Quality Improvement Strategies for Hypertension Management

A Brief, Multifaceted, Generic Intervention to Improve Blood Pressure Control and Reduce Disparities Had Little Effect

BACKGROUND

Poor blood pressure (BP) control and racial disparities therein may be a function of clinical inertia and ineffective communication about BP care.

METHODS

We compared two different interventions (electronic medical record reminder for BP care (Reminder only, [RO]), and clinician training on BP care-related communication skills plus the reminder (Reminder + Training, [R+T]) with usual care in three primary care clinics, examining BP outcomes among 8,866 patients, and provider-patient communication and medication adherence among a subsample of 793.

RESULTS

Clinician counseling improved most at R+T. BP improved overall; R+T had a small but significantly greater reduction in diastolic BP (DBP; -1.7 mm Hg). White patients at RO experienced greater overall improvements in BP control. Site and race disparities trends suggested that disparities decreased at R+T, either stayed the same or decreased at Control; and stayed the same or increased at RO.

CONCLUSIONS

More substantial or racial/ethnically tailored interventions are needed.

Adherence to Treatment in Hypertension

The lack of adherence to treatment in hypertension affects approximately 30 % of patients. The elderly, those with several co-morbidities, social isolation, low incomes or depressive symptoms are the most vulnerable to this problem. There is no ideal method to quantify the adherence to the treatment. Indirect methods are recommended in clinical practice. Any intervention strategy should not blame the patient and try a collaborative approach. It is recommended to involve the patient in decision-making. The clinical interview style must be patient-centered including motivational techniques. The improvement strategies that showed greater effectiveness in the compliance of hypertension treatment were: treatment simplification, appointment reminders systems, blood pressure self-monitoring, organizational improvements and nurse and pharmacists care. The combination of different interventions are recommended against isolated interventions.

Population Care Management and Team-Based Approach to Reduce Racial Disparities among African Americans/Blacks with Hypertension

OBJECTIVES

At Kaiser Permanente, national Equitable Care Health Outcomes (ECHO) Reports with a baseline measurement of 16 Healthcare Effectiveness Data and Information Set measures stratified by race and ethnicity showed a disparity of 8.1 percentage points in blood pressure (BP) control rates between African- American/black (black) and white members. The aims of this study were to describe a population care management team-based approach to improve BP control for large populations and to explain how a culturally tailored, patient-centered approach can address this racial disparity.

METHODS

These strategies were implemented through: 1) physician-led educational programs on treatment intensification, medication adherence, and consistent use of clinical practice guidelines; 2) building strong care teams by defining individual roles and responsibilities in hypertension management; 3) redesign of the care delivery system to expand access; and 4) programs on culturally tailored communication tools and self-management.

RESULTS

At a physician practice level where 65% of patients with hypertension were black, BP control rates (< 140/90 mmHg) for blacks improved from 76.6% to 81.4%, and control rates for whites increased from 82.9% to 84.2%. The racial gap narrowed from 6.3% to 2.8%. As these successful practices continue to spread throughout the program, the health disparity gap in BP control has decreased by 50%, from 8.1% to 3.9%.

CONCLUSION

A sustainable program to collect self-reported race, ethnicity, and language preference data integrated with successful population care management programs provided the foundation for addressing health disparities. Cultural tailoring of a multilevel team-based approach closed the gap for blacks with hypertension.

Challenges and opportunities for implementation of interventions to prevent and control CVD in low-resource settings: a report from CESCAS in Argentina

In Argentina, cardiovascular diseases cause an estimated 100,000 deaths and more than 250,000 coronary heart disease and stroke events annually, at a cost of more than $1 billion international dollars. Despite progress in the implementation of several programs to combat noncommunicable diseases in Argentina over the past few years, most health resources are still dedicated to infectious diseases and maternal and child health. The Institute for Clinical Effectiveness and Health Policy, an independent academic institution affiliated with the University of Buenos Aires medical school, runs the South American Centre of Excellence in Cardiovascular Health (CESCAS), a center devoted to epidemiology, implementation, and policy research. At the CESCAS, there are 3 ongoing randomized clinical trials focused on implementation science: 1) a mobile health intervention, for preventing the progression of prehypertension in low-income, urban settings in Argentina, Guatemala, and Peru; 2) a comprehensive approach to preventing and controlling hypertension in low-resource settings in Argentina; and 3) an educational approach to improving physicians' effectiveness in the detection, treatment, and control of hypercholesterolemia and high cardiovascular disease risk in low-resource settings in Argentina. All of these trials involve the design and implementation of complex interventions for changing the behaviors of providers and patients. The rationale of each of the 3 studies, the design of the interventions, and the evaluation of processes and outcomes are described in this article, together with the barriers and enabling factors associated with implementation-research studies. There is a strong need in Argentina and all of Latin America for building the health-research capacity and infrastructure necessary for undertaking implementation studies that will translate evidence from research findings into improvements in health policy and practice with regard to cardiovascular diseases and their risk factors.

A Successful Multifaceted Trial to Improve Hypertension Control in Primary Care: Why Did it Work?

BACKGROUND

It is important to understand which components of successful multifaceted interventions are responsible for study outcomes, since some components may be more important contributors to the intervention effect than others.

OBJECTIVE

We conducted a mediation analysis to determine which of seven factors had the greatest effect on change in systolic blood pressure (BP) after 6 months in a trial to improve hypertension control.

DESIGN

The study was a preplanned secondary analysis of a cluster-randomized clinical trial. Eight clinics in an integrated health system were randomized to provide usual care to their patients (n = 222), and eight were randomized to provide a telemonitoring intervention (n = 228).

PARTICIPANTS

Four hundred three of 450 trial participants completing the 6-month follow-up visit were included.

INTERVENTIONS

Intervention group participants received home BP telemonitors and transmitted measurements to pharmacists, who adjusted medications and provided advice to improve adherence to medications and lifestyle modification via telephone visits.

MAIN MEASURES

Path analytic models estimated indirect effects of the seven potential mediators of intervention effect (defined as the difference between the intervention and usual care groups in change in systolic BP from baseline to 6 months). The potential mediators were change in home BP monitor use, number of BP medication classes, adherence to BP medications, physical activity, salt intake, alcohol use, and weight.

KEY RESULTS

The difference in change in systolic BP was 11.3 mmHg. The multivariable mediation model explained 47 % (5.3 mmHg) of the intervention effect. Nearly all of this was mediated by two factors: an increase in medication treatment intensity (24 %) and increased home BP monitor use (19 %). The other five factors were not significant mediators, although medication adherence and salt intake improved more in the intervention group than in the usual care group.

CONCLUSIONS

Most of the explained intervention effect was attributable to the combination of self-monitoring and medication intensification. High adherence at baseline and the relatively low intensity of resources directed toward lifestyle change may explain why these factors did not contribute to the improvement in BP.

Value of a facilitated quality improvement initiative on cardiovascular disease risk: findings from an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events (AT GOAL)

RATIONALE, AIMS AND OBJECTIVES

In the United States, cardiovascular disease (CVD) is the leading cause of death. The US Centers for Disease Control and Prevention contracted an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events (AT GOAL) programme as part of its effort to identify strategies to address CVD risk factors.

METHODS

This study analysed patient-level data from 7527 patients in 43 primary care practices. The researchers assessed average change in control rates for CVD-related measures across practices, and then across patients between baseline and a patient's last visit during the practice's tenure in the programme (referred to as 'end line') using repeated measures analysis of variance and random effects generalized least squares, respectively.

