups.

Yip et al. published in 2018 a RCT aimed to evaluate whether nurse-led repeat prescription could provide non-inferior disease control and be accepted by Chinese patients with controlled hypertension in primary care clinics (15). Hypertensive adults were randomized to nurse or usual care group for regular clinical follow-up for 12 months. The non-inferiority margins for SBP and DBP were 6.6 mmHg and 3.7 mmHg respectively.

These three studies showed concordant results:

- Systematic review and meta-analysis, Stephen et al. (13): significant reductions in both SBP and DBP at 6 months or less (-6.29 mmHg and − 4.15 mmHg for SBP and DBP respectively). Results also showed improvement in treatment adherence and physical activity.
- RCT, Mudinger et al. (14): data showed no significant difference between the two groups for the SBP level (137 mmHg versus 139 mmHg, P = 0.28) but DBP level reading was significantly lower in intervention group (82 mmHg versus 85 mmHg, P = 0.04).
- RCT, Yip et al. (15): No significant difference was found in BP level between the two groups, and no adverse events were observed. The nurse-led repeat prescription was well accepted, and consulting APNs was not inferior to consulting a doctor for the hypertension management. Nevertheless, the need for further prescriptions may have been low because of the good control of hypertension. In consequence, consultation with a doctor may not have been necessary and these results may not be reproducible in a sample of uncontrolled hypertensive patients.

Three retrospective cohort studies with a lower level of evidence showed similar results (17–19). There were either significant differences in the reduction in SBP and DBP and better control of hypertension in favor of the APN group, or significant reductions between the beginning and end of the study in both groups with a significantly larger reduction in SBP in the experimental group. Participants were equivalent in terms of complexity of hypertension management and co-morbidities (or statistical analysis generated a comparability). The main retrospective cohort study, published by Wright et al. in 2011, had a sample of 684 participants and showed a rate of controlled hypertensives higher in the cohort followed by an APN (70.5% versus 63.2%), and a lower mean number of antihypertensive medications in the intervention group (1.6 versus 1.8, P = .01) (17). It should be noted that these two groups were not comparable initially but a propensity score analyses allowed us to obtain reliable results. In 1983, Reichgott & al. compared 3 groups in their retrospective cohort study: patients partially followed by the nurse (n = 168) (91%), patients followed only by the nurse (n = 94) (51%) and patients followed only by the doctor (n = 16) (9%) (18). Results showed a better BP control in patients managed jointly or solely by nurses (with physician supervision) than in patients managed solely by physicians. No change in SBP was found in the physician-only group but DBP was significantly higher than at the first visit (P < .05). Taylor et al. also showed in a retrospective cohort study, published in 2012, significant reductions in SBP and DBP, but the power of this study remained limited by the sample size of 100 participants (50 in each group) (19).

The authors of the systematic reviews and meta-analyses deplored the heterogeneity of interventions and the lack of high-quality evidence in this area, as well as the variation in outcome measures and ratios between the included studies. They highlighted the need for more research projects in this area (12, 13).

As a reminder, this scoping review aimed to map existing data about the impact of an APN intervention on BP control in hypertension management, focusing on studies with nursing interventions including prescribing skills to explore a range of advanced practice nursing skills. The eight references included in this scoping review showed concordant results and all agreed on the beneficial impact of APNs on BP control, despite heterogeneous levels of evidence.

This finding encourages us to think about the care pathways for hypertensive patients in the actual context of physician shortage. Greater involvement of APNs in the hypertension management could facilitate and extend the reach and scope of traditional healthcare in three interrelated ways. First, it would reduce the need for physicians to mediate the routine tasks of managing antihypertensive therapy. Second, the management system would encourage physicians to focus their energies on problem cases, such as those individuals who fail to achieve satisfactory control. Third, the management system would reinforce the value of collaboration among teams of health professionals (16). This type of care pathway is particularly relevant in regions where nurses provide a large proportion of healthcare. For example, in East Africa, where nurses provide 80% of healthcare, it would be a shame not to involve these health professionals in the management of the world's leading chronic disease (5, 20, 21).

