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The Hypertension Team: The Role of the Pharmacist, Nurse, and Teamwork in Hypertension Therapy
The Journal of Clinical Hypertension
Abstract
J Clin Hypertens (Greenwich).
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.
... Team-based care coordinates care among general practitioners, pharmacists, nurses and others, and requires sharing of clinical and laboratory data, and medications. 44 This increased capacity allows for improved patient follow-up, medication management and adherence support. 44 Multidisciplinary teams linking general practitioners, pharmacists and nurses can significantly improve blood pressure control, and have formed the cornerstone of international successes in various settings in the United States and Canada, 44 with positive signs also in nursecoordinated hypertension care in Australia. ...
... 44 This increased capacity allows for improved patient follow-up, medication management and adherence support. 44 Multidisciplinary teams linking general practitioners, pharmacists and nurses can significantly improve blood pressure control, and have formed the cornerstone of international successes in various settings in the United States and Canada, 44 with positive signs also in nursecoordinated hypertension care in Australia. 45,46 The 2022 Strengthening Medicare taskforce report 24 states that general practitioners are "struggling to meet increasingly complex demand", encouraging teambased care. ...
... 44 This increased capacity allows for improved patient follow-up, medication management and adherence support. 44 Multidisciplinary teams linking general practitioners, pharmacists and nurses can significantly improve blood pressure control, and have formed the cornerstone of international successes in various settings in the United States and Canada, 44 with positive signs also in nursecoordinated hypertension care in Australia. 45,46 The 2022 Strengthening Medicare taskforce report 24 states that general practitioners are "struggling to meet increasingly complex demand", encouraging teambased care. ...
... In addition to gathering information on their general impressions, we focused on examining the users' ability to navigate through and utilize different components of the WHISE app. Thus, the objective of this paper is to summarize the process involved in this usability testing trial to evaluate the WHISE app's functionality and maximize user satisfaction (29)(30)(31). ...
... Qualtrics survey data was analyzed using SPSS version 28.0.1.1 (30). A descriptive analysis was conducted for data obtained from the Qualtrics surveys, obtaining frequencies and percentages for categorical questions, and means with standard deviations were recorded for continuous measures (31). ...
Background
High blood pressure (hypertension) disproportionately affects African American/Black (Black) women. Previous research suggests that self-managing hypertension may be challenging, yet mobile applications (apps) can help to empower patients and increase medication adherence. We developed questions to test the usability of evaluating the WHISE (Wellness, Hypertension, Information Sharing, Self-Management, Education) mobile app for Black women with hypertension.
Methods
Fifteen participants completed usability testing; five were potential app users (Black women with hypertension); each invited two of their peers to participate. Each testing session (n=5) included a brief overview of the app, time for participants to complete surveys and have an active discussion about the app (concurrent and retrospective think-aloud, concurrent and retrospective probing, per usability.gov), and observation of participants’ body language during the session. Testing sessions were designed to familiarize participants with the app’s features and examine their navigating ability.
Results
The app received overwhelmingly positive feedback, with 80% of participants finding it to be a valuable tool in hypertension management. Participants praised the app’s user-friendliness and educational value, with one stating, ‘It is a good educational piece for helping people manage hypertension, at least to understand its basics.’ Another participant highlighted the potential for community support, saying, ‘Having a community, having some people to be accountable, to check in with and see how things are going, could encourage and motivate people to be more diligent about managing their hypertension.’ Some participants also provided constructive feedback, suggesting font size adjustments (73%) and color scheme changes (60%) for certain screens.
Conclusions
Based on the feedback we received, we were able to mitigate the participants’ concerns about font size and color and create tutorial videos to guide future users in using the app. We completed these changes prior to deploying the app in our randomized clinical controlled trial.
... The diagnosis and ongoing assessment of hypertensive patients involve the measurement of blood pressure, necessitating a precise measurement technique. Primary Care (PC) settings offer an optimal environment for the application of protocols and clinical practice guidelines (CPG) for the diagnosis and management of hypertension [5,6]. However, the implementation of these protocols requires specific knowledge and training of medical and nursing professionals. ...
... The initial draft of the questionnaire was prepared based on the previous published literature [5,6,8,[10][11][12]. The face-validation was conducted by the two experts (one from cardiology and one from internal medicine). ...
Objective: The objective of the current study was to assess the education intervention impact on their knowledge regarding blood pressure measurement and diagnosis. Method: An interventional study was conducted among medical students at Xi'an Jiaotong University, health science centre, Shaanxi, China. The study participant was final year's medical student who completed the compulsory internship. A self-developed and validated questionnaire was used in the current study. An educational intervention was conducted by one author (MK) who had good hands-on blood pressure measurement. The data was analyzed using SPSS v25. Result: A total of 94 students were participated in the study. Overall knowledge regarding hypertension diagnosis was significantly improved in post intervention group. The participant knowledge was significant increased regarding preparation of patient before taking of blood pressure (p > 0.001) and impact of cuff size on blood pressure reading in (p > 0.001) post intervention compared to pre-intervention. In addition, participants significantly more knowledgeable regarding impact of nervousness and cold on false diagnosis of blood pressure (p > 0.001) and time of subsequent measurement of blood pressure in post intervention group (p > 0.001). Conclusion: The medical education intervention regarding blood pressure measurement and diagnosi s significantly improved the medical student knowledge.
... Additionally, several systematic reviews including mostly studies conducted in the US have been conducted. The results of those reviews have found that pharmacist care interventions improve health-related quality of life [35]; reduce medication underuse in older people [36]; clinical, and/or humanistic outcomes in patients from racial/ethnic minority groups [37]; As well as improvements in specific diseases such as hypertension, heart failure or diabetes [38][39][40][41]. However, those systematic reviews also found limitations in the studies assessing pharmaceutical care that may limit the applicability of the results of the studies [42]. ...
... And, while Nunavut and Yukon do not allow pharmacists to provide any of the above services, it should be noted that these provinces account for the smallest Canadian populations at only 0.1% or 36,000 people each. Newfoundland and Labrador found that 90% of responders felt that pharmacists were healthcare professionals just like nurses and doctors, and only 10% felt the main role of pharmacists was counting pills [38]. ...
Pharmaceutical care in the US and Canada is regulated at the level of the state/province generating differences in the practice of pharmacy across the countries. Pharmacist counseling and utilization review are generally required to be offered at dispensing in community pharmacies. There is a trend toward the development of pharmaceutical care services provided at the community pharmacy, the integration of the pharmacist in the healthcare team, and the implementation of collaborative agreements expanding the role of the pharmacist in patient care. This chapter is divided into two sections, one for the United States of America, and one for Canada. In 2015, there were 65,280 US community pharmacies [1], representing one pharmacy per 4915 people. US community pharmacies dispensed a total of 4065 million prescriptions with an average of 12.6 prescriptions per inhabitant and a total cost of $379,247 million in the same year [2]. Community pharmacy expenditures represented over 10% of US healthcare expenditures [3]. Public programs including Medicare and Medicaid and other federal and state programs covered over 50% of the pharmaceutical expenditures in the country. In 2015, community pharmacies dispensed 83.3% of the prescriptions and accounted for 68% of the pharmacy expenditures, while mail-order pharmacies dispended 16.7% of the prescriptions and accounted for 31.9% of the expenditures. Pharmacy chains represented 41.2%
... Team-based care offers a promising approach to reduce some barriers to hypertension control [15][16][17][18][19][20]. In a 2006 meta-analysis of 28 studies, most of which included a nurse or a pharmacist team member as a care manager, average BP dropped by 10/4 mmHg, and the absolute proportion of patients achieving BP control improved by 20% [15]. ...
... Despite the public health importance of improving hypertension control, progress at the U.S. population level has been disappointingly slow [6,7]. Research over the last several decades has shown that reorganizing clinical practice to empower non-physician practitioners and patients to work together to encourage self-management, adjust antihypertensive therapy, and conduct follow up in a team-based approach to hypertension care is a potent strategy to improve hypertension control [15][16][17][18][19][20][21]. A modeling study found that nationwide adoption of team-based care for uncontrolled hypertension could reduce uncontrolled hypertension by 13% and prevent 638,000 CV events over 10 years [19]. ...
Background:
Uncontrolled 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/objectives:
To 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.
Methods:
The 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.
Conclusion:
This 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.
... Using a multidisciplinary team approach is one of the best ways to treat hypertension. In comparison to usual care, randomized controlled trials (RCTs) of teambased hypertension therapy, which included nurse or pharmacist interventions, showed improvements in blood pressure control targets and decreased both SBP and diastolic blood pressure (DBP) [58]. Adherence Improving Interventions: ...
... As previously reported, implementation of the AMA MAP BP program is associated with a small decline in TI [27,29]. Other interventions to reduce TI among older adults include the incorporation of self-measured BP into clinic workflow and team-based approaches for hypertension management [30][31][32]. ...
Therapeutic inertia (TI), or failure to escalate or initiate BP lowering medications when BP is uncontrolled, increases with advancing age and may in part be due to perceived fall risk. This study examined the association of a fall risk assessment, based on patient response to three questions administered by trained staff, with uncontrolled BP (≥140/90 mmHg) during a clinic visit and with TI during clinic visits with uncontrolled BP among 13 893 patients age ≥ 65 years corresponding to 41 122 primary care visits. Separate generalized linear mixed effects models were used to examine the association of fall risk (low, moderate, and high) with uncontrolled BP and with TI at a clinic visit after adjustment for demographics, comorbidities, and total number of visits. Baseline mean age was 73.0 years (standard deviation [SD] 5.6), 43.3% were men and questionnaire‐assessed fall risk severity was low in 73.6%, moderate in 14.3%, and high in 12.2%. Compared to low fall risk, the adjusted odds of uncontrolled BP during a clinic visit were 0.97 (95% CI: 0.89, 1.06) and 0.90 (95% CI: 0.82, 0.98) with moderate and high fall risk, respectively. In contrast, adjusted odds of TI during a clinic visit with BP ≥ 140/90 mmHg was 1.16 (95% CI: 1.01, 1.34) and 1.30 (95% CI: 1.11, 1.52) with moderate and high fall risk, respectively, compared to low fall risk. These findings suggest that perceived fall risk severity may be one of several factors that influence hypertension management in older adults.
... Telemedicine can lead to clinically significant and lasting BP reductions in conjunction with active co-interventions such as web-based or telephone feedback, counseling, and systematic medication titration. 8,15 In the HOME BP trial, a digital intervention with a prespecified individualized drug titration plan resulted in a mean 3 mm Hg greater reduction in systolic BP compared to usual care. 16 Other trials also show that telemonitoring and novel interdisciplinary models of care involving pharmacists paired with SMBP show promise in improving BP control rates compared with usual care. ...
Background:
Self-measurement of blood pressure (SMBP) is endorsed by current guidelines for diagnosing and managing hypertension (HTN). We surveyed individuals in a rural healthcare system on practices and attitudes related to SMBP that could guide future practice.
Methods:
: Survey questions were sent via an online patient portal to a random sample of 56,275 patients with either BP >140/90 mmHg or cardiovascular care in the system. Questions addressed home blood pressure (BP) monitor ownership, use, willingness to purchase, desire to share data with providers, perceptions of patient education, and patient-centeredness of care. Multivariable logistic regression was used to examine patient characteristics associated with SMBP behaviors.
Results:
The overall response rate was 12%, and 8.4% completed all questions. Most respondents, 60.9%, owned a BP monitor, while 51.5% reported checking their BP at home the month prior. Among device owners, 45.1% reported receiving instructions on SMBP technique, frequency, and readings interpretation. Only 29.2% reported sharing readings with providers in the last six months, whereas 57.9% said they would be willing to do so regularly. Older age, female sex, and higher income were associated with a higher likelihood of device ownership. Younger age, lower income, and Medicaid insurance were associated with a greater willingness to share SMBP results with providers regularly.
Conclusions:
While a significant proportion of respondents performed SMBP regularly, many reported insufficient education on SMBP, and few shared their home BP readings with providers. Patient-centered interventions and telemedicine-based care are opportunities that emerged in our survey that could enhance future HTN care.