RESULTS

Among non-diabetic patients, there were significant increases in control rates for overall blood pressure (74.3% to 78.0%, P = 0.0002), systolic blood pressure (70.3% to 80.6%, P = 0.0099), diastolic blood pressure (90.1% to 92.7%, P = 0.0001) and low-density lipoprotein (LDL; 48.6% to 53.1%, P = 0.0001) between baseline and end line. Among diabetic patients, there was a significant increase in diastolic blood pressure control (59.8% to 61.9%, P = 0.0141). While continuous CVD-related outcomes show an overall trend between baseline and end line, patients with uncontrolled measures at baseline showed a decrease between baseline and end line relative to their counterparts who were controlled at baseline.

CONCLUSIONS

Findings from the AT GOAL evaluation support the value of a facilitated quality improvement (QI) initiative on managing CVD risk.

Effect of Disease Improvement with Self-Measurement Compliance (Measurement Frequency Level) in SmartCare Hypertension Management Service

BACKGROUND

This study's purpose was to analyze the effect of the SmartCare pilot project, which was conducted in 2011 in South Korea. Recent studies of telehealth mostly compare the intervention group and the control group. Therefore, it is necessary to analyze the disease improvement effect depending on the self-measurement compliance (measurement frequency level) of patients who are receiving the hypertension management services.

MATERIALS AND METHODS

In the SmartCare center, health managers (nurses, nutritionists, and exercise prescribers) monitored the measurement data transmitted by participants through the SmartCare system. The health managers provided the prevention, consultation, and education services remotely to patients. Of the 231 participants who were enrolled in the study, the final analysis involved 213 individuals who completed their blood pressure measurements and SmartCare services until the end of a 6-month service period. The evaluated measurement group was classified into three groups (Low, Middle, and High) by evenly dividing the monthly average frequency of measurement for 6 months. The evaluation indices were systolic blood pressure (SBP), diastolic blood pressure (DBP), weight, and body mass index (BMI); this information was transmitted through the SmartCare system.

RESULTS

For changes in the evaluation indices after 6 months compared with the initial baseline, in the Low Group, SBP and DBP slightly decreased, and weight and BMI slightly increased (difference not statistically significant). In the Middle Group, SBP and DBP decreased slightly (difference not statistically significant); however, both weight and BMI decreased (difference statistically significant). In the High Group, SBP, DBP, weight, and BMI decreased (difference statistically significant).

CONCLUSIONS

Patients who received the SmartCare services with higher measurement frequency levels at home showed greater effectiveness regarding the provided services compared with those patients with lower levels of BP, weight, and BMI control.

Integrating empowerment evaluation and quality improvement to achieve healthcare improvement outcomes

While the body of evidence-based healthcare interventions grows, the ability of health systems to deliver these interventions effectively and efficiently lags behind. Quality improvement approaches, such as the model for improvement, have demonstrated some success in healthcare but their impact has been lessened by implementation challenges. To help address these challenges, we describe the empowerment evaluation approach that has been developed by programme evaluators and a method for its application (Getting To Outcomes (GTO)). We then describe how GTO can be used to implement healthcare interventions. An illustrative healthcare quality improvement example that compares the model for improvement and the GTO method for reducing hospital admissions through improved diabetes care is described. We conclude with suggestions for integrating GTO and the model for improvement.

Understanding the modifiable health systems barriers to hypertension management in Malaysia: a multi-method health systems appraisal approach

Background

The growing burden of non-communicable diseases in middle-income countries demands models of care that are appropriate to local contexts and acceptable to patients in order to be effective. We describe a multi-method health system appraisal to inform the design of an intervention that will be used in a cluster randomized controlled trial to improve hypertension control in Malaysia.

Methods

A health systems appraisal was undertaken in the capital, Kuala Lumpur, and poorer-resourced rural sites in Peninsular Malaysia and Sabah. Building on two systematic reviews of barriers to hypertension control, a conceptual framework was developed that guided analysis of survey data, documentary review and semi-structured interviews with key informants, health professionals and patients. The analysis followed the patients as they move through the health system, exploring the main modifiable system-level barriers to effective hypertension management, and seeking to explain obstacles to improved access and health outcomes.

Results

The study highlighted the need for the proposed intervention to take account of how Malaysian patients seek treatment in both the public and private sectors, and from western and various traditional practitioners, with many patients choosing to seek care across different services. Patients typically choose private care if they can afford to, while others attend heavily subsidised public clinics. Public hypertension clinics are often overwhelmed by numbers of patients attending, so health workers have little time to engage effectively with patients. Treatment adherence is poor, with a widespread belief, stemming from concepts of traditional medicine, that hypertension is a transient disturbance rather than a permanent asymptomatic condition. Drug supplies can be erratic in rural areas. Hypertension awareness and education material are limited, and what exist are poorly developed and ineffective.

Conclusion

Despite having a relatively well funded health system offering good access to care, Malaysia's health system still has significant barriers to effective hypertension management.

Discussion

The study uncovered major patient-related barriers to the detection and control of hypertension which will have an impact on the design and implementation of any hypertension intervention. Appropriate models of care must take account of the patient modifiable health systems barriers if they are to have any realistic chance of success; these findings are relevant to many countries seeking to effectively control hypertension despite resource constraints.

Evaluation of the quality of care of a multi-disciplinary Risk Factor Assessment and Management Programme for Hypertension (RAMP-HT)

BACKGROUND

There is some evidence to support a risk-stratified, multi-disciplinary approach to manage patients with hypertension in primary care. The aim of this study is to evaluate the quality of care (QOC) of a multi-disciplinary Risk Assessment and Management Programme for Hypertension (RAMP-HT) for hypertensive patients in busy government-funded primary care clinics in Hong Kong. The objectives are to develop an evidence-based, structured and comprehensive evaluation framework on quality of care, to enhance the QOC of the RAMP-HT through an audit spiral of two evaluation cycles and to determine the effectiveness of the programme in reducing cardiovascular disease (CVD) risk.

METHOD/DESIGN

A longitudinal study is conducted using the Action Learning and Audit Spiral methodologies to measure whether pre-set target standards of care intended by the RAMP-HT are achieved. A structured evaluation framework on the quality of structure, process and outcomes of care has been developed based on the programme objectives and literature review in collaboration with the programme workgroup and health service providers. Each participating clinic is invited to complete a structure of care evaluation questionnaire in each evaluation cycle. The data of all patients who have enrolled into the RAMP-HT in the pre-defined evaluation periods are used for the evaluation of the process and outcomes of care in each evaluation cycle. For evaluation of the effectiveness of RAMP-HT, the primary outcomes including blood pressure (both systolic and diastolic), low-density lipoprotein cholesterol and estimated 10-year CVD risk of RAMP-HT participants are compared to those of hypertensive patients in usual care without RAMP-HT.

DISCUSSION

The QOC and effectiveness of the RAMP-HT in improving clinical and patient-reported outcomes for patients with hypertension in normal primary care will be determined. Possible areas for quality enhancement and standards of good practice will be established to inform service planning and policy decision making.

Evaluation of pharmacist care for hypertension in the Veterans Affairs patient-centered medical home: a retrospective case-control study

OBJECTIVE

The study objective was to evaluate a pharmacist hypertension care management program within the patient-centered medical home.

METHODS

This was a retrospective case-control study. Cases included all patients with hypertension who were referred to the care management program, and controls included patients with hypertension who were not referred to the program during the same 1-year period. Each case was matched to a maximum of 3 controls on the basis of primary care physician, age ±5 years, gender, diagnoses of diabetes and kidney disease, baseline systolic blood pressure ±10 mm Hg, and number of unique antihypertensive medications. Pharmacists provided a hypertension care management program under an approved scope of practice that allowed pharmacists to meet individually with patients, adjust medications, and provide patient education. Primary outcomes were systolic blood pressure and diastolic blood pressure at 6 and 12 months. Multivariate regression models compared each blood pressure end point between cases and controls adjusting for age, comorbidities, baseline blood pressure, and baseline number of blood pressure medications.