For several years now, International and European Societies in Hypertension have agreed on the relevance of involving nurses (whether in advanced practice or not) in hypertension management. In 2020, the International Society of Hypertension (ISH) Guidelines Committee extracted evidence-based content presented in recently published guidelines and tailored and standards of care in a practical format that is easy-to-use by clinicians, but also nurses and community health workers, as appropriate (22). In its 2023 guidelines, the European Society of Hypertension (ESH) stated that long-term follow-up may be also carried out by no physician healthcare professionals, such as qualified nurses or pharmacists (3). This approach has already been adopted in some European and other countries, depending on the local organization of health resources. These initiatives demonstrate the place and the growing involvement of nurses, particularly APNs, in hypertension management.

Our review did not highlight the benefit of APNs in adherence to lifestyle recommendations. Only one systematic review and meta-analysis of our review showed improvements in physical activity, general lifestyle measures and medication adherence but results on improvements in diet and reductions in blood alcohol and smoking were inconclusive (13). These dimensions remained hard to evaluate. A systematic review and meta-analysis with 37 RCTs (i.e. 9731 participants) showed that nurse-led interventions (in advanced practice or not) improved diet and physical activity; however, the effect on smoking and alcohol consumption was inconsistent across studies (23). In general, the impact of nursing intervention seems beneficial in terms of optimizing diet and physical activity, but the impact on smoking and alcohol consumption remains difficult to assess.

The effect of patients' knowledge of hypertension and associated risk factors requires further study, and the authors again deplore the lack of evidence.

Beyond hypertension management, the literature tends to show a beneficial impact of APNs in cardiovascular prevention, although the lack of data does not allow us to draw any conclusions. The Community Outreach and Cardiovascular Health (COACH) trial aimed to evaluate the effectiveness of a comprehensive cardiovascular disease risk reduction program delivered by nurse practitioner / community health workers teams versus enhanced usual care to improve lipids, BP, HbA1c and patients' perception of the quality of their chronic illness care. The intervention included tailored educational and behavioral advice to modify lifestyle + pharmacological management (algorithms) and telephone follow-up between visits. Results showed a significant improvement at 12 months in total cholesterol (p < .001), LDL cholesterol (p < .001), BP (-6.2 mmHg, p = 0.003 for SBP and − 3.1 mmHg, p = 0.013 for DBP), HbA1c (p = 0.034) and patients’ perceived quality of care for their chronic disease (24). A systematic review and meta-analysis analyzed 11 RCTs to assess the impact of physician-nurse substitution in primary care on clinical parameters (25). Data showed a significant diminution of SBP (-4.27 mmHg, p < .001). Trained APNs appeared to be more effective than doctors in lowering SBP, but similar in lowering DBP, total cholesterol or HbA1c. The authors deplored, however, the lack of evidence to conclude that nursing care leads to better outcomes in terms of clinical parameters than care provided by physicians. Another more recent systematic review and meta-analysis aimed to assess the impact of nurse practitioner-led cardiovascular care (26). The analysis of five RCTS showed a reduction in Framingham risk score of 12% but no statistical difference between nurse practitioner care and usual care for 30-day readmissions, health-related quality of life and length of stay. Here again, the authors deplored the few RCTs evaluating CV care by APNs in the literature and the low to medium quality evidence identified. Despite being insufficient and of poor quality, these data encourage us to think that the added value of APNs is not limited solely to BP control in the hypertension management but could also optimize the global cardiovascular prevention of these patients.

