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Pakhare A, Lahiri A, Shrivastava N, Subba KN, Veera Durga Kurra V, Joshi A, Atal S, Khadanga S, Joshi R. Status of Hypertension Control in Urban Slums of Central India: A community Health Worker-Based Two-Year Follow-Up. Adv Biomed Res 2023; 12:197. [PMID: 37694241 PMCID: PMC10492608 DOI: 10.4103/abr.abr_266_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 04/10/2023] [Accepted: 04/26/2023] [Indexed: 09/12/2023] Open
Abstract
Background Hypertension (HTN) is a leading cause of cardiovascular diseases and its control is poor. There is heterogeneity in levels of blood pressure control among various population subgroups. The present study was conducted within the framework of the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) in India. It aims to estimate the proportion of optimal blood pressure control and identify factors associated with uncontrolled HTN consequent to initial screening. Materials and Methods We assembled a cohort of individuals with HTN confirmed in a baseline screening in sixteen urban slum clusters of Bhopal (2017-2018). Sixteen accredited social health activists were trained from within these slums. Individuals with HTN were linked to primary care providers and followed up for the next two years. Obtaining optimal blood pressure control (defined as SBP <140 and DBP <90 mm of Hg) was a key outcome. Results Of a total of 6174 individuals, 1571 (25.4%) had HTN, of which 813 were previously known and 758 were newly detected during the baseline survey. Two-year follow-up was completed for 1177 (74.9%). Blood pressure was optimally controlled in 301 (26%) at baseline and in 442 (38%) individuals at two years (an absolute increase of 12%; 95% CI 10.2-13.9). Older age, physical inactivity, higher body mass index, and newly diagnosed HTN were significantly associated with uncontrolled blood pressure. Conclusion We found about six of every ten individuals with HTN were on treatment, and about four were optimally controlled. These findings provide a benchmark for NPCDCS, in terms of achievable goals within short periods of follow-up.
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Affiliation(s)
- Abhijit Pakhare
- Department of Community and Family Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Anuja Lahiri
- Department of Community and Family Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Neelesh Shrivastava
- Department of Sociology, Barkatullah University, Bhopal, Madhya Pradesh, India
| | - Krishna N. Subba
- Department of Community and Family Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | | | - Ankur Joshi
- Department of Community and Family Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Shubham Atal
- Department of Pharmacology, AIIMS, Bhopal, Madhya Pradesh, India
| | - Sagar Khadanga
- Department of General Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Rajnish Joshi
- Department of General Medicine, AIIMS, Bhopal, Madhya Pradesh, India
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Ke X, Zhang L, Tang W. Cost-Utility Analysis of the Integrated Care Models for the Management of Hypertension Patients: A Quasi-Experiment in Southwest Rural China. Front Public Health 2021; 9:727829. [PMID: 34966712 PMCID: PMC8710505 DOI: 10.3389/fpubh.2021.727829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Hypertension has become the second-leading risk factor for death worldwide. However, the fragmented three-level “county–township–village” medical and healthcare system in rural China cannot provide continuous, coordinated, and comprehensive health care for patients with hypertension, as a result of which rural China has a low rate of hypertension control. This study aimed to explore the costs and benefits of an integrated care model using three intervention modes—multidisciplinary teams (MDT), multi-institutional pathway (MIP), and system global budget and performance-based payments (SGB-P4P)—for hypertension management in rural China. Methods: A Markov model with 1-year per cycle was adopted to simulate the lifetime medical costs and quality-adjusted life-years (QALYs) for patients. The interventions included Option 1 (MDT + MIP), Option 2 (MDT + MIP + SGB–P4P), and the Usual practice (usual care). We used the incremental cost-effectiveness ratio (ICER), net monetary benefit (NMB), and net health benefit (NHB) to make economic decisions and a 5% discount rate. One-way and probability sensitivity analyses were performed to test model robustness. Data on the blood pressure control rate, transition probability, utility, annual treatment costs, and project costs were from the community intervention trial (CMB-OC) project. Results: Compared with the Usual practice, Option 1 yielded an additional 0.068 QALYs and an additional cost of $229.99, resulting in an ICER of $3,373.75/QALY, the NMB was –$120.97, and the NHB was −0.076 QALYs. Compared with the Usual practice, Option 2 yielded an additional 0.545 QALYs, and the cost decreased by $2,007.31, yielding an ICER of –$3,680.72/QALY. The NMB was $2,879.42, and the NHB was 1.801 QALYs. Compared with Option 1, Option 2 yielded an additional 0.477 QALYs, and the cost decreased by $2,237.30, so the ICER was –$4,688.50/QALY, the NMB was $3,000.40, and the NHB was 1.876 QALYs. The one-way sensitivity analysis showed that the most sensitive factors in the model were treatment cost of ESRD, human cost, and discount rate. The probability sensitivity analysis showed that when willingness to pay was $1,599.16/QALY, the cost-effectiveness probability of Option 1, Option 2, and the Usual practice was 0.008, 0.813, and 0.179, respectively. Conclusions: The integrated care model with performance-based prepaid payments was the most beneficial intervention, whereas the general integrated care model (MDT + MIP) was not cost-effective. The integrated care model (MDT + MIP + SGB-P4P) was suggested for use in the community management of hypertension in rural China as a continuous, patient-centered care system to improve the efficiency of hypertension management.
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Affiliation(s)
- Xiatong Ke
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
| | - Liang Zhang
- School of Medical and Health Management, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China.,Research Center for Rural Health Services, Hubei Province Key Research Institute of Humanities and Social Sciences, Wuhan, China
| | - Wenxi Tang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
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Rodriguez MA, Wang B, Hyoung S, Friedberg J, Wylie-Rosett J, Fang Y, Allegrante JP, Lipsitz SR, Natarajan S. Sustained Benefit of Alternate Behavioral Interventions to Improve Hypertension Control: A Randomized Clinical Trial. Hypertension 2021; 77:1867-1876. [PMID: 33979183 PMCID: PMC8115432 DOI: 10.1161/hypertensionaha.120.15192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Supplemental Digital Content is available in the text. Little is known about the long-term effects of behavioral interventions to improve blood pressure (BP) control. We evaluated whether a telephone-delivered, behavioral stage-matched intervention (SMI), or a nontailored health education intervention (HEI) delivered for 6 months improves BP control (or lowers systolic BP) over 12 months, as well as its sustainability 6 months after intervention implementation ended, compared with usual care in participants with repeated uncontrolled BP at baseline. A 3-arm, randomized controlled trial was designed to evaluate the effectiveness of 2 interventions, each compared with a usual-care control group. Participants were 533 adults with persistent uncontrolled BP who were treated at 2 Veterans Affairs Medical Centers. The intervention was implemented for 6 months, followed by 6 months of observation. Compared with usual care, the odds of having BP under control over 12 months in SMI were 84% higher (odds ratio, 1.84 [95% CI, 1.28–2.67]; P=0.001), and 48% higher in HEI (odds ratio, 1.48 [95% CI, 1.02–2.14]; P=0.04).Over the 12 months, compared with usual care, systolic blood pressure was 2.80 mm Hg lower in SMI ([95% CI, 0.27 to 5.33]; P=0.03) while it was 2.58 mm Hg lower in HEI ([95% CI, −0.40 to 5.55]; P=0.09). From 6 to 12 months, SMI sustained improved BP control and lower systolic blood pressure, while HEI, which did not have significantly better BP control or lower systolic blood pressure at 6 months, appeared to improve BP control and lower systolic blood pressure. SMI and HEI are promising interventions that can be implemented in clinical practice to improve BP management.
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Affiliation(s)
- Maria Antonia Rodriguez
- VA New York Harbor Healthcare System (M.A.R., S.H., J.F., S.N.).,Northcentral University, La Jolla, CA (M.A.R.)
| | - Binhuan Wang
- New York University School of Medicine (B.W., Y.F., S.N.)
| | - Sangmin Hyoung
- VA New York Harbor Healthcare System (M.A.R., S.H., J.F., S.N.)
| | | | | | - Yixin Fang
- New York University School of Medicine (B.W., Y.F., S.N.)
| | - John P Allegrante
- Teachers College (J.P.A.), Columbia University, New York.,Mailman School of Public Health (J.P.A.), Columbia University, New York
| | - Stuart R Lipsitz
- Brigham and Womens Hospital/Harvard Medical School, Boston, MA (S.R.L.)
| | - Sundar Natarajan
- VA New York Harbor Healthcare System (M.A.R., S.H., J.F., S.N.).,New York University School of Medicine (B.W., Y.F., S.N.)
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Appalasamy JR, Quek KF, Md Zain AZ, Joseph JP, Seeta Ramaiah S, Tha KK. An Evaluation of the Video Narrative Technique on the Self-Efficacy of Medication Understanding and Use Among Post-Stroke Patients: A Randomized-Controlled Trial. Patient Prefer Adherence 2020; 14:1979-1990. [PMID: 33116441 PMCID: PMC7585263 DOI: 10.2147/ppa.s253918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Self-efficacy is positively associated with medication understanding and use self-efficacy (MUSE) among post-stroke patients. It is also closely related to knowledge, belief, and perception, which vary among people from different socioeconomic backgrounds and cultures. As interventions using video and peer stories have emerged to be successful on behavior modification, this study aimed to explore the effectiveness of video narratives incorporated with Health Belief constructs on MUSE and its associated factors among patients with stroke at a local setting. METHODS A randomized controlled trial (RCT) for 12 months was carried out on patients diagnosed with stroke at Hospital Kuala Lumpur, Malaysia. The RCT recruited up to 216 eligible patients who were requested to return for two more follow-ups within six months. Consented patients were randomized to either standard care or intervention with video narratives. The control of potential confounding factors was ensured, as well as unbiased treatment review with prescribed medications, only obtained onsite. RESULTS AND DISCUSSION A repeated measure of MUSE mean score differences at T0 (baseline), T2 (6th month) and T4 (12th month) for antithrombotic, antihypertensive, and all medication categories indicated significant within and between groups differences in the intervention group (p<0.05). Moreover, this impact was reflected upon continuous blood pressure (BP) monitoring compared to the control group (F (1214) =5.23, p=0.023, ƞ2=0.024). Though BP measure differences were non-significant between the groups (p=0.552), repeated measure analysis displayed significant mean differences between intervention and control group on BP control over time (F (1.344, 287.55) =8.54, P<0.001, ƞ2=0.038). Similarly, the intervention's positive impact was also present with similar trends for knowledge, illness perception, and the belief about medicine. Though significant differences (p<0.05) of all outcome measures gradually decreased between T2 and T4 in the intervention group; nevertheless, these positive findings confirmed that personalized video narratives were able to motivate and influence MUSE and its associated factors among post-stroke patients. The significant improvement in medication-taking self-efficacy and the sustenance of BP monitoring habits among patients in the intervention group strengthened our conceptual framework's practicality.
