Improving urban African Americans' blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: A randomized clinical trial

BackgroundGiven 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/designWe 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 12 months.DiscussionResults from the ACT study will provide needed evidence on the effectiveness of comprehensive multi-level interventions to improve urban African American patients' hypertension control.     

Rationale and study design of the MyHEART study: A young adult hypertension self-management randomized controlled trial

Young adults (18–39 year-olds) with hypertension have a higher lifetime risk for cardiovascular disease. However, less than 50% of young adults achieve hypertension control in the United States. Hypertension self-management programs are recommended to improve control, but have been targeted to middle-aged and older populations. Young adults need hypertension self-management programs (i.e., home blood pressure monitoring and lifestyle modifications) tailored to their unique needs to lower blood pressure and reduce the risks and medication burden they may face over a lifetime. To address the unmet need in hypertensive care for young adults, we developed MyHEART (My Hypertension Education And Reaching Target), a multi-component, theoretically-based intervention designed to achieve self-management among young adults with uncontrolled hypertension. MyHEART is a patient-centered program, based upon the Self-Determination Theory, that uses evidence-based health behavior approaches to lower blood pressure. Therefore, the objective of this study is to evaluate MyHEART’s impact on changes in systolic and diastolic blood pressure compared to usual care after 6 and 12 months in 310 geographically and racially/ethnically diverse young adults with uncontrolled hypertension. Secondary outcomes include MyHEART’s impact on behavioral outcomes at 6 and 12 months, compared to usual clinical care (increased physical activity, decreased sodium intake) and to examine whether MyHEART’s effects on self-management behavior are mediated through variables of perceived competence, autonomy, motivation, and activation (mediation outcomes). MyHEART is one of the first multicenter, randomized controlled hypertension trials tailored to young adults with primary care. The design and methodology will maximize the generalizability of this study.Trial registrationClinicalTrials.gov Identifier: NCT03158051     

加强患者健康教育对控制血液透析患者高血压的影响

目的调查分析维持性血液透析患者高血压的危险因素,加强患者健康教育,提高血压达标率。方法对177例透析患者进行调查问卷。分析血压控制不达标的原因,有针对性进行健康教育和医疗干预。结果合并高血压维持性血液透析患者112例,其中68例血压未达标(>140/90mmHg)。血压未达标患者的透析间期体质量增长率较血压达标患者高,分别为(6.18±1.83)%和(5.19±1.60)%,差异有统计学意义(P<0.01)。加强患者健康教育,进行医疗护理干预2个月后,血压未达标者透析间期体质量增长量较干预前减少,收缩压和舒张压较干预前均有所下降。结论对透析患者进行相关知识的宣教有助于患者控制体质量增长,降低血压。     

Design and rationale for Home Blood Pressure Telemonitoring and Case Management to Control Hypertension (HyperLink): a cluster randomized trial

BackgroundPatients with high blood pressure (BP) visit a physician an average of 4 times or more per year in the U.S., yet BP is controlled in fewer than half. Practical, robust and sustainable models are needed to improve BP in patients with uncontrolled hypertension.ObjectivesThe Home Blood Pressure Telemonitoring and Case Management to Control Hypertension study (HyperLink) is a cluster-randomized trial designed to determine whether an intervention that combines home BP telemonitoring with pharmacist case management improves BP control compared to usual care at 6 and 12 months in patients with uncontrolled hypertension. Secondary outcomes are maintenance of BP control at 18 months, patient satisfaction with their health care, and costs of care.MethodsHyperLink enrolled 450 hypertensive patients with uncontrolled BP from 16 primary care clinics. Eight clinics were randomized to provide usual care (UC) to their patients (n = 222) and 8 were randomized to provide the telemonitoring intervention (TI) (n = 228). TI patients received home BP telemonitors that internally store and electronically transmit BP data to a secure database. Pharmacist case managers adjust antihypertensive therapy based on the home BP data under a collaborative practice agreement with the clinics' primary care teams. The length of the intervention is 12 months, with follow-up to 18 months to determine the durability of the intervention.ConclusionsWe will test in a real primary care setting whether combining BP telemonitoring and pharmacist case management can achieve and maintain high rates of BP control compared to usual care.     