Only one study was found in literature about the impact of APN intervention on cardiovascular morbidity and mortality among hypertensive adults. This RCT, published in June 2024 in the JAMA, aimed to assess the impact of a nonphysician community health care practitioner–led, multifaceted, intensive BP (BP < 130/80 mmHg) intervention in younger (< 60 years old) and older (≥ 60 years old) individuals with hypertension on cardiovascular morbidity and mortality (27). The nonphysician community health care practitioner had similar skills than APNs, including prescribing skills. In both the aging and younger general population with hypertension, the nonphysician health care practitioner–led intervention did effectively and safely reduce the risk of CV disease and all-cause death. Authors concluded that this effective, feasible, and sustainable strategy should be integrated into hypertension control programs in low-resource settings in China and worldwide for both the older-age and younger population with hypertension.

Strengths and Limitations

Literature was the main limitation of our scoping review, given the lack of data and the poor quality of existing ones. Over and above this observation in the context of this scoping review, several authors made the same observation, sometimes failing to meet all their objectives due to a lack of relevant data.

Another major limitation noted during our preliminary research review was the diversity of interventions found in literature from therapeutic education or phone calls to substitution of physicians in global hypertension management. This diversity made it difficult to estimate the APNs’ impact with a clear vision of their skills and responsibilities in hypertension management. This is due to the profession itself and its field of competence, which can vary considerably from one healthcare system to another. We chose to limit studies with an APN intervention including prescribing ability, to ensure a degree of homogeneity in the interventions.

Moreover, our preliminary research showed that many studies aimed to evaluate the interventions of teams of health professionals including APNs, which did not allow us to evaluate the impact of the APN alone. Finally, even if the APN intervention met our criteria, the study population did not necessarily meet the major criterion of being with hypertension. Only one study could be included in this context because data about the impact of the APN intervention on BP control were available in a subgroup of hypertensive participants. We also chose to limit inclusion to hypertension management to focus on a specific population and obtain more accurate results.

These strategies enabled us to obtain easy-to-read and more specific results on the existing literature and research gaps concerning the impact of APNs with a specific area of skills on BP control in hypertension management, which is the main strength of our exploratory study.

Perspectives

The lack of data and its low level of evidence throughout this scoping review demonstrated the need for research. In 1976, the Taskforce on the Role of Nursing in High BP Control affirmed the importance of conducting research to learn more about nursing interventions to improve hypertension control (28). Although progress has been made since this publication, Hannan & al. launched an urgent call to action for nurses in 2022 to improve hypertension control and cardiovascular health in which they provided information and resources to respond to this call, including research (29). They called on nurse researchers to address current challenges in cardiovascular health and hypertension control, prioritizing research where there is insufficient evidence to guide practice. Nursing researchers were invited to collaborate with nursing educators and nurses with PhDs in nursing to ensure that research findings are implemented in clinical practice without delay. They proposed priority research themes on cardiovascular disease and hypertension, including the development of RCTs aimed to improve hypertension control and cardiovascular risk, and the dissemination and implementation of studies to accelerate the transposition of evidence-based interventions to control hypertension and prevent cardiovascular disease in real clinical settings.

Many themes remain to be explored beyond those outlined in our review. For example, it would be interesting to conduct more studies to assess the cost-effectiveness of care pathways for hypertensive patients with APNs providing long-term follow-up visits and doctors providing complex management. APNs could also bring an important contribution in hypertension management via telemedicine, using tele-health technologies in combination with patient empowerment. Further development of this approach can be expected to make an important addition to follow-up hypertension management in the future (3).

Note that in addition to their clinical roles, nurses lead clinic and community-based research to improve the quality gap in hypertension management by holistically examining social, cultural, economic, and behavioral determinants of hypertension outcomes and designing culturally sensitive interventions to address these determinants (10). Nurse-led clinics and team models of care and research have also contributed to increasing the number of patients receiving high-quality hypertension care and control. Here too, more data are needed to shed light on all these initiatives.

Most of our data came from English-speaking countries. This scoping review highlighted a lack of data in some regions, particularly in Europe. It can be explained by the fact that the APN profession is best established in these regions to date. Other countries are gradually catching up, but research remain needed to demonstrate the benefit of APNs on hypertension control and, more broadly, on cardiovascular morbidity and mortality to encourage its implementation, especially in these regions.