... Sedentary lifestyle and avoidance of regular physical exercise also were found to be factors of concern, in the etiopathogenesis of hypertension . [16,17,18,19,20] Stress levels assessment scores: The techniques to assess stress levels have been useful while trying to manage stress. These are Holmes and Rahe Stress Scale developed in 1967, also called the social readjustment rating scale (SRSS) is a good scale to assess the chronic stress levels. ...
... These health issues have placed significant pressure on the public sector to become more cost-efficient and effective due to the increasing burden of long-term health care and older person health management (Health Promotion Administration, 2016;Park & Kim, 2012). Self-management has effectively reduced the occurrence of triple-high status, slowed its deterioration, and even lowered healthcare spending (Carter et al., 2012;Park & Kim, 2012;Shahbazi et al., 2021). eHealth is an innovative information and healthcare delivery system that, with the help of the internet and citizen-centered public healthcare services, allows people to monitor their physiological situations and develop healthy behaviors more efficiently and effectively (Arfi et al., 2021;Shahbazi et al., 2021;J. ...
With rapid aging and the spread of chronic diseases, public eHealth services are helpful tools to monitor their physiological situations and develop healthy behaviors. However, the studies on older adults adopting public eHealth services have been relatively limited. We propose a modified United Theory of Acceptance and Use of Technology (UTAUT) model, considering the unique adoption patterns of older people. Our study shows that older adults adopting patterns are influenced first by social influence (SI) and facilitating conditions (FC), then influenced by performance expectancy (PE) and effort expectancy (EE). This model includes two moderating effects of performance expectancy (PE) and effort expectancy (EE) between two external constructs of social influence (SI), facilitating conditions (FC), and older adults’ behavioral intention (BI) to adopt public eHealth services. A dataset of 510 questionnaires was collected on the use of a self-monitoring telecare device (Babybot) in Hsinchu City, Taiwan. The results demonstrate that SI and FC positively influence older adults’ adoption of public eHealth services. Furthermore, PE positively moderates the relationship between FC and BI, while EE positively moderates the relationships between FC and BI, and between SI and BI. The findings reveal that PE and EE moderate SI and FC in affecting older adults’ adoption of public eHealth services. This modified UTAUT model provides insights into the unique factors that drive older adults’ adoption behavior. This study offers valuable policy and managerial implications for promoting older adults’ adoption of public eHealth services.
... Furthermore, this review emphasizes the need for more epidemiological research, national-level surveillance data highlighting the changing patterns of CVD risk factors, and mortality among key subpopulations including highrisk individuals, women, and children. • Considering factors such as easy availability (easy to refill), easy to take (once a day single pill combination), along with a reminder methodology while prescribing drugs • Using multifaceted approach involving systematic use of diagnostic tools while deciding on the mono-or dual-therapy approach in early stages [37] • Using of simplified treatment regimen and combination pill concept Healthcare policy makers • Involving a team including clinical pharmacists and nurses in patient management [78] Adherence and Control Patients • Involving family members for seeking medication reminders assistance at home • Being proactive for self-management of health (e.g., self-monitoring of BP) • Using technologies, e.g., iPhone users to set medication reminders record [ ...
Background:
In recent years, Saudi Arabia has witnessed staggering rates of hypertension and dyslipidemia-related cardiovascular (CV) deaths, overburdening the healthcare ecosystem of the country. Appropriate public health interventions can be devised through quantitative mapping of evidence. Identification of potential data gaps can prioritize future research needs and develop a 'best-fit' framework for patient-centric management of hypertension and dyslipidemia.
Methods:
This review quantified data gaps in the prevalence and key epidemiological touchpoints of the patient journey including awareness, screening, diagnosis, treatment, adherence, and control in patients with hypertension and dyslipidemia in Saudi Arabia. Studies published in English between January 2010 and December 2021 were identified through a structured search on MEDLINE, Embase, BIOSIS, and PubMed databases. An unstructured search on public and government websites, including Saudi Ministry of Health, without date limits was carried out to fill data gaps. After exclusion of studies based on predefined criteria, a total of 14 studies on hypertension and 12 studies and one anecdotal evidence for dyslipidemia were included in the final analyses.
Results:
The prevalence of hypertension was reported to be 14.0%-41.8% while that for dyslipidemia was 12.5%-62.0%. The screening rate for hypertension was 100.0% as revealed by the nationwide surveys. Among hypertensive patients, only 27.6%-61.1% patients were aware of their condition, 42.2% patients underwent diagnosis, 27.9%-78.9% patients received antihypertensive treatment, 22.5% patients adhered to treatment medication, while blood pressure (BP) control was achieved in 27.0%-45.0% patients. Likewise, among patients with dyslipidemia, 10.5%-47.3% patients were aware of their condition, 34.6% patients were screened, and 17.8% underwent diagnosis. Although high treatment rates ranging from 40.0%-94.0% were reported, medication adherence recorded was 45.0%-77.4% among the treated patients. The overall low control rates ranged from 28.0%-41.5%.
Conclusions:
The study findings highlight evidence gaps along key touchpoints of patient journey. Reinforcing the efforts for high-quality evidence-based research at a national level may pave a path for better resource utilization and provide guidance to practice and amend health policies for patients, healthcare practitioners (HCPs), and healthcare policy makers for better patient outcomes in Saudi Arabia.
... Pharmacists as one of the health partners of hypertension patients have full duty and responsibility for the patient's clinical outcome [14]. During the study period, patients were given education and counseling regarding therapeutic regimens, the effectiveness of treatment in im- proving better clinical outcomes. ...
The role of pharmacists in the implementation of pharmaceutical care has been shown to improve the outcome of therapy in hypertension patients in various countries. This study aimed to implement pharmaceutical care for hypertension patients and determine its impact on the incidence of drug-related problems (DRPs) and clinical outcomes of hypertension patients in Puskesmas Lubuk Pakam. This study used a comparative experimental method before and after the intervention of 73 hypertension patients in March-August 2021. Identification of the of DRPs was using the PCNE V9.00 standard and blood pressure values were obtained from direct examination of patients. Data were analyzed using the Wilcoxon Signed-Rank test. The results showed that the average DRPs incidence was significantly reduced after the intervention (observation, interview, and education) on the hypertension patients. The average blood pressure before intervention was 154.38 ± 16.20 mmHg and after intervention became 144.04 ± 15.94 mmHg (p value = 0.000). Based on the results of the study, it can be concluded that the application of pharmaceutical care can reduce the incidence of DRPs and improve clinical outcomes in hypertension patients in Puskesmas Lubuk Pakam.
... For every patient, the individualized GIT has combined the minor management team and other different functional management teams according to patient needs [34]. For example, a transitional healthcare team consisting of "geriatric, specialist doctors, specialist nurses", a health promotion team composed of "public health experts, professional assessors, community health educators", and a life cycle management team comprised of "regional healthcare and family members", etc. ...
Background: The increasing prevalence of comorbidities poses a significant challenge to population health management. The World Health Organization (WHO) suggests that an integrated care model relieves the pressure of healthcare management on people with multimorbidity.
Objective: We constructed a conceptual model to manage multiple chronic conditions based on PDSA theory, consisting of four key elements: management team, proceedings, tools, and performance.
Result: The model merges patient-centered care, multidisciplinary team, self-management, and other intervention methods mentioned in previous research. Meanwhile, we rely on big data to set up a decision support platform to realize the whole life cycle health management of comorbid patients.
... Perawat gerontik sebagai ujung tombak pelayanan keperawatan di bagi kelompok lansia perlu mendapatkan update dan pemberian informasi secara berkelanjutan terkait proses mitigasi pada kelompok lansia dan kelompok rentan lainnya sebagai salah satu upaya meminimalisir dampak yang akan terjadi (Anung Ahadi Pradana, 2021;Anung Ahadi Pradana & Rohayati, 2021). Perawat diharapkan dapat memberikan pemahaman berupa penyuluhan atau konseling yang menyeluruh kepada lansia dan keluarganya terkait kondisi penyakit yang dialami serta pencegahan yang dapat dilakukan di rumah (Bahriah et al., 2021;Carter et al., 2012;Livana, P. H. et al., 2018;Prasetyorini, 2017). ...
Perawat gerontik turut berperan penting dalam menjaga kondisi kesehatan lansia agar tetap mampu produktif serta aktif, namun kualitas asuhan keperawatan yang diberikan diketahui dipengaruhi oleh kompetensi dari perawat gerontik. PP IPEGERI sebagai badan sayap PPNI memiliki tugas untuk meningkatkan kompetensi perawat gerontik melalui kegiatan pelatihan keperawatan geriatri dasar. Kegiatan pelatihan keperawatan geriatri dasar dilaksanakan bagi 21 perawat RSUD dr. Chasbullah Abdulmadjid Kota Bekasi, Jawa Barat pada periode 25-29 Juli 2022 (dengan pembagian waktu 3 hari dilakukan secara online melalui zoom dan 2 hari praktik langsung di RSUD). Hasil pretest-posttest dari peserta kemudian dianalisis oleh penulis menggunakan analisis paired t-test dan menghasilkan p-value 0.000 (<0.05). Hasil analisis kegiatan pelatihan keperawatan geriatri dasar yang dilakukan menunjukkan bahwa kegiatan ini mampu berpengaruh positif terhadap peningkatan kompetensi perawat gerontik, sehingga kegiatan ini dapat diupayakan untuk menjadi suatu referensi yang dapat dilakukan secara berkelanjutan oleh para pengambil kebijakan baik di tingkat lokal, regional, maupun nasional.
... This finding was determined by many meta-analyses and systematic reviews. Reviews indicated that team-based care reduce systolic blood pressure by 4-10 mm Hg over usual care (Carter et al., 2012). ...
EPIDEMIOLOGY, DIAGNOSIS AND TREATMENT OF
LIVER ECHINOCOCUS GRANULOSUS
... A Educação Interprofissional (EIP) e a Prática Interprofissional Colaborativa (PIC) são temas em ascensão no campo da saúde global, em que a equipe se tornou uma parte fundamental e de grande importância da reforma do modelo de formação profissional e de atenção à saúde, particularmente no atendimento às diversas morbidades, para uma boa assistência ao usuário. As evidências mostram que a educação interprofissional e a prática colaborativa na área de saúde têm um impacto positivo na melhoria dos resultados dos pacientes 1,2 , pois "preenchem uma lacuna significativa com experiências bemsucedidas nos países que as adotaram e se apresentam como ferramentas importantes na consolidação e fortalecimento do Sistema Único de Saúde" (SUS) 1 e na melhoria na qualidade do cuidado 3 . ...
Educação Interprofissional e Prática Interprofissional Colaborativa são temas emergentes, constituindo-se em componentes fundamentais de formação profissional e de atenção à saúde. Este trabalho teve tem como objetivo analisar as características de prontidão para o trabalho interprofissional bem como o uso da prática colaborativa dos preceptores do internato médico de Porto Velho, Rondônia. Trata-se de um estudo transversal, realizado a partir do questionário The Readiness for Interprofessional Learning Scale, traduzido e validado para o Brasil em 2015, aplicado a 30 profissionais de saúde, entre médicos e enfermeiros, preceptores do internato médico em Atenção Primária à Saúde. Entre os resultados, observou-se que, no domínio “identidade profissional” – que se refere à autonomia profissional e aos objetivos clínicos de cada profissão –, os profissionais avaliados estão nas zonas de alerta e de perigo, sendo as médias apuradas de 3,7483±0,96896 para médicos e de 3,5873±1,09561 para enfermeiros. Faz-se necessário, então, investir na qualificação de profissionais voltada aos temas “trabalho em equipe” e “trabalho colaborativo”, com ênfase no domínio “identidade profissional”.