The pharmacist and the management of arterial hypertension: the role of blood pressure monitoring and telemonitoring

Randomized controlled trials have documented that a team of health care professionals which includes a physician, a nurse and a community pharmacist may improve the benefit and adherence of anti-hypertensive therapy. If such a health care model relies on blood pressure telemonitoring, it can promote a stronger relationship between health care professionals and patients, and further improve BP control of hypertension. The major benefit of this collaborative approach is to center the patient’s management in a tailored way, providing comprehensive and preventive care based on health information technologies. In this review, the authors summarize recent clinical studies that evaluate the role of the community pharmacist in BP measurements, and in hypertension screening and control. The authors also describe the advantages of using blood pressure telemonitoring in home and ambulatory settings to evaluate potential alternatives to primary care in hypertension management.     

Effectiveness of a medical education intervention to treat hypertension in primary care

Background and objectives In Mexico, hypertension is among the top five causes for visits to primary care clinics; its complications are among the main causes of emergency and hospital care. The present study reports the effectiveness of a continuing medical education (CME) intervention to improve appropriate care for hypertension, on blood pressure control of hypertensive patients in primary care clinics. Methods A secondary data analysis was carried out using data of hypertensive patients treated by family doctors who participated in the CME intervention. The evaluation was designed as a pre‐/post‐intervention study with control group in six primary care clinics. The effect of the CME intervention was analysed using multiple logistic regression modelling in which the dependent variable was uncontrolled blood pressure in the post‐intervention patient measurement. Results After the CME intervention, the net reduction of uncontrolled blood pressure between stages in the intervention group was 10.3%. The model results were that being treated by a family doctor who participated in the CME intervention reduced by 53% the probability of lack of control of blood pressure; receiving dietary recommendations reduced 57% the probability of uncontrolled blood pressure. Having uncontrolled blood pressure at the baseline stage increased the probability of lack of control in 166%, and per each unit of increase in body mass index the lack of control increased 7%. Conclusions CME intervention improved the medical decision‐making process to manage hypertension, thus increasing the probability of hypertensive patients to have blood pressure under control.     

Assessment of the association between blood pressure control and health care resource use.

BACKGROUND: Several studies have reported increased health care resource use among hypertensive patients with uncontrolled blood pressure (BP). OBJECTIVE: The purpose of this study was to investigate the relationship between BP control and health care resource use. METHODS: Data were obtained from the Caring for Hypertension on Initiation: Costs and Effectiveness (CHOICE) study, a multicenter feasibility study of actual physician and patient behavior and clinical outcomes in a naturalistic setting. Adult patients with newly diagnosed hypertension were randomized to either Group 1 (treatment with diuretics or beta-blockers) or Group 2 (treatment with calcium channel blockers or angiotensin-converting enzyme inhibitors) and followed for 5 +/- 1 months. Physicians practiced standard care while documenting medications, BP measurements, and health care resource use for their patients. A subsequent analysis evaluating the relationship between BP and physician visits was performed for the whole population and for a subpopulation of patients with at least 4 months of follow-up data. Cox regression was used to model time to next visit. RESULTS: A total of 512 patients with newly diagnosed hypertension were followed: 399 had follow-up data for at least 4 months. Baseline demographic characteristics were similar in the 2 groups. Kaplan-Meier curves and a log-rank test showed that the time to next visit for patients with uncontrolled BP was significantly shorter than for patients whose BP was controlled (P < 0.05). On average, patients with uncontrolled BP (> or = 140/90 mm Hg) had follow-up office visits approximately 13 days earlier than patients with controlled BP (< 140/90 mm Hg). This association remained significant after adjustment for repeated measures, and after exclusion of the first return visit. Cox regression analysis showed that higher systolic and diastolic BP measurements were significantly associated with a shorter time to next visit, after adjustment for age and sex. Total estimated costs during the study period were $170 per patient for medications and $283 per patient for office visits. CONCLUSIONS: In the CHOICE study, higher BP was associated with a shorter time to next visit. Office visits were the main cost driver in the short-term management of hypertension.     

