Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: a randomized controlled trial

PURPOSE

Medication nonadherence, inconsistent patient self-monitoring, and inadequate treatment adjustment exacerbate poor disease control. In a collaborative, team-based, care management program for complex patients (TEAMcare), we assessed patient and physician behaviors (medication adherence, self-monitoring, and treatment adjustment) in achieving better outcomes for diabetes, coronary heart disease, and depression.

METHODS

A randomized controlled trial was conducted (2007–2009) in 14 primary care clinics among 214 patients with poorly controlled diabetes (glycated hemoglobin [HbA_1c] ≥8.5%) or coronary heart disease (blood pressure >140/90 mm Hg or low-density lipoprotein cholesterol >130 mg/dL) with coexisting depression (Patient Health Questionnaire-9 score ≥10). In the TEAMcare program, a nurse care manager collaborated closely with primary care physicians, patients, and consultants to deliver a treat-to-target approach across multiple conditions. Measures included medication initiation, adjustment, adherence, and disease self-monitoring.

RESULTS

Pharmacotherapy initiation and adjustment rates were sixfold higher for antidepressants (relative rate [RR] = 6.20; P <.001), threefold higher for insulin (RR = 2.97; P <.001), and nearly twofold higher for antihypertensive medications (RR = 1.86, P <.001) among TEAMcare relative to usual care patients. Medication adherence did not differ between the 2 groups in any of the 5 therapeutic classes examined at 12 months. TEAMcare patients monitored blood pressure (RR = 3.20; P <.001) and glucose more frequently (RR = 1.28; P = .006).

CONCLUSIONS

Frequent and timely treatment adjustment by primary care physicians, along with increased patient self-monitoring, improved control of diabetes, depression, and heart disease, with no change in medication adherence rates. High baseline adherence rates may have exerted a ceiling effect on potential improvements in medication adherence.     

Integrated management of type 2 diabetes mellitus and depression treatment to improve medication adherence: a randomized controlled trial

PURPOSE

Depression commonly accompanies diabetes, resulting in reduced adherence to medications and increased risk for morbidity and mortality. The objective of this study was to examine whether a simple, brief integrated approach to depression and type 2 diabetes mellitus (type 2 diabetes) treatment improved adherence to oral hypoglycemic agents and antidepressant medications, glycemic control, and depression among primary care patients.

METHODS

We undertook a randomized controlled trial conducted from April 2010 through April 2011 of 180 patients prescribed pharmacotherapy for type 2 diabetes and depression in primary care. Patients were randomly assigned to an integrated care intervention or usual care. Integrated care managers collaborated with physicians to offer education and guideline-based treatment recommendations and to monitor adherence and clinical status. Adherence was assessed using the Medication Event Monitoring System (MEMS). We used glycated hemoglobin (HbA_1c) assays to measure glycemic control and the 9-item Patient Health Questionnaire (PHQ-9) to assess depression.

RESULTS

Intervention and usual care groups did not differ statistically on baseline measures. Patients who received the intervention were more likely to achieve HbA_1c levels of less than 7% (intervention 60.9% vs usual care 35.7%; P <.001) and remission of depression (PHQ-9 score of less than 5: intervention 58.7% vs usual care 30.7%; P <.001) in comparison with patients in the usual care group at 12 weeks.

CONCLUSIONS

A randomized controlled trial of a simple, brief intervention integrating treatment of type 2 diabetes and depression was successful in improving outcomes in primary care. An integrated approach to depression and type 2 diabetes treatment may facilitate its deployment in real-world practices with competing demands for limited resources.     

Health coaching to improve hypertension treatment in a low-income, minority population

PURPOSE

Poor blood pressure control is common in the United States. We conducted a study to determine whether health coaching with home titration of antihypertensive medications can improve blood pressure control compared with health coaching alone in a low-income, predominantly minority population.

METHODS

We randomized 237 patients with poorly controlled hypertension at a primary care clinic to receive either home blood pressure monitoring, weekly health coaching, and home titration of blood pressure medications if blood pressures were elevated (n = 129) vs home blood pressure monitoring and health coaching but no home titration (n = 108). The primary outcome was change in systolic blood pressure from baseline to 6 months.