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Affiliation(s)
- Jamuna Rani Appalasamy
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Kia Fatt Quek
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Anuar Zaini Md Zain
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Joyce Pauline Joseph
- Department of Neurology, Hospital Kuala Lumpur, Ministry of Health, Kuala Lumpur, Malaysia
| | | | - Kyi Kyi Tha
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
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Hornnes AH, Poulsen MB. Blood pressure after follow-up in a stroke prevention clinic. Brain Behav 2020; 10:e01667. [PMID: 32533622 PMCID: PMC7428502 DOI: 10.1002/brb3.1667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/27/2020] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES In Denmark, 25% of hospital admissions with stroke are recurrent strokes. With thrombolytic treatment, more patients survive with only minor disability. This promising development should be followed up by intensive secondary prevention. Hypertension is the most important target. We aimed at testing the hypotheses that early follow-up in a preventive clinic would result in (a) a higher proportion of patients with blood pressure at target and (b) time to stroke recurrence, myocardial infarction, and death would be longer in the intervention group compared to controls. MATERIALS AND METHODS Eligible patients admitted to the stroke unit of Herlev Hospital were randomized shortly before discharge to intervention or control group. Of 78 included participants, data from 73 were available for follow-up 9 months after inclusion. Patients in the intervention group were seen in the clinic within 1 week. In case of hypertension, treatment was initiated or supplied with a new drug. We used individual targets for blood pressure according to diagnosis of stroke and patients' comorbidity. Patients in the intervention group had a median of five visits to the preventive clinic. RESULTS In the intervention group, blood pressure was treated to target in 25 patients (69%) versus 14 (38%) in the control group (p = .007). Median time to first event was 44 months (4-49) in the intervention group and 19 months (4-37) in controls (p = .316). CONCLUSIONS Treatment of hypertension to individual targets after stroke is feasible. It may postpone recurrent stroke and death in stroke survivors.
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Coster S, Li Y, Norman IJ. Cochrane reviews of educational and self-management interventions to guide nursing practice: A review. Int J Nurs Stud 2020; 110:103698. [PMID: 32726709 DOI: 10.1016/j.ijnurstu.2020.103698] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The burden of chronic disease on healthcare services worldwide continues to grow, and the increased development of educational interventions which help patients to better manage their own condition is evident internationally. OBJECTIVES This paper reports on findings of an updated review of Cochrane systematic reviews of interventions designed to improve patients' knowledge and skills to manage chronic disease, with particular reference to nursing contribution and practice. METHODS A broad search strategy was used to search the Cochrane Database of Systematic Reviews to identify reviews of patient education, self-management, and self-care studies. Two reviewers independently assessed eligibility for inclusion and extracted data from the reviews. FINDINGS From a total of 882 reviews, 63 met the inclusion criteria, and 900 studies were identified. Most (68%, n = 43) of the 63 reviews were judged by Cochrane reviewers to provide inadequate evidence of the effectiveness of the interventions reviewed. Information on the profession of the person delivering the intervention was often not available, although 78% (n = 49) of reviews mentioned that nurses were involved in a proportion of studies delivering interventions either independently or as part of a multi-professional team. CONCLUSION Educational programmes have definite benefits for patients suffering from asthma, chronic obstructive pulmonary disorder and stroke, and are promising in areas such as diabetes, epilepsy, cancer care, and mental health. However, it still is not clear what the active ingredients of many successful interventions are. Further research is needed to establish the impact of technology on programme delivery, and to develop programmes tailored for patients with multiple health problems.
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Affiliation(s)
- Samantha Coster
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK.
| | - Yan Li
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK
| | - Ian James Norman
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK
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Hargraves JL, Bonollo D, Person SD, Ferguson WJ. A randomized controlled trial of community health workers using patient stories to support hypertension management: Study protocol. Contemp Clin Trials 2018; 69:76-82. [PMID: 29654929 DOI: 10.1016/j.cct.2018.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 04/02/2018] [Accepted: 04/08/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Uncontrolled hypertension is a significant public health problem in the U.S. with about one half of people able to keep blood pressure (BP) under control. Uncontrolled hypertension leads to increased risk of stroke, heart attack, and death. Furthermore, the social and economic costs of poor hypertension control are staggering. People living with hypertension can benefit from additional educational outreach and support. METHODS This randomized trial conducted at two Community Health Centers (CHCs) in Massachusetts assessed the effect of community health workers (CHWs) assisting patients with hypertension. In addition to the support provided by CHWs, the study uses video narratives from patients who have worked to control their BP through diet, exercise, and better medication adherence. Participants enrolled in the study were randomly assigned to immediate intervention (I) by CHWs or a delayed intervention (DI) (4 to 6 months later). Each participant was asked to meet with the CHW 5 times (twice in person and three times telephonically). Study outcomes include systolic and diastolic BP, diet, exercise, and body mass index. CONCLUSION CHWs working directly with patients, using multiple approaches to support patient self-management, can be effective agents to support change in chronic illness management. Moreover, having culturally appropriate tools, such as narratives available through videos, can be an important, cost effective aid to CHWs. Recruitment and intervention delivery within a busy CHC environment required adaptation of the study design and protocols for staff supervision, data collection and intervention delivery and lessons learned are presented. RETROSPECTIVE TRIAL REGISTRATION Clinical Trials.gov registration submitted 8/17/16: Protocol ID# 5P60MD006912-02 and Clinical trials.gov ID# NCT02874547 Community Health Workers Using Patient Stories to Support Hypertension Management.
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Affiliation(s)
- J Lee Hargraves
- Department of Family and Community Health, University of Massachusetts Medical School, 55 Lake Avenue, North, Worcester, MA 01655, United States.
| | - Debra Bonollo
- Department of Family and Community Health, University of Massachusetts Medical School, 55 Lake Avenue, North, Worcester, MA 01655, United States.
| | - Sharina D Person
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, United States.
| | - Warren J Ferguson
- Department of Family and Community Health, University of Massachusetts Medical School, 55 Lake Avenue, North, Worcester, MA 01655, United States.
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Mendoza Montano C, Fort M, deRamirez M, Cruz J, Ramirez-Zea M. Evaluation of a pilot hypertension management programme for Guatemalan adults. Health Promot Int 2016; 31:363-74. [PMID: 25595280 PMCID: PMC4863869 DOI: 10.1093/heapro/dau117] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Corazón Sano y Feliz is a hypertension management intervention developed to address deficiencies in the management of hypertensive patients in Guatemala. From 2007 to 2009, Corazón Sano y Feliz was pilot-tested in the community of Mixco. Corazón Sano y Feliz comprises a clinical risk assessment and treatment component implemented primarily by nurses, and a health education component implemented by community health workers. To accomplish our secondary objective of determining Corazon Sano y Feliz's potential for change at the patient level, we implemented a one-group pretest-posttest study design to examine changes in clinical measures, knowledge and practices between baseline and the end of the 6-month intervention. Two nurses and one physician set up a hypertension clinic to manage patients according to risk level. Twenty-nine community health workers were trained in CVD risk reduction and health promotion and in turn led six educational sessions for patients. Comparing baseline and 6-month measures, the intervention achieved significant improvements in mean knowledge and behaviour (increase from 54.6 to 59.1 out of a possible 70 points) and significant reductions of mean systolic and diastolic blood pressure (27.2 and 7.7 mmHg), body mass index (from 26.5 to 26.2 kg/m(2)) and waist circumference (89.6-88.9 cm). In this pilot study we obtained preliminary evidence that this community-oriented hypertension management and health promotion intervention model was feasible and achieved significant reduction in risk factors. If scaled up, this intervention has the potential to substantially reduce CVD burden.
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Affiliation(s)
| | - Meredith Fort
- Institute of Nutrition of Central America and Panama-INCAP, Guatemala City, Guatemala
| | - Miriam deRamirez
- Programme of Chronic Diseases, Ministry of Health of Guatemala, Guatemala City, Guatemala
| | - Judith Cruz
- Programme of Chronic Diseases, Ministry of Health of Guatemala, Guatemala City, Guatemala
| | - Manuel Ramirez-Zea
- Institute of Nutrition of Central America and Panama-INCAP, Guatemala City, Guatemala
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Tylee A, Barley EA, Walters P, Achilla E, Borschmann R, Leese M, McCrone P, Palacios J, Smith A, Simmonds R, Rose D, Murray J, van Marwijk H, Williams P, Mann A. UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundDepression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients.ObjectivesOur aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression.DesignThe UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted.SettingThirty-three GP surgeries in south London.ParticipantsAdult patients on GP CHD registers.InterventionsFrom the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up.Main outcome measuresThe main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires.ResultsPersonalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant.ConclusionsChest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice.Trial registrationCurrent Controlled Trials ISRCTN21615909.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- André Tylee
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Elizabeth A Barley
- Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK
| | - Paul Walters
- Weymouth and Portland Community Mental Health Team, Dorset HealthCare University NHS Foundation Trust and Bournemouth University, Dorset, UK
| | - Evanthia Achilla
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rohan Borschmann
- Centre of Adolescent Health, The Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Morven Leese
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Paul McCrone
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jorge Palacios
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Alison Smith
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rosemary Simmonds
- Academic Unit of Primary Health Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Diana Rose
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Joanna Murray
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Harm van Marwijk
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre, Amsterdam, the Netherlands
| | - Paul Williams
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anthony Mann
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Pavlik VN, Chan W, Hyman DJ, Feldman P, Ogedegbe G, Schwartz JE, McDonald M, Einhorn P, Tobin JN. Designing and evaluating health systems level hypertension control interventions for African-Americans: lessons from a pooled analysis of three cluster randomized trials. Curr Hypertens Rev 2016; 11:123-31. [PMID: 25808682 DOI: 10.2174/1573402111666150325234503] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 03/13/2015] [Accepted: 03/24/2015] [Indexed: 01/13/2023]
Abstract
OBJECTIVES African-Americans (AAs) have a high prevalence of hypertension and their blood pressure (BP) control on treatment still lags behind other groups. In 2004, NHLBI funded five projects that aimed to evaluate clinically feasible interventions to effect changes in medical care delivery leading to an increased proportion of AA patients with controlled BP. Three of the groups performed a pooled analysis of trial results to determine: 1) the magnitude of the combined intervention effect; and 2) how the pooled results could inform the methodology for future health-system level BP interventions. METHODS Using a cluster randomized design, the trials enrolled AAs with uncontrolled hypertension to test interventions targeting a combination of patient and clinician behaviors. The 12-month Systolic BP (SBP) and Diastolic BP (DBP) effects of intervention or control cluster assignment were assessed using mixed effects longitudinal regression modeling. RESULTS 2,015 patients representing 352 clusters participated across the three trials. Pooled BP slopes followed a quadratic pattern, with an initial decline, followed by a rise toward baseline, and did not differ significantly between intervention and control clusters: SBP linear coefficient = -2.60±0.21 mmHg per month, p<0.001; quadratic coefficient = 0.167± 0.02 mmHg/month, p<0.001; group by time interaction group by time group x linear time coefficient=0.145 ± 0.293, p=0.622; group x quadratic time coefficient= -0.017 ± 0.026, p=0.525). RESULTS were similar for DBP. The individual sites did not have significant intervention effects when analyzed separately. CONCLUSION Investigators planning behavioral trials to improve BP control in health systems serving AAs should plan for small effect sizes and employ a "run-in" period in which BP can be expected to improve in both experimental and control clusters.
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Affiliation(s)
- Valory N Pavlik
- Clinical Directors Network, Inc. (CDN), New York, NY 10018; Department of Epidemiology and Population Health, Albert Einstein College of Medicine of Yeshiva University/ Montefiore Medical Center, Bronx, NY 10461.