... The treatment regime and its implementation are responsibility of a patient on one side, and the family medicine team on the other one, who should take care of regular controls of these patients with the aim of preventing complications of hypertension (5). Patients should come for regular visits to the family medicine physician or other members of the team and should be on proper diet and regularly use the prescribed treatment (7). This behaviour should not lead to excessive situations that require a drastic change in the treatment of the patient, as well as requests for urgent treatment, except for the newly established state of the patient, which can lead to excess blood pressure (8). ...
Aim To determine most common factors making patients with high blood pressure seek professionally unacceptable treatment of hypertension at the Emergency Department. Methods The survey was conducted at the Emergency Department of the Primary Health Care in Gradačac on randomly selected 207 patients who requested medical help because of high blood pressure. For all patients arterial blood pressure and body mass index (BMI) were measured. A survey about knowledge and attitudes regarding habits that affect high blood pressure as well as the socioeconomic conditions was made. Results Prevalence of 10.3% was found with regard to visits to emergency care by patients due to high blood pressure. Most patients , 127(61.4 %), were overweight and 36(17.4%) were obe-se. Patients who rarely controlled their blood pressure were more frequent visitors of emergency medical services. Stressful situation occurs as a factor in a variety of forms. The survey showed that 76 (36.7%) patients sought medical help even though they had no blood pressure values that required emergency care. Conclusion Poorly organized health care system with no continuous and comprehensive preventive promotional programs caused by inappropriate use of resources in health care. The reorganization of primary care with full implementation of family medicine and greater integration of family medicine with other levels of the health care system should provide a better control and treatment of other diseases such as hypertension.
... In this paper, we illustrate some of the major differences between explanatory and pragmatic clinical trial designs using two projects that addressed the same research question: to compare the effects on blood pressure (BP) of (1) a pharmacist-led telehealth intervention in adults with uncontrolled hypertension with (2) clinicbased primary care. Home BP monitoring combined with care management by a pharmacist or nurse has been shown to lower BP and improve control of hypertension [2][3][4][5][6][7][8][9][10][11][12][13][14]. Like most of the studies in this evidence base the Hyperlink 1 cluster-randomized trial was designed to show efficacy under relatively tightly controlled conditions, although it had broader eligibility criteria than trials that preceded it [15]. ...
Background
Explanatory trials are designed to assess intervention efficacy under ideal conditions, while pragmatic trials are designed to assess whether research-proven interventions are effective in “real-world” settings without substantial research support.
Methods
We compared two trials (Hyperlink 1 and 3) that tested a pharmacist-led telehealth intervention in adults with uncontrolled hypertension. We applied PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) scores to describe differences in the way these studies were designed and enrolled study-eligible participants, and the effect of these differences on participant characteristics and adherence to study interventions.
Results
PRECIS-2 scores demonstrated that Hyperlink 1 was more explanatory and Hyperlink 3 more pragmatic. Recruitment for Hyperlink 1 was conducted by study staff, and 2.9% of potentially eligible patients enrolled. Enrollees were older, and more likely to be male and White than non-enrollees. Study staff scheduled the initial pharmacist visit and adherence to attending this visit was 98%. Conversely for Hyperlink 3, recruitment was conducted by clinic staff at routine encounters and 81% of eligible patients enrolled. Enrollees were younger, and less likely to be male and White than non-enrollees. Study staff did not assist with scheduling the initial pharmacist visit and adherence to attending this visit was only 27%. Compared to Hyperlink 1, patients in Hyperlink 3 were more likely to be female, and Asian or Black, had lower socioeconomic indicators, and were more likely to have comorbidities. Owing to a lower BP for eligibility in Hyperlink 1 (>140/90 mm Hg) than in Hyperlink 3 (>150/95 mm Hg), mean baseline BP was 148/85 mm Hg in Hyperlink 1 and 158/92 mm Hg in Hyperlink 3.
Conclusion
The pragmatic design features of Hyperlink 3 substantially increased enrollment of study-eligible patients and of those traditionally under-represented in clinical trials (women, minorities, and patients with less education and lower income), and demonstrated that identification and enrollment of a high proportion of study-eligible subjects could be done by usual primary care clinic staff. However, the trade-off was much lower adherence to the telehealth intervention than in Hyperlink 1, which is likely to reflect uptake under real-word conditions and substantially dilute intervention effect on BP.
Trial registration
The Hyperlink 1 study (NCT00781365) and the Hyperlink 3 study (NCT02996565) are registered at ClinicalTrials.gov.
... Comorbidity with other diseases also increased the difficulty of selfmanagement (Carter et al., 2012). So managing physical, psychological and social frailty in older people and reducing the feeling of selfneglect were very important for better self-management. ...
Background:
Hypertension is a public health problem globally. Understanding the perceived challenges of low-income older people populations with chronic disease is an obstacle the world is facing today.
Aim:
To explore perceived challenges of self-management in low-income older people with hypertension.
Methods:
Data were collected in three communities from September 2019 to October 2019 by semi-structured interviews. Interviews were audio-taped by digital voice recorder and analysed according to Colaizzi's seven steps.
Results:
Participants demonstrated perceived challenges concerning hypertension self-management. Six themes were identified: hypertension belief bias, family dysfunction, deep-rooted habit, elder self-neglect, medical informatization and supportive health policy. Each theme was identified with several subthemes.
Conclusions:
Findings implied that most of the low-income older people lacked self-management behaviours. Future research is needed to address perceived challenges related to self-management behaviour for patients with hypertension worldwide.
... 78 Team-based care involving pharmacists is an effective strategy to improve hypertension control. 79,80 Trials involving pharmacists result in mean systolic BP reductions of 6.1 mm Hg. 81 Prior researchers have suggested that wider use of pharmacists may be enhanced if they could independently prescribe antihypertensive therapy, without collaborative practice agreements, with reimbursement at levels that covers the costs of their services. 82,83 Team-based care involving nurses improves hypertension outcomes. ...
Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, it remained stable through 2013-2014 and declined to 43.7% in 2017-2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community-clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control.
... It is the productive interactions between the two sides of the model which lead to improved health outcomes [21]. According to the desirable components for an effective chronic disease management identified by the CCM, a proactive health care team has been identified to communicate regularly with self-activated hypertension patients [22][23][24][25]. Based on this integrated management model, the HSMonitor procurers established a framework for requirements and solution design that consists of nine building blocks (Figure 1), divided into three domains: (a) service delivery, (b) devices and integration, and (c) health care organisation. ...
This article describes a user-centred approach taken by a group of five procurers to set specifications for the procurement of value-based research and development services for IT-supported integrated hypertension management. The approach considered the unmet needs of patients and health systems of the involved regions. The procurers established a framework for requirements and a solution design consisting of nine building blocks, divided into three domains: service delivery, devices and integration, and health care organisation. The approach included the development of questionnaires, capturing patients’ and professionals’ views on possible system functionalities, and a template collecting information about the organisation of healthcare, professionals involved and existing IT systems at the procurers’ premises. A total of 28 patients diagnosed with hypertension and 26 professionals were interviewed. The interviewees identified 98 functional requirements, grouped in the nine building blocks. A total of nine use cases and their corresponding process models were defined by the procurers’ working group. As result, a digitally enabled integrated approach to hypertension has been designed to allow citizens to learn how to prevent the development of hypertension and lead a healthy lifestyle, and to receive comprehensive, individualised treatment in close collaboration with healthcare professionals.
... Results from our study have shown a signi cant controlled blood pressure among Educational interventions directed to the patient-led by health care workers, especially pharmacists or community health care workers. According to European and Canadian guidelines, Pharmacists should be the standard care of hypertension as they are valuable in team-based care (TBC) [40,41]. The quality of our study ndings was moderate on average, showing the reliability of our results. ...
Background: In recent decades low- and middle-income countries (LMICs) are witnessing an increase in hypertension and thus becoming a significant public health issue due to associated Cardiovascular disease (CVD) outcomes. Antihypertensive medication adherence is crucial to controlling blood pressure; therefore, this systematic review aimed to evaluate the effectiveness of non-pharmacological interventions on improving blood pressure control and medication adherence in patients with hypertension in LMICs.
Methods: We searched the following databases for relevant literature published between Jan 2005 – Dec 2020: PubMed, EBSCOhost included Academic Search; CINAHL and MEDLINE complete; PubMed; WEB of Science; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews and Google Scholar. Cochrane risk of bias tool (RoB 2) was used to appraise included studies critically, and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to measure the quality of evidence. We conducted a meta‑analysis using DrSimonian-Laid's random-effect model at 95% confidence intervals (CIs). The secondary outcomes of interests were synthesised descriptively as changes in BP adherence outcomes.
Results: We identified 14 eligible randomised controlled trials that presented blood pressure (BP) effectiveness and medication adherence among BP patients aged between 18-75 years. The overall quality of evidence with the majority of trials was moderate. Meta weighed effect (SBP) for 12/14 studies was -4.74 (95% CI:-6.07 to -3.47) and I2 = 57%. Out of 14 eligible studies, (86%) suggested a significant improvement in the proportion of patients with controlled blood pressure (BP < 140/90mmHG) with a positive effect on secondary outcomes such as quality of life.
Conclusion: Non-pharmacological interventions could be effective in managing hypertension. In recommending the need to investigate the feasibility of non-pharmacological evidence in specific LMIC settings, focus should be on an intervention strategy consisting of an educational intervention directed toward the patients, health professionals and organisation. Considering heterogeneity, randomised trials that are well-designed with larger sample sizes are encouraged in LMICs` to help policymakers make well-informed decisions on hypertension management.
Systematic review Registration: PROSPERO registration number: CRD42020172954
... Some of the tasks that clinical pharmacists perform in the United States (such as managing patients on anticoagulation therapy or with uncontrolled diabetes or hypertension) are very timeconsuming tasks. Not only may clinical pharmacists do these tasks better in some cases (as measured by achieving control of the condition or preventing medicationrelated adverse events) [21,22], but they also can relieve physicians of the effort and free up appointments that physicians can then use to fill roles unique to them (such as diagnosis of unknown conditions) [23]. Thus, clinical pharmacists can contribute more not only to improving quality and safety, but also to meeting currently unmet healthcare needs in Israel. ...
Clinical pharmacists have advanced training that enables them to manage medication therapy, including prescribing, titrating, and discontinuing medications, in order to achieve therapeutic goals. In some countries, such as the United States, advances in training, responsibility, legal frameworks, and public acceptance of new roles have proceeded in parallel to expand the scope and contribution of clinical pharmacists over several decades. In this manuscript, we detail seven discrete key parameters of professional advancement for clinical pharmacists, corresponding to the seven areas in which they must advance in order to contribute fully to delivering high-quality medical care. For each key parameter, we briefly summarize the progress made in the United States to date, as well as goals for future progress. We then compare this to the development of the analogous key parameter in Israel. We found that on some key parameters, the development of clinical pharmacy in Israel lags behind the United States. This manuscript can provide a roadmap for the future advancement of clinical pharmacy in Israel, toward its full realization as a profession that can contribute to delivering high-quality medical care.
... 7 The mean blood pressure reductions and mean blood pressure change of -10mmHg are consistent with previous studies 13,14 where pharmacist clinical interventions significantly improved treatment outcomes among hypertensive patients. 24,25 Blood pressure was reduced in the PCI following the implementation of the intervention for a 3-months period. ...
Pharmacists' clinical interventions are an important aspect of pharmacy practice that improve blood pressure reduction and medication adherence. These unique clinical interventions address many barriers to hypertension treatment outcomes, such as blood pressure, and medication adherence. Pharmacists' clinical interventions also directly improve patient's and caregiver's knowledge and understanding about the patient's current medication therapy. The general aim of the study was to assess the impact of pharmacists' clinical intervention on treatment outcomes among hypertensive patients. A multi-cluster, prospective, randomized intervention of 473 Nigerian hypertensive patients in which the impact of pharmacist's clinical interventions was assessed and compared to the routine Standard Medication Dispensing (SMD) practices among adult hypertensive patients. Patients' baseline and end of study blood pressure measurements and medication adherence scores were recorded from baseline to a three months' follow-up visit. The data were collected by using a four-part questionnaire. The data collated were analyzed by descriptive statistics, and Independent t-test. Four hundred fourteen patients completed the study. The results showed that mean blood pressure reductions from baseline and endpoint was statistically significant in the Intervention group. Pharmacists' clinical interventions when implemented have immense benefits of improving treatment outcomes among patients with hypertension. For any health care system to thrive in its management of hypertension, the involvement of pharmacists' clinical interventions is strongly recommended.