RESULTS

A total of 573 patients were referred to the hypertension program; 86% (465/543) had at least 1 matched control and were included as cases in the analyses; 3:1 matching was achieved in 90% (418/465) of cases. At baseline, cases and controls did not differ with respect to age, gender, race, or comorbidity; baseline blood pressure was higher (139.9/80.0 mm Hg vs 136.7/78.2 mm Hg, P ≤ .0002) in the cases compared with controls. Multivariate regression modeling identified significantly lower systolic blood pressure for the cases compared with controls at both 6 and 12 months (6-month risk ratio [RR], 9.7; 95% confidence interval [CI], 2.7-35.3; 12-month RR, 20.3; 95% CI, 4.1-99.2; P < .01 for both comparisons). Diastolic blood pressure was significantly lower at 12 months (RR, 2.9; 95% CI, 1.2-7.1; P < .01) but not at 6 months (RR, 1.0; 95% CI, 0.31-3.4; P = .9) for the cases compared with controls.

CONCLUSIONS

Patients who were referred to the pharmacist hypertension care management program had a significant improvement in most blood pressure outcomes. This program may be an effective method of improving blood pressure control among patients in a medical home model of primary care.

Initiatives to Enhance Primary Care Delivery: Two Examples from the Field

OBJECTIVES

Increasing demands on primary care providers have created a need for systems-level initiatives to improve primary care delivery. The purpose of this paper is to describe and present outcomes for two such initiatives: the Pennsylvania Academy of Family Physicians' Residency Program Collaborative (RPC) and the St. Johnsbury Vermont Community Health Team (CHT).

METHODS

Researchers conducted case studies of the initiatives using mixed methods, including: secondary analysis of program and electronic health record data, systematic document review and interviews.

RESULTS

RPC is a learning collaborative that teaches quality improvement and patient-centeredness to primary care providers, residents, clinical support staff, and administrative staff in residency programs. Results show that participation in a higher number of live learning sessions resulted in a significant increase in patient centered medical home recognition attainment and significant improvements in performance in diabetic process measures including eye exams (14.3%, p=0.004), eye referrals (13.82%, p=0.013), foot exams (15.73%, p=0.003), smoking cessation (15.83%, p=0.012), and self-management goals (25.45%, p=0.001). As a community-clinical linkages model, CHT involves primary care practices, community health workers (CHWs), and community partners. Results suggest that CHT members successfully work together to coordinate comprehensive care for the individuals they serve. Further, individuals exposed to CHWs experienced increased stability in access to health insurance (p=0.001) and prescription drugs (p=0.000), and the need for health education counseling (p=0.000).

CONCLUSION

Findings from this study indicate that these two system-level strategies have the promise to improve primary care delivery. Additional research can determine the extent to which these strategies can improve other health outcomes.

Effects of primary care team social networks on quality of care and costs for patients with cardiovascular disease

PURPOSE

Cardiovascular disease is the leading cause of mortality and morbidity in the United States. Primary care teams can be best suited to improve quality of care and lower costs for patients with cardiovascular disease. This study evaluates the associations between primary care team communication, interaction, and coordination (ie, social networks); quality of care; and costs for patients with cardiovascular disease.

METHODS

Using a sociometric survey, 155 health professionals from 31 teams at 6 primary care clinics identified with whom they interact daily about patient care. Social network analysis calculated variables of density and centralization representing team interaction structures. Three-level hierarchical modeling evaluated the link between team network density, centralization, and number of patients with a diagnosis of cardiovascular disease for controlled blood pressure and cholesterol, counts of urgent care visits, emergency department visits, hospital days, and medical care costs in the previous 12 months.

RESULTS

Teams with dense interactions among all team members were associated with fewer hospital days (rate ratio [RR] = 0.62; 95% CI, 0.50-0.77) and lower medical care costs (-$556; 95% CI, -$781 to -$331) for patients with cardiovascular disease. Conversely, teams with interactions revolving around a few central individuals were associated with increased hospital days (RR = 1.45; 95% CI, 1.09-1.94) and greater costs ($506; 95% CI, $202-$810). Team-shared vision about goals and expectations mediated the relationship between social network structures and patient quality of care outcomes.

CONCLUSIONS

Primary care teams that are more interconnected and less centralized and that have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost.

Nurse practitioner organizational climate in primary care settings: implications for professional practice

The expansion of the nurse practitioner (NP) workforce in primary care is key to meeting the increased demand for care. Organizational climates in primary care settings affect NP professional practice and the quality of care. This study investigated organizational climate and its domains affecting NP professional practice in primary care settings. A qualitative descriptive design, with purposive sampling, was used to recruit 16 NPs practicing in primary care settings in Massachusetts. An interview guide was developed and pretested with two NPs and in 1 group interview with 7 NPs. Data collection took place in spring of 2011. Individual interviews lasted from 30-70 minutes, were audio recorded, and transcribed. Data were analyzed using Atlas.ti 6.0 software by 3 researchers. Content analysis was applied. Three previously identified themes, NP-physician relations, independent practice and autonomy, and professional visibility, as well as two new themes, organizational support and resources and NP-administration relations emerged from the analyses. NPs reported collegial relations with physicians, challenges in establishing independent practice, suboptimal relationships with administration, and lack of support. NP contributions to patient care were invisible. Favorable organizational climates should be promoted to support the expanding of NP workforce in primary care and to optimize recruitment and retention efforts.

Treating complexity: collaborative care for multiple chronic conditions

Individuals with co-morbid chronic medical illness and psychiatric illness are a costly and complex patient population, at high risk for poor outcomes. Health-risk behaviours (e.g. smoking, poor diet, and sedentary lifestyle), side effects from psychiatric medications, and poor quality medical care all contribute to poor outcomes. Individuals with major depression die, on average, 5 to 10 years before their age-matched counterparts. For individuals with severe mental illness such as bipolar disorder or schizophrenia, life expectancy may be up to 20 years shorter. As the majority of this premature mortality is due to cardiovascular disease, there is a critical need to engage these individuals around the care of chronic medical illness.

Check it, change it: a community-based, multifaceted intervention to improve blood pressure control

BACKGROUND

Although home blood pressure (BP) monitoring interventions have shown potential in selected populations, it is unclear whether such strategies can be generalized. We sought to determine whether a multifaceted BP control program that uses a web-based health portal (Heart360), community health coaches, and physician assistant guidance could improve hypertension control in a diverse community setting.

METHODS AND RESULTS

Between September 12, 2010, and November 11, 2011 Check It, Change It, a community-based hypertension quality improvement program, enrolled 1756 patients with hypertension from 8 clinics in Durham County, NC. The Check It, Change It community intervention was evaluated using a prepost study design without a concurrent control. Participants were stratified into 3 tiers according to their initial BP: tier 0 (BP <140/90 mm Hg)=51% of population, tier 1 (BP=140/90-159/99 mm Hg)=30% of total, and tier 2 (BP ≥159/99 mm Hg)=19% of total. Overall, median age was 59 years (interquartile range, 49-69), 67% were female, and 76% black. After 6 months, the mean overall systolic BP declined 4.7 mm Hg. Rates of achieving target BP control (<140/90) increased overall from 51% at baseline to 63% by 6 months, and 69% had either reached their BP target or had reduced their baseline systolic BP by 10 mm Hg or more.

