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Expanding the Role of Nurses to Improve Hypertension Care and Control Globally



The role of the nurse in improving hypertension control has expanded over the past 50 years, complementing and supplementing that of the physician. Nurses' involvement began with measuring and monitoring blood pressure (BP) and patient education and has expanded to become one of the most effective strategies to improve BP control. Today the roles of nurses and nurse practitioners (NPs) in hypertension management involve all aspects of care, including (1) detection, referral, and follow up; (2) diagnostics and medication management; (3) patient education, counseling, and skill building; (4) coordination of care; (5) clinic or office management; (6) population health management; and (7) performance measurement and quality improvement. The patient-centered, multidisciplinary team is a key feature of effective care models that have been found to improve care processes and control rates. In addition to their clinical roles, nurses lead clinic and community-based research to improve the hypertension quality gap and ethnic disparities by holistically examining social, cultural, economic, and behavioral determinants of hypertension outcomes and designing culturally sensitive interventions to address these determinants.
Expanding the Role of Nurses to Improve
Hypertension Care and Control Globally
Cheryl R. Dennison Himmelfarb, RN, ANP, PhD, FAAN, FAHA, FPCNA,
Yvonne Commodore-Mensah, RN, PhD, Martha N. Hill, RN, PhD, FAAN, FAHA
Baltimore, MD; and Atlanta, GA
The role of the nurse in improving hypertension control has expanded over the past 50 years, com-
plementing and supplementing that of the physician. Nursesinvolvement began with measuring and
monitoring blood pressure (BP) and patient education and has expanded to become one of the most
effective strategies to improve BP control. Today the roles of nurses and nurse practitioners (NPs) in
hypertension management involve all aspects of care, including (1) detection, referral, and follow up; (2)
diagnostics and medication management; (3) patient education, counseling, and skill building; (4)
coordination of care; (5) clinic or ofce management; (6) population health management; and (7) per-
formance measurement and quality improvement. The patient-centered, multidisciplinary team is a key
feature of effective care models that have been found to improve care processes and control rates. In
addition to their clinical roles, nurses lead clinic and community-based research to improve the
hypertension quality gap and ethnic disparities by holistically examining social, cultural, economic, and
behavioral determinants of hypertension outcomes and designing culturally sensitive interventions to
address these determinants.
KEY WORDS hypertension, nurse, team-based care, quality
©2016 The Authors. Published by Elsevier Inc. on behalf of Icahn School of Medicine at Mount Sinai. This is
an open access article under the CC BY-NC-ND license (
Hypertension is a global public health issue, and it is
estimated that by 2025 more than 1.5 billion indi-
viduals worldwide will have hypertension, account-
ing for up to 50% of heart disease risk and 75% of
stroke risk.
Lowering blood pressure (BP) through
lifestyle modication, antihypertensive medications,
or both can substantially reduce an individuals risk
for subsequent cardiovascular disease (CVD) and
Even a moderate reduction in systolic BP
(SBP) of 10 mm Hg or diastolic blood pressure
(DBP) of 5 mm Hg has been found to decrease
average risk of mortality from coronary heart disease
and stroke by 22% and 41%, respectively.
Despite clear benets of hypertension treatment
to reduce CVD morbidity and mortality, a large
proportion of diagnosed and undiagnosed patients
with hypertension are not receiving optimal care.
In the United States, despite decades of national
public and professional education, among those
with hypertension, approximately 25% are unaware
and almost 30% are not engaged hypertension
Among the 45% with diagnosed hypertension
and in care, BP control is achieved in only 64%
overall, and rates remain as low as 39% among
The authors have no conicts of interest to disclose. All authors had an active role in writing the manuscript.
From the Johns Hopkins University School of Nursing, Baltimore, MD (CRDH, MNH); and the Nell Hodgson Woodruff School of Nursing, Emory
University, Atlanta, GA (YC-M). Address correspondence to C.R.D.H. (
Annals of Global Health
ª2016 The Authors. Published by Elsevier Inc.
on behalf of Icahn School of Medicine at Mount Sinai
VOL. 82, NO. 2, 2016
ISSN 2214-9996
Mexican American men.
Although control rates
overall have increased over the past 10 years, ethnic
disparities in care and control remain, with Mexican
Americans less likely to be in hypertension care and
African Americans, Hispanics, and Mexican Amer-
icans achieving lower control rates compared with
The difference in hypertension outcomes
achieved with current practices and outcomes possi-
ble using hypertension care best practices is known
as the quality gap, and this gap is at least partly
responsible for the loss of thousands of lives each
Expanding the role of nurses is one of the
most effective strategies to improve BP control.
This paper reviews the expanding roles of nurses
in diverse practice settings and in team-based care
and provides examples of nurse-led research aimed
at reducing hypertension health disparities.
The role of nurses has been recognized for nearly
50 years in public and professional education to
improve hypertension control promoted by the US
National High Blood Pressure Education Programs
Joint National Committee reports and other publi-
Nursesinvolvement began with measur-
ing and monitoring BP and patient education. The
role expanded in the 1960s and early 1970s to sup-
plement and complement that of the physician as
the number of newly identied patients grew after
Veterans Administration and Hypertension Detec-
tion and Follow-up Program studies demonstrating
the benets of controlling hypertension.
quently, with evidence-based protocols to guide
practice nurses and training programs, such as those
provided by the American Heart Association, nurses
gained the skills to assess patientshealth status,
adjust medications, and address barriers to hyper-
tension care and control, thus becoming more
involved in the assessment and management of
hypertension. The establishment of nurse-run clin-
ics was a further expansion of the nurses role.