... The experience of European countries shows that the solution to the issue of providing the population with quality and affordable drugs is in the sphere of influence of society in all countries, we believe that the future of pharmacy, its development as part of the pharmaceutical supply system, as well as its interdisciplinary and intersectoral nature, are closely linked to changes in socio-economic, political, cultural and educational life of Ukraine. According to a modern model of hypertension management, the patient and not his/her disease has a central role and is directly involved in his/her health care management in collaboration with the physician, family, and community, each other interacting in different ways to influence and support health decision [6]. This approach also emphasizes that patients with the same disease are nonetheless different from one another, due to differences in genetic predisposition as well as underlying mechanisms for high BP. ...
Objective:
The aim: The aim of the study was to study drug consumption in pharmacotherapy of arterial hypertension in a hospital setting.
Patients and methods:
Materials and methods: In the course of work medical cards of patients of the Kyiv regional Cardiac Dispensary in the conditions of inpatient treatment were used. Methods such as: questionnaire, pharmacoeconomic, expert assessments were used.
Results:
Results: One of the main issues of drug supply for the population, in particular for patients with arterial hypertension, is the study of the demand and consumption of drugs. The drugs used to treat hypertension belong to different pharmacotherapeutic groups and are used in the treatment of a number of other diseases. Recent years of development of the domestic pharmaceutical market are characterized by an increase in the number of these drugs.
Conclusion:
Conclusions: One of the main issues of drug supply for the population, in particular for patients with arterial hypertension, is the study of the demand and consumption of drugs. As a result of the study, an analysis of the range of drugs for the treatment of hypertension, a comparative study of the market of offers and prices for the treatment of hypertension was carried out.
... The doctor category was more likely to report optimising profession, role and care compared to the therapist category. Other studies have found that this inter-disciplinary model of care involving physicians, pharmacists and nurses improved the management of hypertension in individuals with chronic diseases [48,49]. Our study results highlight the importance of collaboration among members of the multi-disciplinary team to optimise health care provision to individuals with CLP. ...
Background
Collaboration among different categories of health professionals is essential for quality patient care, especially for individuals with cleft lip and palate (CLP). This study examined interprofessional collaboration (IPC) among health professionals in all CLP specialised centres in South Africa’s public health sector.
Methods
During 2017, a survey was conducted among health professionals at all the specialised CLP centres in South Africa’s public health sector. Following informed consent, each member of the CLP team completed a self-administered questionnaire on IPC, using the Interprofessional Competency Framework Self-Assessment Tool. The IPC questionnaire consists of seven domains with 51 items: care expertise (8 items); shared power (4 items); collaborative leadership (10 items); shared decision-making (2 items); optimising professional role and scope (10 items); effective group function (9 items); and competent communication (8 items). STATA®13 was used to analyse the data. Descriptive analysis of participants and overall mean scores were computed for each domain and analysed using ANOVA. All statistical tests were conducted at 5% significance level.
Results
We obtained an 87% response rate, and 52 participants completed the questionnaire. The majority of participants were female 52% (n = 27); with a mean age of 41.9 years (range 22–72). Plastic surgeons accounted for 38.5% of all study participants, followed by speech therapists (23.1%), and professional nurses (9.6%). The lowest mean score of 2.55 was obtained for effective group function (SD + -0.50), and the highest mean score of 2.92 for care expertise (SD + -0.37). Explanatory factor analysis showed that gender did not influence IPC, but category of health professional predicted scores on the five categories of shared power (p = 0.01), collaborative leadership (p = 0.04), optimising professional role and scope (p = 0.03), effective group function (p = 0.01) and effective communication (p = 0.04).
Conclusion
The seven IPC categories could be used as a guide to develop specific strategies to enhance IPC among CLP teams. Institutional support and leadership combined with patient-centred, continuing professional development in multi-disciplinary meetings will also enrich IPC.
... Estudos anteriores envolvendo tamanhos de amostras modestos sugeriram a importância dos enfermeiros na melhora da adesão a tratamentos antihipertensivos e do efeito de jaleco branco. [6][7][8][9][10][11] Da mesma forma, a abordagem ativa de farmacêuticos, educadores físicos e nutricionistas parece contribuir para melhorar a adesão e o controle da PA. 12,13 Entretanto, é crucial definir se toda a estrutura de equipe disponível (e não os 'compartimentos' distintos) pode contribuir para a eficácia do controle da PA. Em outras palavras, o todo é melhor do que qualquer componente individual ou a soma das partes? ...
... Большинство из них показало, что проведение вторичной профилактики медсестрами привело к увеличению приверженности к лечению, соблюдению принципов здорового образа жизни и значительному снижению уровня холестерина среди пациентов с ССЗ. Положительные результаты также были связаны с образовательной деятельностью медсестер, повторных проверок, а также более продолжительным индивидуальным консультированием медсестрами, по сравнению с докторами [13]. Роль медсестры в улучшении контроля гипертонии расширилась за последние 50 лет, дополнив роль врача. ...
... A collaborative model of care has the potential to further improve health outcomes. One example is the collaborative model of care for the management of hypertension, whereby integrating nurses in the provision of medical services to hypertensive patients reduced systolic blood pressure by 4-6 mmHg compared to usual care [26]. ...
Objectives: This study compares two methods of providing CVD risk score on the percentage of appropriate statin therapy for primary prevention of CVD in family medicine clinics, according to American Heart Association guidelines.
Methods: Participants were non-diabetic patients aged 40 to 75 with a recently ordered low-density lipoprotein (LDL) level, not on statin therapy and free of CVD. The first intervention is passive with a display of the score on the EMR in the vital signs section and lasted for three months. The second intervention is collaborative where the nurses calculate the risk score and displayed it to the physician along with therapy recommendations. Electronic health records were reviewed to randomly select medical charts of eligible patients.
Results: 162 charts were randomly selected out of 547 eligible charts and included in the analysis, including 60 charts for the baseline group. Among moderate-risk patients, the percentage of appropriate statin initiation was 0% at baseline and after the intervention; yet it increased to (33.3% [7.5-70.1, 95% CI] after intervention 2. Among high risk patients, percentage of appropriate statin initiation was 9.1% [0.1-41.3, 95% CI], 11.1% [1.4, 34.7, 95% CI] and 28.6% [8.4, 58.1, 95% CI] during baseline, intervention 1 and intervention 2, respectively.
Conclusion: The provision of the CVD risk score alone as clinical decision support is not enough to improve statin initiation for primary prevention. The nurse collaboration can improve guideline-concordant statin initiation.
... 3 Studies have demonstrated that pharmacists, including community pharmacists, can make valuable contributions to multidisciplinary CCM teams. [4][5][6][7][8] To standardize and incentivize CCM, the Centers for Medicare and Medicaid Services (CMS) introduced the CCM reimbursement system. 9 CMS considers CCM an integral part of primary care that positively impacts patient health outcomes and quality of care; 10 this initiative came to connect the fee-for-service and value-based models. ...
Introduction
Pharmacist‐physician collaboration has shown positive results in improving patient outcomes. Chronic care management (CCM) is a reimbursable service for Medicare beneficiaries in the community setting which includes comprehensive care management and other activities. The pharmacist contribution to CCM services and their associated impact on patient health outcomes has not been fully explored.
Objectives
The objectives of this study were to: (a) implement a collaborative CCM service between a community pharmacy and family medicine clinic for their common hypertensive patients; (b) measure blood pressure change for patients receiving the CCM intervention; and (c) report financial viability for the community pharmacy and family practice clinic partnership.
Methods
Single group prospective pilot intervention in an independent community pharmacy and family medicine clinic in a small city in the Midwest United States. Forty‐five patients with uncontrolled hypertension who are patients to both community pharmacy and clinic were recruited, and 26 received CCM interventions in person or over the telephone from the community pharmacists to manage medications for hypertension. Our main outcomes were blood pressure values and financial viability.
Results
Twenty‐six patients received at least one community pharmacist encounter. These patients had an average 7.3 mm Hg decline ( P = .006) in systolic blood pressure (SBP) and a 2.4 mm Hg decline ( P = .079) in diastolic blood pressure (DBP) at 9 months. The total revenue over the study period was 2785 and $3057, respectively.
Conclusion
The community pharmacy/clinic collaboration resulted in improved blood pressure control, a new source of revenue for the community pharmacy, and increased revenue for the clinic. Further research is needed on CCM revenue sharing between physicians and pharmacists to generalize the results.
... Various other studies have indicated that patients have a strong willingness to engage with pharmacists via telehealth/telemedicine platforms. 17,18 This suggests growing support for telehealth/telemedicine technology platforms for becoming a viable alternative for patients traveling to a destination to receive meaningful interactions with their health care providers. ...
Objectives:
To assess patients' knowledge of blood pressure (BP) and their comfort level with using technology, including a Bluetooth-enabled BP device and pharmacist telemonitoring. The secondary objective was to discover if pharmacist interventions improved BP readings.
Setting:
The study took place in Pharmacy Plus and the Family Medicine Department at the University of South Florida in Tampa, FL.
Practice description:
The pharmacists within Pharmacy Plus and the Family Medicine Department are part of the interdisciplinary team providing care to patients and seeking to achieve optimal patient outcomes. Pharmacy Plus breaks away from the traditional behind-the-counter model using innovative technology to create a personalized experience for patients.
Practice innovation:
During this pilot study, the patients received a Bluetooth-enabled BP monitor and were asked to obtain their BP readings at least once daily for 6 weeks. The patients' electronic health records automatically captured the BP readings, which were reviewed by the study pharmacists. The patients had an appointment with the pharmacists once weekly via a telehealth platform through which they were counseled on their weekly average BP, BP goals, lifestyle modifications, and proper use of the devices.
Evaluation:
The patients completed a prestudy survey assessing their baseline knowledge of BP, comfort level when using technology, and ease in working with pharmacists. Reliability and satisfaction in using the BP device and telehealth communication with pharmacists were also assessed poststudy.
Results:
Twelve patients enrolled, with 9 completing the study. There was a statistically significant increase in patients' knowledge of BP and an improvement in the recommended lifestyle modifications. In addition, comfort level regarding communication with the pharmacist was statistically significantly improved. The patients responded positively to using the Bluetooth-enabled BP monitor and telehealth for receiving health care services.
Conclusion:
Using Bluetooth-enabled BP monitors that report results in real time into electronic health records, along with pharmacist interventions within a team-based care model, may result in improved BP control and patient outcomes.
BACKGROUND
Globally, only 13.8% of patients with hypertension have their blood pressure (BP) controlled. Trials testing interventions to overcome barriers to BP control have produced mixed results. Type of health care professional delivering the intervention may play an important role in intervention success. The goal of this meta-analysis is to determine which health care professionals are most effective at delivering BP reduction interventions.
METHODS
We searched Medline and Embase (until December 2023) for randomized controlled trials of interventions targeting barriers to hypertension control reporting who led intervention delivery. One hundred articles worldwide with 116 comparisons and 90 474 participants with hypertension were included. Trials were grouped by health care professional, and the effects of the intervention on systolic and diastolic BP were combined using random effects models and generalized estimating equations.
RESULTS
Pharmacist-led interventions , community health worker–led interventions, and health educator–led interventions resulted in the greatest systolic BP reductions of −7.3 (95% CI, −9.1 to −5.6), −7.1 (95% CI, −10.8 to −3.4), and −5.2 (95% CI, −7.8 to −2.6) mm Hg, respectively. Interventions led by multiple health care professionals, nurses, and physicians also resulted in significant systolic BP reductions of −4.2 (95% CI, −6.1 to −2.4), −3.0 (95% CI, −4.2 to −1.9), and −2.4 (95% CI, −3.4 to −1.5) mm Hg, respectively. Similarly, the greatest diastolic BP reductions were −3.9 (95% CI, −5.2 to −2.5) mm Hg for pharmacist-led and −3.7 (95% CI, −6.6 to −0.8) mm Hg for community health worker–led interventions. In pairwise comparisons, pharmacist were significantly more effective than multiple health care professionals, nurses, and physicians at delivering interventions.