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11
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McAreavey D, Vidal JS, Aspelund T, Eiriksdottir G, Schelbert EB, Kjartansson O, Cao JJ, Thorgeirsson G, Sigurdsson S, Garcia M, Harris TB, Launer LJ, Gudnason V, Arai AE. Midlife Cardiovascular Risk Factors and Late-Life Unrecognized and Recognized Myocardial Infarction Detect by Cardiac Magnetic Resonance: ICELAND-MI, the AGES-Reykjavik Study. J Am Heart Assoc 2016; 5:JAHA.115.002420. [PMID: 26873683 PMCID: PMC4802464 DOI: 10.1161/jaha.115.002420] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background Associations of atherosclerosis risk factors with unrecognized myocardial infarction (UMI) are unclear. We investigated associations of midlife risk factors with UMI and recognized MI (RMI) detected 31 years later by cardiac magnetic resonance. Methods and Results The Reykjavik Study (1967–1991) collected serial risk factors in subjects, mean (SD) age 48 (7) years. In ICELAND‐MI (2004–2007), 936 survivors (76 (5) years) were evaluated by cardiac magnetic resonance. Analysis included logistic regression and random effects modeling. Comparisons are relative to subjects without MI. At baseline midlife evaluation, a modified Framingham risk score was significantly higher in RMI and in UMI versus no MI (7.4 (6.3)%; 7.1 (6.2)% versus 5.4 (5.8)%, P<0.001). RMI and UMI were more frequent in men (65%, 64% versus 43%; P<0.0001). Baseline systolic and diastolic blood pressure were significantly higher in UMI (138 (17) mm Hg versus 133 (17) mm Hg; P<0.006; 87 (10) mm Hg versus 84 (10) mm Hg; P<0.02). Diastolic BP was significantly higher in RMI (88 (10) mm Hg versus 84 (10) mm Hg; P<0.02). Cholesterol and triglycerides were significantly higher in RMI (6.7 (1.1) mmol/L versus 6.2 (1.1) mmol/L; P=0.0005; and 1.4 (0.7) mmol/L versus 1.1 (0.7) mmol/L; P<0.003). Cholesterol trended higher in UMI (P=0.08). Serial midlife systolic BP was significantly higher in UMI versus no MI (β [SE] = 2.69 [1.28] mm Hg, P=0.04). Serial systolic and diastolic BP were significantly higher in RMI versus no MI (4.12 [1.60] mm Hg, P=0.01 and 2.05 [0.91] mm Hg, P=0.03) as were cholesterol (0.43 [0.11] mmol/L, P=0.0001) and triglycerides (0.3 [0.06] mmol/L, P<0.0001). Conclusions Midlife vascular risk factors are associated with UMI and RMI detected by cardiac magnetic resonance 31 years later. Systolic blood pressure was the most significant modifiable risk factor associated with later UMI.
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Affiliation(s)
| | - Jean-Sébastien Vidal
- AP-HP, Hôpital Broca, Service de Gérontologie I, and Université Paris Descartes, Sorbonne Paris cité, Paris, France
| | - Thor Aspelund
- The Icelandic Heart Association, Kopavogur, Iceland University of Iceland, Reykjavik, Iceland
| | | | | | | | - Jie J Cao
- National Heart Lung and Blood Institute, NIH, Bethesda, MD
| | - Gudmundur Thorgeirsson
- The Icelandic Heart Association, Kopavogur, Iceland University of Iceland, Reykjavik, Iceland
| | | | - Melissa Garcia
- Laboratory of Epidemiology, Demography, and Biometry, Intramural Research Program, National Institute on Aging, NIH, Bethesda, MD
| | - Tamara B Harris
- Laboratory of Epidemiology, Demography, and Biometry, Intramural Research Program, National Institute on Aging, NIH, Bethesda, MD
| | - Lenore J Launer
- Laboratory of Epidemiology, Demography, and Biometry, Intramural Research Program, National Institute on Aging, NIH, Bethesda, MD
| | - Vilmundur Gudnason
- The Icelandic Heart Association, Kopavogur, Iceland University of Iceland, Reykjavik, Iceland
| | - Andrew E Arai
- National Heart Lung and Blood Institute, NIH, Bethesda, MD
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12
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Kim J, Thrift AG, Nelson MR, Bladin CF, Cadilhac DA. Personalized medicine and stroke prevention: where are we? Vasc Health Risk Manag 2015; 11:601-11. [PMID: 26664130 PMCID: PMC4671759 DOI: 10.2147/vhrm.s77571] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
There are many recommended pharmacological and non-pharmacological therapies for the prevention of stroke, and an ongoing challenge is to improve their uptake. Personalized medicine is seen as a possible solution to this challenge. Although the use of genetic information to guide health care could be considered as the apex of personalized medicine, genetics is not yet routinely used to guide prevention of stroke. Currently personalized aspects of prevention of stroke include tailoring interventions based on global risk, the utilization of individualized management plans within a model of organized care, and patient education. In this review we discuss the progress made in these aspects of prevention of stroke and present a case study to illustrate the issues faced by health care providers and patients with stroke that could be overcome with a personalized approach to the prevention of stroke.
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Affiliation(s)
- Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia ; Public Health, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Mark R Nelson
- Discipline of General Practice, School of Medicine, Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Christopher F Bladin
- Public Health, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia ; Eastern Health Clinical School, Monash University, Clayton, VIC, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia ; Public Health, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
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13
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Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model. J Gen Intern Med 2015; 30:1147-55. [PMID: 25749880 PMCID: PMC4510247 DOI: 10.1007/s11606-015-3231-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 01/13/2015] [Accepted: 02/03/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Only half of hypertensive adults achieve blood pressure (BP) control in the United States, and it is unclear how BP control rates may be improved most effectively and efficiently at the population level. OBJECTIVE We sought to compare the potential effects of system-wide isolated improvements in medication adherence, visit frequency, and higher physician prescription rate on achieving BP control at 52 weeks. DESIGN We developed a Markov microsimulation model of patient-level, physician-level, and system-level processes involved in controlling hypertension with medications. The model is informed by data from national surveys, cohort studies and trials, and was validated against two multicenter clinical trials (ALLHAT and VALUE). SUBJECTS We studied a simulated, nationally representative cohort of patients with diagnosed but uncontrolled hypertension with a usual source of care. INTERVENTIONS We simulated a base case and improvements of 10 and 50%, and an ideal scenario for three modifiable parameters: visit frequency, treatment intensification, and medication adherence. Ideal scenarios were defined as 100% for treatment intensification and adherence, and return visits occurring within 4 weeks of an elevated office systolic BP. MAIN OUTCOME BP control at 52 weeks of follow-up was examined. RESULTS Among 25,000 hypothetical adult patients with uncontrolled hypertension (systolic BP ≥ 140 mmHg), only 18% achieved BP control after 52 weeks using base-case assumptions. With 10/50%/idealized enhancements in each isolated parameter, enhanced treatment intensification achieved the greatest BP control (19/23/71%), compared with enhanced visit frequency (19/21/35%) and medication adherence (19/23/26%). When all three processes were idealized, the model predicted a BP control rate of 95% at 52 weeks. CONCLUSION Substantial improvements in BP control can only be achieved through major improvements in processes of care. Healthcare systems may achieve greater success by increasing the frequency of clinical encounters and improving physicians' prescribing behavior than by attempting to improve patient adherence to medications.
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Chowdhury EK, Ademi Z, Moss JR, Wing LMH, Reid CM. Cost-utility of angiotensin-converting enzyme inhibitor-based treatment compared with thiazide diuretic-based treatment for hypertension in elderly Australians considering diabetes as comorbidity. Medicine (Baltimore) 2015; 94:e590. [PMID: 25738481 PMCID: PMC4553958 DOI: 10.1097/md.0000000000000590] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The objective of this study was to examine the cost-effectiveness of angiotensin-converting enzyme inhibitor (ACEI)-based treatment compared with thiazide diuretic-based treatment for hypertension in elderly Australians considering diabetes as an outcome along with cardiovascular outcomes from the Australian government's perspective.We used a cost-utility analysis to estimate the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained. Data on cardiovascular events and new onset of diabetes were used from the Second Australian National Blood Pressure Study, a randomized clinical trial comparing diuretic-based (hydrochlorothiazide) versus ACEI-based (enalapril) treatment in 6083 elderly (age ≥65 years) hypertensive patients over a median 4.1-year period. For this economic analysis, the total study population was stratified into 2 groups. Group A was restricted to participants diabetes free at baseline (n = 5642); group B was restricted to participants with preexisting diabetes mellitus (type 1 or type 2) at baseline (n = 441). Data on utility scores for different events were used from available published literatures; whereas, treatment and adverse event management costs were calculated from direct health care costs available from Australian government reimbursement data. Costs and QALYs were discounted at 5% per annum. One-way and probabilistic sensitivity analyses were performed to assess the uncertainty around utilities and cost data.After a treatment period of 5 years, for group A, the ICER was Australian dollars (AUD) 27,698 (&OV0556; 18,004; AUD 1-&OV0556; 0.65) per QALY gained comparing ACEI-based treatment with diuretic-based treatment (sensitive to the utility value for new-onset diabetes). In group B, ACEI-based treatment was a dominant strategy (both more effective and cost-saving). On probabilistic sensitivity analysis, the ICERs per QALY gained were always below AUD 50,000 for group B; whereas for group A, the probability of being below AUD 50,000 was 85%.Although the dispensed price of diuretic-based treatment of hypertension in the elderly is lower, upon considering the potential enhanced likelihood of the development of diabetes in addition to the costs of treating cardiovascular disease, ACEI-based treatment may be a more cost-effective strategy in this population.
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Affiliation(s)
- Enayet K Chowdhury
- From the Centre of Cardiovascular Research and Education in Therapeutics (EKC, ZA, CMR), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Institute of Pharmaceutical Medicine (ZA), University of Basel, Basel, Switzerland; School of Population Health (JM), The University of Adelaide; and Department of Clinical Pharmacology (LMHW), School of Medicine, Flinders University, Adelaide, Australia
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15
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Ephraim PL, Hill-Briggs F, Roter DL, Bone LR, Wolff JL, Lewis-Boyer L, Levine DM, Aboumatar HJ, Cooper LA, Fitzpatrick SJ, Gudzune KA, Albert MC, Monroe D, Simmons M, Hickman D, Purnell L, Fisher A, Matens R, Noronha GJ, Fagan PJ, Ramamurthi HC, Ameling JM, Charlston J, Sam TS, Carson KA, Wang NY, Crews DC, Greer RC, Sneed V, Flynn SJ, DePasquale N, Boulware LE. Improving urban African Americans' blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: a randomized clinical trial. Contemp Clin Trials 2014; 38:370-82. [PMID: 24956323 PMCID: PMC4169070 DOI: 10.1016/j.cct.2014.06.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/10/2014] [Accepted: 06/13/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given their high rates of uncontrolled blood pressure, urban African Americans comprise a particularly vulnerable subgroup of persons with hypertension. Substantial evidence has demonstrated the important role of family and community support in improving patients' management of a variety of chronic illnesses. However, studies of multi-level interventions designed specifically to improve urban African American patients' blood pressure self-management by simultaneously leveraging patient, family, and community strengths are lacking. METHODS/DESIGN We report the protocol of the Achieving Blood Pressure Control Together (ACT) study, a randomized controlled trial designed to study the effectiveness of interventions that engage patient, family, and community-level resources to facilitate urban African American hypertensive patients' improved hypertension self-management and subsequent hypertension control. African American patients with uncontrolled hypertension receiving health care in an urban primary care clinic will be randomly assigned to receive 1) an educational intervention led by a community health worker alone, 2) the community health worker intervention plus a patient and family communication activation intervention, or 3) the community health worker intervention plus a problem-solving intervention. All participants enrolled in the study will receive and be trained to use a digital home blood pressure machine. The primary outcome of the randomized controlled trial will be patients' blood pressure control at 12months. DISCUSSION Results from the ACT study will provide needed evidence on the effectiveness of comprehensive multi-level interventions to improve urban African American patients' hypertension control.