RESULTS

Both the home-titration arm and the no–home-titration arm had a reduction in systolic blood pressure, with no significant difference between them. When both arms were combined and analyzed as a before-after study, there was a mean decrease in systolic blood pressure of 21.8 mm Hg (P <.001) as well as a decrease in the number of primary care visits from 3.5 in the 6 months before the study to 2.6 during the 6-month study period (P <.001) and 2.4 in the 6 months after the study (P <.001). The more coaching encounters patients had, the greater their reduction in blood pressure.

CONCLUSIONS

Blood pressure control in a low-income, minority population can be improved by teaching patients to monitor their blood pressure at home and having nonprofessional health coaches assist patients, in particular, by counseling them on medication adherence. The improved blood pressure control can be achieved while reducing the time spent by physicians.     

Improved Outcomes in Diabetes Care for Rural African Americans

PURPOSE

Rural low-income African American patients with diabetes have traditionally poorer clinical outcomes and limited access to state-of-the-art diabetes care. We determined the effectiveness of a redesigned primary care model on patients’ glycemic, blood pressure, and lipid level control.

METHODS

In 3 purposively selected, rural, fee-for-service, primary care practices, African American patients with type 2 diabetes received point-of-care education, coaching, and medication intensification from a diabetes care management team made up of a nurse, pharmacist, and dietitian. In 5 randomly selected control practices matched for practice and patient characteristics, African American patients received usual care. Using univariate and multivariate adjusted models, we evaluated the effects of the intervention on intermediate (median 18 months) and long-term (median 36 months) changes in glycated hemoglobin (hemoglobin A_1c) levels, blood pressure, and lipid levels, as well as the proportion of patients meeting target values.

RESULTS

Among 727 randomly selected rural African American diabetic patients (368 intervention, 359 control), intervention patients had a significantly greater reduction in mean hemoglobin A_1c levels at intermediate (−0.5 % vs −0.2%; P <.05) and long-term (−0.5% vs −0.10%; P <.005) follow-up in univariate and multivariate models. The proportion of patients achieving a hemoglobin A_1c level of less than 7.5% (68% vs 59%, P <.01) and/or a systolic blood pressure of less than 140 mm Hg (69% vs 57%, P <.01) was also significantly greater in intervention practices in multivariate models.

CONCLUSION

Redesigning care strategies in rural fee-for-service primary care practices for African American patients with established diabetes results in significantly improved glycemic control relative to usual care.Key words: diabetes, improved outcomes, African Americans, delivery redesign, rural, patient-centered medical homes     

社区高血压患者综合干预效果评价

目的：评价社区高血压患者综合干预效果。方法：对自愿加入综合干预组的无锡市华庄社区82例高血压患者,进行为期一年的综合干预,开展问卷调查、持续强化高血压相关知识健康教育、体格检查、个体化用药指导、定期血压监测以及血生化检查等指标,比较干预前后患者高血压知晓率、治疗率、控制率。结果：干预后高血压患者收缩压和舒张压分别为（135.93±11.63）mm Hg和（86.12±9.36）mm Hg,均低于干预前的（145.01±12.58）mm Hg和（93.16±8.38）mm Hg（P〈0.001）;高血压知晓率、治疗率和控制率分别为81.71%、90.24%和84.15%,较干预前的62.20%、71.95%和63.41%提高（P〈0.05）。结论：综合干预措施可以使患者血压水平控制良好,提高患者高血压知晓率、治疗率和控制率,促进患者建立健康生活方式。坚持社区高血压综合干预可使高血压患者获益。     