CONCLUSIONS
Pharmacists and community health workers are most effective at leading BP intervention implementation and should be prioritized in future hypertension control efforts.
Purpose
Postpartum hypertension (PPHTN) poses increased risks, including of stroke. Timely assessment and management by clinicians is imperative but challenging. Team-based care involving pharmacists has shown promise in improving blood pressure control, yet its application in PPHTN management remains unexplored. The objective of this study was to determine the impact and feasibility of an interprofessional model for PPHTN management.
Summary
This initiative implemented a novel interprofessional model at a safety-net hospital to address previous workflow limitations. Ambulatory care pharmacists collaborated with an obstetric nurse (OBRN) and a maternal fetal medicine specialist to manage high-risk patients with PPHTN utilizing electronic consults (e-consults). Data collection and symptom assessment were completed by an OBRN via telemedicine appointments. Pharmacists employed a collaborative practice agreement based on a preestablished algorithm to initiate medications. Data on patient demographics, consult volume, prescriptions, and pharmacist comfort were collected during the first quarter of full integration. Pharmacists completed 55 e-consults and generated 54 prescriptions. The average time spent per chart review was 12.5 minutes, and the average time to completion of e-consults was 54 minutes. Forty-five unique patients received care, who were primarily non–English-speaking and non-Hispanic Black patients. Pharmacists reported moderate to high comfort levels in managing PPHTN based on the algorithm and provided feedback leading to workflow adjustments.
Conclusion
Integration of pharmacists into PPHTN care enables prompt medication initiation and titration. This innovative model, involving remote blood pressure monitoring, telemedicine visits with an OBRN, and e-consults completed by pharmacists, ensures delivery of timely and equitable care and improved access across a diverse population.
Given the burden of cardiovascular disease (CVD) and prediction of its escalation in the coming years, primordial, primary, secondary, and tertiary preventive measures are essential across all settings. Nurses and advanced practice registered nurses (APRNs) have proven to deliver safe and effective chronic disease care as part of a multidisciplinary team. As CVD and its risk factors link with community health measures, community-based cardiovascular preventive initiatives which focus on health equity are essential and will be presented. Finally, innovative care delivery models are explored.
Purpose
As reported in most European countries, the percentage of treated hypertensive patients achieving a well-controlled blood pressure (e.g. < 140/90 mmHg) is insufficient. This represents a major health concern particularly in countries with a high prevalence of cardiovascular events such as stroke. Therefore, there is a need to develop national programs to increase not only the awareness regarding elevated blood pressure but also the percentage of treated patients achieving recommended blood pressure targets. The present paper describes the new initiative of the Portuguese Society of Hypertension (PSH) to achieveat least 70% of controlled hypertensive patients, followed in primary care, in 2026.
Materials and Methods
The strategies used to improve blood pressure control are aimed at healthcare professionals and general population and include governmental and organizational interventions. To be able to analyze the control rate of HTN patients, and using BI-CSP reports (the Primary Care health unit platform), every six months, we will be addressing the proportion of HTN patients (age: 18-65 years) with BP < 140/90 mmHg and the proportion of HTN patients with at least one blood pressure recorded in the last semester.
Conclusion
With Mission 70/26, the PHS aims to improve awareness among all health professionals and community alike about the problem of uncontrolled HTN and its role in the consequent disability and high mortality rate from cardiovascular causes.
Background
Lack of initiation or escalation of blood pressure (BP) lowering medication when BP is uncontrolled, termed therapeutic inertia (TI), increases with age and may be influenced by comorbidities.
Methods
We examined the association of age and comorbidities with TI in 22,665 visits with a systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg among 7,415 adults age ≥ 65 years receiving care in clinics that implemented a hypertension quality improvement program. Generalized linear mixed models were used to determine the association of comorbidity number with TI by age group (65-74 and ≥ 75 years) after covariate adjustment.
Results
Baseline mean age was 75.0 years (standard deviation 7.8); 41.4% were male. TI occurred in 79.0% and 83.7% of clinic visits in age groups 65-74 and ≥ 75 years, respectively. In age group 65-74 years, prevalence ratio of TI with two, three to four, and ≥ five comorbidities compared with zero comorbidities was 1.07 (95% confidence interval [CI]: 1.04, 1.12), 1.08 (95% CI: 1.05, 1.12), and 1.15 (95% CI: 1.10, 1.20), respectively. The number of comorbidities was not associated with TI prevalence in age group ≥ 75-year years. After implementation of the improvement program, TI declined from 80.3% to 77.2% in age group 65-74 years and from 85.0% to 82.0% in age group ≥ 75 years (p<0.001 for both groups).
Conclusions
TI was common among older adults but not associated with comorbidities after age ≥ 75 years. A hypertension improvement program had limited impact on TI in older patients.
Health systems have been quickly adopting telemedicine throughout the United States, especially since the onset of the COVID-19 pandemic. However, there are limited data on whether adding pharmacist-led home blood pressure (BP) telemonitoring to office-based usual care improves BP. We searched PubMed/MEDLINE and Embase for randomized controlled trials from January 2000 until April 2022, comparing studies on pharmacist-led home BP telemonitoring with usual care. Six randomized controlled trials, including 1,550 participants, satisfied the inclusion criteria. There were 774 participants in the pharmacist-led telemonitoring group and 776 in the usual care group. The addition of pharmacist-led telemonitoring to usual care was associated with a significant decrease in systolic BP (mean difference -8.09, 95% confidence interval -11.15 to -5.04, p <0.001, I2 = 72%) and diastolic BP (mean difference -4.19, 95% confidence interval -5.58 to -2.81, p <0.001, I2 = 42%) compared with usual care. In conclusion, this meta-analysis showed that adding pharmacist-led home BP telemonitoring to usual care achieves better BP control than usual care alone.
Document Reviewers
Luis Alcocer (Mexico), Christina Antza (Greece), Mustafa Arici (Turkey), Eduardo Barbosa (Brazil), Adel Berbari (Lebanon), Luís Bronze (Portugal), John Chalmers (Australia), Tine De Backer (Belgium), Alejandro de la Sierra (Spain), Kyriakos Dimitriadis (Greece), Dorota Drozdz (Poland), Béatrice Duly-Bouhanick (France), Brent M. Egan (USA), Serap Erdine (Turkey), Claudio Ferri (Italy), Slavomira Filipova (Slovak Republic), Anthony Heagerty (UK), Michael Hecht Olsen (Denmark), Dagmara Hering (Poland), Sang Hyun Ihm (South Korea), Uday Jadhav (India), Manolis Kallistratos (Greece), Kazuomi Kario (Japan), Vasilios Kotsis (Greece), Adi Leiba (Israel), Patricio López-Jaramillo (Colombia), Hans-Peter Marti (Norway), Terry McCormack (UK), Paolo Mulatero (Italy), Dike B. Ojji (Nigeria), Sungha Park (South Korea), Priit Pauklin (Estonia), Sabine Perl (Austria), Arman Postadzhian (Bulgaria), Aleksander Prejbisz (Poland), Venkata Ram (India), Ramiro Sanchez (Argentina), Markus Schlaich (Australia), Alta Schutte (Australia), Cristina Sierra (Spain), Sekib Sokolovic (Bosnia and Herzegovina), Jonas Spaak (Sweden), Dimitrios Terentes-Printzios (Greece), Bruno Trimarco (Italy), Thomas Unger (The Netherlands), Bert-Jan van den Born (The Netherlands), Anna Vachulova (Slovak Republic), Agostino Virdis (Italy), Jiguang Wang (China), Ulrich Wenzel (Germany), Paul Whelton (USA), Jiri Widimsky (Czech Republic), Jacek Wolf (Poland), Grégoire Wuerzner (Switzerland), Eugene Yang (USA), Yuqing Zhang (China).
Introduction:
Hypertension management remains a major public health challenge in primary care. Innovative interventions to improve blood pressure (BP) control are needed. One approach is through community-based models of care with the involvement of pharmacists and other non-physician healthcare professionals. Our objective is to systematically review the evidence of the impact of pharmacist care alone or in collaboration with other healthcare professionals on BP among hypertensive outpatients compared with usual care. Because these interventions can be complex, with various components, the effect size may differ between the type of interventions. One major focus of our study will be to assess carefully the heterogeneity in the effects of these interventions to identify which ones work best in a given healthcare setting.
Methods and analysis:
Systematic searches of the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (Embase) and Central Register of Controlled Trials (CENTRAL) databases will be conducted. Randomised controlled trials assessing the effect of pharmacist interventions on BP among outpatients will be included. Examples for pharmacist interventions are patient education, feedback to physician and medication management. The outcome will be the change in BP or BP at follow-up or BP control. Results will be synthesised descriptively and, if appropriate, will be pooled across studies to perform meta-analyses. If feasible, we will also perform a network meta-analysis to compare interventions that have not been compared directly head-to-head by using indirect evidence. Heterogeneity in the effect will be evaluated through prespecified subgroup and stratified analyses, accounting notably for the type and intensity of interventions, patients' characteristics and healthcare setting.
Ethics and dissemination:
Ethical approval is not required as the results will be drawn from currently available published literature. Outcomes of the review will be shared through peer-reviewed journal and used for implementation policy.
Prospero registration number:
CRD42021279751.
Disclaimer
In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
Purpose
To explore the perceptions of pharmacists and administrators who had an integral role in designing and operationalizing an integrated community pharmacist hypertension management program with collaboration between an academic medical center and a regional chain community pharmacy.
Summary
Community pharmacists (n = 3), ambulatory care pharmacists (n = 2), medical directors (n = 2), and health-system (n = 1) and pharmacy (n = 1) administrators reported positive experiences engaging with the hypertension management program. Strengths of the program included comprehensive training by the ambulatory care pharmacists, community pharmacist access to the electronic health record (EHR), and primary care providers who were receptive to referring patients and accepting recommendations from the community pharmacists. All participants felt that the program had a positive outlook and saw opportunity for expansion, such as extended hours of operation, new locations, and additional pharmacists.
Conclusion
Pharmacists are well positioned to extend hypertension management programs from primary care clinics into local pharmacists if they have appropriate training, access to the EHR, and ongoing support from collaborating primary care offices. Additional research using implementation science methods is needed to further test the scalability and replicability of the program among different patient populations, community pharmacies, and health systems.
Introduction
Arterial hypertension is the main factor in attributable mortality. It is therefore considered one of the most important public health problems. Health professionals require special training and skills to make a diagnosis. No studies have been found in the literature search that use a validated instrument (questionnaire) to assess health professionals’ theoretical and practical knowledge in diagnosing hypertension or measuring blood pressure.
Aim
To design and validate an instrument for gauging health professionals’ theoretical knowledge in measuring blood pressure for the initial diagnosis of hypertension.
Methodology
Design, development, and validation of a questionnaire in three languages (English, Spanish, and Catalan) to assess knowledge based on the Rasch-item response theory model.
Results
A questionnaire in three languages was constructed and validated. It consisted of 23 questions on the theoretical knowledge of the initial diagnosis of hypertension and was called the ARC questionnaire. It met all the Rasch-IRT model criteria: item- and person-fit measurement, unidimensionality, local independence, invariance, targeting, and reliability.
Conclusions
The ARC questionnaire is a validated tool that enables objective and uniform analyses of knowledge in the initial diagnosis of hypertension among medical and nursing professionals, comparing them over time. It allows for established strategies to be developed to enhance this knowledge.
Objective
To evaluate the effectiveness of person-centred quality improvement strategies on the management and control of adults with hypertension in primary care.