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Affiliation(s)
- Patti L Ephraim
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Felicia Hill-Briggs
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Johns Hopkins University School of Nursing, Baltimore, MD, USA.
| | - Debra L Roter
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Lee R Bone
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Jennifer L Wolff
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - LaPricia Lewis-Boyer
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - David M Levine
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Hanan J Aboumatar
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Armstrong Institute for Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - Lisa A Cooper
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | - Kimberly A Gudzune
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Michael C Albert
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins Community Physicians, Johns Hopkins University, Baltimore, MD, USA.
| | - Dwyan Monroe
- Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA; Institute for Public Health Innovation, Washington, DC, USA.
| | - Michelle Simmons
- Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA.
| | - Debra Hickman
- Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA; Sisters Together and Reaching, Baltimore, MD, USA.
| | - Leon Purnell
- Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA; The Men's Center, Baltimore, MD, USA.
| | - Annette Fisher
- Community Advisory Board, Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, Baltimore, MD, USA; American Heart Association, Baltimore, MD, USA.
| | | | - Gary J Noronha
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Peter J Fagan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Hema C Ramamurthi
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jessica M Ameling
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jeanne Charlston
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | - Kathryn A Carson
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Nae-Yuh Wang
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Deidra C Crews
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of Nephrology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Raquel C Greer
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Valerie Sneed
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Sarah J Flynn
- University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Nicole DePasquale
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - L Ebony Boulware
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins University School of Nursing, Baltimore, MD, USA; Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
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Ryan R, Santesso N, Lowe D, Hill S, Grimshaw J, Prictor M, Kaufman C, Cowie G, Taylor M. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014; 2022:CD007768. [PMID: 24777444 PMCID: PMC6491214 DOI: 10.1002/14651858.cd007768.pub3] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use. OBJECTIVES To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence. METHODS SEARCH METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012. SELECTION CRITERIA We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. DATA COLLECTION AND ANALYSIS We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses. MAIN RESULTS We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity. AUTHORS' CONCLUSIONS This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, School of Public Health and Human Biosciences, La Trobe University, Bundoora, VIC, Australia, 3086
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Clark CE, Horvath IA, Taylor RS, Campbell JL. Doctors record higher blood pressures than nurses: systematic review and meta-analysis. Br J Gen Pract 2014; 64:e223-32. [PMID: 24686887 PMCID: PMC3964448 DOI: 10.3399/bjgp14x677851] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 11/11/2013] [Accepted: 12/20/2013] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The magnitude of the 'white coat effect', the alerting rise in blood pressure, is greater for doctors than nurses. This could bias interpretation of studies on nurse-led care in hypertension, and risks overestimating or overtreating high blood pressure by doctors in clinical practice. AIM To quantify differences between blood pressure measurements made by doctors and nurses. DESIGN AND SETTING Systematic review and meta-analysis using searches of MEDLINE, CENTRAL, CINAHL, Embase, journal collections, and conference abstracts. METHOD Studies in adults reporting mean blood pressures measured by doctors and nurses at the same visit were selected, and mean blood pressures extracted, by two reviewers. Study risk of bias was assessed using modified Cochrane criteria. Outcomes were pooled across studies using random effects meta-analysis. RESULTS In total, 15 studies (11 hypertensive; four mixed hypertensive and normotensive populations) were included from 1899 unique citations. Compared with doctors' measurements, nurse-measured blood pressures were lower (weighted mean differences: systolic -7.0 [95% confidence interval {CI} = -4.7 to -9.2] mmHg, diastolic -3.8 [95% CI = -2.2 to -5.4] mmHg). For studies at low risk of bias, differences were lower: systolic -4.6 (95% CI = -1.9 to -7.3) mmHg; diastolic -1.7 (95% CI = -0.1 to -3.2) mmHg. White coat hypertension was diagnosed more frequently based on doctors' than on nurses' readings: relative risk 1.6 (95% CI =1.2 to 2.1). CONCLUSIONS The white coat effect is smaller for blood pressure measurements made by nurses than by doctors. This systematic difference has implications for hypertension diagnosis and management. Caution is required in pooling data from studies using both nurse- and doctor-measured blood pressures.
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Affiliation(s)
- Christopher E Clark
- Primary Care Research Group, Institute of Health Services Research, University of Exeter Medical School, Exeter, UK
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18
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Ogedegbe G, Tobin JN, Fernandez S, Cassells A, Diaz-Gloster M, Khalida C, Pickering T, Schwartz JE. Counseling African Americans to Control Hypertension: cluster-randomized clinical trial main effects. Circulation 2014; 129:2044-51. [PMID: 24657991 DOI: 10.1161/circulationaha.113.006650] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Gbenga Ogedegbe
- From the Division of Health and Behavior and Center for Healthful Behavior Change, Department of Population Health, New York University Langone Medical Center, New York, NY (G.O., S.F.); Clinical Directors Network, New York, NY (J.N.T., A.C., M.D.-G., C.K.); Department of Epidemiology and Population Health, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY (J.N.T.); Center for Clinical and Translational Science, Rockefeller University, New York, NY (J.N.T.); Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (T.P., J.E.S.); Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, NY (J.E.S.).
| | - Jonathan N Tobin
- From the Division of Health and Behavior and Center for Healthful Behavior Change, Department of Population Health, New York University Langone Medical Center, New York, NY (G.O., S.F.); Clinical Directors Network, New York, NY (J.N.T., A.C., M.D.-G., C.K.); Department of Epidemiology and Population Health, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY (J.N.T.); Center for Clinical and Translational Science, Rockefeller University, New York, NY (J.N.T.); Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (T.P., J.E.S.); Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, NY (J.E.S.)
| | - Senaida Fernandez
- From the Division of Health and Behavior and Center for Healthful Behavior Change, Department of Population Health, New York University Langone Medical Center, New York, NY (G.O., S.F.); Clinical Directors Network, New York, NY (J.N.T., A.C., M.D.-G., C.K.); Department of Epidemiology and Population Health, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY (J.N.T.); Center for Clinical and Translational Science, Rockefeller University, New York, NY (J.N.T.); Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (T.P., J.E.S.); Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, NY (J.E.S.)
| | - Andrea Cassells
- From the Division of Health and Behavior and Center for Healthful Behavior Change, Department of Population Health, New York University Langone Medical Center, New York, NY (G.O., S.F.); Clinical Directors Network, New York, NY (J.N.T., A.C., M.D.-G., C.K.); Department of Epidemiology and Population Health, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY (J.N.T.); Center for Clinical and Translational Science, Rockefeller University, New York, NY (J.N.T.); Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (T.P., J.E.S.); Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, NY (J.E.S.)
| | - Marleny Diaz-Gloster
- From the Division of Health and Behavior and Center for Healthful Behavior Change, Department of Population Health, New York University Langone Medical Center, New York, NY (G.O., S.F.); Clinical Directors Network, New York, NY (J.N.T., A.C., M.D.-G., C.K.); Department of Epidemiology and Population Health, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY (J.N.T.); Center for Clinical and Translational Science, Rockefeller University, New York, NY (J.N.T.); Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (T.P., J.E.S.); Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, NY (J.E.S.)
| | - Chamanara Khalida
- From the Division of Health and Behavior and Center for Healthful Behavior Change, Department of Population Health, New York University Langone Medical Center, New York, NY (G.O., S.F.); Clinical Directors Network, New York, NY (J.N.T., A.C., M.D.-G., C.K.); Department of Epidemiology and Population Health, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY (J.N.T.); Center for Clinical and Translational Science, Rockefeller University, New York, NY (J.N.T.); Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (T.P., J.E.S.); Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, NY (J.E.S.)
| | - Thomas Pickering
- From the Division of Health and Behavior and Center for Healthful Behavior Change, Department of Population Health, New York University Langone Medical Center, New York, NY (G.O., S.F.); Clinical Directors Network, New York, NY (J.N.T., A.C., M.D.-G., C.K.); Department of Epidemiology and Population Health, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY (J.N.T.); Center for Clinical and Translational Science, Rockefeller University, New York, NY (J.N.T.); Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (T.P., J.E.S.); Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, NY (J.E.S.)
| | - Joseph E Schwartz
- From the Division of Health and Behavior and Center for Healthful Behavior Change, Department of Population Health, New York University Langone Medical Center, New York, NY (G.O., S.F.); Clinical Directors Network, New York, NY (J.N.T., A.C., M.D.-G., C.K.); Department of Epidemiology and Population Health, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY (J.N.T.); Center for Clinical and Translational Science, Rockefeller University, New York, NY (J.N.T.); Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY (T.P., J.E.S.); Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, NY (J.E.S.)
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Chowdhury EK, Owen A, Krum H, Wing LMH, Ryan P, Nelson MR, Reid CM. Barriers to achieving blood pressure treatment targets in elderly hypertensive individuals. J Hum Hypertens 2013; 27:545-51. [PMID: 23448846 PMCID: PMC3747330 DOI: 10.1038/jhh.2013.11] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 01/09/2013] [Accepted: 01/13/2013] [Indexed: 11/26/2022]
Abstract
High blood pressure (BP) is highly prevalent among the elderly, and even with pharmacological therapy BP is difficult to control to guideline recommended levels. Although poor compliance to therapy is associated with less BP control, little is known regarding other barriers to attaining on-treatment target BP. This study examined factors associated with achieving on-treatment target BP in 6010 hypertensive participants aged 65-84 years from the Second Australian National Blood Pressure study. Participants were followed for a median of 4.1 years, with BP monitored every 6 months. 'Target BP' was defined as a reduction of systolic/diastolic BP of at least 20/10 mm Hg and BP <160/90 mm Hg from randomization in two consecutive follow-up visits. Cox regression was used to identify factors associated with achieving target BP from a number of baseline and in-study factors. Mean BP at randomization was 168/91 mm Hg and patients had a median of 9 (range: 2-20) study visits. Target BP was achieved in 50% of patients. Demographic factors associated with achieving target BP were male gender, living in a regional area; and clinical factors included history of antihypertensive therapy, increased plasma creatinine, lower pretreatment pulse pressure and in-study use of multiple BP-lowering drugs. Those aged >80 years and seeking care from multiple doctors (hazard ratio 0.40, 95% confidence interval 0.36-0.45, P<0.001) were less likely to achieve target BP. These findings identify clinical markers that can be targeted for intervention, but also demographic factors related to service delivery, which may provide further opportunity for achieving better BP control in hypertensive elderly.
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Affiliation(s)
- E K Chowdhury
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - A Owen
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - H Krum
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - L M H Wing
- Department of Clinical Pharmacology, School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - P Ryan
- Discipline of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - M R Nelson
- Menzies Research Institute Tasmania, University of Tasmania, Hobart, Tasmania, Australia
| | - C M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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20
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Gwadry-Sridhar FH, Manias E, Lal L, Salas M, Hughes DA, Ratzki-Leewing A, Grubisic M. Impact of interventions on medication adherence and blood pressure control in patients with essential hypertension: a systematic review by the ISPOR medication adherence and persistence special interest group. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:863-871. [PMID: 23947982 DOI: 10.1016/j.jval.2013.03.1631] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 03/09/2013] [Accepted: 03/16/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To systematically review the evidence on the impact of interventions to improve medication adherence in adults prescribed antihypertensive medications. METHODS An electronic search was undertaken of articles published between 1979 and 2009, without language restriction, that focused on interventions to improve antihypertensive medication adherence among patients (≥18 years) with essential hypertension. Studies must have measured adherence as an outcome of the intervention. We followed standard guidelines for the conduct and reporting of the review and conducted a narrative synthesis of reported data. RESULTS Ninety-seven articles were identified for inclusion; 35 (35 of 97, 36.1%) examined interventions to directly improve medication adherence, and the majority (58 of 97, 59.8%) were randomized controlled trials. Thirty-four (34 of 97, 35.1%) studies reported a statistically significant improvement in medication adherence. DISCUSSION/CONCLUSIONS Interventions aimed at improving patients' knowledge of medications possess the greatest potential clinical value in improving adherence with antihypertensive therapy. However, we identified several limitations of these studies, and advise future researchers to focus on using validated adherence measures, well-designed randomized controlled trials with relevant adherence and clinical outcomes, and guidelines on the appropriate design and analysis of adherence research.
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Affiliation(s)
- Femida H Gwadry-Sridhar
- Faculty of Science, Department of Computer Science, The University of Western Ontario, London, Ontario, Canada.