Effects of lifestyle intervention on neck, shoulder, elbow and wrist symptoms

OBJECTIVES: The objective of this study was to determine whether lifestyle intervention to control hypertension can affect neck, shoulder, elbow, and wrist symptoms. METHODS: In a randomized controlled trial, 731 employees from 45 worksites were assigned for 12 months to lifestyle intervention in a rehabilitation center or to usual care provided by occupational or primary health care services. The participants had a systolic blood pressure of 140-179 mm Hg or a diastolic blood pressure of 90-109 mm Hg, or antihypertensive drug treatment. In addition to the cardiovascular risk factors, the occurrences of neck, shoulder, elbow, and wrist symptoms and disability during the previous 12 months were recorded before the intervention and 1 year later. RESULTS: The reported disability due to neck pain during the previous 12 months fell significantly more (-7%) in the intervention group than in the group in usual care (-2%). The perceived shoulder pain during the previous 7 days also decreased significantly more in the intervention group than in the control group among the women (net change 16%) and among the participants who were more highly physically active (net change 10%). Weight, body mass index, and waist and hip circumferences decreased, and physical activity increased, substantially more in the intervention group. The changes in elbow or wrist pain and related disability did not differ significantly between the intervention and control groups. CONCLUSIONS: Lifestyle intervention to control hypertension has a favorable impact on perceived disability due to neck pain.     

Eating habits, obesity related behaviors, and effects of Danhak exercise in elderly Koreans

The aims of this study were to evaluate obesity-related dietary behaviors and to determine long-term exercise effects on obesity and blood lipid profiles in elderly Korean subjects. A total of 120 subjects, aged 60-75 yr, were recruited, and obesity-related dietary behaviors were determined. An exercise intervention was conducted with 35 qualified elderly females for 6 months, and body composition and blood lipids were measured 6 times at 4 week intervals. At baseline, mean BMI (kg/m²) was 24.8 for males and 23.1 for females. The females had better eating habits than the males and were more concerned with reading nutrition labels on food products (P < 0.001); they also preferred convenience foods less than the male subjects (P < 0.05). Obese individuals were more likely than overweight or normal weight individuals to misperceive their weight (P < 0.001). Those with a high BMI responded feeling more depressed (P < 0.01), lacking self-confidence (P < 0.01), and feeling isolated (P < 0.01), as well as having more difficulty doing outdoor activities (P < 0.01). After exercise, body fat (%) and WHR were significantly reduced (P < 0.05), while body weight and BMI were also decreased without statistical significance. Total cholesterol and blood HDL were significantly improved (207.1 mg/dl vs. 182.6 mg/dl, HDL: 45.6 mg/dl vs. 50.6 mg/dl, P < 0.05). Other benefits obtained from exercise were improvements in self-confidence (26.4%), movement (22.6%), stress-relief (18.9%), and depression (13.2%). In conclusion, elderly females had better eating habits and were more concerned with nutrition information and healthy diets compared to elderly males. However, misperceptions of weight and obesity-related stress tended to be very high in females who were overweight and obese, which can be a barrier to maintain normal weight. Long-term Danhak practice, a traditional Korean exercise, was effective at reducing body fat (%) and abdominal obesity, and improved lipid profiles, self-confidence, and stress.     

HUB City Steps: A 6-Month Lifestyle Intervention Improves Blood Pressure among a Primarily African-American Community

The effectiveness of community-based participatory research (CBPR) efforts to address the disproportionate burden of hypertension among African Americans remains largely untested. The objective of this 6-month, noncontrolled, pre-/post-experimental intervention was to examine the effectiveness of a CBPR intervention in achieving improvements in blood pressure, anthropometric measures, biological measures, and diet. Conducted in 2010, this multicomponent lifestyle intervention included motivational enhancement, social support provided by peer coaches, pedometer diary self-monitoring, and monthly nutrition and physical activity education sessions. Of 269 enrolled participants, 94% were African American and 85% were female. Statistical analysis included generalized linear mixed models using maximum likelihood estimation. From baseline to 6 months, blood pressure decreased significantly: mean (±standard deviation) systolic blood pressure decreased from 126.0±19.1 to 119.6±15.8 mm Hg, P=0.0002; mean diastolic blood pressure decreased from 83.2±12.3 to 78.6±11.1 mm Hg, P<0.0001). Sugar intake also decreased significantly as compared with baseline (by approximately 3 tsp; P<0.0001). Time differences were not apparent for any other measures. Results from this study suggest that CBPR efforts are a viable and effective strategy for implementing nonpharmacologic, multicomponent, lifestyle interventions that can help address the persistent racial and ethnic disparities in hypertension treatment and control. Outcome findings help fill gaps in the literature for effectively translating lifestyle interventions to reach and engage African-American communities to reduce the burden of hypertension.     