Methods
A systematic review and meta-analysis was conducted using the Medline, Cochrane Central Register for Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature, and APA PsycINFO databases (January 1980 to March 2020). Randomized controlled trials that evaluated person-centred quality improvement strategies for the management and control of essential hypertension among adults (18 years) in primary care were included. Random effects models were used to estimate weighted mean differences (WMD) for the change in systolic and diastolic blood pressures (SBP, DBP) from baseline; risk ratios (RR) were calculated for the proportion of participants achieving target blood pressures, for each quality improvement strategy assessed. A qualitative review of the implementation details of the interventions was conducted to identify common components of interventions that were effective in improving blood pressure outcomes.
Results
Eight studies were included (total of 5654 patients). Findings favour use of person-centred quality improvement interventions over usual care (RR = 1.23 [95% CI: 1.01; 1.48]) for improving blood pressure outcomes. Self-management (RR = 1.43 [95% CI: 1.23; 1.65]) had the greatest effects on blood pressure targets. Clinician education resulted in the greatest SBP reduction (WMD:6.09 mmHg [95% CI: 2.32; 9.85]), while patient education and patient reminder systems (both WMD:4.86 mmHg [95% CI: 0.88; 8.83]) saw the most improvements in DBP. While interventions varied in their strategy implementation, common features of effective interventions included tailored communication with patients, use of health information technology, and multidisciplinary collaboration.
Conclusion
Person-centred quality improvement strategies were effective in improving blood pressure outcomes. Further research is needed regarding the context of implementing interventions to provide greater insight into the components of a person-centred quality improvement intervention most effective in improving hypertension outcomes.
Background:
We developed a remote cardiovascular risk service (CVRS) managed by clinical pharmacists to support primary care teams. The purpose of this study was to examine whether the CVRS could improve guideline adherence in primary care clinics with diverse geographic and patient characteristics.
Methods:
This study was a cluster-randomized trial initiated in 20 primary care clinics across the US. Clinics were stratified as high or low minority and then randomized to receive the intervention or maintain usual care for 12 months. The primary outcome was adherence to relevant The Guideline Advantage (TGA) criteria met. TGA is a compilation of criteria from practice guidelines intended to improve the quality of primary care. Post-hoc outcomes included changes in individual TGA measures.
Results:
A total of 401 study subjects were included in the analysis. Mean TGA scores remained the same in the intervention group (n=193, 0.72) and slightly decreased in the usual care group (n=208, 0.67 to 0.66) over the 12-month study period. There was no significant difference between the mean TGA scores in intervention and usual care groups for the overall population at 12 months (0.72 versus 0.66 respectively, p=0.10). For under-represented minority subjects, there was no significant difference between TGA scores at 12 months (n=186; 0.70 versus 0.67, respectively, p=0.50). In a post-hoc analysis of subjects uncontrolled at baseline, there was a significant improvement in systolic BP at 12 months in the intervention group versus usual care (model-based difference of -8.03mmHg, p=0.03).
Conclusions:
Improvements in individual TGA measures were limited, in part, due to higher than expected baseline TGA scores. Future studies of this model should focus on patients with uncontrolled conditions at high risk for cardiovascular events.
Clinical trial registration:
ClinicalTrials.gov Identifier: NCT02215408; https://clinicaltrials.gov/ct2/show/NCT02215408?id=NCT02215408.
Background
Primary care physicians were prompted to refer eligible patients with uncontrolled hypertension (HTN) to a program that offered home blood pressure telemonitoring and pharmacist care management. Understanding attitudes, barriers and facilitators, and use of team care in this program provides insight into how physicians incorporate team care into their practice.
Objective
To understand physician attitudes and use of team care in the context of a study intervention that included telehealth with pharmacist care management.
Methods
Clinicians that were part of the telehealth intervention arm of the Hyperlink 3 study and had at least 20 opportunities to refer an eligible patient with hypertension to a clinical pharmacist were invited to be interviewed. Nine physician interviews were conducted, recording and transcribed. Each interview lasted approximately 30 minutes and followed an interview guide, allowing for some variation and deeper dives into content based on clinician response. Three research staff coded each interview and sorted coded text to identify patterns at the physician level and then identified themes across interviews using a comparative process.
Results
Physicians had an overall positive attitude about team care. Communication, access, trust and perceived role competency in team members influenced physician engagement in team care. Individualized practice styles influenced how physicians utilized team care and which care team members they involved most often. All physicians felt their individual style best achieved high quality care.
Conclusion
For health care teams to be most effective, an understanding of how a physician’s practice style influences their use of team care is likely to be more successful than a one size fits all approach. Incorporating practice style into key factors necessary for high functioning teams such as communication, access and trust is necessary for health care teams to thrive.
Background
Uncontrolled or undiagnosed hypertension (HTN) is estimated to be as high as 46% in emergency departments (EDs). Uncontrolled HTN contributes significantly to cardiovascular morbidity and disproportionately affects communities of color. EDs serve high risk populations with uncontrolled conditions that are often missed by other clinical settings and effective interventions for uncontrolled HTN in the ED are critically needed. The ED is well situated to decrease the disparities in HTN control by providing a streamlined intervention to high risk populations that may use the ED as their primary care.
Methods
Targeting of UnControlled Hypertension in the Emergency Department (TOUCHED), is a two-arm single site randomized controlled trial of 770 adults aged 18–75 presenting to the ED with uncontrolled HTN comparing (1) usual care, versus (2) an Educational and Empowerment (E2) intervention that integrates a Post-Acute Care Hypertension Consultation (PACHT-c) with a mobile health BP self-monitoring kit. The primary outcome is differences in mean systolic blood pressure (SBP) at 6-months post enrollment. Secondary outcomes include differences in mean SBP and mean diastolic BP (DBP) at 3-months and mean DBP at 6-months. Additionally, improvement in cardiovascular risk score, medication adherence, primary care engagement, and HTN knowledge will also be assessed as part of this study.
Conclusions
The TOUCHED trial will be instrumental in determining the effectiveness of a brief ED-based intervention that is portable to other urban EDs with high-risk populations.
Trial registration
clinicaltrials.gov Identifier: NCT03749499.
What is known and objective:
Hypertension (HTN) and chronic kidney disease (CKD) are recognized as silent killers because they are asymptomatic conditions that contribute to the burden of multiple comorbidities. The achievement of a blood pressure (BP) goal can dramatically reduce the risks of CKD. In this study, we aimed to assess the effectiveness of pharmacist intervention on BP control in patients with CKD and evaluate the usefulness of home-based BP telemonitoring.
Methods:
The terms "chronic kidney disease," "pharmacist," "BP" and "randomized controlled trial (RCT)" were used five databases to search for information regarding pharmacist intervention on BP control in patients with CKD. The inclusion criteria were as follows: (a) studies for adult patients with uncontrolled HTN and (b) studies with adequate data for meta-analysis. The primary outcome was an evaluation of achievement of BP goal in patients with CKD. The secondary outcome was usefulness of home-based BP telemonitoring by pharmacists in patients with CKD.
Results and discussion:
Six RCTs were identified and included in the meta-analysis with a total of 2573 patients (mean age 66.0 years and 63.9% male). Pharmacist interventions resulted in significantly better BP control vs usual care (OR = 1.53, 95% CI = 1.15-2.04, P < .01). Pharmacist interventions using home-based BP telemonitoring were significantly superior to control/usual care (OR = 2.03, 95% CI = 1.49-2.77, P < .01), whereas pharmacist interventions without home-based BP telemonitoring did not significantly improve BP control compared to that with control/usual care (OR = 1.30, 95% CI = 0.97-1.75, P = .08). Home-based BP telemonitoring supported team-based care for HTN in these studies. In addition, patient self-monitoring with telemedicine devices might enhance patients' abilities to manage their condition by pharmacist instruction.
What is new and conclusion:
The findings of this meta-analysis showed that pharmacist interventions with home-based BP telemonitoring improve BP control among adult patients with CKD.
Purpose
Improve patient access to clinical pharmacy services and decrease pharmacist technical task workload in primary care (PC) clinics.
Summary
Due to concerns with the amount of technical tasks performed by University of Wisconsin Health PC clinical pharmacists negatively impacting their capacity to care for patients and perform clinical tasks, the pharmacy department piloted a new PC pharmacy technician role that involved completion of technical tasks previously performed by PC pharmacists. PC pharmacist daily technical and clinical activities were identified through shadowing and quantified by a 4-week period of work sampling. A PC pharmacist workgroup determined the technical tasks that would be appropriate for a pharmacy technician to complete and developed the technician workflows. A PC pharmacy technician was implemented during a 3-week pilot, when pharmacist daily technical and clinical activities were quantified through work sampling. Following implementation, a 52.7% (P < 0.001) relative reduction and a 10.2% (P < 0.001) relative increase in pharmacist technical and clinical activities, respectively, were identified. Additionally, a 10% relative increase from the previous 3-month average was observed in the PC pharmacist rolling patient panel size during the pilot period, correlating with an increase of patient access to pharmacist clinical services.
Conclusion
Up to 17% of PC pharmacist daily activities are technical tasks. Leveraging pharmacy technicians to support pharmacists with completion of these tasks increases patient access to clinical pharmacy services but requires additional staff resources.
Patient-shared electronic health records provide opportunities for care outside of office visits. However, those who might benefit may be unable to or choose not to use these resources, while others might not need them.
Electronic Communications and Home Blood Pressure Monitoring (e-BP) was a randomized trial that demonstrated that Web-based pharmacist care led to improved blood pressure (BP) control. During recruitment we attempted to contact all patients with hypertension from 10 clinics to determine whether they were eligible and willing to participate. We wanted to know whether particular subgroups, particularly those from vulnerable populations, were less willing to participate or unable to because they lacked computer access.
From 2005 to 2006, we sent invitation letters to and attempted to recruit 9298 patients with hypertension. Eligibility to participate in the trial included access to a computer and the Internet, an email address, and uncontrolled BP (BP ≥ 140/90 mmHg). Generalized linear models within a modified Poisson regression framework were used to estimate the relative risk (RR) of ineligibility due to lack of computer access and of having uncontrolled BP.
We were able to contact 95.1% (8840/9298) of patients. Those refusing participation (3032/8840, 34.3%) were significantly more likely (P < .05) to be female, be nonwhite, have lower levels of education, and have Medicaid insurance. Among patients who answered survey questions, 22.8% (1673/7354) did not have computer access. Older age, minority race, and lower levels of education were risk factors for lack of computer access, with education as the strongest predictor (RR 2.63, 95% CI 2.30-3.01 for those with a high school degree compared to a college education). Among hypertensive patients with computer access who were willing to participate, African American race (RR 1.22, 95% CI 1.06-1.40), male sex (RR 1.28, 95% CI 1.18-1.38), and obesity (RR 1.53, 95% CI 1.31-1.79) were risk factors for uncontrolled BP.
Older age, lower socioeconomic status, and lower levels of education were associated with decreased access to and willingness to participate in a Web-based intervention to improve hypertension control. Failure to ameliorate this may worsen health care disparities.
Clinicaltrials.gov NCT00158639; http://www.clinicaltrials.gov/ct2/show/NCT00158639 (Archived by WebCite at http://www.webcitation.org/5v1jnHaeo).
To review trials of nurse led interventions for hypertension in primary care to clarify the evidence base, establish whether nurse prescribing is an important intervention, and identify areas requiring further study.
Systematic review and meta-analysis.
Ovid Medline, Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database.
Randomised controlled trials of nursing interventions for hypertension compared with usual care in adults.
Systolic and diastolic blood pressure, percentages reaching target blood pressure, and percentages taking antihypertensive drugs. Intervention effects were calculated as relative risks or weighted mean differences, as appropriate, and sensitivity analysis by study quality was undertaken.