Today around the globe, particularly in underserved
low- and middle-income countries, as the numbers
of people with hypertension and attention to non-
communicable diseases increase, the role of nurses
continues to expand. The role increasingly focuses
on advanced practice nurses, known as nurse practi-
tioners (NPs), who have legal authority to prescribe
antihypertensive and other medications and practice
independently or in teams, which requires attention
to the legal scope of nursing practice.
A key feature of the most effective hypertension care
models is a multidisciplinary team that collaborates
in delivering hypertension care services.
A team-
based approach is patient centered, with care
tailored to meet patientsneeds. It is often imple-
mented as part of a multi-faceted approach, with
systems support for clinical decision making (eg,
treatment algorithms), communication, and patient
self-management. Team-based hypertension care
includes the patient, the patients primary care
provider, and other professionals such as nurses,
pharmacists, physician assistants, dieticians, social
workers, and community health workers. These
professionals complement the activities of the
primary care provider by providing process support
and sharing the responsibilities of hypertension
care, which include medication management,
active patient follow-up, and adherence and self-
management support. Team-based hypertension
care has been reported to increase the proportion
of individuals remaining in care with controlled
BP and reduced SBP and DBP.
controlled trials (RCTs) and meta-analyses of
RCTs of team-based hypertension care involving
nurse or pharmacist intervention demonstrated
reductions in SBP and DBP and greater achieve-
ment of BP goals when compared with usual
Similarly, a systematic review of 52 studies
of team-based primary care for patients with pri-
mary hypertension found reductions in SBP and
DBP and greater achievement of BP goals when
compared with usual care, although team-based
approaches varied greatly across studies.
less, the important ndings on the impact of team-
related factors on BP outcomes were identied: (1)
Larger improvements in BP outcomes were found
when team members could make changes to medi-
cations independent of the primary care provider or
provide medication recommendations and make
changes with primary care providers approval com-
pared with providing only adherence support and
information on medication and hypertension. (2)
Improvement in the proportion of patients with
controlled BP was similar for studies in both health
care and community settings.
A systematic review
of studies, including 8 RCTs, examining the effect
of community health workers in team-based hyper-
tension care found improvements in BP control,
appointment keeping, and hypertension medication
Himmelfarb et al.AnnalsofGlobalHealth,VOL.82,NO.2,2016
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Team-based care aims to achieve effective con-
trol of hypertension and reduce the consequences
of uncontrolled hypertension. Delineation of indi-
vidual team member roles based on knowledge, skill
set, and availability, as well as patientsneeds, allows
the primary provider to delegate routine matters to
the team, thereby permitting more time to manage
complex and critical issues facing patients with
hypertension. Specic roles of nurses in team-
based hypertension care are delineated next.
The roles of nurses and NPs in hypertension man-
agement involve all aspects of care, including (1)
detection, referral, and follow up; (2) diagnostics
and medication management; (3) patient education,
counseling, and skill building; (4) coordination of
care; (5) clinic or ofce management; (6) population
health management; and (7) performance measure-
ment and quality improvement.
Detection, Referral, and Follow-up. Nurses rou-
tinely measure BP in most health care settings using
BP measurement best practices as part of initial and
ongoing assessments of each patient.
In addition,
nurses lead BP screening and verication initiatives
in community, work site, church, school, and other
settings. Once BP is measured and recorded, the
nurse analyzes data to determine if the readings are
in the normal or hypertensive range per site proto-
col. A system to ag records can help ensure that
uncontrolled hypertension is recognized and treated.
In addition, nurses assess the patients level of car-
diovascular risk. There are a number of tools, such
as Framingham Cardiovascular Disease Risk
Pooled Cohort Equations,
and Reynolds Risk Score,
that are helpful in
guiding health care providers as they assess car-
diovascular risk; these tools also can be used in
patient education efforts.
It may be necessary to
refer the patient to urgent care depending on BP
levels and symptoms or to specialist evaluation for
persistent uncontrolled BP despite intervention or
for abnormal renal or vascular ndings.
play an important role in implementing referrals and
educating patients regarding the purpose and
importance of referral.
Follow-up between visits via telephone, mail, or
digital strategies can be effective to reinforce goals
of entering and remaining in care and engaging in
treatment and can enhance providerepatient rela-
tionship. It is essential to follow up on missed
appointments to maintain contact with the patient
and to reinforce the importance of achieving BP
goals. Nurses often are the rst health professionals
to detect hypertension and therefore have a key role
in communicating with patients and other health
professionals to enforce treatment guidelines
through development and appropriate revision of
the patients treatment plan.
Diagnostics and Medication Management. Nurses
or NPs are also responsible for the diagnostic and
pharmacological aspects of hypertension manage-
ment. Using well-dened protocols based on
national treatment guidelines, NPs prescribe and
titrate medications to achieve BP control.
discussed earlier, nurse-led hypertension manage-
ment has been demonstrated to result in greater
rates of BP control than those achieved with
standard care. These improved outcomes have
resulted from nurses placing a greater number of
patients on medications, altering drug regimens
more often in response to inadequate BP control,
and placing a higher proportion of patients on
multiple drug regimens to achieve greater control.
In addition to management of hypertension, nurses
have been shown to effectively manage other car-
diovascular risk factors, such as diabetes
Patient Education, Counseling, and Skill Building. In
the majority of hypertension care settings, nurses
provide the education, counseling, and skill build-
ing necessary to ensure that patients are undertak-
ing lifestyle changes that may favorably inuence
Nurses actively engage patients in care
using a combination of strategies to prevent, rec-
ognize, and respond to adherence problems and
thereby maximize long-term adherence and BP
They also use effective, evidence-
based strategies to promote BP control; these
strategies are identied in Table 1 and are clustered
under the following general approaches: identify
knowledge, attitudes, beliefs, and experiences;
educate about conditions and treatment; indi-
vidualize the regimen; provide reinforcement;
promote social support; and collaborate with other
It is important to consider that
patient education is a means to an end. That is,
knowledge is necessary but insufcient to bring
about desired behaviors without development of
skills and multiple other reinforcing factors. The
ultimate goal is for the patient to have the neces-
sary skills and resources, including knowledge, to
follow treatment recommendations and achieve
and sustain BP control.