Improving management of resistant hypertension: Rationale and protocol for a cluster randomized trial addressing physician managers in primary care

BackgroundResistant hypertension (RH) is defined as uncontrolled blood pressure (BP) despite ≥ 3 antihypertensive agents. It is estimated to account for 12–28% of all hypertensive patients. Despite a higher risk of cardiovascular events, hypertension therapy in these patients is often insufficient. In a previous study we successfully tested an evidence-based, physician manager-centered hypertension management.MethodsFor this cluster randomized trial (CRT), a random sample of 102 German primary care practices will be randomized into two study arms (1:1). Physician managers and practice assistants of the intervention arm will participate in three-session medical education on hypertension management to implement 1) standardized diagnostic and therapeutic procedures for RH patients, 2) structured recall of patients with uncontrolled BP, and 3) teaching and supervision of RH patients on BP self-measurements. Practice tools are provided to facilitate implementation, e.g., how to distinguish true from pseudo RH and guideline-based medication selection. Physicians will specify guideline-algorithms for their practice to manage RH. A secured web-based peer-group exchange with hypertension specialists is offered to both professional groups. Physicians of both study arms will consecutively recruit patients with RH. BP will be measured by ambulatory BP monitoring at baseline and after 12 months. The primary endpoint is defined as treatment success with either normalized BP (24 h < 130/80 mm Hg) and/or a reduction by ≥ 20 mm Hg systolic and/or ≥ 10 mm Hg diastolic. Secondary analyses will focus on changes in physicians' knowledge and practice routines.DiscussionThis CRT will determine the effectiveness of a physician manager-centered intervention on treatment success in high-risk patients.     

Effects of a Website designed to improve the management of migraines

OBJECTIVE: The aim was to examine the effect of using a Web-based computer program that provides personalized feedback to migraine patients, on the interactions of patients and providers. Background.-Despite the widespread availability of evidence-based migraine treatment guidelines, patients often do not receive optimal treatment to reduce migraine pain and disability. METHODS: To address these quality gaps in migraine care, we developed a Web-based computer program, to be used by migraine patients before doctor visits. The feedback is designed to prompt patients to ask questions that lead to higher quality of care. This study was conducted to examine the effect of using the program on migraine-specific doctor-patient communications. Patients were randomized to use the Website before (intervention) or after (control) a visit with their provider. The outcome measures were the migraine-specific topics discussed during the visit, measured by an exit survey after the visit. RESULTS: Fifty of 53 subjects randomized completed the postvisit measures (94%). Overall, the mean age was 42.0 years, most patients were female (86.5%), all were white, and 58.5% saw a headache specialist during their visit. Most (75.0%) reported having headaches at least once per week and 48.1% rated their headaches as "severe." Intervention patients were significantly more likely to "discuss whether you had migraine headaches or some other type of headache?" (89.3% vs 54.5%; P < .01) and to "discuss whether or not there may be a more serious cause of your headaches?" (50.0% vs 13.6%; P < .01). Intervention patients were more likely to report discussing 8 of 12 migraine-related topics more frequently and a greater overall number of topics (5.5 vs 4.3) than control patients. This difference was not statistically significant. CONCLUSIONS: These results suggest that the Website may have a positive impact on migraine-specific doctor-patient communications. A larger study, including important quality of life and utilization outcomes, is warranted.     