A novel approach to office blood pressure measurement: 30-minute office blood pressure vs daytime ambulatory blood pressure

PURPOSE Current office blood pressure measurement (OBPM) is often not executed according to guidelines and cannot prevent the white-coat effect. Serial, automated, oscillometric OBPM has the potential to overcome both these problems. We therefore developed a 30-minute OBPM method that we compared with daytime ambulatory blood pressure.METHODS Patients referred to a primary care diagnostic center for 24-hour ambulatory blood pressure monitoring (ABPM) had their blood pressure measured using the same validated ABPM device for both ABPM and 30-minute OBPMs. During 30-minute OBPM, blood pressure was measured automatically every 5 minutes with the patient sitting alone in a quiet room. The mean 30-minute OBPM (based on t = 5 to t = 30 minutes) was compared with mean daytime ABPM using paired t tests and the approach described by Bland and Altman on method comparison.RESULTS We analyzed data from 84 patients (mean age 57 years; 61% female). Systolic and diastolic blood pressures differed from 0 to 2 mm Hg (95% confidence interval, −2 to 2 mm Hg and from 0 to 3 mm Hg) between mean 30-minute OBPM and daytime ABPM, respectively. The limits of agreement were between −19 and 19 mm Hg for systolic and −10 and 13 mm Hg for diastolic blood pressures. Both 30-minute OBPM and daytime ABPM classified normotension, white-coat hypertension, masked hypertension, and sustained hypertension equally.CONCLUSIONS The 30-minute OBPM appears to agree well with daytime ABPM and has the potential to detect white-coat and masked hypertension. This finding makes 30-minute OBPM a promising new method to determine blood pressure during diagnosis and follow-up of patients with elevated blood pressures.     

Leveraging Electronic Health Records to Develop Measurements for Processes of Care

Objectives

To assess the reliability of data in electronic health records (EHRs) for measuring processes of care among primary care physicians (PCPs) and examine the relationship between these measures and clinical outcomes.

Data Sources/Study Setting

EHR data from 15,370 patients with diabetes, 49,561 with hypertension, in a group practice serving four Northern California counties.

Study Design/Methods

Exploratory factor analysis (EFA) and multilevel analyses of the relationships between processes of care variables and factor scales with control of hemoglobin A1c, blood pressure (BP), and low density lipoprotein (LDL) among patients with diabetes and BP among patients with hypertension.

Principal Findings

Volume of e-messages, number of days to the third-next-available appointment, and team communication emerged as reliable factors of PCP processes of care in EFA (Cronbach''s alpha = 0.73, 0.62, and 0.91). Volume of e-messages was associated with higher odds of LDL control (≤100) (OR = 1.13, p < .05) among patients with diabetes. Frequent in-person visits were associated with better BP (OR = 1.02, p < .01) and LDL control (OR = 1.01, p < .01) among patients with diabetes, and better BP control (OR = 1.04, p < .01) among patients with hypertension.

Conclusions

The EHR offers process of care measures which can augment patient-reported measures of patient-centeredness. Two of them are significantly associated with clinical outcomes. Future research should examine their association with additional outcomes.     

Nurse-led adherence support in hypertension: a randomized controlled trial

BACKGROUND: Lack of medication adherence is a common reason for poor control of blood pressure in the community, increasing the risk of heart attacks and strokes. OBJECTIVE: To evaluate the effect of nurse-led adherence support for people with uncontrolled high blood pressure compared with usual care. METHODS: We recruited 245 women and men with uncontrolled hypertension (> or = 150/90 mmHg) from 21 general practices in Bristol, UK. Participants were randomized to receive nurse-led adherence support or usual care alone. Main outcome measures were adherence to medication ('timing compliance') and blood pressure. RESULTS: Mean baseline timing compliance (+/- SD) was high in both the intervention (90.8 +/- 15.6%) and the control group (94.5 +/- 7.6%). There was no evidence of an effect of the intervention on timing compliance at follow-up (adjusted difference in means -1.0%; 95% confidence interval (CI) -5.1 to 3.1). There was also no difference at follow-up between the groups with regard to systolic blood pressure (-2.7 mmHg; 95% CI -7.2 to 1.8) or diastolic blood pressure (0.2 mmHg; 95% CI -1.9 to 2.3). Projected costs for the primary care sector per consultation were 6.60 pound sterling for the intervention compared with 5.08 pound sterling for usual care. CONCLUSION: In this study, adherence to blood pressure medication was much higher than previously reported. There was no evidence of an effect of nurse-led adherence support on medication adherence or blood pressure compared with usual care. Nurse-led adherence support was also more expensive from a primary care perspective.     