This scoping review highlighted the significant benefit of APN intervention on BP control in hypertension management but also revealed a lack of data, particularly of good quality. Given the available data, APNs could provide considerable leverage in optimizing the management of the world's leading chronic disease. Good quality methodological research is still needed to provide reliable and relevant data to further demonstrate the benefit of APNs in the control of hypertension, and beyond, in cardiovascular morbidity and mortality. These findings could enhance their role in international and European guidelines for the hypertension management and strengthen the establishment of the profession internationally.

APN

Advanced Practice Nurse

(S/D)BP

(Systolic/Diastolic) Blood Pressure

ESH

European Society of Hypertension

ICN

International Council of Nurses

ISH

International Society of Hypertension

LDL

Low-Density Lipoproteine

WHO

World Health Organization

HTN

Hypertension

RCT

Randomized Controlled Trial

Ethics approval and consent to participate:
Not applicable.

Consent for publication:
Not applicable.

Availability of data and materials:
All data generated or analysed during this study are included in this published article [and its supplementary information files].

Competing interests:
The authors declare that they have no competing interests.

JV reports, outside the submitted work, financial support from Boston Scientific SAS, Vitalaire, and AstraZeneca.

HL reports, outside the submitted work, financial support from Servier and Abbott France.

JB reports, outside the submitted work, compensations as speaker/chairman/ consultant/educational activities from Astrazeneca, Bayer, ElKendi, Galapagos, Hikma, Leurquin, Omron, Organon, Sanofi Aventis, Viiv, Vivactis, Vivoptim the last 2 years.

Funding:
None.

Authors' contributions:
JV conducted this scoping review. HL provided a review of references. JB supervised the scoping review. All authors reviewed the manuscript.

Aknowledgements:
Not applicable.