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21
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Suárez C. Single-pill telmisartan and amlodipine: a rational combination for the treatment of hypertension. Drugs 2012; 71:2295-305. [PMID: 22085386 DOI: 10.2165/11594510-000000000-00000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Despite the well documented benefits conferred by adequate control of hypertension, the majority of hypertensive patients display suboptimal control and few patients achieve blood pressure (BP) levels <140/90 mmHg. As a consequence, combination therapy will be required in the majority of patients to achieve target BP. Fixed-dose combinations of antihypertensives not only simplify treatment regimens, contributing to enhanced patient adherence, they provide superior BP-lowering efficacy and an improved tolerability profile. Fixed-dose combinations have become the strategy of choice in high-risk patients or those with stage 2-3 hypertension. The combination of a renin-angiotensin system inhibitor (RASI) with a calcium channel blocker (CCB) is a first-line combination that, in addition to its antihypertensive efficacy, reduces oedema, the main adverse effect of the dihydropyridine CCB and the main factor limiting their use. In morbidity/mortality studies, this fixed-dose combination has also demonstrated superiority over a RASI combined with a diuretic. The single-pill combination of telmisartan and amlodipine has been shown to produce a dose-dependent BP-lowering effect significantly greater than that of either agent administered as monotherapy. These findings have been confirmed by ambulatory BP monitoring in patients with stage 1 and 2 hypertension, which demonstrated that single-pill telmisartan/amlodipine provides substantial 24-hour BP-lowering efficacy. A higher proportion of patients achieved 24-hour BP goals of <130/80 mm Hg on combination therapy. The superior efficacy of combination therapy has been demonstrated across a broad range of patients, including those with moderate-to-severe hypertension, diabetes mellitus and obesity. Moreover, combined use of telmisartan and amlodipine reduces the incidence of amlodipine-induced oedema, making it a preferred combination for the treatment of hypertension.
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Affiliation(s)
- Carmen Suárez
- Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Universitario de La Princesa, Madrid, Spain.
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22
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Hebert PL, Sisk JE, Tuzzio L, Casabianca JM, Pogue VA, Wang JJ, Chen Y, Cowles C, McLaughlin MA. Nurse-led disease management for hypertension control in a diverse urban community: a randomized trial. J Gen Intern Med 2012; 27:630-9. [PMID: 22143452 PMCID: PMC3358388 DOI: 10.1007/s11606-011-1924-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 04/25/2011] [Accepted: 09/29/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treated but uncontrolled hypertension is highly prevalent in African American and Hispanic communities. OBJECTIVE To test the effectiveness on blood pressure of home blood pressure monitors alone or in combination with follow-up by a nurse manager. DESIGN Randomized controlled effectiveness trial. PATIENTS Four hundred and sixteen African American or Hispanic patients with a history of uncontrolled hypertension. Patients with blood pressure ≥150/95, or ≥140/85 for patients with diabetes or renal disease, at enrollment were recruited from one community clinic and four hospital outpatient clinics in East and Central Harlem, New York City. INTERVENTION Patients were randomized to receive usual care or a home blood pressure monitor plus one in-person counseling session and 9 months of telephone follow-up with a registered nurse. During the trial, the home monitor alone arm was added. MAIN MEASURES Change in systolic and diastolic blood pressure at 9 and 18 months. KEY RESULTS Changes from baseline to 9 months in systolic blood pressure relative to usual care was -7.0 mm Hg (Confidence Interval [CI], -13.4 to -0.6) in the nurse management plus home blood pressure monitor arm, and +1.1 mm Hg (95% CI, -5.5 to 7.8) in the home blood pressure monitor only arm. No statistically significant differences in systolic blood pressure were observed among treatment arms at 18 months. No statistically significant improvements in diastolic blood pressure were found across treatment arms at 9 or 18 months. Changes in prescribing practices did not explain the decrease in blood pressure in the nurse management arm. CONCLUSIONS A nurse management intervention combining an in-person visit, periodic phone calls, and home blood pressure monitoring over 9 months was associated with a statistically significant reduction in systolic, but not diastolic, blood pressure compared to usual care in a high risk population. Home blood pressure monitoring alone was no more effective than usual care.
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Affiliation(s)
- Paul L Hebert
- Department of Health Services, University of Washington School of Public Health, Washington, DC, USA.
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Huebschmann AG, Mizrahi T, Soenksen A, Beaty BL, Denberg TD. Reducing clinical inertia in hypertension treatment: a pragmatic randomized controlled trial. J Clin Hypertens (Greenwich) 2012; 14:322-9. [PMID: 22533659 DOI: 10.1111/j.1751-7176.2012.00607.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Clinical inertia is a major contributor to poor blood pressure (BP) control. The authors tested the effectiveness of an intervention targeting physician, patient, and office system factors with regard to outcomes of clinical inertia and BP control. A total of 591 adult primary care patients with elevated BP (mean systolic BP ≥ 140 mm Hg or mean diastolic BP ≥ 90 mm Hg) were randomized to intervention or usual care. An outreach coordinator raised patient and provider awareness of unmet BP goals, arranged BP-focused primary care clinic visits, and furnished providers with treatment decision support. The intervention reduced clinical inertia (-29% vs -11%, P=.001). Nonetheless, change in BP did not differ between intervention and usual care (-10.1/-4.1 mm Hg vs -9.1/-4.5 mm Hg, P=.50 and 0.71 for systolic and diastolic BP, respectively). Future primary care-focused interventions might benefit from the use of specific medication titration protocols, treatment adherence support, and more sustained patient follow-up visits.
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Affiliation(s)
- Amy G Huebschmann
- Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1, 12631 East 17th Avenue, Mailstop B180, Aurora, CO 80045, USA.
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Carter BL, Bosworth HB, Green BB. The hypertension team: the role of the pharmacist, nurse, and teamwork in hypertension therapy. J Clin Hypertens (Greenwich) 2012; 14:51-65. [PMID: 22235824 PMCID: PMC3257828 DOI: 10.1111/j.1751-7176.2011.00542.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 08/14/2011] [Indexed: 01/13/2023]
Abstract
Team-based care is one of the key components of the patient-centered medical home. Studies have consistently demonstrated that teams involving pharmacists or nurses in patient management can significantly improve blood pressure control. These findings have been demonstrated in several meta-analyses and systematic reviews. These reviews have generally found that team-based care can reduce systolic blood pressure by 4-10 mm Hg over usual care. However, these reviews have also concluded that many of the studies had various limitations and that additional research should be conducted. The present state of the art review paper will highlight newer studies, many of which were funded by the National Institutes of Health. Newer strategies involve telephone and/or web-based management which is an evolving area to improve blood pressure control in large populations. Social media and other technology is currently being investigated to assist pharmacists or nurses in communicating with patients to improve hypertension management. Few cost-effectiveness analyses have been performed but generally have found favorable costs for team-based care when considering the potential to reduce morbidity and mortality. The authors will suggest additional research that needs to be conducted to help evaluate strategies to best implement team-based care to improve blood pressure management.
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Affiliation(s)
- Barry L Carter
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA.
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Fernandez S, Tobin JN, Cassells A, Diaz-Gloster M, Kalida C, Ogedegbe G. The counseling African Americans to Control Hypertension (CAATCH) Trial: baseline demographic, clinical, psychosocial, and behavioral characteristics. Implement Sci 2011; 6:100. [PMID: 21884616 PMCID: PMC3179927 DOI: 10.1186/1748-5908-6-100] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 09/01/2011] [Indexed: 02/07/2023] Open
Abstract
Background Effectiveness of combined physician and patient-level interventions for blood pressure (BP) control in low-income, hypertensive African Americans with multiple co-morbid conditions remains largely untested in community-based primary care practices. Demographic, clinical, psychosocial, and behavioral characteristics of participants in the Counseling African American to Control Hypertension (CAATCH) Trial are described. CAATCH evaluates the effectiveness of a multi-level, multi-component, evidence-based intervention compared with usual care (UC) in improving BP control among poorly controlled hypertensive African Americans who receive primary care in Community Health Centers (CHCs). Methods Participants included 1,039 hypertensive African Americans receiving care in 30 CHCs in the New York Metropolitan area. Baseline data on participant demographic, clinical (e.g., BP, anti-hypertensive medications), psychosocial (e.g., depression, medication adherence, self-efficacy), and behavioral (e.g., exercise, diet) characteristics were gathered through direct observation, chart review, and interview. Results The sample was primarily female (71.6%), middle-aged (mean age = 56.9 ± 12.1 years), high school educated (62.4%), low-income (72.4% reporting less than $20,000/year income), and received Medicaid (35.9%) or Medicare (12.6%). Mean systolic and diastolic BP were 150.7 ± 16.7 mm Hg and 91.0 ± 10.6 mm Hg, respectively. Participants were prescribed an average of 2.5 ± 1.9 antihypertensive medications; 54.8% were on a diuretic; 33.8% were on a beta blocker; 41.9% were on calcium channel blockers; 64.8% were on angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs). One-quarter (25.6%) of the sample had resistant hypertension; one-half (55.7%) reported medication non-adherence. Most (79.7%) reported one or more co-morbid medical conditions. The majority of the patients had a Charlson Co-morbidity score ≥ 2. Diabetes mellitus was common (35.8%), and moderate/severe depression was present in 16% of participants. Participants were sedentary (835.3 ± 1,644.2 Kcal burned per week), obese (59.7%), and had poor global physical health, poor eating habits, high health literacy, and good overall mental health. Conclusions A majority of patients in the CAATCH trial exhibited adverse lifestyle behaviors, and had significant medical and psychosocial barriers to adequate BP control. Trial outcomes will shed light on the effectiveness of evidence-based interventions for BP control when implemented in real-world medical settings that serve high numbers of low-income hypertensive African-Americans with multiple co-morbidity and significant barriers to behavior change.
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Affiliation(s)
- Senaida Fernandez
- Center for Healthful Behavior Change, Division of General Internal Medicine, Department of Medicine, New York University School of Medicine, 550 First Avenue, New York, NY, USA
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Nuckols TK, Aledort JE, Adams J, Lai J, Go MH, Keesey J, McGlynn E. Cost implications of improving blood pressure management among U.S. adults. Health Serv Res 2011; 46:1124-57. [PMID: 21306365 PMCID: PMC3165181 DOI: 10.1111/j.1475-6773.2010.01239.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine the cost-effectiveness of improving blood pressure management from the payer perspective. DATA SOURCE/STUDY SETTING Medical record data for 4,500 U.S. adults with hypertension from the Community Quality Index (CQI) study (1996-2002), pharmaceutical claims from four Massachusetts health plans (2004-2006), Medicare fee schedule (2009), and published literature. STUDY DESIGN A probability tree depicted blood pressure management over 2 years. DATA COLLECTION/EXTRACTION METHODS We determined how frequently CQI study subjects received recommended care processes and attained accepted treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided. PRINCIPAL FINDINGS Relative to current care, improved care would cost payers U.S.$170 more per hypertensive person annually (2009 dollars). The incremental cost per person newly attaining treatment goals over 2 years would be U.S.$1,696 overall, U.S.$801 for moderate hypertension, and U.S.$850 for severe hypertension. Among people with severe hypertension, blood pressure would decline substantially but seldom reach goal; the incremental cost per person attaining a relaxed goal (≤ stage 1) would be U.S.$185. CONCLUSIONS Under the Health Care Effectiveness Data and Information Set program, which monitors the attainment of blood pressure treatment goals, payers will find it slightly more cost-effective to improve care for moderate than severe hypertension. Having a secondary, relaxed goal would substantially increase payers' incentive to improve care for severe hypertension.
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Affiliation(s)
- Teryl K Nuckols
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA.