Cardiovascular risk management and its impact on hypertension control in primary care in low-resource settings: a cluster-randomized trial

Objective

To evaluate a simple cardiovascular risk management package for assessing and managing cardiovascular risk using hypertension as an entry point in primary care facilities in low-resource settings.

Methods

Two geographically distant regions in two countries (China and Nigeria) were selected and 10 pairs of primary care facilities in each region were randomly selected and matched. Regions were then randomly assigned to a control group, which received usual care, or to an intervention group, which applied the cardiovascular risk management package. Each facility enrolled 60 consecutive patients with hypertension. Intervention sites educated patients about risk factors at baseline and initiated treatment with hydrochlorothiazide at 4 months in patients at medium risk of a cardiovascular event, according to a standardized treatment algorithm. Systolic blood pressure change from baseline to 12 months was the primary outcome measure.

Findings

The study included 2397 patients with baseline hypertension: 1191 in 20 intervention facilities and 1206 in 20 control facilities. Systolic and diastolic blood pressure decreased more in intervention patients than in controls. However, at 12 months more than half of patients still had uncontrolled hypertension (systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg). Behavioural risk factors had improved among intervention patients in Nigeria but not in China. Only about 2% of hypertensive patients required referral to the next level of care.

Conclusion

Even in low-resource settings, hypertensive patients can be effectively assessed and managed in primary care facilities.     

Occult Nighttime Hypertension in Daytime Normotensive Older Patients With Obstructive Sleep Apnea

ObjectivesTo assess nighttime blood pressure (BP), the dipping phenomenon and the relationships between nighttime BP, and polysomnography parameters in older patients with obstructive sleep apnea (OSA) who have been identified by their primary care physician as being normotensive during the daytime.DesignCross-sectional study.SettingUniversity hospital-based geriatric sleep center.ParticipantsDaytime normotensive, community-dwelling older adults, consecutively referred by their primary care physicians for suspicion of OSA.MeasurementsOvernight polysomnography and 24-hour ambulatory blood pressure measurement (ABPM). Daytime hypertension defined as systolic BP ≥135 mm Hg and/or diastolic BP ≥85 mm Hg. Nighttime hypertension defined as systolic BP ≥120 mm Hg and/or diastolic BP ≥70 mm Hg. Dipper pattern characterized by nighttime fall of mean BP ≥10%.ResultsForty-five participants (30 OSA; 15 non-OSA) completed the study (76.9 ± 6.2 years old). ABPM indicated clinically significant nighttime systolic (132.5 ± 16.0) and diastolic (72.6 ± 9.4) hypertension in patients with OSA previously classified as daytime normotensives and found only a mild degree of nighttime systolic hypertension (123.7 ± 16.1) in patients without OSA (P = .105). A significant nondipping phenomenon was found in patients with OSA (–0.5 ± 7.4 vs 5.4 ± 6.4; P = .016). Nighttime mean BP (r = 0.301; P = .049) and dipping status (r = –0.478; P = .001) were correlated with apnea-hypopnea index. A significant correlation was found between systolic BP (r = 0.321; P = .035), diastolic BP (r = 0.373; P = .013), mean BP (r = 0.359; P = .018), and hypoxia (sleep time spend with SaO2 <90%).ConclusionDaytime normotensive older adults with OSA are at high risk for having occult nighttime hypertension. Thus, 24-hour ABPM may be appropriate for older patients with OSA whose clinical blood pressure does not display any daytime elevation.     