Development and evaluation of a nurse-led hypertension management model: A randomized controlled trial

BackgroundThe hypertension prevalence rate is increasing but the control rate is unsatisfactory. Nurse-led healthcare may be an effective way to improve outcomes for hypertensive patients but more evidence is required especially at the community level.ObjectiveThis study aims to establish a nurse-led hypertension management model and to test its effectiveness at the community level.DesignA single-blind, randomized controlled trial was performed in an urban community healthcare center in China. Hypertensive patients with uncontrolled blood pressure (systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg) were randomly allocated into two groups: the study group (n = 67) and the control group (n = 67). The nurse-led hypertension management model included four components (delivery system design, decision support, clinical information system and self-management support). Patients in the control group received usual care. Patients in the study group received a 12-week period of hypertension management. The patient outcomes, which involved blood pressure, self-care behaviors, self-efficacy, quality of life and satisfaction, were assessed at three time points: the baseline, immediately after the intervention and 4 weeks after the intervention.ResultsAfter the intervention, the blood pressure of patients in the study group decreased significantly compared to those in the control group, and the mean reduction of systolic/diastolic blood pressure in the study and control groups was 14.37/7.43 mmHg and 5.10/2.69 mmHg, respectively (p < 0.01). In addition, patients in the study group had significantly greater improvement in self-care behaviors than those in the control group (p < 0.01). The study group had a higher level of satisfaction with hypertensive care than the control group (p < 0.01). No statistically significant difference in self-efficacy and quality of life was detected between the two groups after the intervention.ConclusionsThe nurse-led hypertension management model is feasible and effective in improving the outcomes of patients with uncontrolled blood pressure at the community level.     

Patient contributions during primary care consultations for hypertension after self-reporting via a mobile phone self-management support system

Objective: This paper reports on how the clinical consultation in primary care is performed under the new premises of patients’ daily self-reporting and self-generation of data. The aim was to explore and describe the structure, topic initiation and patients’ contributions in follow-up consultations after eight weeks of self-reporting through a mobile phone-based hypertension self-management support system.

Design: A qualitative, explorative study design was used, examining 20 audio- (n?=?10) and video-recorded (n?=?10) follow-up consultations in primary care hypertension management, through interaction analysis. Clinical trials registry: ClinicalTrials.gov NCT01510301.

Setting: Four primary health care centers in Sweden.

Subjects: Patients with hypertension (n?=?20) and their health care professional (n?=?7).

Results: The consultations comprised three phases: opening, examination and closing. The most common topic was blood pressure (BP) put in relation to self-reported variables, for example, physical activity and stress. Topic initiation was distributed symmetrically between parties and BP talk was lifestyle-centered. The patients’ contributed to the interpretation of BP values by connecting them to specific occasions, providing insights to the link between BP measurements and everyday life activities.

Conclusion: Patients’ contribution through interpretations of BP values to specific situations in their own lives brought on consultations where the patient as a person in context became salient. Further, the patients’ and health care professionals’ equal contribution during the consultations showed actively involved patients. The mobile phone-based self-management support system can thus be used to support patient involvement in consultations with a person-centered approach in primary care hypertension management

• Key points

• The clinical consultation is important to provide opportunities for patients to gain understanding of factors affecting high blood pressure, and for health care professionals to motivate and promote changes in life-style.

  • This study shows that self-reporting as base for follow-up consultations in primary care hypertension management can support patients and professionals to equal participation in clinical consultations.

  • Self-reporting combined with increased patient–health care professional interaction during follow-up consultations can support patients in understanding the blood pressure value in relation to their daily life.

  • These findings implicate that the interactive mobile phone self-management support system has potential to support current transformations of patients as recipients of primary care, to being actively involved in their own health.