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Ryan R, Santesso N, Hill S, Lowe D, Kaufman C, Grimshaw J. Consumer-oriented interventions for evidence-based prescribing and medicines use: an overview of systematic reviews. Cochrane Database Syst Rev 2011:CD007768. [PMID: 21563160 DOI: 10.1002/14651858.cd007768.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Numerous systematic reviews exist on interventions to improve consumers' medicines use, but this research is distributed across diseases, populations and settings. The scope and focus of reviews on consumers' medicines use also varies widely. Such differences create challenges for decision makers seeking review-level evidence to inform decisions about medicines use. OBJECTIVES To synthesise the evidence from systematic reviews on the effects of interventions which target healthcare consumers to promote evidence-based prescribing for, and medicines use, by consumers. We sought evidence on the effects on health and other outcomes for healthcare consumers, professionals and services. METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching both databases from start date to Issue 3 2008. We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. Standardised forms were used to extract data, and reviews were assessed for methodological quality using the AMSTAR instrument. We used standardised language to summarise results within and across reviews; and a further synthesis step was used to give bottom-line statements about intervention effectiveness. Two review authors selected reviews, extracted and analysed data. We used a taxonomy of interventions to categorise reviews. MAIN RESULTS We included 37 reviews (18 Cochrane, 19 non-Cochrane), of varied methodological quality.Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation, skills acquisition and information provision. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most commonly reported outcome, but others such as clinical (health and wellbeing), service use and knowledge outcomes were also reported. Reviews rarely reported adverse events or harms, and the evidence was sparse for several populations, including children and young people, carers, and people with multimorbidity.Promising interventions to improve adherence and other key medicines use outcomes (eg adverse events, knowledge) included self-monitoring and self-management, simplified dosing and interventions directly involving pharmacists. Other strategies showed promise in relation to adherence but their effects were less consistent. These included reminders; education combined with self-management skills training, counselling or support; financial incentives; and lay health worker interventions.No interventions were effective to improve all medicines use outcomes across all diseases, populations or settings. For some interventions, such as information or education provided alone, the evidence suggests ineffectiveness; for many others there is insufficient evidence to determine effects on medicines use outcomes. AUTHORS' CONCLUSIONS Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform these decisions and also to consider the range of interventions available; while researchers and funders can use this overview to determine where research is needed. However, the limitations of the literature relating to the lack of evidence for important outcomes and specific populations, such as people with multimorbidity, should also be considered.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, Australian Institute for Primary Care & Ageing, La Trobe University, Bundoora, VIC, Australia, 3086
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Cost-effectiveness of a hypertension management programme in an elderly population: a Markov model. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2011; 9:4. [PMID: 21466695 PMCID: PMC3084155 DOI: 10.1186/1478-7547-9-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 04/05/2011] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Mounting evidence shows that multi-intervention programmes for hypertension treatment are more effective than an isolated pharmacological strategy. Full economic evaluations of hypertension management programmes are scarce and contain methodological limitations. The aim of the study was to evaluate if a hypertension management programme for elderly patients is cost-effective compared to usual care from the perspective of a third-party payer. METHODS We built a cost-effectiveness model using published evidence of effectiveness of a comprehensive hypertension programme vs. usual care for patients 65 years or older at a community hospital in Buenos Aires, Argentina. We explored incremental cost-effectiveness between groups. The model used a life-time framework adopting a third-party payer's perspective. Incremental cost-effectiveness ratio (ICER) was calculated in International Dollars per life-year gained. We performed a probabilistic sensitivity analysis (PSA) to explore variable uncertainty. RESULTS The ICER for the base-case of the "Hypertension Programme" versus the "Usual care" approach was 1,124 International Dollars per life-year gained. PSA did not significantly influence results. The programme had a probability of 43% of being dominant (more effective and less costly) and, overall, 95% chance of being cost-effective. DISCUSSION Results showed that "Hypertension Programme" had high probabilities of being cost-effective under a wide range of scenarios. This is the first sound cost-effectiveness study to assess a comprehensive hypertension programme versus usual care. This study measures hard outcomes and explores robustness through a probabilistic sensitivity analysis. CONCLUSIONS The comprehensive hypertension programme had high probabilities of being cost-effective versus usual care. This study supports the idea that similar programmes could be the preferred strategy in countries and within health care systems where hypertension treatment for elderly patients is a standard practice.
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Pezzin LE, Feldman PH, Mongoven JM, McDonald MV, Gerber LM, Peng TR. Improving blood pressure control: results of home-based post-acute care interventions. J Gen Intern Med 2011; 26:280-6. [PMID: 20945114 PMCID: PMC3043175 DOI: 10.1007/s11606-010-1525-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Revised: 08/18/2010] [Accepted: 09/07/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Blood pressure (BP) control remains elusive for many Americans. Although home health nurses are uniquely positioned to help vulnerable individuals achieve BP control, hypertension (HTN) management has not been a high priority in post-acute care. OBJECTIVE To examine the effects of two home-based interventions designed to improve BP outcomes among high-risk African-American patients. DESIGN Cluster randomized controlled trial. PARTICIPANTS A total of 845 newly admitted patients with uncontrolled HTN (JNC7 stages 1 or 2). INTERVENTIONS The "basic" intervention delivered key HTN information to clinicians and patients, and a home BP monitor to patients, while the patients received usual post-acute care. The "augmented" intervention provided more intensive and extensive HTN information, monitoring and feedback for 3 months beyond the index home care admission. MEASURES Primary: BP control. Secondary: reductions in mmHG SBP and DBP, improvements in proportions improving JNC7 stage or achieving clinically meaningful reductions in SBP and DBP. METHODS Multivariate regression models. KEY RESULTS The basic intervention produced no significant BP improvements; the augmented intervention significantly improved stage 2 patients' outcomes. Among stage 2 patients, the augmented intervention increased BP control by 8.7 percentage points relative to usual care (8.9% vs. 17.6%; p=0.01), yielded an 8.3 mmHG relative reduction in SBP (p=0.01), and increased the proportion achieving at least a 20 mmHG reduction in SBP by 16.4 percentage points (p=0.01). CONCLUSION Among stage 2 patients, a nurse-led intervention providing additional HTN medication review and patient self-management support during the 3-month post-acute care period yielded significant improvements in 3-month BP control, plus improvements in secondary BP outcomes.
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Affiliation(s)
- Liliana E Pezzin
- Department of Medicine and Center for Patient Care and Outcomes Research (PCOR), Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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McBane S, Halstater B. Evaluation of beliefs about hypertension in a general population. J Prim Care Community Health 2011; 2:96-9. [PMID: 23804742 DOI: 10.1177/2150131910387609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Hypertension affects millions of people in the United States, yet many do not reach their blood pressure goals. Existing data indicate that self-management skills improve chronic disease management. Beliefs and attitudes are an important component of self management. This pilot study was designed to evaluate the beliefs of the general public on hypertension. METHODS One hundred patients of Duke Family Medicine were verbally consented to receive a survey consisting of 16 true/false questions. Included subjects were 18 years and older and comfortable answering questions in English. The questions addressed self-management behaviors, definition, and complications of hypertension. Basic demographic data were collected. Descriptive statistics were performed on the data. RESULTS Of 120 patients screened, 100 met inclusion criteria and agreed to participate in the study. Demographic data indicated that surveyed subjects were similar to the general clinic population: 69% were women, 51% African American, and 55% age 45 years and older. A total of 79% of subjects answered 13 or more questions correctly. The 3 most commonly missed questions addressed fatality of hypertension, adverse effects of medications, and potential for curing hypertension. CONCLUSION Hypertension is a prevalent issue affected by many factors. Beliefs of the general population, including the role of self-management, seem consistent with current medical knowledge. However, this study only evaluated beliefs not behaviors of patients. Further study is needed to elucidate patient-oriented factors that may limit control of hypertension.
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Affiliation(s)
- Sarah McBane
- University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences
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Hill MN, Miller NH, DeGeest S. Adherence and persistence with taking medication to control high blood pressure. ACTA ACUST UNITED AC 2011; 5:56-63. [DOI: 10.1016/j.jash.2011.01.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 06/15/2010] [Indexed: 10/18/2022]
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Park YH, Song M, Cho BL, Lim JY, Song W, Kim SH. The effects of an integrated health education and exercise program in community-dwelling older adults with hypertension: a randomized controlled trial. PATIENT EDUCATION AND COUNSELING 2011; 82:133-137. [PMID: 20434864 DOI: 10.1016/j.pec.2010.04.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 01/31/2010] [Accepted: 04/02/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE the aim of this study was to examine the effectiveness of HAHA (Healthy Aging and Happy Aging) program, which is an integrated health education and exercise program for community-dwelling older adults with hypertension. METHODS older adults with hypertension from one senior center were randomly allocated to experimental (n=18) or control group (n=22). Experimental group received health education, individual counseling and tailored exercise program for 12 weeks. RESULTS the mean ages were 71 years (experimental group) and 69 (control group). After the intervention, systolic blood pressure of experimental group was significantly decreased than that of control group. Scores of exercise self-efficacy, general health, vitality, social functioning, and mental health in SF-36 were statistically higher than those of control group. CONCLUSION the HAHA program was effective in control of systolic blood pressure and improving self-efficacy for exercise and health-related quality of life.
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Affiliation(s)
- Yeon-Hwan Park
- College of Nursing & The Research Institute of Nursing Science, Seoul National University, Seoul, South Korea
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D’Avino M, Scala D, Cozzolino S, Andria B, Simone C, Buonomo G, Colucciello G, Caruso G, Pantalena M, Di Giovanni MR, Manzillo RF, Caruso D. “Dieciannidivitainpiù”: realizzazione e valutazione di un progetto di educazione terapeutica al paziente iperteso. Risultati preliminari. ITALIAN JOURNAL OF MEDICINE 2010. [DOI: 10.1016/j.itjm.2010.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Evidence-based Nursing Practice for Health Promotion in Adults With Hypertension: A Literature Review. Asian Nurs Res (Korean Soc Nurs Sci) 2010; 4:227-45. [DOI: 10.1016/s1976-1317(11)60007-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 07/30/2010] [Accepted: 11/18/2010] [Indexed: 01/02/2023] Open
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Weber CA, Ernst ME, Sezate GS, Zheng S, Carter BL. Pharmacist-physician comanagement of hypertension and reduction in 24-hour ambulatory blood pressures. ACTA ACUST UNITED AC 2010; 170:1634-9. [PMID: 20937921 DOI: 10.1001/archinternmed.2010.349] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pharmacist-physician comanagement of hypertension has been shown to improve office blood pressures (BPs). We sought to describe the effect of such a model on 24-hour ambulatory BPs. METHODS We performed a prospective, cluster-randomized, controlled clinical trial, enrolling 179 patients with uncontrolled hypertension from 5 primary care clinics in Iowa City, Iowa. Patients were randomized by clinic to receive pharmacist-physician collaborative management of hypertension (intervention) or usual care (control) for a 9-month period. In the intervention group, pharmacists helped patients to identify barriers to BP control, counseled on lifestyle and dietary modifications, and adjusted antihypertensive therapy in collaboration with the patients' primary care providers. Patients were seen by pharmacists a minimum of every 2 months. Ambulatory BP was measured at baseline and at study end. RESULTS Baseline and end-of-study ambulatory BP profiles were evaluated for 175 patients. Mean (SD) ambulatory systolic BPs (SBPs), reported in millimeters of mercury, were reduced more in the intervention group than in the control group: daytime change in (Δ) SBP, 15.2 (11.5) vs 5.5 (13.5) (P < .001); nighttime ΔSBP, 12.2 (14.8) vs 3.4 (13.3) (P < .001); and 24-hour ΔSBP, 14.1 (11.3) vs 5.5 (12.5) (P < .001). More patients in the intervention group than in the control group had their BP controlled at the end of the study (75.0% vs 50.7%) (P < .001), as defined by overall 24-hour ambulatory BP monitoring. CONCLUSION Pharmacist-physician collaborative management of hypertension achieved consistent and significantly greater reduction in 24-hour BP and a high rate of BP control. Trial Registration clinicaltrials.gov Identifier: NCT00201045.