Compared with usual care, interventions that included a stepped treatment algorithm showed greater reductions in systolic blood pressure (weighted mean difference -8.2 mm Hg, 95% confidence interval -11.5 to -4.9), nurse prescribing showed greater reductions in blood pressure (systolic -8.9 mm Hg, -12.5 to -5.3 and diastolic -4.0 mm Hg, -5.3 to -2.7), telephone monitoring showed higher achievement of blood pressure targets (relative risk 1.24, 95% confidence interval 1.08 to 1.43), and community monitoring showed greater reductions in blood pressure (weighted mean difference, systolic -4.8 mm Hg, 95% confidence interval -7.0 to -2.7 and diastolic -3.5 mm Hg, -4.5 to -2.5).
Nurse led interventions for hypertension require an algorithm to structure care. Evidence was found of improved outcomes with nurse prescribers from non-UK healthcare settings. Good quality evidence from UK primary health care is insufficient to support widespread employment of nurses in the management of hypertension within such healthcare systems.
Hypertension is a major risk factor for cardiovascular disease and treatment and control of hypertension reduces risk. The Healthy People 2010 goal was to achieve blood pressure (BP) control in 50% of the US population.
To assess progress in treating and controlling hypertension in the United States from 1988-2008.
The National Health and Nutrition Examination Survey (NHANES) 1988-1994 and 1999-2008 in five 2-year blocks included 42 856 adults aged older than 18 years, representing a probability sample of the US civilian population.
Hypertension was defined as systolic BP of at least 140 mm Hg and diastolic BP of at least 90 mm Hg, self-reported use of antihypertensive medications, or both. Hypertension control was defined as systolic BP values of less than 140 mm Hg and diastolic BP values of less than 90 mm Hg. All survey periods were age-adjusted to the year 2000 US population.
Rates of hypertension increased from 23.9% (95% confidence interval [CI], 22.7%-25.2%) in 1988-1994 to 28.5% (95% CI, 25.9%-31.3%; P < .001) in 1999-2000, but did not change between 1999-2000 and 2007-2008 (29.0%; 95% CI, 27.6%-30.5%; P = .24). Hypertension control increased from 27.3% (95% CI, 25.6%-29.1%) in 1988-1994 to 50.1% (95% CI, 46.8%-53.5%; P = .006) in 2007-2008, and BP among patients with hypertension decreased from 143.0/80.4 mm Hg (95% CI, 141.9-144.2/79.6-81.1 mm Hg) to 135.2/74.1 mm Hg (95% CI, 134.2-136.2/73.2-75.0 mm Hg; P = .02/P < .001). Blood pressure control improved significantly more in absolute percentages between 1999-2000 and 2007-2008 vs 1988-1994 and 1999-2000 (18.6%; 95% CI, 13.3%-23.9%; vs 4.1%; 95% CI, -0.5% to 8.8%; P < .001). Better BP control reflected improvements in awareness (69.1%; 95% CI, 67.1%-71.1%; vs 80.7%; 95% CI, 78.1%-83.0%; P for trend = .03), treatment (54.0%; 95% CI, 52.0%-56.1%; vs 72.5%; 95% CI, 70.1%-74.8%; P = .004), and proportion of patients who were treated and had controlled hypertension (50.6%; 95% CI, 48.0%-53.2%; vs 69.1%; 95% CI, 65.7%-72.3%; P = .006). Hypertension control improved significantly between 1988-1994 and 2007-2008, across age, race, and sex groups, but was lower among individuals aged 18 to 39 years vs 40 to 59 years (P < .001) and 60 years or older (P < .001), and in Hispanic vs white individuals (P = .004).
Blood pressure was controlled in an estimated 50.1% of all patients with hypertension in NHANES 2007-2008, with most of the improvement since 1988 occurring after 1999-2000. Hypertension control was significantly lower among younger than middle-aged individuals and older adults, and Hispanic vs white individuals.
Pharmacists can affect the delivery of primary care by addressing the challenges of medication therapy management. Most office visits involve medications for chronic conditions and require assessment of medication effectiveness, the cost of therapies, and patients' adherence with medication regimens. Pharmacists are often underused in conducting these activities. They perform comprehensive therapy reviews of prescribed and self-care medications, resolve medication-related problems, optimize complex regimens, design adherence programs, and recommend cost-effective therapies. Pharmacists should play key roles as team members in medical homes, and their potential to serve effectively in this role should be evaluated as part of medical home demonstration projects.
Past work suggests that the degree of similarity between patient and physician attitudes may be an important predictor of patient-centered outcomes.
To examine the extent to which patient and provider symmetry in health locus of control (HLOC) beliefs was associated with objectively derived medication refill adherence in patients with co-morbid diabetes mellitus (DM) and hypertension (HTN).
Eighteen primary care physicians at the VA Iowa City Medical Center and affiliated clinics; 246 patients of consented providers with co-morbid DM and HTN.
Established patient-physician dyads were classified into three groups according to the similarity of their HLOC scores (assessed in parallel). Data analysis utilized hierarchical linear modeling (HLM) to account for clustering of patients within physicians.
Objectively derived medication refill adherence was computed using data from the VA electronic pharmacy record; blood pressure and HgA1c values were considered as secondary outcomes.
Physician-patient dyads holding highly similar beliefs regarding the degree of personal control that individual patients have over health outcomes showed significantly higher overall and cardiovascular medication regimen adherence (p = 0.03) and lower diastolic blood pressure (p = 0.02) than in dyads in which the patient held a stronger belief in their own personal control than did their treating physician. Dyads in which patients held a weaker belief in their own personal control than did their treating physician did not differ significantly from symmetrical dyads. The same pattern was observed after adjustment for age, physician sex, and physician years of practice.
These data are the first to demonstrate the importance of attitudinal symmetry on an objective measure of medication adherence and suggest that a brief assessment of patient HLOC may be useful for tailoring the provider's approach in the clinical encounter or for matching patients to physicians with similar attitudes towards care.
We propose evaluation of a multi-component home automated telemanagement system providing integrated support to both clinicians and patients in implementing hypertension treatment guidelines. In a randomized clinical study, 550 blacks with hypertension are followed for 18 months. The major components of the intervention and control groups are identical and are based on the current standard of care. For the purpose of this study, we define "standard of care" as the expected evidence-based care provided according to the current hypertension treatment guidelines. Although intervention and control groups are similar in terms of their care components, they differ in the mode of care delivery. For the control group the best attempt is made to deliver all components of a guideline-concordant care in a routine clinical environment whereas for the intervention group the routine clinical environment is enhanced with health information technology that assists clinicians and patients in working together in implementing treatment guidelines. The home automated telemanagement system guides patients in following their individualized treatment plans and helps care coordination team in monitoring the patient progress. The study design is aimed at addressing the main question of this trial: whether the addition of the information technology-enhanced care coordination in the routine primary care setting can improve delivery of evidence-based hypertension care in blacks. The outcome parameters include quality of life, medical care use, treatment compliance, psychosocial variables, and improvement in blood pressure control rates. The trial will provide insight on the potential impact of information technology-enhanced care coordination in blacks with poorly controlled hypertension.
Studies have demonstrated that blood pressure (BP) control can be improved when clinical pharmacists assist with patient management. The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control.
This was a prospective, cluster randomized, controlled clinical trial with clinics randomized to a control group (n = 3) or to an intervention group (n = 3). The study enrolled 402 patients (mean age, 58.3 years) with uncontrolled hypertension. Clinical pharmacists made drug therapy recommendations to physicians based on national guidelines. Research nurses performed BP measurements and 24-hour BP monitoring.
The mean (SD) guideline adherence scores increased from 49.4 (19.3) at baseline to 53.4 (18.1) at 6 months (8.1% increase) in the control group and from 40.4 (22.6) at baseline to 62.8 (13.5) at 6 months (55.4% increase) in the intervention group (P = .09 for adjusted between-group comparison). The mean BP decreased 6.8/4.5 mm Hg in the control group and 20.7/9.7 mm Hg in the intervention group (P < .05 for between-group systolic BP comparison). The adjusted difference in systolic BP was -12.0 (95% confidence interval [CI], -24.0 to 0.0) mm Hg, while the adjusted difference in diastolic BP was -1.8 (95% CI, -11.9 to 8.3) mm Hg. The 24-hour BP levels showed similar effect sizes. Blood pressure was controlled in 29.9% of patients in the control group and in 63.9% of patients in the intervention group (adjusted odds ratio, 3.2; 95% CI, 2.0-5.1; P < .001).
A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group. Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management.
clinicaltrials.gov Identifier: NCT00201019.
The Take Control of Your Blood Pressure trial evaluated the effect of a multicomponent telephonic behavioral lifestyle intervention, patient self-monitoring, and both interventions combined compared with usual care on reducing systolic blood pressure during 24 months. The combined intervention led to a significant reduction in systolic blood pressure compared with usual care alone. We examined direct and patient time costs associated with each intervention.
We conducted a prospective economic evaluation alongside a randomized controlled trial of 636 patients with hypertension participating in the study interventions. Medical costs were estimated using electronic data representing medical services delivered within the health system. Intervention-related costs were derived using information collected during the trial, administrative records, and published unit costs.
During 24 months, patients incurred a mean of 22,054) in inpatient costs and 9,368) in outpatient costs, with no significant differences among the intervention groups. With base-case assumptions, intervention costs were estimated at 2) for home blood pressure monitoring, 64) for the behavioral intervention (416 (s.d., 585 (s.d., 55 (s.d., 741 (s.d., $529) for the combined intervention.
Our analysis demonstrated that the interventions are cost-additive to the health-care system in the short term and that patients' time costs are nontrivial.
Fewer than 40% of persons with hypertension in the United States have adequate blood pressure (BP) control.
To compare 2 self-management interventions for improving BP control among hypertensive patients.
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).
2 university-affiliated primary care clinics.
636 hypertensive patients.
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.
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.
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.
Combined home BP monitoring and tailored behavioral telephone intervention improved BP control, systolic BP, and diastolic BP at 24 months relative to usual care. .
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.
We reviewed the evidence on the barriers and drivers to the use of interactive consumer health information technology (health IT) by specific populations, namely the elderly, those with chronic conditions or disabilities, and the underserved.
We searched MEDLINE, CINHAHL, PsycINFO the Cochrane Controlled Trials Register and Database of Systematic Reviews, ERIC, and the American Association of Retired Persons (AARP) AgeLine databases. We focused on literature 1990 to present.
We included studies of all designs that described the direct use of interactive consumer health IT by at least one of the populations of interest. We then assessed the quality and abstracted and summarized data from these studies with regard to the level of use, the usefulness and usability, the barriers and drivers of use, and the effectiveness of the interactive consumer health IT applications.
We identified and reviewed 563 full-text articles and included 129 articles for abstraction. Few of the studies were specifically designed to compare the elderly, chronically ill, or underserved with the general population. We did find that several types of interactive consumer health IT were usable and effective in multiple settings and with all of our populations of interest. Of the studies that reported the impact of interactive consumer health IT on health outcomes, a consistent finding of our review was that these systems tended to have a positive effect when they provided a complete feedback loop that included: Monitoring of current patient status. Interpretation of this data in light of established, often individualized, treatment goals. Adjustment of the management plan as needed. Communication back to the patient with tailored recommendations or advice. Repetition of this cycle at appropriate intervals. Systems that provided only one or a subset of these functions were less consistently effective. The barriers and drivers to use were most often reported as secondary outcomes. Many studies were hampered by usability problems and unreliable technology, primarily due to the research being performed on early stage system prototypes. However, the most common factor influencing the successful use of the interactive technology by these specific populations was that the consumers' perceived a benefit from using the system. Convenience was an important factor. It was critical that data entry not be cumbersome and that the intervention fit into the user's daily routine. Usage was more successful if the intervention could be delivered on technology consumers used every day for other purposes. Finally, rapid and frequent interactions from a clinician improved use and user satisfaction.
The systems described in the studies we examined depended on the active engagement of consumers and patients and the involvement of health professionals, supported by the specific technology interventions. Questions remain as to: The optimal frequency of use of the system by the patient, which is likely to be condition-specific. The optimal frequency of use or degree of involvement by health professionals. Whether the success depends on repeated modification of the patient's treatment regimen or simply ongoing assistance with applying a static treatment plan. However, it is clear that the consumer's perception of benefit, convenience, and integration into daily activities will serve to facilitate the successful use of the interactive technologies for the elderly, chronically ill, and underserved.