     

Blood pressure checks and diagnosing hypertension (BP-CHECK): Design and methods of a randomized controlled diagnostic study comparing clinic,home, kiosk,and 24-hour ambulatory BP monitoring

BackgroundThe US Preventive Services Task Force recommends out-of-office blood pressure (BPs) before making a new diagnosis of hypertension, using 24-h ambulatory (ABPM) or home BP monitoring (HBPM), however this is not common in routine clinical practice. Blood Pressure Checks and Diagnosing Hypertension (BP-CHECK) is a randomized controlled diagnostic study assessing the comparability and acceptability of clinic, home, and kiosk-based BP monitoring to ABPM for diagnosing hypertension. Stakeholders including patients, providers, policy makers, and researchers informed the study design and protocols.MethodsAdults aged 18–85 without diagnosed hypertension and on no hypertension medication with elevated BPs in clinic and at the baseline research visit are randomized to one of 3 regimens for diagnosing hypertension: (1) clinic BPs, (2) home BPs, or (3) kiosk BPs; all participants subsequently complete ABPM. The primary outcomes are the comparability (with daytime ABPM mean systolic and diastolic BP as the reference standard) and acceptability (e.g., adherence to, patient-reported outcomes) of each method compared to ABPM. Longer-term outcomes are assessed at 6-months including: patient-reported outcomes, primary care providers' diagnosis of hypertension; and BP control. We report challenges experienced and our response to these.ResultsEnrollment began in May of 2017 with a target of randomizing 510 participants. BP thresholds for diagnosing hypertension in the US changed after the trial started. We discuss the stakeholder process used to assess and respond to these changes.Conclusion and public health impactBP-CHECK will inform which hypertension diagnostic methods are most accurate, acceptable, and feasible to implement in primary care.     

Improvement of adherence in the treatment of hypertension

Blood pressure control rates remain poor in the majority of patients with hypertension. One cause of suboptimal treatment of hypertension is poor medication adherence. Medication non-adherence was 29.7% in Japanese hypertensive patients and poor adherence group showed high blood pressure levels compared with good adherence group. Many factors, race, sex, age, cognitive function, side effect, and cost benefit contribute to the medication adherence. Young male subjects showed poor adherence and new visit and no comorbidity were also main factors of antihypertensive drug discontinuation. Pharmacy care and active health promotion improved medication adherence. Fixed-dose combination therapy also improved adherence and blood pressure control.     

Socioeconomic status affects achievement of blood pressure target in hypertension: contemporary results from the Swedish primary care cardiovascular database

ObjectiveTo assess the relation between socioeconomic status and achievement of target blood pressure in hypertension.DesignRetrospective longitudinal cohort study between 2001 and 2014.SettingPrimary health care in Skaraborg, Sweden.Subjects48,254 patients all older than 30 years, and 53.3% women, with diagnosed hypertension.Main outcome measuresProportion of patients who achieved a blood pressure target <140/90 mmHg in relation to the country of birth, personal disposable income, and educational level.ResultsPatients had a lower likelihood of achieving the blood pressure target if they were born in a Nordic country outside Sweden [risk ratio 0.92; 95% confidence interval (CI) 0.88–0.97], or born in Europe outside the Nordic countries (risk ratio 0.87; 95% CI 0.82–0.92), compared to those born in Sweden. Patients in the lowest income quantile had a lower likelihood to achieve blood pressure target, as compared to the highest quantile (risk ratio 0.93; 95% CI 0.90–0.96). Educational level was not associated with outcome. Women but not men in the lowest income quantile were less likely to achieve the blood pressure target. There was no sex difference in achieved blood pressure target with respect to the country of birth or educational level.ConclusionIn this real-world population of primary care patients with hypertension in Sweden, being born in a foreign European country and having a lower income were factors associated with poorer blood pressure control.

KEY POINTS

• The association between socioeconomic status and achieving blood pressure targets in hypertension has been ambiguous.
• •In this study of 48,254 patients with hypertension, lower income was associated with a reduced likelihood to achieve blood pressure control.
• •Being born in a foreign European country is associated with a lower likelihood to achieve blood pressure control.
• •We found no association between educational level and achieved blood pressure control.