CONCLUSIONS

A multicomponent-tiered hypertension program was associated with improved BP control in a diverse community-based population.

Comprehensive approach for hypertension control in low-income populations: rationale and study design for the hypertension control program in Argentina

Although the efficacy and effectiveness of lifestyle modifications and antihypertensive pharmaceutical treatment for the prevention and control of hypertension and concomitant cardiovascular disease have been demonstrated in randomized controlled trials, this scientific knowledge has not been fully applied in the general population, especially in low-income communities. This article summarizes interventions to improve hypertension management and describes the rationale and study design for a cluster randomized trial testing whether a comprehensive intervention program within a national public primary care system will improve hypertension control among uninsured hypertensive men and women and their families. We will recruit 1,890 adults from 18 clinics within a public primary care network in Argentina. Clinic patients with uncontrolled hypertension, their spouses and hypertensive family members will be enrolled. The comprehensive intervention program targets the primary care system through health care provider education, a home-based intervention among patients and their families (home delivery of antihypertensive medication, self-monitoring of blood pressure [BP], health education for medication adherence and lifestyle modification) conducted by community health workers and a mobile health intervention. The primary outcome is net change in systolic BP from baseline to month 18 between intervention and control groups among hypertensive study participants. The secondary outcomes are net change in diastolic BP, BP control and cost-effectiveness of the intervention. This study will generate urgently needed data on effective, practical and sustainable intervention programs aimed at controlling hypertension and concomitant cardiovascular disease in underserved populations in low- and middle-income countries.

Under the same roof: co-location of practitioners within primary care is associated with specialized chronic care management

BACKGROUND

International and national bodies promote interdisciplinary care in the management of people with chronic conditions. We examine one facilitative factor in this team-based approach - the co-location of non-physician disciplines within the primary care practice.

METHODS

We used survey data from 330 General Practices in Ontario, Canada and New Zealand, as a part of a multinational study using The Quality and Costs of Primary Care in Europe (QUALICOPC) surveys. Logistic and linear multivariable regression models were employed to examine the association between the number of disciplines working within the practice, and the capacity of the practice to offer specialized and preventive care for patients with chronic conditions.

RESULTS

We found that as the number of non-physicians increased, so did the availability of special sessions/clinics for patients with diabetes (odds ratio 1.43, 1.25-1.65), hypertension (1.20, 1.03-1.39), and the elderly (1.22, 1.05-1.42). Co-location was also associated with the provision of disease management programs for chronic obstructive pulmonary disease, diabetes, and asthma; the equipment available in the centre; and the extent of nursing services.

CONCLUSIONS

The care of people with chronic disease is the 'challenge of the century'. Co-location of practitioners may improve access to services and equipment that aid chronic disease management.

A new model for nurse practitioner utilization in primary care: increased efficiency and implications

BACKGROUND

Nurse practitioners (NPs) play an important role in providing quality primary care. However, little is known about organizational processes that best utilize NPs in care delivery and what kind of resources and support NPs need to deliver quality care within their organizations. In primary care settings, NPs often receive little support from ancillary personnel compared with physicians.

PURPOSE

The aim of this article was to compare the productivity and cost efficiency of NP utilization models implemented in primary care sites with and without medical assistant (MA) support.

METHODOLOGY/APPROACH

We develop queueing models for these NP utilization models, of which the parameters are extracted from literature or government reports. Appropriate analyses are conducted to generate formulas and values for the productivity and cost efficiency. Sensitivity analyses are conducted to investigate different scenarios and to verify the robustness of findings.

FINDINGS

The productivity and cost efficiency of these models improve significantly if NPs have access to MA support in serving patients. On the basis of the model parameters we use, the average cost of serving a patient can be reduced by 9%-12% if MAs are hired to support NPs. Such improvements are robust across practice environments with different variability in provider service times. Improving provider service rate is a much more effective strategy to increase productivity compared with reducing the variability in provider service times.

PRACTICE IMPLICATIONS

To contain costs and improve the utilization of NPs in primary care settings, MA assistance for NPs is necessary.

Achieved blood pressures in the secondary prevention of small subcortical strokes (SPS3) study: challenges and lessons learned

BACKGROUND

Lowering blood pressure (BP) after stroke remains a challenge, even in the context of clinical trials. The Secondary Prevention of Small Subcortical Strokes (SPS3) BP protocol, BP management during the study, and achieved BPs are described here.

METHODS

Patients with recent symptomatic lacunar stroke were randomized to 1 of 2 levels of systolic BP (SBP) targets: lower: <130mm Hg, or higher: 130-149mm Hg. SBP management over the course of the trial was examined by race/ethnicity and other baseline conditions.

RESULTS

Mean SBP decreased for both groups from baseline to the last follow-up, from 142.4 to 126.7mm Hg for the lower SBP target group and from 143.6 to 137.4mm Hg for the higher SBP target group. At baseline, participants in both groups used an average of 1.7±1.2 antihypertensive medications, which increased to a mean of 2.4±1.4 (lower group) and 1.8±1.4 (higher group) by the end-study visit. It took an average of 6 months for patients to reach their SBP target, sustained to the last follow-up. Black participants had the highest proportion of SBP ≥150mm Hg at both study entry (40%) and end-study visit (17%), as compared with whites (9%) and Hispanics (11%).

CONCLUSIONS

These results show that it is possible to safely lower BP even to a SBP goal <130mm Hg in a variety of patients and settings, including private and academic centers in multiple countries. This provides further support for protocol-driven care in lowering BP and consequently reducing the burden of stroke.

[Implementation of ontology-based clinical decision support system for management of interactions between antihypertensive drugs and diet]

PURPOSE

The influence of dietary composition on blood pressure is an important subject in healthcare. Interactions between antihypertensive drugs and diet (IBADD) is the most important factor in the management of hypertension. It is therefore essential to support healthcare providers' decision making role in active and continuous interaction control in hypertension management. The aim of this study was to implement an ontology-based clinical decision support system (CDSS) for IBADD management (IBADDM). We considered the concepts of antihypertensive drugs and foods, and focused on the interchangeability between the database and the CDSS when providing tailored information.

METHODS

An ontology-based CDSS for IBADDM was implemented in eight phases: (1) determining the domain and scope of ontology, (2) reviewing existing ontology, (3) extracting and defining the concepts, (4) assigning relationships between concepts, (5) creating a conceptual map with CmapTools, (6) selecting upper ontology, (7) formally representing the ontology with Protégé (ver.4.3), (8) implementing an ontology-based CDSS as a JAVA prototype application.

RESULTS

We extracted 5,926 concepts, 15 properties, and formally represented them using Protégé. An ontology-based CDSS for IBADDM was implemented and the evaluation score was 4.60 out of 5.

CONCLUSION

We endeavored to map functions of a CDSS and implement an ontology-based CDSS for IBADDM.

Patient-related barriers to hypertension control in a Nigerian population

BACKGROUND

Hypertension control is a challenge globally. Barriers to optimal control exist at the patient, physician, and health system levels. Patient-related barriers in our environment are not clear. The aim of this study was to identify patient-related barriers to control of hypertension among adults with hypertension in a semiurban community in South-East Nigeria.

METHODS

This was a cross-sectional descriptive study of patients with a diagnosis of hypertension and on antihypertensive medication.