Despite rapid advances in the clinical and psycho-educational management of diabetes, the quality of care received by the average patient with diabetes remains lackluster.
The age-specific relevance of blood pressure to cause-specific mortality is best assessed by collaborative meta-analysis of individual participant data from the separate prospective studies. Methods Information was obtained on each of one million adults with no previous vascular disease recorded at baseline in 61 prospective observational studies of blood pressure and mortality. During 12.7 million person-years at risk, there were about 56 000 vascular deaths (12 000 stroke, 34000 ischaemic heart disease [IHD], 10000 other vascular) and 66 000 other deaths at ages 40-89 years. Meta-analyses, involving "time-dependent" correction for regression dilution, related mortality during each decade of age at death to the estimated usual blood pressure at the start of that decade. Findings Within each decade of age at death, the proportional difference in the risk of vascular death associated with a given absolute difference in usual blood pressure is about the same down to at least 115 mm Hg usual systolic blood pressure (SBP) and 75 mm Hg usual diastolic blood pressure (DBP), below which there is little evidence. At ages 40-69 years, each difference of 20 mm Hg usual SBP (or, approximately equivalently, 10 mm Hg usual DBP) is associated with more than a twofold difference in the stroke death rate, and with twofold differences in the death rates from IHD and from other vascular causes. All of these proportional differences in vascular mortality are about half as extreme at ages 80-89 years as at,ages 40-49 years, but the annual absolute differences in risk are greater in old age. The age-specific associations are similar for men and women, and for cerebral haemorrhage and cerebral ischaemia. For predicting vascular mortality from a single blood pressure measurement, the average of SBP and DBP is slightly more informative than either alone, and pulse pressure is much less informative. Interpretation Throughout middle and old age, usual blood pressure is strongly and directly related to vascular (and overall) mortality, without any evidence of a threshold down to at least 115/75 mm Hg.
MAIN RESULTS: 56 RCTs met our inclusion criteria. The methodological quality of included studies was variable. An organized system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure (weighted mean difference -8.2/-4.2 mmHg, -11.7/-6.5 mmHg, -10.6/-7.6 mmHg for 3 strata of entry blood pressure) and all-cause mortality at five years follow-up (6.4% versus 7.8%, difference 1.4%) in a single large RCT- the Hypertension Detection and Follow-Up study. Other interventions had variable effects. Self-monitoring was associated with moderate net reduction in diastolic blood pressure (weighted mean difference (WMD): -2.0 mmHg, 95%CI: -2.7 to -1.4 mmHg, respectively. Appointment reminders increased the proportion of individuals who attended for follow-up. RCTs of educational interventions directed at patients or health professionals were heterogeneous but appeared unlikely to be associated with large net reductions in blood pressure by themselves. Health professional (nurse or pharmacist) led care may be a promising way of delivering care, with the majority of RCTs being associated with improved blood pressure control, but requires further evaluation.
The chronic care model is a guide to higher-quality chronic illness
management within primary care. The model predicts that improvement in its
6 interrelated components—self-management support, clinical information
systems, delivery system redesign, decision support, health care organization,
and community resources—can produce system reform in which informed,
activated patients interact with prepared, proactive practice teams. Case
studies are provided describing how components of the chronic care model have
been implemented in the primary care practices of 4 health care organizations.
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. 475 patients (75%) completed the 24-month BP follow-up. RESULTS: 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) for the behavioral intervention group, -0.6 mm Hg (CI, -3.6 to 2.3) for the BP monitoring group, and -3.9 mm Hg (CI, -6.9 to -0.9) for the combined intervention group; patterns were similar patterns were for diastolic BP. Limitation: Generalizability is limited because 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. Primary Funding Source: National Heart, Lung, and Blood Institute; Pfizer Foundation Health Communication Initiative; and the American Heart Association.
To compare costs associated with a physician-pharmacist collaborative intervention with costs of usual care.
Cost analysis using health care utilization and outcome data from two prospective, cluster-randomized, controlled clinical trials.
Eleven community-based medical offices.
A total of 496 patients with hypertension; 244 were in the usual care (control) group and 252 were in the intervention group.
To compare the costs, we combined cost data from the two trials. Total costs included costs of provider time, laboratory tests, and antihypertensive drugs. Provider time was calculated based on an online survey of intervention pharmacists and the National Ambulatory Medical Care Survey. Cost parameters were taken from the Bureau of Labor Statistics for average wage rates, the Medicare laboratory fee schedule, and a publicly available Web site for drug prices. Total costs were adjusted for patient characteristics. Adjusted total costs were 445.75 in the control group (difference 224.27-515.56. The intervention cost required to have one additional patient achieve blood pressure control within 6 months was 329.16/24.6%). The cost over 6 months to lower systolic and diastolic blood pressure 1 mm Hg was 94.32, respectively.
The physician-pharmacist collaborative intervention increased not only blood pressure control but also the cost of care. Additional research, such as a cost-benefit or a cost-minimization analysis, is needed to assess whether financial savings related to reduced morbidity and mortality achieved from better blood pressure control outweigh the cost of the intervention.
OBJECTIVE: To assess the effect of a physician and pharmacist teamwork approach to uncontrolled hypertension in a medical resident teaching clinic, for patients who failed to meet the recommended goals of the fifth Joint National Commission on Detection, Evaluation and Treatment of High Blood Pressure.
HYPOTHESIS: Physician and pharmacist teamwork can improve the rate of meeting national blood pressure goals in patients with previously uncontrolled hypertension.
DESIGN: A single-blinded randomized controlled trial lasting 6 months.
SETTING: A primary care outpatient teaching clinic.
PATIENTS: A sample of 95 adult hypertensive patients who failed to meet national blood pressure goals based on three consecutive visits over a 6-month period.
INTERVENTION: Patients were randomly assigned to a control arm of standard medical care or to an intervention arm in which a physician and pharmacist worked together as a team.
MAIN RESULTS: At study completion, the percentage of patients achieving national goals due to intervention was more than double the percentage in the control arm (55% vs 20%, p < .001). Systolic blood pressure declined 23 mm Hg in the intervention arm versus 11 mm Hg in the control arm (p < .01). Diastolic blood pressure declined 14 and 3 mm Hg in the intervention and control arms, respectively (p < .001). The intervention worked equally as well in men and women and demonstrated noticeable promise in a minority of mixed-ancestry Hawaiians in whom hypertension is of special concern.
CONCLUSIONS: Patients who fail to achieve national blood pressure goals under standard outpatient medical care may benefit from a program that includes a physician and pharmacist teamwork approach.
Diabet. Med. 28, 250–261 (2011)
Background Previous reviews demonstrate uncertainty about the effectiveness of nurse-led interventions in the management of hypertension. No specific reviews in diabetes have been identified. We have systematically reviewed the evidence for effectiveness of nurse-led interventions for people with diabetes mellitus.
Methods In this systematic review and meta-analysis, searches of Medline, Embase, CINAHL and the Cochrane Central Trials register were undertaken to identify studies comparing any intervention conducted by nurses in managing hypertension in diabetes with usual doctor-led care. Additional citations were identified from papers retrieved and correspondence with authors. Outcome measures were absolute systolic and diastolic blood pressure, change in blood pressure, proportions achieving study target blood pressure and proportions prescribed anti-hypertensive medication.
Results Eleven studies were identified. Interventions included adoption of treatment algorithms, nurse-led clinics and nurse prescribing. Meta-analysis showed greater reductions in blood pressure in favour of any nurse-led interventions (systolic weighted mean difference −5.8 mmHg, 95% CI −9.6 to −2.0; diastolic weighted mean difference −4.2 mmHg, 95% CI −7.6 to −0.7) compared with usual doctor-led care. No overall superiority in achievement of study targets or in the use of medication was evident for any nurse-based interventions over doctor-led care.
Conclusions There is some evidence for improved blood pressure outcomes with nurse-led interventions for hypertension in people with diabetes compared with doctor-led care. Nurse-based interventions require an algorithm to structure care and there is some preliminary evidence for better outcomes with nurse prescribing. Further work is needed to elucidate which nurse-led interventions are most effective.
To determine if a multimodal intervention composed of patient education, home blood pressure (BP) monitoring, BP measurement reporting to an interactive voice response (IVR) phone system, and clinical pharmacist follow-up improves BP control compared with usual care.
Prospective study with patient enrollment, medication consultation and adjustment, remote BP monitoring, and follow-up at 6 months.
This randomized controlled trial was conducted at 3 healthcare systems in Denver, Colorado, including a large health maintenance organization, a Veterans Affairs medical center, and a county hospital. At each site, patients with uncontrolled BP were randomized to the multimodal intervention vs usual care for 6 months, with the primary end point of BP reduction.
Of 338 patients randomized, 283 (84%) completed the study, including 138 intervention patients and 145 usual care patients. Baseline BP was higher in the intervention group vs the usual care group (150.5/89.4 vs 143.8/85.3 mm Hg). At 6 months, BPs were similar in the intervention group vs the usual care group (137.4 vs 136.7 mm Hg, P = .85 for systolic; 82.9 vs 81.1 mm Hg, P = .14 for diastolic). However, BP reductions were greater in the intervention group vs the usual care group (−13.1 vs −7.1 mm Hg, P = .006 for systolic; −6.5 vs −4.2 mm Hg, P = .07 for diastolic). Adherence to medications was similar between the 2 groups, but intervention patients had a greater increase in medication regimen intensity.
A multimodal intervention of patient education, home BP monitoring, BP measurement reporting to an IVR system, and clinical pharmacist follow-up achieved greater reductions in BP compared with usual care.
To determine which of 3 interventions was most effective in improving blood pressure (BP) control, we performed a 4-arm randomized trial with 18-month follow-up at the primary care clinics at a Veterans Affairs Medical Center.
Eligible patients were randomized to either usual care or 1 of 3 telephone-based intervention groups: (1) nurse-administered behavioral management, (2) nurse- and physician-administered medication management, or (3) a combination of both. Of the 1551 eligible patients, 593 individuals were randomized; 48% were African American. The intervention telephone calls were triggered based on home BP values transmitted via telemonitoring devices. Behavioral management involved promotion of health behaviors. Medication management involved adjustment of medications by a study physician and nurse based on hypertension treatment guidelines.
The primary outcome was change in BP control measured at 6-month intervals over 18 months. Both the behavioral management and medication management alone showed significant improvements at 12 months-12.8% (95% confidence interval [CI], 1.6%-24.1%) and 12.5% (95% CI, 1.3%-23.6%), respectively-but not at 18 months. In subgroup analyses, among those with poor baseline BP control, systolic BP decreased in the combined intervention group by 14.8 mm Hg (95% CI, -21.8 to -7.8 mm Hg) at 12 months and 8.0 mm Hg (95% CI, -15.5 to -0.5 mm Hg) at 18 months, relative to usual care.
Overall intervention effects were moderate, but among individuals with poor BP control at baseline, the effects were larger. This study indicates the importance of identifying individuals most likely to benefit from potentially resource intensive programs.
clinicaltrials.gov Identifier: NCT00237692.
The medical care system is not very effective in modifying health behavior of individuals, in particular, ensuring patient compliance with medication regimens, healthy diets, regular physical activity, and regular health screening, and in the avoidance of substance abuse. Telephone-Linked Care (TLC) is a telecommunications technology that enables computer-controlled telephone counseling with patients in their homes. It has been applied to the task of improving a number of different health behaviors. Randomized controlled studies suggest that use of the system for as little as 3 months is associated with improvement in adherence to medication regimens, dietary change in hypercholesterolemia, and increased physical activity among sedentary individuals. Future work involves applying the technology to other important health behaviors, optimally using health behavior theory in the system design, targeting use of TLC to the most appropriate patient groups, incorporating new computer and telecommunications technology into the system, and interfacing TLC into the health care delivery system.
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