Annals of Global Health, VOL. 82, NO. 2, 2016 Himmelfarb et al.
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Table 1. Strategies to Promote Blood Pressure Control
Identify knowledge, attitudes, beliefs, and experience
AAssess patients understanding and acceptance of the diagnosis and expectations of being in care.
AAssess cultural beliefs and practices that may inuence care and adherence.
ADiscuss patients concerns and clarify misunderstandings.
Educate about conditions and treatment
AInform patient of blood pressure (BP) level.
AEstablish with patients a goal BP.
AInform patient about recommended treatment, providing specic oral and written information.
AElicit concerns and questions and provide opportunities for patient to state-specic behaviors to carry out treatment
AEmphasize need to continue treatment, that patient cannot tell if BP is elevated, and that control does not mean cure.
ATeach self-monitoring skills.
Individualize the regimen
AActively engage patients in their own care by promoting shared decision making, with emphasis on social and cultural factors,
including health literacy.
AInclude patient in decision making.
ASimplify the regimen.
AIncorporate treatment into patients daily lifestyle.
ASet, with the patient, realistic short-term objectives for specic components of the treatment plan.
AEncourage discussion of side effects and concerns.
AEncourage self-monitoring of BP.
APrioritize critical aspects of the regimen.
AImplement treatment plan in steps.
AModify dosages or change medications to reduce side effects.
AMinimize cost of therapy.
AIndicate you will ask about adherence at next visit.
AWhen weight loss is established as a treatment goal, discourage quick weight loss regimens, fasting, or unscientic methods, because
these are associated with weight cycling, which may increase cardiovascular morbidity and mortality.
Provide follow-up and reinforcement
AProvide feedback regarding BP level.
AAsk about behaviors to achieve BP control.
AGive positive feedback for behavioral and BP improvement.
AHold exit interviews to clarify regimen.
AMake appointment for next visit before patient leaves the ofce.
AUse appointment reminders and contact patients to conrm appointments.
ASchedule more frequent visits to counsel nonadherent patients.
AContact and follow up with patients who missed appointments.
AConsider clinician-patient contracts.
AConsider home visits.
AEstablish regular, structured follow-up mechanisms and reminder systems to monitor patientsprogress both in the ofce and
AProvide the most appropriate evidence-based tools and resources designed to maximize self-management (including health behavior
change, lifestyle modication, etc.).
Promote social support
AEducate family members to be part of the BP control process and provide daily reinforcement.
ASuggest small-group activities to enhance mutual support and motivation.
Collaborate with other professionals
ADraw on complementary skills and knowledge of nurses, pharmacists, comm unity health workers, dieticians, optometrists, dentists,
and physician assistants.
AFacilitate communication and care coordination among various team members, patient, family, and caregivers.
AAssure awareness and effective use of evidence-based diagnosis and treatment guidelines by all team members.
AFollow a single, personalized plan of care based on individual patients characteristics and needs.
ARefer patients for more intensive counseling or specialty evaluation.
Himmelfarb et al.AnnalsofGlobalHealth,VOL.82,NO.2,2016
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Identify knowledge, attitudes, beliefs, and
experiences. A classic framework is useful in guiding
nurses and other professionals to provide patient
education, counseling, and skill building and facili-
tate patientsattainment of the following 4 critical
behaviors, which are necessary to achieve and sustain
long-term BP control: (1) Make the decision to
control BP; (2) follow treatment recommendations
(eg, medication taking and lifestyle changes) as
prescribed; (3) monitor progress toward the BP goal;
and (4) resolve barriers that prevent reaching the
The premise of this evidence-based frame-
work is that active participation by the patient as the
decision maker and problem solver with the nurse or
other health professional functioning as advisor or
guide favors successful management of hypertension.
The patients understanding and acceptance of the
diagnosis and expectations of being in care are
assessed, patient concerns addressed, and mis-
understandings claried.
Educate about conditions and treatment. Adequate
knowledge of hypertension, consequences of uncon-
trolled hypertension, and treatment regimen is
essential to achieve BP control. It has been found
that patients who receive education and counseling
on hypertension management exhibit increased
Nurses practice patient-centered
care, engaging the patient in shared decision mak-
ing and establishing mutually agreed on BP goals.
Patients must always be informed of BP and related
diagnostic testing values. This provides an ideal
opportunity to assess patient knowledge, educate,
establish clear goals, and discuss progress toward
goals with the patient. Nurses emphasize the need
to continue treatment even when BP control has
been achieved (ie, control does not mean cure).
Nurses also play a key role in educating patients
regarding the necessary self-monitoring skills (eg,
home BP monitoring). In addition to patient edu-
cation and skill building, effective communication
and a trustful relationship between the patient and
nurse are of paramount importance to achieve sus-
tained BP control.
Individualize the regimen. Successful education
and counseling to promote adherence to treatment
regimen and BP control requires that nurses and
other health professionals individualize care to max-
imize patientsmotivation to control their hyperten-
sion by remaining in care, maintaining a healthy
lifestyle, taking prescribed medication, and moni-
toring progress toward goals. Nurse efforts to indi-
vidualize the regimen should focus on social and
cultural factors, including health literacy, self-care
behaviors, and skills necessary to hypertension
control as well as patient response to the treatment
Nurses assist patients to incorporate the
treatment regimen into his or her daily lifestyle,
which is required for long-term sustainability.