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Affiliation(s)
- Cynthia A Weber
- Department of Pharmacy Practice and Science, The University of Iowa, Iowa City, 52242, USA
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Ashton CM, Holt CL, Wray NP. A patient self-assessment tool to measure communication behaviors during doctor visits about hypertension. PATIENT EDUCATION AND COUNSELING 2010; 81:275-314. [PMID: 20435427 DOI: 10.1016/j.pec.2010.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 12/13/2009] [Accepted: 01/31/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To develop a preliminary version of a post-doctor visit self-assessment tool that patients with hypertension can use to evaluate their communication behaviors. High-quality communication between patient and doctor may have a positive effect on blood pressure control in hypertensive patients. Patients' communicative behaviors such as asking questions influence those of doctors, but most existing measurement tools assess doctors' behaviors rather than patients'. METHODS The tool is intended for use by African American or Caucasian American adults with hypertension, regardless of literacy level. The project included theory-based development of the item pool, usability testing (8 individuals), and cognitive response testing (13 additional individuals). MAIN RESULTS After multiple iterations, the preliminary version includes 138 items in 7 theory-based domains. CONCLUSION AND PRACTICE IMPLICATIONS The self-assessment tool is ready for testing of item and scale reliability and validity and consequent item reduction. This tool could prove useful in trials evaluating whether patients with hypertension who learn to be better communicators are more likely to achieve blood pressure control. In addition, because it asks patients to reflect on their use of specific behaviors that can be learned, the tool might also help patients in clinical practice to assume more active roles during their medical interactions.
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Affiliation(s)
- Carol M Ashton
- The Methodist Hospital Research Institute, 6550 Fannin Street, Houston, TX 77030, USA.
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Hill MN, Miller NH, DeGeest S. ASH position paper: Adherence and persistence with taking medication to control high blood pressure. J Clin Hypertens (Greenwich) 2010; 12:757-64. [PMID: 21029338 PMCID: PMC8673243 DOI: 10.1111/j.1751-7176.2010.00356.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 06/15/2010] [Indexed: 01/23/2023]
Abstract
Nonadherence and poor or no persistence in taking antihypertensive medications results in uncontrolled high blood pressure, poor clinical outcomes, and preventable health care costs. Factors associated with nonadherence are multilevel and relate not only to the patient, but also to the provider, health care system, health care organization, and community. National guideline committees have called for more aggressive approaches to implement strategies known to improve adherence and technologies known to enable changes at the systems level, including improved communication among providers and patients. Improvements in adherence and persistence are likely to be achieved by supporting patient self-management, a team approach to patient care, technology-supported office practice systems, better methods to measure adherence, and less clinical inertia. Integrating high blood pressure control into health care policies that emphasize and improve prevention and management of chronic illness remains a challenge. Four strategies are proposed: focusing on clinical outcomes; empowering informed, activated patients; developing prepared proactive practice teams; and advocating for health care policy reform. With hypertension remaining the most common reason for office visits, the time is now.
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Affiliation(s)
- Martha N Hill
- Johns Hopkins University School of Nursing, Baltimore, MD, USA.
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Hendriks JLM, Nieuwlaat R, Vrijhoef HJM, de Wit R, Crijns HJGM, Tieleman RG. Improving guideline adherence in the treatment of atrial fibrillation by implementing an integrated chronic care program. Neth Heart J 2010; 18:471-7. [PMID: 20978591 PMCID: PMC2954299 DOI: 10.1007/bf03091818] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Background / Objectives. Atrial fibrillation (AF) is a very frequent and complex disease often associated with other medical conditions. The Euro Heart Survey (EHS) on AF showed that adherence to guidelines may reduce morbidity and mortality in AF patients. Therefore a nurse-driven, guideline-based, ICT-supported integrated chronic care program (ICCP) was developed and implemented in daily practice. The objective of this study is to evaluate the clinical feasibility of the ICCP, with guideline adherence as the endpoint.Methods. 111 ambulant patients referred for treatment of their AF were enrolled in the ICCP. In this group, patients underwent standardised clinical testing and were subsequently managed by a nurse, supported by a dedicated ICT program and supervised by cardiologists. For comparison, we used a recent historical control group of 102 patients who participated in the Maastricht part of the Euro Heart Survey (EHS) on AF. Results. Guideline adherence was excellent within the ICCP and compared favourably with the EHS-AF data concerning both clinical testing (trigger factors recorded in 100 vs. 44%; echocardiogram performed in 99 vs. 88%; thyroid-stimulating hormone level recorded in 96% vs. 63%) as well as treatment (antithrombotic therapy in 90 vs. 78%; rhythm control avoided in completely asymptomatic patients in 100 vs. 54%; class I drugs avoided in patients with structural heart disease in 90 vs. 95%; rhythm control avoided in permanent AF patients in 100 vs. 92%). Conclusion. The high level of guideline adherence suggests that a nurse-driven, guideline-based, ICT-supported ICCP for AF patients is feasible. (Neth Heart J 2010;18:471-7.).
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Affiliation(s)
- J L M Hendriks
- Department of Cardiology, University Hospital Maastricht, and Department of Health Care & Nursing Sciences; Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
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Huizinga MM, Bleich SN, Beach MC, Clark JM, Cooper LA. Disparity in physician perception of patients' adherence to medications by obesity status. Obesity (Silver Spring) 2010; 18:1932-7. [PMID: 20186132 PMCID: PMC3149807 DOI: 10.1038/oby.2010.35] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Physician perception of medication adherence may alter prescribing patterns. Perception of patients has been linked to readily observable factors, such as race and age. Obesity shares a similar stigma to these factors in society. We hypothesized that physicians would perceive patients with a higher BMI as nonadherent to medication. Data were collected from the baseline visit of a randomized clinical trial of patient-physician communication (240 patients and 40 physicians). Physician perception of patient medication adherence was measured on a Likert scale and dichotomized as fully adherent or not fully adherent. BMI was the predictor of interest. We performed Poisson regression analyses with robust variance estimates, adjusting for clustering of patients within physicians, to examine the association between BMI and physician perception of medication adherence. The mean (s.d.) BMI was 32.6 (7.7) kg/m(2). Forty-five percent of patients were perceived as nonadherent to medications by their physicians. Higher BMI was significantly and negatively associated with being perceived as adherent to medication (prevalence ratio (PrR) 0.76, 95% confidence interval (CI): 0.64-0.90; P = 0.002; per 10 kg/m(2) increase in BMI). BMI remained significantly and negatively associated with physician perception of medication adherence after adjustment for patient and physician characteristics (PrR 0.80, 95% CI: 0.66-0.96; P = 0.020). In this study, patients with higher BMI were less likely to be perceived as adherent to medications by their providers. Physician perception of medication adherence has been shown to affect prescribing patterns in other studies. More work is needed to understand how this perception may affect the care of patients with obesity.
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Affiliation(s)
- Mary Margaret Huizinga
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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McNamara K, Philpot B, Janus ED, Dunbar JA. Greater Green Triangle Diabetes Prevention Program: remaining treatment gaps in hypertension and dyslipidaemia. Aust J Rural Health 2010; 18:43-4. [PMID: 20136814 DOI: 10.1111/j.1440-1584.2009.01120.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Kevin McNamara
- Greater Green Triangle University Department of Rural Health, Flinders University and Deakin University, Warrnambool, Australia.
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McAlister FA, Majumdar SR, Padwal RS, Fradette M, Thompson A, Tsuyuki R, Grover SA, Dean N, Shuaib A. The preventing recurrent vascular events and neurological worsening through intensive organized case-management (PREVENTION) trial protocol [clinicaltrials.gov identifier: NCT00931788]. Implement Sci 2010; 5:27. [PMID: 20385021 PMCID: PMC2868046 DOI: 10.1186/1748-5908-5-27] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 04/12/2010] [Indexed: 11/10/2022] Open
Abstract
Background Survivors of transient ischemic attack (TIA) or stroke are at high risk for recurrent vascular events and aggressive treatment of vascular risk factors can reduce this risk. However, vascular risk factors, especially hypertension and high cholesterol, are not managed optimally even in those patients seen in specialized clinics. This gap between the evidence for secondary prevention of stroke and the clinical reality leads to suboptimal patient outcomes. In this study, we will be testing a pharmacist case manager for delivery of stroke prevention services. We hypothesize this new structure will improve processes of care which in turn should lead to improved outcomes. Methods We will conduct a prospective, randomized, controlled open-label with blinded ascertainment of outcomes (PROBE) trial. Treatment allocation will be concealed from the study personnel, and all outcomes will be collected in an independent and blinded manner by observers who have not been involved in the patient's clinical care or trial participation and who are masked to baseline measurements. Patients will be randomized to control or a pharmacist case manager treating vascular risk factors to guideline-recommended target levels. Eligible patients will include all adult patients seen at stroke prevention clinics in Edmonton, Alberta after an ischemic stroke or TIA who have uncontrolled hypertension (defined as systolic blood pressure (BP) > 140 mm Hg) or dyslipidemia (fasting LDL-cholesterol > 2.00 mmol/L) and who are not cognitively impaired or institutionalized. The primary outcome will be the proportion of subjects who attain 'optimal BP and lipid control'(defined as systolic BP < 140 mm Hg and fasting LDL cholesterol < 2.0 mmol/L) at six months compared to baseline; 12-month data will also be collected for analyses of sustainability of any effects. A variety of secondary outcomes related to vascular risk and health-related quality of life will also be collected. Conclusions Nearly one-quarter of those who survive a TIA or minor stroke suffer another vascular event within a year. If our intervention improves the provision of secondary prevention therapies in these patients, the clinical (and financial) implications will be enormous.
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Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine, University of Alberta Hospital, 8440 112 Street, Edmonton, Canada.
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Buzza CD, Williams MB, Vander Weg MW, Christensen AJ, Kaboli PJ, Reisinger HS. Part II, provider perspectives: should patients be activated to request evidence-based medicine? A qualitative study of the VA project to implement diuretics (VAPID). Implement Sci 2010; 5:24. [PMID: 20298564 PMCID: PMC2856519 DOI: 10.1186/1748-5908-5-24] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 03/18/2010] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Hypertension guidelines recommend the use of thiazide diuretics as first-line therapy for uncomplicated hypertension, yet diuretics are under-prescribed, and hypertension is frequently inadequately treated. This qualitative evaluation of provider attitudes follows a randomized controlled trial of a patient activation strategy in which hypertensive patients received letters and incentives to discuss thiazides with their provider. The strategy prompted high discussion rates and enhanced thiazide-prescribing rates. Our objective was to interview providers to understand the effectiveness and acceptability of the intervention from their perspective, as well as the suitability of patient activation for more widespread guideline implementation. METHODS Semi-structured phone interviews were conducted with 21 primary care providers. Interviews were transcribed verbatim and reviewed by the interviewer before being analyzed for content. Interviews were coded, and relevant themes and specific responses were identified, grouped, and compared. RESULTS Of the 21 providers interviewed, 20 (95%) had a positive opinion of the intervention, and 18 of 20 (90%) thought the strategy was suitable for wider use. In explaining their opinions of the intervention, many providers discussed a positive effect on treatment, but they more often focused on the process of patient activation itself, describing how the intervention facilitated discussions by informing patients and making them more pro-active. Regarding effectiveness, providers suggested the intervention worked like a reminder, highlighted oversights, or changed their approach to hypertension management. Many providers also explained that the intervention 'aligned' patients' objectives with theirs, or made patients more likely to accept a change in medications. Negative aspects were mentioned infrequently, but concerns about the use of financial incentives were most common. Relevant barriers to initiating thiazide treatment included a hesitancy to switch medications if the patient was at or near goal blood pressure on a different anti-hypertensive. CONCLUSIONS Patient activation was acceptable to providers as a guideline implementation strategy, with considerable value placed on the activation process itself. By 'aligning' patients' objectives with those of their providers, this process also facilitated part of the effectiveness of the intervention. Patient activation shows promise for wider use as an implementation strategy, and should be tested in other areas of evidence-based medicine. TRIAL REGISTRATION National Clinical Trial Registry number NCT00265538.