     

Design of a pragmatic cluster-randomized trial comparing telehealth care and best practice clinic-based care for uncontrolled high blood pressure

BackgroundUncontrolled hypertension is the largest single contributor to all-cause and cardiovascular mortality in the U.S. population. Nurse- and pharmacist-led team-based care and telehealth care interventions have been shown to result in large and lasting improvements in blood pressure (BP); however, it is unclear how successfully these can be implemented at scale in real-world settings. It is also uncertain how telehealth interventions impact patient experience compared to traditional clinic-based care.Aims/objectivesTo compare the effects of two evidence-based blood pressure care strategies in the primary care setting: (1) best-practice clinic-based care and (2) telehealth care with home BP telemonitoring and management by a clinical pharmacist. To evaluate implementation using mixed-methods supported by the RE-AIM framework and Consolidated Framework for Implementation Research.MethodsThe design is a cluster-randomized comparative effectiveness pragmatic trial in 21 primary care clinics (9 clinic-based care, 12 telehealth care). Adult patients (age 18–85) with hypertension are enrolled via automated electronic health record (EHR) tools during primary care encounters if BP is elevated to ≥150/95 mmHg at two consecutive visits. The primary outcome is change in systolic BP over 12 months as extracted from the EHR. Secondary outcomes are change in key patient-reported outcomes over 6 months as measured by surveys. Qualitative data are collected at various time points to investigate implementation barriers and help explain intervention effects.ConclusionThis pragmatic trial aims to inform health systems about the benefits, strengths, and limitations of implementing home BP telemonitoring with pharmacist management for uncontrolled hypertension in real-world primary care settings.     

社区高血压患者的护理模式的探讨

目的 探讨居家护理对高血压患者血压控制及依从性的影响.方法 以性别、年龄、高血压等级为配对条件,筛选80例(40对)满足配对的高血压患者随机分为居家组和常规组,每组40例.居家组给予程序式居家护理、常规组常规性社区护理,共干预6个月.结果 两组患者干预3、6个月后降压效果及依从性差异均存在显著性意义(P＜0.05).结论 程序式居家护理可提高高血压患者的依从性,促进血压的降低,有利于患者生存质量提高,同时具有可操作性与实用性,值得在社区护理中推广应用.     

Web-based care management in patients with poorly controlled diabetes

OBJECTIVE: To assess the effects of web-based care management on glucose and blood pressure control over 12 months in patients with poorly controlled diabetes. RESEARCH DESIGN AND METHODS: For this study, 104 patients with diabetes and HbA(1c) (A1C) > or =9.0% who received their care at a Department of Veterans Affairs medical center were recruited. All participants completed a diabetes education class and were randomized to continue with their usual care (n = 52) or receive web-based care management (n = 52). The web-based group received a notebook computer, glucose and blood pressure monitoring devices, and access to a care management website. The website provided educational modules, accepted uploads from monitoring devices, and had an internal messaging system for patients to communicate with the care manager. RESULTS: Participants receiving web-based care management had lower A1C over 12 months (P < 0.05) when compared with education and usual care. Persistent website users had greater improvement in A1C when compared with intermittent users (-1.9 vs. -1.2%; P = 0.051) or education and usual care (-1.4%; P < 0.05). A larger number of website data uploads was associated with a larger decline in A1C (highest tertile -2.1%, lowest tertile -1.0%; P < 0.02). Hypertensive participants in the web-based group had a greater reduction in systolic blood pressure (P < 0.01). HDL cholesterol rose and triglycerides fell in the web-based group (P < 0.05). CONCLUSIONS: Web-based care management may be a useful adjunct in the care of patients with poorly controlled diabetes.     

高血压患者社区护理体会

目的探讨高血压患者的社区护理，对患者自我保健意识和控制血压的作用，与社区医护人员相互学习和借鉴。方法针对本社区68例高血压患者，给予高血压知识指导、饮食保健指导和血压监测等社区护理。结果68例高血压患者，社区护理前后比较，对遵医行为和血压监测比较，差异具有显著性（P〈0．01）。结论高血压患者自我保健意识增强，遵医行为建立。有效控制血压，预防或减少并发症的发生。