Nurses work with patients to mutually develop
realistic, outcomes-oriented goals and strategies for
attaining the goals. Equally important, nurses follow
up with patients often to assess progress toward
goals and, if necessary, to revise strategies for
attaining goals.
Nurses are trained to provide counseling regard-
ing lifestyle modication, which is recommended
for all hypertensive patients with lifestyle risk factors
(eg, obesity, physical inactivity, high-sodium diet,
and alcohol consumption).
Weight loss, which
may be the most successful nonpharmacological
technique for lowering BP, requires behavior change
in both diet and physical activity patterns. Such
nonpharmacological approaches include helping
patients to initiate or maintain an aerobic exercise
program and limit sodium intake and alcohol con-
sumption to 1 to 2 drinks per day. In addition,
many hypertensive patients present with multiple
risk factors for cardiovascular disease. Nurses also
provide education and counseling for smoking ces-
sation and lipid reduction to help patients further
lower their risk of cardiovascular disease. Modifying
lifestyle behaviors requires many clinical interven-
tions: assessment of an individuals baseline behav-
iors; education about how to make the appropriate
changes; counseling to develop strategies such as
setting short-term goals and self-monitoring that
will ensure the achievement and maintenance of
the changes; working with patients to identify and
resolve barriers to adherence and BP control; and
reinforcement of progress toward behavior change
The extent to which patients are able to adhere
to treatment recommendations is a major issue in
BP control and depends on many factors. Review
of adherence in randomized controlled trials on car-
diovascular disease prevention strategies identied
the following successful approaches: signed agree-
ments, behavioral skill training, self-monitoring,
telephone or mail contact, spouse or other key
person support, self-efcacy enhancement, contin-
gency contracting, exercise prescriptions, external
cognitive aids, persuasive communication, nurse-
managed clinics, and work- or school-based pro-
Improving patient and primary provider
adherence to evidence-based guidelines is a multile-
vel challengedthe patient, the provider, the health
Annals of Global Health, VOL. 82, NO. 2, 2016 Himmelfarb et al.
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care setting and system, and the societal health care
system. Multiple strategies are required beginning
with patient and provider education, counseling,
and skill building.
Another important aspect of individualizing the
regimen to promote BP control involves assessing
potential barriers to BP control. Nurses are moti-
vated and trained to assess and address common
barriers to BP control. Barriers may include knowl-
edge decits, limited access to health care or phar-
macy, inadequate communication with clinicians,
cost of care and medications, complexity of the reg-
imen, adverse effects of medication, transportation
to and from the visit, work schedule, inconvenient
clinic or ofce location or difculty scheduling
appointments, child or elder care, or other compet-
ing life demands.
After identication of bar-
riers, nurses work with patients and collaborating
health professionals to minimize or eliminate the
barriers, thereby promoting BP control.
Provide reinforcement. It is important to work
with individual patients to ensure that they under-
stand what is necessary to achieve treatment goals
and that they participate in treatment decisions.
Nurse responsiveness to patient concerns, along
with joint problem solving to prevent or minimize
barriers to care and treatment as well as provide
reinforcement and support, is crucial. Provision of
reminders, outreach, and follow-up services are
benecial. Follow-up on missed visits and between
visits via phone or digital methods can be effective
to reinforce goals and enhance the providerepatient
relationship. Success in implementing the treatment
regimen to achieve BP control requires frequent
monitoring of BP, modication of treatment regi-
men, and interaction with the patient. These roles
require training and dedicated time to provide the
education and counseling necessary to build skills
for and reinforce successful behavior change.
Promote social support. Nurses also effectively
educate family members and friends to participate
in the BP control process. Family members can
play a fundamental role providing daily reinforce-
ment of the patients efforts to achieve BP control.
If the patient desires greater family participation,
family members should be encouraged to attend
and participate in clinic visits. In addition, some
patients may benet from small group activities
(eg, clinic support groups or group visits) to enhance
social support and motivation.
Collaborate with other professionals. In planning
care, nurses work in conjunction with the patient
and members of the hypertension management
team to achieve and sustain BP control. Achieving
and sustaining BP goals over time requires continu-
ous educational and behavioral strategies, an indi-
vidualized regimen, and reinforcement so that
patients have the knowledge, skills, motivation,
and resources to carry out treatment recommenda-
tions. Successful BP control requires that patients
know what behaviors are necessary and develop
skills in problem identication and problem solving
to address barriers. Strategies to help patients
develop these skills need to be adapted so that
they are culturally salient and feasible for staff to
Coordination of Care. Long-term maintenance of
hypertension control requires continual monitoring
of BP, relling of prescriptions, provision of coun-
seling and reinforcement of behavior change efforts,
and titration of therapy as indicated. Each patients
management must be individualized, with costs
minimized. Patients often see different providers
at several settings for various health problems, ll
prescriptions in more than 1 pharmacy, receive
inconsistent messages, and experience interruption
of therapy and inadequate communication among
providers. Nurses are skilled at building and main-
taining both informal and formal collaborative link-
ages among providers, resources, and services within
and external to their practice setting. Further, nurses
assist patients in understanding complex treatment
regimen and navigating through the challenging
and highly complex health care structure and
Manage the Clinic or Ofce. Nurses often are in the
position of managing or planning for the initiation
of a hypertension clinic.
