Implementation of a Structured, Protocol-Based Hypertension Management Strategy in Romanian Primary Care: A Single-Arm Exploratory Study

Background: In Romania, blood pressure (BP) control remains suboptimal despite increasing treatment rates. Multicomponent interventions have been shown to improve BP control internationally but require adaptation for resource-constrained settings. This study assessed whether a structured intervention could improve BP control within the constraints of Romanian primary care. Methods: This single-arm exploratory study was conducted in a primary care practice in Târgu Mureș, Romania, and consecutively enrolled 500 adults with uncontrolled hypertension (≥140/90 mmHg). A 12-month follow-up was completed in October 2024. The intervention comprised culturally adapted counseling (five to seven minutes for uncontrolled BP and two to three minutes for controlled BP), protocol-guided medication optimization, and specialist referral when clinically indicated. The primary outcome was achievement of target BP <140/90 mmHg at 12 months. Results: Of the 500 enrolled participants with uncontrolled hypertension, 449 (89.8%) completed the 12-month follow-up. At study completion, 32.7% (95% confidence interval (CI) = 28.4-37.3) achieved target BP control, with mean reductions of 20.5 ± 9.2 mmHg in systolic BP and 10.3 ± 5.7 mmHg in diastolic BP. BP control rates differed substantially according to baseline hypertension severity, reaching 77.0% (95% CI = 69.6-84.3) among participants with Stage 1 hypertension compared with 15.5% (95% CI = 11.5-19.4) among those with Stage 2 hypertension (p < 0.001). In multivariable analysis, Stage 2 hypertension at baseline emerged as the strongest independent predictor of failure to achieve BP control (adjusted odds ratio (OR) = 0.05, 95% CI = 0.03-0.09; p < 0.001). Diabetes mellitus was associated with higher odds of BP control, although this association did not retain independent statistical significance after adjustment (adjusted OR = 1.64, 95% CI = 0.99-2.72; p = 0.055). Implementation of the structured intervention was associated with substantially higher rates of treatment optimization among participants who achieved BP control compared with those who remained uncontrolled (100% vs. 30.8%, p < 0.001). Conclusions: A structured, protocol-based approach to hypertension management was feasible in routine Romanian primary care and achieved clinically meaningful improvements in BP control. Treatment optimization emerged as the key process associated with successful outcomes. These findings support the potential of scalable, low-resource interventions to improve hypertension control, but require confirmation in controlled, multicenter studies before broader implementation.