RESULTS

A total of 252 participants were included in the survey, and comprised 143 males (56.7%) and 109 females (43.3%). The mean age of the participants was 56.6±12.7 years, with a diagnosis of hypertension for a mean duration of 6.1±3.3 years. Among these patients, 32.9% had controlled blood pressure, while 39.3% and 27.8%, respectively, had stage 1 and stage 2 hypertension according to the Seventh Report of the Joint National Committee on Prevention, Detection and Evaluation of High Blood Pressure. Only 23.4% knew the consequences of poor blood pressure control and 64% were expecting a cure from treatment even when the cause of hypertension was not known. Furthermore, 68.7% showed low adherence to medication, the reported reasons for which included forgetfulness (61.2%), financial constraints (56.6%), high pill burden (22.5%), side effects of medication (17.3%), and low measured blood pressure (12.1%). Finally, knowledge and practice of the lifestyle modifications necessary for blood pressure control was inadequate among the participants.

CONCLUSION

Poor knowledge regarding hypertension, unrealistic expectations of treatment, poor adherence with medication, unawareness of lifestyle modification, and failure to apply these were identified as patient-related barriers to blood pressure control in this study.

Team-based care and improved blood pressure control: a community guide systematic review

CONTEXT

Uncontrolled hypertension remains a widely prevalent cardiovascular risk factor in the U.S. team-based care, established by adding new staff or changing the roles of existing staff such as nurses and pharmacists to work with a primary care provider and the patient. Team-based care has the potential to improve the quality of hypertension management. The goal of this Community Guide systematic review was to examine the effectiveness of team-based care in improving blood pressure (BP) outcomes.

EVIDENCE ACQUISITION

An existing systematic review (search period, January 1980-July 2003) assessing team-based care for BP control was supplemented with a Community Guide update (January 2003-May 2012). For the Community Guide update, two reviewers independently abstracted data and assessed quality of eligible studies.

EVIDENCE SYNTHESIS

Twenty-eight studies in the prior review (1980-2003) and an additional 52 studies from the Community Guide update (2003-2012) qualified for inclusion. Results from both bodies of evidence suggest that team-based care is effective in improving BP outcomes. From the update, the proportion of patients with controlled BP improved (median increase=12 percentage points); systolic BP decreased (median reduction=5.4 mmHg); and diastolic BP also decreased (median reduction=1.8 mmHg).

CONCLUSIONS

Team-based care increased the proportion of people with controlled BP and reduced both systolic and diastolic BP, especially when pharmacists and nurses were part of the team. Findings are applicable to a range of U.S. settings and population groups. Implementation of this multidisciplinary approach will require health system-level organizational changes and could be an important element of the medical home.

Improving hypertension self-management with community health coaches

Approximately two thirds of those older than 60 years have a hypertension diagnosis. The aim of our program, Health Coaches for Hypertension Control, is to improve hypertension self-management among rural residents older than 60 years through education and support offered by trained community volunteers called Health Coaches. Participants received baseline and follow-up health risk appraisals with blood work, educational materials, and items such as blood pressure monitors and pedometers. Data were collected at baseline, 8 weeks, and 16 weeks on 146 participants who demonstrated statistically significant increases in hypertension-related knowledge from baseline to 8 weeks that persisted at 16 weeks, as well as significant improvements in stage of readiness to change behaviors and in actual behaviors. Furthermore, clinically significant decreases in all outcome measures were observed, with statistically significant changes in systolic blood pressure (-5.781 mmHg; p = .001), weight (-2.475 lb; p < .001), and glucose (-5.096 mg/dl; p = .004) after adjusting for multiple comparisons. Although 40.4% of participants met the Healthy People 2020 definition of controlled hypertension at baseline, the proportion of participants meeting this definition at 16 weeks postintervention increased to 51.0%. This article describes a university-community-hospital system model that effectively promotes hypertension self-management in a rural Appalachian community.

Finding a BETTER way: a qualitative study exploring the prevention practitioner intervention to improve chronic disease prevention and screening in family practice

Background

Our randomized controlled trial (The BETTER Trial) found that training a clinician to become a Prevention Practitioner (PP) in family practices improved chronic disease prevention and screening (CDPS). PPs were trained on CDPS and provided prevention prescriptions tailored to participating patients. For this embedded qualitative study, we explored perceptions of this new role to understand the PP intervention.

Methods

We used grounded theory methodology and purposefully sampled participants involved in any capacity with the BETTER Trial. Two physicians and one coordinator in each of two cities (Toronto, Ontario and Edmonton, Alberta) conducted eight individual semi-structured interviews and seven focus groups. We used an interview guide and documented research activities through an audit trail, journals, field notes and memos. We analyzed the data using the constant comparative method throughout open coding followed by theoretical coding.

Results

A framework and process involving external and internal practice facilitation using the new role of PP was thought to impact CDPS. The PP facilitated CDPS through on-going relationships with patients and practice team members. Key components included: 1) approaching CDPS in a comprehensive manner, 2) an individualized and personalized approach at multiple levels, 3) integrated continuity that included linking the patients and practices to CPDS resources, and 4) adaptability to different practices and settings.

Conclusions

The BETTER framework and key components are described as impacting CDPS through a process that involved a new role, the PP. The introduction of a novel role of a clinician within the primary care practice with skills in CDPS could appropriately address gaps in prevention and screening.

The impact of a measurement and feedback intervention on blood pressure control in ambulatory cardiology practice

BACKGROUND

Although hypertension is a modifiable cardiovascular risk factor, up to one-third of ambulatory patients have uncontrolled blood pressure (BP). We evaluated the impact of a targeted provider feedback intervention on rates of BP control.

METHODS

Clinic BP readings were aggregated among approximately 3,000 hypertensive patients followed up in 42 outpatient cardiology clinic practices at a large quaternary care academic medical center. Physician practices received quarterly reports on BP control rates. Provider-specific reports were benchmarked vs overall peer performance and distributed quarterly between September 2011 and September 2012. Rates of BP control were evaluated before and after the intervention. Medical record reviews were performed for a subset of patients with uncontrolled BP before (n = 300) and after (n = 300) the intervention to evaluate provider responses and interventions.

RESULTS

At baseline, 27.9% of clinic patients had uncontrolled BP. After one 1 of reports, the rate of uncontrolled BP remained unchanged (27.7%, P = .86). Analysis of provider performance revealed a subset of providers who consistently outperform their peers. In the sample of patients selected for medical record reviews, at baseline (n = 300) and follow-up (n = 300), cardiologists discussed BP in 80% of clinic notes for patients with uncontrolled BP. Cardiologists more frequently documented repeat measurements after the intervention (28.0% vs 35.7%, P = .04). No other changes were found in documentation of provider responses to BP.

CONCLUSIONS

Clinician-specific audit and feedback reports as a stand-alone intervention did not affect overall BP control rates in cardiology clinics. Future BP control interventions should consider real-time patient-specific reminders, provider incentive programs, and patient engagement interventions.

Counseling African Americans to Control Hypertension: cluster-randomized clinical trial main effects

BACKGROUND

Data are limited on the implementation of evidence-based multilevel interventions targeted at blood pressure (BP) control in hypertensive blacks who receive care in low-resource primary care practices.

METHODS AND RESULTS

Counseling African Americans to Control Hypertension is a cluster-randomized clinical trial in which 30 community health centers were randomly assigned to the intervention condition (IC) or usual care (UC). Patients at the IC sites received patient education, home BP monitoring, and monthly lifestyle counseling, whereas physicians attended monthly hypertension case rounds and received feedback on their patients' home BP readings and chart audits. Patients and physicians at the UC sites received printed patient education material and hypertension treatment guidelines, respectively. The primary outcome was BP control, and secondary outcomes were mean changes in systolic and diastolic BPs at 12 months, assessed with an automated BP device. A total of 1059 patients (mean age, 56 years; 28% men, 59% obese, and 36% with diabetes mellitus) were enrolled. The BP control rate was similar in both groups (IC=49.3% versus UC=44.5%; odds ratio, 1.21 [95% confidence interval, 0.90-1.63]; P=0.21). In prespecified subgroup analyses, the intervention was associated with greater BP control in patients without diabetes mellitus (IC=54.0% versus UC=44.7%; odds ratio, 1.45 [confidence interval, 1.02-2.06]); and small-sized community health centers (IC=51.1% versus UC=39.6%; odds ratio, 1.45 [confidence interval, 1.04-2.45]).