Nurses often direct or
coordinate the efforts of other team members who
are working within the clinic or providing direct
consultation. To enhance consistency and quality of
care and to facilitate adherence to treatment
guidelines, decision support systems (electronic and
paper) such as ow sheets, treatment algorithms,
and feedback reminders may be developed. In
addition, it may be the responsibility of the nurse to
hire, supervise, and train the community health
workers to deliver appropriate intervention strat-
egies and other staff, such as ofce assistants and
receptionists, to measure BP, schedule appoint-
ments, make reminder telephone calls, obtain lab-
oratory results, and enter data to support evaluation
of clinical outcomes. Nurses inuence utilization of
resources, including appropriate length of visits and
caseload size, as well as optimizing reimbursement
for services in the hypertension clinic setting.
Himmelfarb et al.AnnalsofGlobalHealth,VOL.82,NO.2,2016
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It is imperative that all health professionals who
measure BP use correct measurement technique.
In addition to ensuring proper BP measurement
technique among staff, nurses often are responsible
for ensuring that BP measurement equipment is
properly calibrated and functioning.
Population Health Management. The paradigm
shift from care of 1 patient at a time, either in the
dyad of 1 physician with 1 patient or, more recently,
the team approach, to the responsibility to care for
large numbers of patients has occurred in the past
decade. New models of managing care promoted
by health systems and governments have focused
on measuring and reimbursing improved outcomes
and controlling costs of care.
Improving health for populations of people to
reduce risk factors, morbidity, and mortality calls
for integration of public health and prevention prin-
ciples with traditional medical care. Hypertension is
a prominent condition being targeted because of its
prevalence and the benets of controlling it. Public
advocacy to improve health of large numbers of peo-
ple and sensible policy making requires evidence of
effective interventions. The evidence justifying
expanded roles for nurses in hypertension care and
control is abundant.
According to the recent Healthcare Trends and
Forecasts survey,
population health management
(56%) ranked highest among 3 key areas of value-
based priorities in 2014 by health professionals.
Population health management requires a variety
of skills, including care coordination, decision mak-
ing, and project management, and is needed in
communities where disparities in chronic conditions
exist. By mapping health care services to the needs
of the population, nurses and NPs formulate an
overall health care strategy that improves hyperten-
sion care quality and reduces health disparities.
Nurses can implement technology to identify and
analyze these populationsmost pressing health
needs and, in collaboration with other health care
team members, design appropriate interventions to
preempt or satisfy these needs.
Performance Measurement and Quality
Improvement. The universal need to measure and
improve the hypertension care processes and out-
comes is well established, and often it is the nurse
in the hypertension care setting who has responsibil-
ity for leading these efforts. Efforts to improve subop-
timal hypertension care have included the use of
performance measures, which are a standardized,
validated approach to assess whether correct health
care processes are being performed and desired
patient outcomes are being achieved. Hypertension
quality improvement strategies, including audit and
feedback on performance, provider education, patient
education, self-management support, patient
reminder systems (for follow-up appointments, blood
pressure checks, and self-management), and care
delivery system changes, have been demonstrated to
reduce blood pressure and improve blood pres-
In addition, multicomponent and multi-
level strategies to improve the organization and
delivery of hypertension care at the local community,
health care delivery system, and national levels and
have been found to improve blood pressure control.
With the expanding evolution of health informa-
tion technologies, strategies such as electronic health
records, registry databases, telehealth, digital health
(eHealth), and the use of mobile computing
and communication technologies (mHealth) are
increasingly deployed by nurses and other members of
the care team as tools to facilitate improvements in
health behaviors and hypertension control.
Hypertension care teams are using these tools to
enable appointment scheduling, reminders, and
follow-up; tracking BP control trends and large-scale
queries to support population health management
strategies with identication of undiagnosed or
undertreated hypertension; assessing frequency of
clinic visits, emergency room visits, and hospital-
izations; facilitating and monitoring medication
prescriptions and rells; monitoring and promoting
self-management behaviors, including medication
adherence, diet, and physical activity; and provision of
decision support for antihypertensive medication
titration using evidence-based protocols and treat-
ment algorithms. They show promise as adjunctive
strategies to improve hypertension care and
In addition to their traditional clinical roles, nurses
have been involved in the conduct of clinic- and
community-based research to improve the hyperten-
sion quality gap and ethnic disparities in hyperten-
sion outcomes dating as far back as 1950.
In the
21st century, nurses are leading research teams to
examine social, cultural, economic, and behavioral
determinants of hypertension outcomes. The follow-
ing studies are exemplars of nursesroles in leading
research to improve hypertension care and control.
Annals of Global Health, VOL. 82, NO. 2, 2016 Himmelfarb et al.
MarcheApril 2016: 243253 NursesRole in Global Hypertension Care
The Comprehensive High Blood Pressure Care
and Control in Young Urban Black Men Study
was a nurse-led 5-year RCT of hypertensive urban
African-American men (N ¼309) that evaluated
the effectiveness of a more intensive comprehensive
educational-behavioral-pharmacological intervention
by an NPecommunity health workerephysician
(NP/CHW/MD) team and a less intensive education
and referral intervention in controlling BP and mini-
mizing progression of left ventricular hypertrophy
(LVH) and renal insufciency. At the 36-month
follow-up, the more intensive intervention led to a
lower BP and decreased progression of LVH. At 5
years, LVH prevalence in the more intensive group
was lower compared with the less intensive group
(37% vs 56%, P¼0.02). However, between-group
signicant difference in BP control (more intensive
44%, less intensive 31%, P¼0.05) at 3 years was
not sustained to the 5-year follow-up period. By using
a multifaceted, individually tailored, multidisciplinary
team approach with free medications, this study dem-
onstrated that it was possible to recruit and retain a
cohort of inner-city young African-American men
with hypertension, improve BP control, and reduced
barriers to BP control.