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Affiliation(s)
- Colin D Buzza
- The Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VA Medical Center, 601 Highway 6 West, Mail Stop 152, Iowa City, IA, 52246-2208, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Monica B Williams
- The Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VA Medical Center, 601 Highway 6 West, Mail Stop 152, Iowa City, IA, 52246-2208, USA
| | - Mark W Vander Weg
- The Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VA Medical Center, 601 Highway 6 West, Mail Stop 152, Iowa City, IA, 52246-2208, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Alan J Christensen
- The Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VA Medical Center, 601 Highway 6 West, Mail Stop 152, Iowa City, IA, 52246-2208, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Department of Psychology, University of Iowa, Iowa City, IA, USA
| | - Peter J Kaboli
- The Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VA Medical Center, 601 Highway 6 West, Mail Stop 152, Iowa City, IA, 52246-2208, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Heather Schacht Reisinger
- The Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VA Medical Center, 601 Highway 6 West, Mail Stop 152, Iowa City, IA, 52246-2208, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Scott I. What are the most effective strategies for improving quality and safety of health care? Intern Med J 2010; 39:389-400. [PMID: 19580618 DOI: 10.1111/j.1445-5994.2008.01798.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
There is now a plethora of different quality improvement strategies (QIS) for optimizing health care, some clinician/patient driven, others manager/policy-maker driven. Which of these are most effective remains unclear despite expressed concerns about potential for QIS-related patient harm and wasting of resources. The objective of this study was to review published literature assessing the relative effectiveness of different QIS. Data sources comprising PubMed Clinical Queries, Cochrane Library and its Effective Practice and Organization of Care database, and HealthStar were searched for studies of QIS between January 1985 and February 2008 using search terms based on an a priori QIS classification suggested by experts. Systematic reviews of controlled trials were selected in determining effect sizes for specific QIS, which were compared as a narrative meta-review. Clinician/patient driven QIS were associated with stronger evidence of efficacy and larger effect sizes than manager/policy-maker driven QIS. The most effective strategies (>10% absolute increase in appropriate care or equivalent measure) included clinician-directed audit and feedback cycles, clinical decision support systems, specialty outreach programmes, chronic disease management programmes, continuing professional education based on interactive small-group case discussions, and patient-mediated clinician reminders. Pay-for-performance schemes directed to clinician groups and organizational process redesign were modestly effective. Other manager/policy-maker driven QIS including continuous quality improvement programmes, risk and safety management systems, public scorecards and performance reports, external accreditation, and clinical governance arrangements have not been adequately evaluated with regard to effectiveness. QIS are heterogeneous and methodological flaws in much of the evaluative literature limit validity and generalizability of results. Based on current best available evidence, clinician/patient driven QIS appear to be more effective than manager/policy-maker driven QIS although the latter have, in many instances, attracted insufficient robust evaluations to accurately determine their comparative effectiveness.
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Affiliation(s)
- I Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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Baltzan MA, Wolkove N. Persistent sleep apnea is common and needs to be found. Sleep Med 2010; 11:115-6. [DOI: 10.1016/j.sleep.2009.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Accepted: 06/22/2009] [Indexed: 11/26/2022]
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Lekoubou A, Awah P, Fezeu L, Sobngwi E, Kengne AP. Hypertension, diabetes mellitus and task shifting in their management in sub-Saharan Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2010; 7:353-63. [PMID: 20616978 DOI: 10.3390/ijerph7020353] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Accepted: 01/23/2010] [Indexed: 12/18/2022]
Abstract
Chronic diseases are becoming increasingly important in sub-Saharan Africa (SSA). The current density and distribution of health workforce suggest that SSA cannot respond to the growing demand for chronic disease care, together with the frequent infectious diseases. Innovative approaches are therefore needed to rapidly expand the health workforce. In this article, we discuss the evidences in support of nurse-led strategies for chronic disease management in SSA, with a focus on hypertension and diabetes mellitus.
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Affiliation(s)
- Alain Lekoubou
- Department of Internal Medicine and Specialities, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Cameroon.
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Kengne AP, Awah PK, Fezeu LL, Sobngwi E, Mbanya JC. Primary health care for hypertension by nurses in rural and urban sub-Saharan Africa. J Clin Hypertens (Greenwich) 2010; 11:564-72. [PMID: 19817937 DOI: 10.1111/j.1751-7176.2009.00165.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To implement a nurse-led protocol for the care of hypertension, 5 clinics were established in Yaounde (urban) and Bafut (rural) in Cameroon. International guidelines were adapted and 10 nurses were trained. The initial cohort of patients was referred from a field survey. The program proceeded for 26 months and 454 patients (45% urban) were registered in the clinics. Relative to urban participants, rural participants were more often women (59% vs 45%, P=.002) and less likely to have diabetes (7.2% vs 41.2%, P<.001). Between baseline and final visits, systolic and diastolic blood pressures dropped by 11.7 mm Hg (95% confidence interval, 8.9-14.4) and 7.8 (95% confidence interval, 5.9-9.6), respectively (P<.001). These changes were consistent in subgroups and after adjustment. Most dropouts occurred around the initial visit and among urban participants and nondiabetics. Nurse-led clinics are effective for improving hypertension care in these settings and require implementation and validation through controlled trials.
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Affiliation(s)
- Andre P Kengne
- The George Institute for International Health, The University of Sydney, Sydney, Australia.
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Bosworth HB, Olsen MK, Grubber JM, Neary AM, Orr MM, Powers BJ, Adams MB, Svetkey LP, Reed SD, Li Y, Dolor RJ, Oddone EZ. Two self-management interventions to improve hypertension control: a randomized trial. Ann Intern Med 2009; 151:687-95. [PMID: 19920269 PMCID: PMC2892337 DOI: 10.7326/0003-4819-151-10-200911170-00148] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Fewer than 40% of persons with hypertension in the United States have adequate blood pressure (BP) control. OBJECTIVE To compare 2 self-management interventions for improving BP control among hypertensive patients. DESIGN A 2 x 2 randomized trial, stratified by enrollment site and patient health literacy status, with 2-year follow-up. (ClinicalTrials.gov registration number: NCT00123058). SETTING 2 university-affiliated primary care clinics. PATIENTS 636 hypertensive patients. INTERVENTION A centralized, blinded, and stratified randomization algorithm was used to randomly assign eligible patients to receive usual care, a behavioral intervention (bimonthly tailored, nurse-administered telephone intervention targeting hypertension-related behaviors), home BP monitoring 3 times weekly, or the behavioral intervention plus home BP monitoring. MEASUREMENTS The primary outcome was BP control at 6-month intervals over 24 months. RESULTS 475 patients (75%) completed the 24-month BP follow-up. At 24 months, improvements in the proportion of patients with BP control relative to the usual care group were 4.3% (95% CI, -4.5% to 12.9%) in the behavioral intervention group, 7.6% (CI, -1.9% to 17.0%) in the home BP monitoring group, and 11.0% (CI, 1.9%, 19.8%) in the combined intervention group. Relative to usual care, the 24-month difference in systolic BP was 0.6 mm Hg (CI, -2.2 to 3.4 mm Hg) for the behavioral intervention group, -0.6 mm Hg (CI, -3.6 to 2.3 mm Hg) for the BP monitoring group, and -3.9 mm Hg (CI, -6.9 to -0.9 mm Hg) for the combined intervention group; patterns were similar for diastolic BP. LIMITATION Changes in medication use and diet were monitored only in intervention participants; 24-month outcome data were missing for 25% of participants, BP control was adequate at baseline in 73% of participants, and the study setting was an academic health center. CONCLUSION Combined home BP monitoring and tailored behavioral telephone intervention improved BP control, systolic BP, and diastolic BP at 24 months relative to usual care. .
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Affiliation(s)
- Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Center for Aging and Human Development, Duke Hypertension Center, and Duke Clinical Research Institute, Duke University, Durham, North Carolina 27703, USA.
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Abstract
PURPOSE The purpose of this article is to discuss the holistic evaluation of the hypertensive patient and review evidence-based nonpharmacological treatments to help patients achieve maximum therapeutic benefits with minimal side effects. DATA SOURCES Health sciences literature was reviewed using the following databases: Medline, PubMed, and Cumulative Index to Nursing and Allied Health Literature. CONCLUSIONS Hypertension remains a major public health problem, affecting 65 million Americans and contributing to excess morbidity, mortality, and indirect and direct healthcare costs. Improving clinical outcomes will reduce human suffering as well as the economic burden associated with this disease. Nonpharmacological strategies are recommended as successful primary and adjunctive treatment options for lowering blood pressure. Moreover, the benefits of many of these approaches extend to and promote overall health and well-being. IMPLICATIONS FOR PRACTICE Nurse practitioners who incorporate nonpharmacological options in the management of hypertension can improve clinical outcomes.
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Affiliation(s)
- M Elayne DeSimone
- Stony Brook University School of Nursing, Stony Brook, New York 11794-8240, USA.
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Faria C, Wenzel M, Lee KW, Coderre K, Nichols J, Belletti DA. A narrative review of clinical inertia: focus on hypertension. ACTA ACUST UNITED AC 2009; 3:267-76. [DOI: 10.1016/j.jash.2009.03.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 02/26/2009] [Accepted: 03/01/2009] [Indexed: 11/15/2022]
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Scisney-Matlock M, Bosworth HB, Giger JN, Strickland OL, Harrison RV, Coverson D, Shah NR, Dennison CR, Dunbar-Jacob JM, Jones L, Ogedegbe G, Batts-Turner ML, Jamerson KA. Strategies for implementing and sustaining therapeutic lifestyle changes as part of hypertension management in African Americans. Postgrad Med 2009; 121:147-59. [PMID: 19491553 DOI: 10.3810/pgm.2009.05.2015] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
African Americans with high blood pressure (BP) can benefit greatly from therapeutic lifestyle changes (TLC) such as diet modification, physical activity, and weight management. However, they and their health care providers face many barriers in modifying health behaviors. A multidisciplinary panel synthesized the scientific data on TLC in African Americans for efficacy in improving BP control, barriers to behavioral change, and strategies to overcome those barriers. Therapeutic lifestyle change interventions should emphasize patient self-management, supported by providers, family, and the community. Interventions should be tailored to an individual's cultural heritage, beliefs, and behavioral norms. Simultaneously targeting multiple factors that impede BP control will maximize the likelihood of success. The panel cited limited progress with integrating the Dietary Approaches to Stop Hypertension (DASH) eating plan into the African American diet as an example of the need for more strategically developed interventions. Culturally sensitive instruments to assess impact will help guide improved provision of TLC in special populations. The challenge of improving BP control in African Americans and delivery of hypertension care requires changes at the health system and public policy levels. At the patient level, culturally sensitive interventions that apply the strategies described and optimize community involvement will advance TLC in African Americans with high BP.
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Affiliation(s)
- Margaret Scisney-Matlock
- Division of Acute Critical and Long-Term Care Programs, School of Nursing, The University of Michigan, Ann Arbor, MI 48109-0482, USA.
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