Aguilard S, Colson S, Inthavong K. Advanced practice nursing implementation strategies in hospital: a review of the literature. Sante Publique Vandoeuvre–Nancy Fr. 2017;29(2):241–54.
International council of nurses. Guidelines on advanced practice nursing 2020 [Internet]. 2020. https://www.icn.ch/resources/publications-and-reports/guidelines-advanced-practice-nursing-2020
Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, Januszewicz A, et al. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens. 2023;41(12):1874–2071.
World Health Organization. A global brief on hypertension: silent killer, global public health crisis: World Health Day 2013 [Internet]. 2013 [cited 2023 Feb 4]. https://www.who.int/publications-detail-redirect/a-global-brief-on-hypertension-silent-killer-global-public-health-crisis-world-health-day-2013
World Health Organization W. Hypertension [Internet]. 2023 [cited 2023 Jun 27]. https://www.who.int/news-room/fact-sheets/detail/hypertension
Olsen MH, Angell SY, Asma S, Boutouyrie P, Burger D, Chirinos JA, et al. A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension. Lancet. 2016;388(10060):2665–712.
Elnaem MH, Mosaad M, Abdelaziz DH, Mansour NO, Usman A, Elrggal ME, et al. Disparities in Prevalence and Barriers to Hypertension Control: A Systematic Review. Int J Environ Res Public Health. 2022;19(21):14571.
Grave C, Gautier A, Gane J, Gabet A, Lacoin F, Olié V, Prévention. Dépistage et prise en charge de l’HTA en France, le point de vue des médecins généralistes, France, 2019. BEH [Internet]. 2019; file:///C:/Users/4027850/AppData/Local/Temp/283648_spf00001637-1.pdf
Bengtson A, Drevenhorn E. The nurse’s role and skills in hypertension care: a review. Clin Nurse Spec CNS. 2003;17(5):260–8.
Himmelfarb CRD, Commodore-Mensah Y, Hill MN. Expanding the Role of Nurses to Improve Hypertension Care and Control Globally. Ann Glob Health. 2016;82(2):243–53.
Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. JBI Evid Implement. 2015;13(3):141.
Clark CE, Smith LFP, Taylor RS, Campbell JL. Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis. BMJ. 2010;341:c3995.
Stephen C, Halcomb E, Fernandez R, McInnes S, Batterham M, Zwar N. Nurse-led interventions to manage hypertension in general practice: A systematic review and meta-analysis. J Adv Nurs. 2022;78(5):1281–93.
Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai WY, Cleary PD, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA. 2000;283(1):59–68.
Yip BHK, Lee EKP, Sit RWS, Wong C, Li X, Wong ELY, et al. Nurse-led hypertension management was well accepted and non-inferior to physician consultation in a Chinese population: a randomized controlled trial. Sci Rep. 2018;8(1):10302.
Rudd P, Miller NH, Kaufman J, Kraemer HC, Bandura A, Greenwald G, et al. Nurse management for hypertension. A systems approach. Am J Hypertens. 2004;17(10):921–7.
Wright WL, Romboli JE, DiTulio MA, Wogen J, Belletti DA. Hypertension treatment and control within an independent nurse practitioner setting. Am J Manag Care. 2011;17(1):58–65.
Reichgott MJ, Pearson S, Hill MN. The Nurse Practitioner’s Role in Complex Patient Management: Hypertension. J Natl Med Assoc. 1983;75(12):1197–204.
Taylor D, van der Merwe V, van der Merwe W. Nurse titration clinics to achieve rapid control of blood pressure. N Z Med J. 2012;125(1355):31–40.
Spies LA, Bader SG, Opollo JG, Gray J. Nurse-Led Interventions for Hypertension: A Scoping Review With Implications for Evidence-Based Practice. Worldviews Evid Based Nurs. 2018;15(4):247–56.
Zhou B, Carrillo-Larco RM, Danaei G, Riley LM, Paciorek CJ, Stevens GA, et al. Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. Lancet. 2021;398(10304):957–80.
Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension global hypertension practice guidelines. J Hypertens. 2020;38(6):982–1004.
Bulto L, Roseleur J, Noonan S, Pinero De Plaza A, Champion S, Dafny HA, et al. Effectiveness of nurse-led interventions to manage hypertension and lifestyle behaviour effectively: a systematic review and meta-analysis. Europace. 2023;25(Suppl 1):euad122763.
Jerilyn K, Allen, Dennison-Himmelfarb CR, Szanton SL, Bone L, Hill MN, Levine DM, et al. Community Outreach and Cardiovascular Health (COACH) Trial: a randomized, controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers. Circ Cardiovasc Qual Outcomes. 2011;4(6):595–602.
Martínez-González NA, Tandjung R, Djalali S, Huber-Geismann F, Markun S, Rosemann T. Effects of Physician-Nurse Substitution on Clinical Parameters: A Systematic Review and Meta-Analysis. PLoS ONE. 2014;9(2):e89181.
Smigorowsky MJ, Sebastianski M, Sean McMurtry M, Tsuyuki RT, Norris CM. Outcomes of nurse practitioner-led care in patients with cardiovascular disease: A systematic review and meta-analysis. J Adv Nurs. 2020;76(1):81–95.
Guo X, Ouyang N, Sun G, Zhang N, Li Z, Zhang X et al. Multifaceted Intensive Blood Pressure Control Model in Older and Younger Individuals With Hypertension: A Randomized Clinical Trial. JAMA Cardiol [Internet]. 2024 Jun 18 [cited 2024 Jul 22]; https://doi.org/10.1001/jamacardio.2024.1449
National Institutes Of Health, et al, et al. Nursing Education in High Blood Pressure Control. Report of the Task Force on the Role of Nursing in High Blood Pressure Control. ERIC Clearinghouse; 1976.
Hannan JA, Commodore-Mensah Y, Tokieda N, Smith AP, Gawlik KS, Murakami L, et al. Improving hypertension control and cardiovascular health: An urgent call to action for nursing. Worldviews Evid Based Nurs. 2022;19(1):6–15.

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Impact of Advanced Practice Nurses on Blood Pressure Control in Hypertension Management: A Scoping Review

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