With respect to international studies, the HiHi
was a cross-sectional descriptive study
(N ¼403) of periurban black South Africans that
examined determinants of hypertension care control
to identify opportunities to improve hypertension
outcomes and quality of care. Using the
as the guiding
framework, it was observed that signicant and
interrelated predictors of lower SBP and DBP or
BP control were fewer antihypertensive medica-
tions, better compliance to hypertension recommen-
dations, younger age, female sex, higher education,
and moderate alcohol consumption.
interventions at the patient, provider, and system
level were identied as important areas to address
to improve hypertension care and control in primary
health care settings in South Africa.
The COACH trial
was an RCT evaluating the
effectiveness of a comprehensive program of CVD
risk reduction delivered by NP/CHW teams versus
enhanced usual care to improve lipids, BP, and gly-
cated hemoglobin in primarily low-income patients
in urban community health centers (N ¼525). The
NP/CHW intervention included aggressive phar-
macological management, tailored low-literacy edu-
cational materials, and behavioral counseling for
lifestyle modication and problem solving to
address barriers to adherence and control. A
signicantly greater improvement in SBP
(difference ¼6.2 mm Hg), DBP (difference ¼
3.1 mm Hg), and perceptions of the quality of
chronic illness care compared with the enhanced
usual care group was observed.
Commodore-Mensah et al
conducted a
cross-sectional epidemiological study (N ¼253) to
examine the association between acculturation and
CVD risk factors, including hypertension, in the
growing African immigrant population in the
United States, which is often studied as a homoge-
nous group with the dominant African-American
population. Hypertension diagnosis, treatment,
and control were 40%, 53%, and 50%, respectively,
and prevalence of overweight and obesity was 88%.
African immigrants who identied equally with the
US society and their African culture (integrationists)
were more likely to have controlled BP than those
who identied more with their African culture (tra-
ditionalists) (68% vs 25%; P¼0.011). This study
examined disparities in CVD risk from an ethnic
perspective rather than a racial perspective
inform the implementation of culturally tailored
public health interventions in this ethnic minority
Using the principles of community-based partic-
ipatory research, the Self-Help Intervention
Program for High Blood Pressure Care (SHIP-
was a 15-month trial that consisted of
6-week behavioral education followed by home tele-
monitoring of BP and bilingual nurse telephone
counseling for 12 months among Korean immi-
grants (N ¼359). The research team adapted and
translated evidence-based hypertension treatment
guidelines and behavioral recommendations into
more culturally relevant education materials for
rst-generation Korean immigrants. The interven-
tion resulted in a sharp increase in BP control rates,
which was sustained over 12 months. At baseline,
BP control was achieved in only 30% of the sample.
After the initial education period (approximately 3
months), BP control was achieved in 73% of the
participants, and this level of control continuously
improved over a 12-month follow-up period
(83.2%, P<0.001).
Nurses have been involved in hypertension care and
control for as long as the eld has been formally
addressed by professional societies, voluntary non-
prot organizations, and governments, approxi-
mately 50 years. The roles initially involved
Himmelfarb et al.AnnalsofGlobalHealth,VOL.82,NO.2,2016
NursesRole in Global Hypertension Care MarcheApril 2016: 243253
assisting in ofce evaluation by measuring BP and
educating patients. As nursesskills evolved through
on-the-job or graduate training, their roles in hyper-
tension evolved to include physical assessment,
medication and lifestyle prescription, and greater
independent practice. Nurse-led clinics and team
models of care and research have evolved and
contributed to increasing the number of patients
receiving high-quality hypertension care and con-
trol. Nurses have assumed leadership roles in the
conduct of research to improve hypertension care
quality and reduce ethnic disparities by holistically
examining social, cultural, economic, and behavioral
determinants of hypertension outcomes and
designing culturally sensitive interventions geared
at addressing these factors.
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... 17 Hipertansiyon yönetiminde hemşirelerin tespit, sevk ve izlem; tanı ve tedavi yönetimi; hasta eğitimi, danışmanlık ve beceri geliştirme; bakım koordinasyonu ve performans ölçümü ve kalite geliştirme gibi bakımın tüm yönlerini içeren rolleri bulunmaktadır. 18 T Te es sp pi it t, , s se ev vk k v ve e i iz zl le em m: Hipertansiyonu olan tüm hastalar için tıbbi öykü ve fizik muayene gereklidir. Temel hedef geriye dönüşümsüz hızlandırıcı faktörleri, organ hasarı varlığını ve diyabet, sigara içme gibi ek kardiyovasküler risk faktörlerini belirlemektir. ...
... 11 Hemşireler hipertansiyonun tespitinde genellikle ilk sağlık profesyonelleri olup, sağlık kuruluşlarının çoğunda kan basıncı ölçümü yapmakta ve farklı ortamlarda kan basıncı tarama ve doğrulama girişimlerine öncülük etmekte ve sevk uygulamalarında ve hasta eğitimlerinde hayati önem taşımaktadırlar. 18 Bu nedenle hemşireler hipertansiyonun erken tespitini kolaylaştırmak için yetişkinlerin kan basınçlarını uygun olan her fırsatta değerlendirmeli, doğru teknik, uygun manşet boyutu olan ve uygun şekilde bakımı yapılan/kalibre edilmiş cihaz kullanmalıdır. 19 Ayrıca hipertansiyon başlangıçta tespit edildiğinde hemşirelik değerlendirmesi, kan basıncının sık aralıklarla ve sonra rutin olarak planlanan aralıklarla dikkatlice izlenmesini içermektedir. ...