Impact of electronic health record clinical decision support on diabetes care: a randomized trial

PURPOSE We wanted to assess the impact of an electronic health record–based diabetes clinical decision support system on control of hemoglobin A_1c (glycated hemoglobin), blood pressure, and low-density lipoprotein (LDL) cholesterol levels in adults with diabetes.METHODS We conducted a clinic-randomized trial conducted from October 2006 to May 2007 in Minnesota. Included were 11 clinics with 41 consenting primary care physicians and the physicians’ 2,556 patients with diabetes. Patients were randomized either to receive or not to receive an electronic health record (EHR)–based clinical decision support system designed to improve care for those patients whose hemoglobin A_1c, blood pressure, or LDL cholesterol levels were higher than goal at any office visit. Analysis used general and generalized linear mixed models with repeated time measurements to accommodate the nested data structure.RESULTS The intervention group physicians used the EHR-based decision support system at 62.6% of all office visits made by adults with diabetes. The intervention group diabetes patients had significantly better hemoglobin A_1c (intervention effect −0.26%; 95% confidence interval, −0.06% to −0.47%; P=.01), and better maintenance of systolic blood pressure control (80.2% vs 75.1%, P=.03) and borderline better maintenance of diastolic blood pressure control (85.6% vs 81.7%, P =.07), but not improved low-density lipoprotein cholesterol levels (P = .62) than patients of physicians randomized to the control arm of the study. Among intervention group physicians, 94% were satisfied or very satisfied with the intervention, and moderate use of the support system persisted for more than 1 year after feedback and incentives to encourage its use were discontinued.CONCLUSIONS EHR-based diabetes clinical decision support significantly improved glucose control and some aspects of blood pressure control in adults with type 2 diabetes.     

Comparison of nutrient intake, life style variables, and pregnancy outcomes by the depression degree of pregnant women

The aim of this study was to analyse effects that the degree of depression have on the life style variables, nutrient intake, iron indices and pregnancy outcome. Subjects were 114 pregnant women who were receiving prenatal care at a hospital in Seoul. We collected data for general characteristics and lifestyle variables from general survey instrument and for depression score from the questionnaire on depression. Dietary intakes of subjects were estimated by 24 hour dietary recall method. Also we analysed iron indices and pregnancy outcomes. We classified subjects by 10 point, which was the average depression score, into two groups [Low depression score group (LS) : High depression score group (HS)]. As to the intakes of total calcium, plant-calcium, plant-iron, potassium, total folate and dietary folate, LS group was far higher than HS group (P < 0.05, P < 0.05, P < 0.01, P < 0.001, P < 0.05, and P < 0.01, respectively). As to pre-pregnancy alcohol drinking, LS group had 41.9% in non-drinker, which was far higher than 28% in HS group in non-drinker (P < 0.05). As for drinking coffee during pre-pregnancy, pregnant women who don''t drink coffee in LS group took 43.6%, which was higher than 38% in HS group (P < 0.01). Regarding delivery type, the cesarean section in LS group (18%) was significantly lower than that in HS group (45%) (P < 0.01). Bivariate analysis showed that birth weight was significantly associated with the gestational age (P < 0.01). The pregnant women with higher depression score tended to have undesirable life habit, which might affect negative pregnancy outcomes. A better understanding of how depression and intake of nutrients work together to modulate behavior will be benefit nutritional research.     

Correlation of blood pressure with plasma ascorbic acid

In a nutrition survey of 247 Chinese Americans (38% men and 62% women) aged 60–96, the mean plasma ascorbic acid was found to be lower than that of white Americans. The association between their blood pressure and plasma ascorbic acid was explored by analysis of covariance and multiple regression, adjusting for age, sex, body mass index, alcohol and cigarette consumption, dietary Na:K ratio, serum Ca:P ratio and physical activity level. Inverse associations were observed between plasma ascorbic acid and systolic blood pressure (p<.001) and diastolic blood pressure (p<.01). Subjects in the lowest quartile of plasma ascorbic acid had a mean systolic blood pressure which was 17.6 mm Hg higher than those in the highest quartile; their mean diastolic blood pressure was higher by 5.5 mm Hg. We speculate that subclinical vitamin C deficiency may be a risk factor for hypertension in Chinese Americans.     

Effect of a UK pay-for-performance program on ethnic disparities in diabetes outcomes: interrupted time series analysis

PURPOSE

We wanted to examine the long-term effects of the Quality and Outcomes Framework (QOF), a major pay-for-performance program in the United Kingdom, on ethnic disparities in diabetes outcomes.