CONCLUSIONS

A practice-based, multicomponent intervention was no better than UC in improving BP control among hypertensive blacks. Future research on the implementation of behavioral modification strategies for hypertension control in low-resource settings should focus on the development of more efficient and tailored interventions in this high-risk population.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00233220.

Staffing patterns of primary care practices in the comprehensive primary care initiative

PURPOSE

Despite growing calls for team-based care, the current staff composition of primary care practices is unknown. We describe staffing patterns for primary care practices in the Centers for Medicare and Medicaid Services (CMS) Comprehensive Primary Care (CPC) initiative.

METHODS

We undertook a descriptive analysis of CPC initiative practices' baseline staffing using data from initial applications and a practice survey. CMS selected 502 primary care practices (from 987 applicants) in 7 regions based on their health information technology, number of patients covered by participating payers, and other factors; 496 practices were included in this analysis.

RESULTS

Consistent with the national distribution, most of the CPC initiative practices included in this study were small: 44% reported 2 or fewer full-time equivalent (FTE) physicians; 27% reported more than 4. Nearly all reported administrative staff (98%) and medical assistants (89%). Fifty-three percent reported having nurse practitioners or physician assistants; 47%, licensed practical or vocational nurses; 36%, registered nurses; and 24%, care managers/coordinators-all of these positions are more common in larger practices. Other clinical staff were reported infrequently regardless of practice size. Compared with other CPC initiative practices, designated patient-centered medical homes were more likely to have care managers/coordinators but otherwise had similar staff types. Larger practices had fewer FTE staff per physician.

CONCLUSIONS

At baseline, most CPC initiative practices used traditional staffing models and did not report having dedicated staff who may be integral to new primary care models, such as care coordinators, health educators, behavioral health specialists, and pharmacists. Without such staff and payment for their services, practices are unlikely to deliver comprehensive, coordinated, and accessible care to patients at a sustainable cost.

Factors associated with the adoption of a patient education intervention among first responders, King County, Washington, 2010-2011

Introduction

This study investigated facilitators and barriers to adoption of an at-scene patient education program by firefighter emergency medical technicians (EMTs) in King County, Washington.

Methods

We consulted providers of emergency medical services (EMS) to develop a patient education pamphlet in the form of a tear-off sheet that could be attached to the EMT medical incident report. The pamphlet included resources for at-scene patient education on high blood pressure, blood glucose, falls, and social services. The program was launched in 29 fire departments in King County, Washington, on January 1, 2010, and a formal evaluation was conducted in late 2011. We developed a survey based on diffusion theory to assess 1) awareness of the pamphlet, 2) evaluation of the pamphlet attributes, 3) encouragement by peers and superiors for handing out the pamphlet, 4) perceived behavioral norms, and 5) demographic variables associated with self-reported adoption of the at-scene patient education program. The survey was completed by 822 (40.1%) of 2,047 firefighter emergency medical technicians. We conducted bivariate and multivariable analyses to assess associations between independent variables and self-reported adoption of the program.

Results

Adoption of the at-scene patient education intervention was significantly associated with positive evaluation of the pamphlet, encouragement from peers and superiors, and perceived behavioral norms. EMS providers reported they were most likely to hand out the pamphlet to patients in private residences who were treated and left at the scene.

Conclusion

Attributes of chronic disease prevention programs and encouragement from peers and supervisors are necessary in diffusion of patient education interventions in the prehospital care setting.

Effect of home telemonitoring on glycemic and blood pressure control in primary care clinic patients with diabetes

OBJECTIVE

Patient self-management support may be augmented by using home-based technologies that generate data points that providers can potentially use to make more timely changes in the patients' care. The purpose of this study was to evaluate the effectiveness of short-term targeted use of remote data transmission on treatment outcomes in patients with diabetes who had either out-of-range hemoglobin A1c (A1c) and/or blood pressure (BP) measurements.

MATERIALS AND METHODS

A single-center randomized controlled clinical trial design compared in-home monitoring (n=55) and usual care (n=53) in patients with type 2 diabetes and hypertension being treated in primary care clinics. Primary outcomes were A1c and systolic BP after a 12-week intervention.

RESULTS

There were no significant differences between the intervention and control groups on either A1c or systolic BP following the intervention.

CONCLUSIONS

The addition of technology alone is unlikely to lead to improvements in outcomes. Practices need to be selective in their use of telemonitoring with patients, limiting it to patients who have motivation or a significant change in care, such as starting insulin. Attention to the need for effective and responsive clinic processes to optimize the use of the additional data is also important when implementing these types of technology.

Improving chronic disease prevention and screening in primary care: results of the BETTER pragmatic cluster randomized controlled trial

BACKGROUND

Primary care provides most of the evidence-based chronic disease prevention and screening services offered by the healthcare system. However, there remains a gap between recommended preventive services and actual practice. This trial (the BETTER Trial) aimed to improve preventive care of heart disease, diabetes, colorectal, breast and cervical cancers, and relevant lifestyle factors through a practice facilitation intervention set in primary care.

METHODS

Pragmatic two-way factorial cluster RCT with Primary Care Physicians' practices as the unit of allocation and individual patients as the unit of analysis. The setting was urban Primary Care Team practices in two Canadian provinces. Eight Primary Care Team practices were randomly assigned to receive the practice-level intervention or wait-list control; 4 physicians in each team (32 physicians) were randomly assigned to receive the patient-level intervention or wait-list control. Patients randomly selected from physicians' rosters were stratified into two groups: 1) general and 2) moderate mental illness. The interventions involved a multifaceted, evidence-based, tailored practice-level intervention with a Practice Facilitator, and a patient-level intervention involving a one-hour visit with a Prevention Practitioner where patients received a tailored 'prevention prescription'. The primary outcome was a composite Summary Quality Index of 28 evidence-based chronic disease prevention and screening actions with pre-defined targets, expressed as the ratio of eligible actions at baseline that were met at follow-up. A cost-effectiveness analysis was conducted.

RESULTS

789 of 1,260 (63%) eligible patients participated. On average, patients were eligible for 8.96 (SD 3.2) actions at baseline. In the adjusted analysis, control patients met 23.1% (95% CI: 19.2% to 27.1%) of target actions, compared to 28.5% (95% CI: 20.9% to 36.0%) receiving the practice-level intervention, 55.6% (95% CI: 49.0% to 62.1%) receiving the patient-level intervention, and 58.9% (95% CI: 54.7% to 63.1%) receiving both practice- and patient-level interventions (patient-level intervention versus control, P < 0.001). The benefit of the patient-level intervention was seen in both strata. The extra cost of the intervention was $26.43CAN (95% CI: $16 to $44) per additional action met.

CONCLUSIONS

A Prevention Practitioner can improve the implementation of clinically important prevention and screening for chronic diseases in a cost-effective manner.