... 11 Hemşireler hipertansiyon yönetiminin farmakolojik yönünden de sorumlu olup, tedavi süresince hastanın ilaç tedavisine uyumunu ve yaşam biçimi deği-şikliklerini değerlendirerek uyumu iyileştirmeye yönelik yöntemler geliştirmelidir. 9,18 Hemşire öncülüğünde hipertansiyon yönetiminin daha fazla kan basıncı kontrol oranı sağladığı görülmüştür. 18 Halk sağlığı hemşireleri tarafından birinci basamakta hipertansif bireylerle ilaca uyumu ve sağlıklı yaşam biçimi davranışlarını iyileştirmeye yönelik yapılan randomize kontrol gruplu bir çalışmada girişim gruplarına ayda bir kez olmak üzere, ikisi evde toplam altı kez eğitim verilmiştir. ...
Full-text available
ronik hastalıklar uzun süren ve yavaş ilerleyen hastalıklar olarak tanımlan-maktadır. 1 Hastalığa neden olan bir mikroorganizmanın bulunup bulunma-ması hastalıkların bulaşıcı ya da bulaşıcı olmayan gruplara ayrılmasına neden olmaktadır. Hastalığın seyrine göre de hızlı seyredenler akut, yavaş seyredenler kro-nik olarak isimlendirilmekte olup, bulaşıcı hastalıklar daha çok akut, bulaşıcı ol-mayan hastalıklar ise kronik olarak ifade edilmektedir. 2 Bulaşıcı olmayan hastalıkların insani, sosyal ve ekonomik sonuçları tüm ülkelerde hissedilmekle bir-likte özellikle yoksul ve savunmasız toplumlarda bu sonuçlar yıkıcı olmaktadır. Bu-laşıcı olmayan hastalıkların yükünü azaltmak sürdürülebilir kalkınma için öncelikli ve gerekli bir koşuldur. Evrensel olarak ölümlerin başta gelen nedenlerine bakıldı-ğında, bulaşıcı olmayan hastalıklar 2012 yılında dünyada 56 milyon ölümün 38 mil-yonundan (%68) sorumlu tutulmaktadır. Bu ölümlerin %40'ından fazlası 70 yaşın altında olan erken ölümlerdir. Bulaşıcı olmayan hastalıklar nedeniyle ölümlerin yaklaşık dörtte üçünün (28 milyon) ve erken ölümlerin çoğunun (%82), düşük ve orta gelirli ülkelerde görüldüğü bildirilmektedir. 3 Dünyada ve Türkiye'de son yıl-27 Hipertansiyon ve Kronik Obstrüktif Akciğer Hastalığında Bakımın Yönetimi ve Hemşirelik Ö ÖZ ZE ET T Kronik hastalıklar dünyada ve ülkemizde giderek artan en önemli sağlık sorunlarından bi-ridir. Kontrol edilmediğinde önemli komplikasyonlara neden olan kronik hastalıklar yaşam kalite-sini olumsuz yönde etkilemektedir. Sağlık profesyonellerinden biri olan hemşireler kronik hastalıkların değiştirilebilir risk etkenleri ile mücadele, erken tanı ve hastalığın kontrol altına alı-narak olası komplikasyonların önlenmesinde önemli konumdadırlar. Ekip çalışmasını gerektir-mekte olan kronik hastalıkların yönetiminde hemşireler bütüncül bir yaklaşımla ve eşgüdüm içerisinde önemli rol ve sorumluluklar üstlenmektedirler. Bu derleme çalışmasında dünyada ve ül-kemizde sık görülen hipertansiyon ve kronik obstrüktif akciğer hastalığının doğası, etkileri, bu has-talıklarla mücadele ve bakımın yönetiminde hemşireliğin öneminin vurgulanması amaçlanmıştır. A An na ah ht ta ar r K Ke el li im me el le er r: : Kronik bakım yönetimi; hipertansiyon; pulmoner hastalık, kronik obstrüktif; hemşirelik A AB BS ST TR RA AC CT T Chronic diseases are one of the most significant health problems increasingly in our country and the world. Chronic diseases, which cause significant complications when not being controlled, affect quality of life negatively. Nurses, who are one of the health professionals, have in a prominent positionin the fight against changeable risk factors of chronic diseases, early diagnosis and prevention of possible complications by controlling the disease. In the management of chronic diseases that require teamwork, nurses assume important roles and responsibilities in a holistic approach and coordination. For this reason, in this review study it is aimed to emphasize the nature and effects of hypertension and chronic obstructive lung diseases and the importance of nursing in fight against these diseases and management of care. K Ke ey yw wo or rd ds s: : Chronic care management; hypertension; pulmonary disease, chronic obstructive; nursing
... Today roles of nurses and practitioners involve all aspects of care in hypertension management. These include detection, referral, follow up, diagnostics management, medication management, patient education, counseling, skill building, coordination of care, clinic management, office management, population health management, performance measurement and quality improvement (Himmelfarb et al., 2016). ...
... The patient-centered, multidisciplinary team is a key feature of effective care models that have been found to improve care processes and control rates. In addition to their clinical roles, nurses lead clinic and community-based research to improve the hypertension quality gap and ethnic disparities by holistically examining social, cultural, economic, and behavioral determinants of hypertension outcomes and designing culturally sensitive interventions to address these determinants (Himmelfarb et al., 2016). ...
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... Some of the factors that are associated with missed appointments include lack of hypertension knowledge, experience of medication side effects, forgetfulness, transportation challenges, a feeling that appointments are not helpful, lack of trust and health professionals' communication behaviour during consultations [48,49]. Consequently, a particular factor associated with non-compliance of an individual hypertensive patient should guide interventions that improve appointment keeping compliance [49,50]. ...
