Patient education and provider decision support to control blood pressure in primary care: A cluster randomized trial

doi:10.1016/j.ahj.2008.11.003

American Heart Journal

Volume 157, Issue 3, March 2009, Pages 450-456

https://doi.org/10.1016/j.ahj.2008.11.003 Get rights and content

Background

Less than one third of the 65 million Americans with hypertension have adequate blood pressure (BP) control. This study examined the effectiveness of 2 interventions for improving patient BP control.

Methods

This was a 2-level (primary care provider and patient) cluster randomized trial with 2-year follow-up occurring among patients with hypertension enrolled from a Veterans Affairs Medical Center primary care clinic. Primary care providers (n = 17) in the intervention received computer-generated decision support designed to improve guideline concordant medical therapy at each visit; control providers (n = 15) received a reminder at each visit. Patients received usual care or a bimonthly tailored nurse-delivered behavioral telephone intervention to improve hypertension treatment. The primary outcome was proportion of patients who achieved a BP <140/90 mm Hg (<130/85 for diabetic patients) over the 24-month intervention.

Results

Of the 816 eligible patients contacted, 190 refused and 38 were excluded. The 588 enrolled patients had a mean age of 63 years, 43% had adequate baseline BP control, and 482 (82%) completed the 24-month follow-up. There were no significant differences in amount of change in BP control in the 3 intervention groups as compared to the hypertension reminder control group. In secondary analyses, rates of BP control for all patients receiving the patient behavioral intervention (n = 294) improved from 40.1% to 54.4% at 24 months (P = .03); patients in the nonbehavioral intervention group improved from 38.2% to 43.9% (P = .38), but there was no between-group differences at the end of the study.

Conclusion

The brief behavioral intervention showed improved outcomes over time, but there were not significant between group differences.

Section snippets

Design, setting, and recruitment

The study was a longitudinal cluster randomized trial; the interventions occurred at 2 levels (provider and patient), and patients were nested within providers and followed over time.

Patients

The patients' mean age was 63 years, 98% were male, and 40% were African American (see Table I). A significant percent of the sample reported no exercise (44%) in the last week, 25% were current smokers, and 37% had diabetes. Baseline mean SBP was 140 mm Hg (SD = 18), DBP was 76 mm Hg (SD = 11), and 40% of the sample had their BP under control at baseline.

Primary analyses

Over the 2 years of the intervention, there were no significant differences in amount of change in BP control in each of the intervention

Discussion

We examined the effects of both a patient behavioral intervention delivered by telephone to patients along with a provider decision support intervention directed at providers in an attempt to improve overall BP control among adults with hypertension treated in primary care. We did not observe a significant improvement in BP control across the 3 intervention groups relative to the reminder control group over the 2-year follow-up. In secondary analyses, we observed improvements in BP control

Conclusion

Computer-based decision support patient management system delivered at the point of care did not result in significant improvements in BP control, whereas a telephone-delivered patient intervention resulted in meeting our a priori specified clinically significant end point; this difference was not statistically significant from the control group. A brief nurse-administered telephone intervention may have a clinical effect on BP control rates in a primary care setting. With 65 million of the US

Disclosures

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Acknowledgements

We wish to thank the EON Group at Stanford Medical Informatics, the ATHENA Group at VA Palo Alto Health Care System, and Brian B. Hoffman, MD, collaborators on developing the ATHENA Decision Support System. Earlier results were presented at the 2005 American Heart Association Conference, Dallas, TX.

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: Clinical trial registration no. NCT00105716.

: Dr. George A. Mensah served as guest editor for this manuscript.

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Clinical InvestigationHypertensionPatient education and provider decision support to control blood pressure in primary care: A cluster randomized trial

Background

Methods

Results

Conclusion

Section snippets

Design, setting, and recruitment

Patients

Primary analyses

Discussion

Conclusion

Disclosures

Acknowledgements

Am Heart J

Contemp Clin Trials

J Am Med Inform Assoc

Patient Educ Couns

Am J Prev Med

The burden of adult hypertension in the United States 1999 to 2000. A rising tide

Hypertension

Prevalence and costs of chronic conditions in the VA health care system

Med Care Res Rev

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report

Jama

The multilevel compliance challenge: recommendations for a call to action. A statement for healthcare professionals

Circulation

A model of psychosocial and cultural antecedents of blood pressure control

J Nat Med Assoc

Overcome clinical inertia to control systolic blood pressure

Arch Intern Med

Adherence to medication

N Engl J Med

Understanding and improving patient compliance

Ann Intern Med

Clinical Investigation
Hypertension
Patient education and provider decision support to control blood pressure in primary care: A cluster randomized trial