Creating a transdisciplinary research center to reduce cardiovascular health disparities in Baltimore, Maryland: lessons learned

Cardiovascular disease (CVD) disparities continue to have a negative impact on African Americans in the United States, largely because of uncontrolled hypertension. Despite the availability of evidence-based interventions, their use has not been translated into clinical and public health practice. The Johns Hopkins Center to Eliminate Cardiovascular Health Disparities is a new transdisciplinary research program with a stated goal to lower the impact of CVD disparities on vulnerable populations in Baltimore, Maryland. By targeting multiple levels of influence on the core problem of disparities in Baltimore, the center leverages academic, community, and national partnerships and a novel structure to support 3 research studies and to train the next generation of CVD researchers. We also share the early lessons learned in the center's design.

Barriers and facilitators to evidence-based blood pressure control in community practice

INTRODUCTION

The Electronic Communications and Home Blood Pressure Monitoring trial (e-BP) demonstrated that team care incorporating a pharmacist to manage hypertension using secure E-mail with patients resulted in almost twice the rate of blood pressure (BP) control compared with usual care. To translate e-BP into community practices, we sought to identify contextual barriers and facilitators to implementation.

METHODS

Interviews were conducted with medical providers, staff, pharmacists, and patients associated with community-based primary care clinics whose physician leaders had expressed interest in implementing e-BP. Transcripts were analyzed using qualitative template analysis, incorporating codes derived from the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Barriers included incorporating an unfamiliar pharmacist into the health care team, lack of information technology resources, and provider resistance to using a single BP management protocol. Facilitators included the intervention's perceived potential to improve quality of care, empower patients, and save staff time. Sustainability of the intervention emerged as an overarching theme.

CONCLUSION

A qualitative approach to planning for translation is recommended to gain an understanding of contexts and to collaborate to adapt interventions through iterative, bidirectional information gathering. Interviewees affirmed that web pharmacist care offers small primary care practices a means to expand their workforce and provide patient-centered care. Reproducing e-BP in these practices will be challenging, but our interviewees expressed eagerness to try and were optimistic that a tailored intervention could succeed.

Improving refill adherence and hypertension control in black patients: Wisconsin TEAM trial

OBJECTIVE

To assess the effectiveness and sustainability of a 6-month Team Education and Adherence Monitoring (TEAM) intervention for black patients with hypertension in community chain pharmacies.

DESIGN

Cluster randomized trial.

SETTING

28 chain pharmacies (14 TEAM and 14 control) in five Wisconsin cities from December 2006 to February 2009.

PARTICIPANTS

576 black patients with hypertension.

INTERVENTION

Trained pharmacist-technician teams implemented a 6-month intervention using scheduled visits, Brief Medication Questionnaires (BMQs), and novel toolkits for facilitating medication adherence and pharmacist feedback to patients and physicians. Control participants received patient information only.

MAIN OUTCOME MEASURES

Refill adherence (≥80% days covered) and changes in systolic blood pressure (SBP), diastolic blood pressure, and blood pressure control using blinded assessments at 6 and 12 months.

RESULTS

At baseline, all patients had blood pressure of 140/90 mm Hg or more. Of those eligible, 79% activated the intervention (mean 4.25 visits). Compared with control participants at 6 months, TEAM participants achieved greater improvements in refill adherence (60% vs. 34%, P < 0.001), SBP (-12.62 vs. -5.31 mm Hg, P < 0.001), and blood pressure control (50% vs. 36%, P = 0.01). Six months after intervention discontinuation, TEAM participants showed sustained improvements in refill adherence ( P < 0.001) and SBP ( P = 0.004), though the difference in blood pressure control was not significant ( P < 0.05) compared with control participants. Analysis of intervention fidelity showed that patients who received the full intervention during months 1 through 6 achieved significantly greater 6- and 12-month improvements in refill adherence and blood pressure control compared with control participants.

CONCLUSION

A team-based intervention involving community chain pharmacists, pharmacy technicians, and novel toolkits led to significant and sustained improvements in refill adherence and SBP in black patients with hypertension.

Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial

IMPORTANCE

Only about half of patients with high blood pressure (BP) in the United States have their BP controlled. Practical, robust, and sustainable models are needed to improve BP control in patients with uncontrolled hypertension.

OBJECTIVES

To determine whether an intervention combining home BP telemonitoring with pharmacist case management improves BP control compared with usual care and to determine whether BP control is maintained after the intervention is stopped.

DESIGN, SETTING, AND PATIENTS

A cluster randomized clinical trial of 450 adults with uncontrolled BP recruited from 14,692 patients with electronic medical records across 16 primary care clinics in an integrated health system in Minneapolis-St Paul, Minnesota, with 12 months of intervention and 6 months of postintervention follow-up.

INTERVENTIONS

Eight clinics were randomized to provide usual care to patients (n = 222) and 8 clinics were randomized to provide a telemonitoring intervention (n = 228). Intervention patients received home BP telemonitors and transmitted BP data to pharmacists who adjusted antihypertensive therapy accordingly.

MAIN OUTCOMES AND MEASURES

Control of systolic BP to less than 140 mm Hg and diastolic BP to less than 90 mm Hg (<130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 and 12 months. Secondary outcomes were change in BP, patient satisfaction, and BP control at 18 months (6 months after intervention stopped).

RESULTS

At baseline, enrollees were 45% women, 82% white, mean (SD) age was 61.1 (12.0) years, and mean systolic BP was 148 mm Hg and diastolic BP was 85 mm Hg. Blood pressure was controlled at both 6 and 12 months in 57.2% (95% CI, 44.8% to 68.7%) of patients in the telemonitoring intervention group vs 30.0% (95% CI, 23.2% to 37.8%) of patients in the usual care group (P = .001). At 18 months (6 months of postintervention follow-up), BP was controlled in 71.8% (95% CI, 65.0% to 77.8%) of patients in the telemonitoring intervention group vs 57.1% (95% CI, 51.5% to 62.6%) of patients in the usual care group (P = .003). Compared with the usual care group, systolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months (-10.7 mm Hg [95% CI, -14.3 to -7.3 mm Hg]; P<.001), at 12 months (-9.7 mm Hg [95% CI, -13.4 to -6.0 mm Hg]; P<.001), and at 18 months (-6.6 mm Hg [95% CI, -10.7 to -2.5 mm Hg]; P = .004). Compared with the usual care group, diastolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months (-6.0 mm Hg [95% CI, -8.6 to -3.4 mm Hg]; P<.001), at 12 months (-5.1 mm Hg [95% CI, -7.4 to -2.8 mm Hg]; P<.001), and at 18 months (-3.0 mm Hg [95% CI, -6.3 to 0.3 mm Hg]; P = .07).

CONCLUSIONS AND RELEVANCE

Home BP telemonitoring and pharmacist case management achieved better BP control compared with usual care during 12 months of intervention that persisted during 6 months of postintervention follow-up.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00781365.

Transforming hypertension management using mobile health technology for telemonitoring and self-care support

Achieving and sustaining good blood pressure control continues to be a challenge for many reasons including nonadherence with prescribed treatment and lifestyle measures, shortage of primary care physicians especially in less populated areas, and variations in physicians' practice behaviour. Many strategies have been advocated to improve outcomes with the greatest success being achieved using nurse or pharmacist-led interventions in which they were given the authority to prescribe or alter antihypertensive treatment. However, this treatment approach, which historically involved 1-on-1 visits to a doctor's office or pharmacy, proved costly, was not scalable, and did not actively engage patients in treatment decision-making. Several electronic health interventions have been designed to overcome these limitations. Though more patient-centred and often effective, they required wired connections and a personal computer, and logging on for Internet access and navigating computer screens greatly reduced access for many older patients. Furthermore, it is unclear whether the benefits were related to better case management or technological advances. Mobile health (mHealth) technology circumvents the technical challenges of electronic health systems and provides a more flexible platform to enhance patient self-care. mHealth applications are particularly appropriate for interventions that depend on patients' sustained adherence to monitoring schedules and prescribed treatments. Studies from our group in hypertension and other chronic conditions have shown improved health outcomes using mHealth applications that have undergone rigourous usability testing. Nonetheless, the inability of most electronic medical record systems to receive and process information from mobile devices continues to be a major impediment in realizing the full potential of mHealth technology.