METHODS

We undertook an interrupted time series analysis of electronic medical record data of diabetes patients registered with 29 family practices in South West London, United Kingdom. Main outcome measures were mean hemoglobin A_1c (HbA_1c), total cholesterol, and blood pressure.

RESULTS

The introduction of QOF was associated with initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained only in black patients (annual decrease: −1.68 mm Hg; 95% CI, −2.41 to −0.95 mm Hg). Initial improvements in diastolic blood pressure in white patients (−1.01 mm Hg; 95% CI, −1.79 to −0.24 mm Hg) and in cholesterol in white (−0.13 mmol/L; 95% CI, −0.21 to −0.05 mmol/L) and black (−0.10 mmol/L; 95% CI, −0.20 to −0.01 mmol/L) patients were not sustained in the post-QOF period. There was no beneficial impact of QOF on HbA_1c in any ethnic group. Existing disparities in risk factor control remained largely intact (for example; mean HbA_1c: white 7.5%, black 7.8%, south Asian 7.8%; P <.05) at the end of the study period.

CONCLUSION

A universal pay-for-performance scheme did not appear to address important disparities in chronic disease management over time. Targeted quality improvement strategies may be required to improve health care in vulnerable populations.     

Studies in hypertension: implications for clinical medicine

Population studies that demonstrated risk from elevation of blood pressure were a necessary foundation for a sound clinical approach to hypertension. Clinical trials then demonstrated that lowering pressure with drug therapy dramatically reduced risk of cardiovascular catastrophes, including death. The U.S. Veterans Administration (VA) study proved the need to treat moderate and severe hypertension, but left unproven the benefit for so-called mild hypertension (diastolic blood pressure 90–104 mm Hg). The Hypertension Detection and Follow-up Program (HDFP) investigated applicability of VA findings to the “average” hypertensive, particularly to the majority in the range 90–104 mm Hg. Two randomly constituted groups, Stepped Care (SC) and Referred Care (RC), included 10,940 hypertensives, age 30–69, identified in population-based screening in 14 communities, and followed for 5 years. Almost $\text{3}\text{4}$ (71%) were so-called mild hypertensives. SC patients were treated vigorously in special clinical centers to lower pressure to a diastolic goal no higher than 80–90 mm Hg (depending on entry level), starting with low dose diuretics and adding medication stepwise as needed, until the goal was reached. RC patients were treated by usual sources of medical care. A larger proportion of SC than RC patients were on therapy and at the goal each year of the study. The fifth year diastolic average was 84 mm Hg in SC and 89 mm Hg in RC. The 5-year all causes mortality rate was 17% lower in SC than RC. In the mild hypertension stratum, this difference was 20%. Clinical implications from the HDFP trial include demonstration of: the validity of the VA findings on the benefit of treating moderate and severe hypertension; the benefit of treatment also for those with sustained average diastolic pressures 90–104 mm Hg; the utility of lowering pressure before target organ damage; the utility of stepwise drug treatment to a normotensive goal; the ability to achieve long-term patient adherence; the contribution of nonphysician personnel in helping achieve these aims. The possible role of non-pharmacologic measures was not tested in these trials and remains an important question in determining best methods for control of hypertension.     

Personalized versus usual care of previously uncontrolled hypertensive patients: An exploratory analysis

This study was conducted to explore whether the quality of provider care may contribute to blood pressure reduction and whether other factors related to the treatment of hypertension may explain decline in blood pressure. In the study, 46 uncontrolled (greater than or equal to 140/90 mm Hg), medically treated hypertensive patients who received more personalized care differed significantly in the magnitude of blood pressure reduction from 36 usual-care patients (10/7 vs 2/2 mm Hg means for systolic and diastolic blood pressure reduction, respectively). About twice as many experimental patients as controls were reclassified as having "controlled" blood pressure, and this difference reached statistical significance. A multiple regression analysis for personalized-care subjects showed that no dynamic variables were related to blood pressure changes. It was postulated that more personalized care may have accounted for the significant difference between groups in blood pressure reduction. Similar personalized monitoring services might be important additions to usual medical care in order to control blood pressure more fully in high-risk hypertensive patients.