Incremental costs associated with physician and pharmacist collaboration to improve blood pressure control

STUDY OBJECTIVE

To compare costs associated with a physician-pharmacist collaborative intervention with costs of usual care.

DESIGN

Cost analysis using health care utilization and outcome data from two prospective, cluster-randomized, controlled clinical trials.

SETTING

Eleven community-based medical offices.

PATIENTS

A total of 496 patients with hypertension; 244 were in the usual care (control) group and 252 were in the intervention group.

MEASUREMENTS AND MAIN RESULTS

To compare the costs, we combined cost data from the two trials. Total costs included costs of provider time, laboratory tests, and antihypertensive drugs. Provider time was calculated based on an online survey of intervention pharmacists and the National Ambulatory Medical Care Survey. Cost parameters were taken from the Bureau of Labor Statistics for average wage rates, the Medicare laboratory fee schedule, and a publicly available Web site for drug prices. Total costs were adjusted for patient characteristics. Adjusted total costs were $774.90 in the intervention group and $445.75 in the control group (difference $329.16, p<0.001). In a sensitivity analysis, the difference in adjusted total costs between the two groups ranged from $224.27-515.56. The intervention cost required to have one additional patient achieve blood pressure control within 6 months was $1338.05, determined by the difference in costs divided by the difference in hypertension control rates between the groups ($329.16/24.6%). The cost over 6 months to lower systolic and diastolic blood pressure 1 mm Hg was $36.25 and $94.32, respectively.

CONCLUSION

The physician-pharmacist collaborative intervention increased not only blood pressure control but also the cost of care. Additional research, such as a cost-benefit or a cost-minimization analysis, is needed to assess whether financial savings related to reduced morbidity and mortality achieved from better blood pressure control outweigh the cost of the intervention.

A multi-level system quality improvement intervention to reduce racial disparities in hypertension care and control: study protocol

Background

Racial disparities in blood pressure control have been well documented in the United States. Research suggests that many factors contribute to this disparity, including barriers to care at patient, clinician, healthcare system, and community levels. To date, few interventions aimed at reducing hypertension disparities have addressed factors at all of these levels. This paper describes the design of Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a multi-level system quality improvement project. By intervening on multiple levels, this project aims to reduce disparities in blood pressure control and improve guideline concordant hypertension care.

Methods

Using a pragmatic trial design, we are implementing three complementary multi-level interventions designed to improve blood pressure measurement, provide patient care management services and offer expanded provider education resources in six primary care clinics in Baltimore, Maryland. We are staggering the introduction of the interventions and will use Statistical Process Control (SPC) charting to determine if there are changes in outcomes at each clinic after implementation of each intervention. The main hypothesis is that each intervention will have an additive effect on improvements in guideline concordant care and reductions in hypertension disparities, but the combination of all three interventions will result in the greatest impact, followed by blood pressure measurement with care management support, blood pressure measurement with provider education, and blood pressure measurement only. This study also examines how organizational functioning and cultural competence affect the success of the interventions.

Discussion

As a quality improvement project, Project ReD CHiP employs a novel study design that specifically targets multi-level factors known to contribute to hypertension disparities. To facilitate its implementation and improve its sustainability, we have incorporated stakeholder input and tailored components of the interventions to meet the specific needs of the involved clinics and communities. Results from this study will provide knowledge about how integrated multi-level interventions can improve hypertension care and reduce disparities.

Trial Registration

ClinicalTrials.gov NCT01566864

Physician-pharmacist co-management and 24-hour blood pressure control

The objectives of this study were to compare indices of 24-hour blood pressure (BP) following a physician-pharmacist collaborative intervention and to describe the associated changes in antihypertensive medications. This was a secondary analysis of a prospective, cluster-randomized clinical trial conducted in 6 family medicine clinics randomized to co-managed (n=3 clinics, 176 patients) or control (n=3 clinics, 198 patients) groups. Mean ambulatory systolic BP (SBP) was significantly lower in the co-managed vs the control group: daytime BP 122.8 mm Hg vs 134.4 mm Hg (P<.001); nighttime SBP 114.8 mm Hg vs 123.7 mm Hg (P<.001); and 24-hour SBP 120.4 mm Hg vs 131.8 mm Hg (P<.001), respectively. Significantly more drug changes were made in the co-managed than in the control group (2.7 vs 1.1 changes per patient, P<.001), and there was greater diuretic use in co-managed patients (79.6% vs 62.6%, P<.001). Ambulatory BPs were significantly lower for the patients who had a diuretic added during the first month compared with those who never had a diuretic added (P<.01). Physician-pharmacist co-management significantly improved ambulatory BP compared with the control group. Antihypertensive drug therapy was intensified much more for patients in the co-managed group.

Depression and cardiovascular disease

Approximately one out of every five patients with cardiovascular disease (CVD) suffers from major depressive disorder (MDD). Both MDD and depressive symptoms are risk factors for CVD incidence, severity and outcomes. Great progress has been made in understanding potential mediators between MDD and CVD, particularly focusing on health behaviors. Investigators have also made considerable strides in the diagnosis and treatment of depression among patients with CVD. At the same time, many research questions remain. In what settings is depression screening most effective for patients with CVD? What is the optimal screening frequency? Which therapies are safe and effective? How can we better integrate the care of mental health conditions with that of CVD? How do we motivate depressed patients to change health behaviors? What technological tools can we use to improve care for depression? Gaining a more thorough understanding of the links between MDD and heart disease, and how best to diagnose and treat depression among these patients, has the potential to substantially reduce morbidity and mortality from CVD.

Systematic review of quality improvement interventions directed at cancer specialists

PURPOSE

Summary evidence on the effectiveness of quality improvement interventions (QIIs) directed at cancer specialists is needed for two reasons. First, there are some innovations over which only cancer specialists have control (eg, surgical technique or chemotherapy regimen). Second, implementation of QIIs has opportunity costs; the time and money spent on an ineffective QII might be better spent on direct patient care.

METHODS

Medical Subject Headings and text words for "quality improvement" were combined with those for "neoplasm" to search MEDLINE, PsycINFO, CINAHL, and EMBASE from January 1990 to August 2012 for studies of QIIs directed at cancer specialists (eg, medical/radiation oncologist, surgeon). All study designs were included.

RESULTS

Five thousand seven hundred eighty-one articles were screened, but only 12 met the inclusion criteria, including three cluster randomized controlled trials (cRCTs), seven uncontrolled before-and-after comparisons, and two cross-sectional studies. All 12 studies were conducted in response to concerns about quality of care. No cRCT showed a benefit of the QIIs tested. Some uncontrolled before-and-after and cross-sectional studies reported a benefit from the QII, but these studies are difficult to interpret because of concerns about uncontrolled confounding. Interventions in all studies were multifaceted, but descriptions of different components were limited, and only one study examined their separate impact.

CONCLUSION

The published evidence about how to facilitate timely and consistent adoption of new clinical knowledge by cancer specialists into everyday clinical practice is thin. More investment is needed in research about the solution (QIIs) to match the investment in research about the problem (inconsistent/slow adoption of innovative cancer treatments).