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Hospitalisation of chronic diseases can be costly and time-consuming to patients with chronic diseases, and success of management of chronic diseases is in the primary care. This chapter gives a detailed description of primary health and its role in the management of chronic diseases. Hypertension as a chronic disease of interest and its management in the primary healthcare (PHC) context are also to be discussed in detail. However, to give this chapter clarity, a brief description of the country Lesotho will be given. The summary of the country will highlight major barriers to health care which mainly include poverty, difficult topography with no or poor infrastructure which hinder access to primary health care. Situational analysis is made with regard to current practice. The potential role of a pharmacist in the care and treatment of hypertension is explored. Best practices, need for policy change, guidelines and implementation plans will be highlighted. The aim of the chapter is to evaluate how chronic diseases are managed at the primary health care. The objectives include: a) to explore primary health care concept, b) to critically evaluate PHC concept in an African country and c) to describe human resource needs to meet the demands of PHC chronic diseases management.
Purpose: Nurse-led digital health interventions (DHIs) for people with chronic disease are increasing. However, the effect of nurse-led DHIs on blood pressure control and hypertension self-management remains unclear. This study aimed to identify the characteristics of nurse-led DHIs for people with hypertension and compared the effect size of nurse-led DHIs with that of usual care to establish evidence for the development of effective nursing interventions using technologies. Design: Systematic review and meta-analysis. Methods: This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews of Intervention (PRISMA) guidelines and registered the protocol in PROSPERO. Studies published from 2000 to August 5, 2021, were searched using the international databases: PubMed; Embase; Cochrane Central Register of Controlled Trials; Web of Science; CINAHL; Korean databases: RISS, KISS, KMBASE; and NDSL. Risk of bias 2.0 was used for evaluating the quality of studies. The primary outcome was blood pressure control. The secondary outcomes were self-management, medication adherence, and diet adherence. Publication bias was assessed using the funnel plot and Egger's regression tests. Findings: The systematic review included 26 studies. A meta-analysis of 21 studies was conducted to calculate the effect size and identify heterogeneity among the included studies. In our meta-analysis, we observed that nurse-led DHIs reduced systolic blood pressure by 6.49 mmHg (95% confidence interval [CI]: -8.52 to -4.46, I2 = 75.4%, p < 0.05) and diastolic blood pressure by 3.30 mmHg (95% CI: -4.58 to -2.01, I2 = 70.3%, p < 0.05) when compared with usual care. Concerning secondary outcomes, the effect size on self-management, medication adherence, and diet adherence was 0.98 (95% CI: 0.58 to 1.37, I2 = 63.2%, p < 0.05), 1.05 (95% CI: 0.41 to 1.69, I2 = 92.5%, p < 0.05), and 0.80 (95% CI: 0.17 to 1.42, I2 = 80.5%, p < 0.05), respectively. Conclusion: Nurse-led DHIs were more effective in reducing blood pressure and enhancing self-management than usual care among people with hypertension. Therefore, as new technologies are being rapidly developed and applied in healthcare systems, further studies and policy support are needed to utilize the latest digital innovations with nursing interventions. Clinical relevance: This study could be used to identify that nurse-led interventions may take advantage of real-time communication by employing digital technologies for improving blood control and self-management behaviors such as medication adherence and diet adherence. Using nurse-led DHIs allows nurses to provide patient-centered interventions such as reflecting on patients' needs and shared decision-making without space constraints and limited treatment time.
Cardiovascular disease and cancer are 2 of the leading causes of death worldwide. Although improvements in outcomes have been noted for both disease entities, the success of cancer therapies has come at the cost of at times very impactful adverse events such as cardiovascular events. Hypertension has been noted as both, a side effect as well as a risk factor for the cardiotoxicity of cancer therapies. Some of these dynamics are in keeping with the role of hypertension as a cardiovascular risk factor not only for heart failure, but also for the development of coronary and cerebrovascular disease, and kidney disease and its association with a higher morbidity and mortality overall. Other aspects such as the molecular mechanisms underlying the amplification of acute and long-term cardiotoxicity risk of anthracyclines and increase in blood pressure with various cancer therapeutics remain to be elucidated. In this review, we cover the latest clinical data regarding the risk of hypertension across a spectrum of novel anticancer therapies as well as the underlying known or postulated pathophysiological mechanisms. Furthermore, we review the acute and long-term implications for the amplification of the development of cardiotoxicity with drugs not commonly associated with hypertension such as anthracyclines. An outline of management strategies, including pharmacological and lifestyle interventions as well as models of care aimed to facilitate early detection and more timely management of hypertension in patients with cancer and survivors concludes this review, which overall aims to improve both cardiovascular and cancer-specific outcomes.
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Objectives: Mechanisms underlying relationships among patients' health literacy, diabetes distress, diabetes education, and provider counseling for self-care of chronic conditions are unclear. This study tested these relationships using SEM with adult patients with comorbid diabetes and hypertension in rural WV. Methods: Ninety-one participants of a 12-week self-management program reported on diabetes self-care (diet, exercise, blood glucose (BG) monitoring) and related provider counseling. Results: Based on patient report, providers' recommendations included following a low-fat diet, eating fruits/ vegetables, limiting sweets, a daily low-level of exercise and/or exercise ≥20 minutes three times/week, and BG monitoring. Provider recommendations were shown to be associated with patients' self-care behaviors (r=0.22, p<0.05). Multiple factors directly influenced provider recommendations: diabetes distress, health literacy, and family history of diabetes. A positive association was also noted between prior diabetes education and provider recommendations and diabetes self-care (r=0.44, p<0.001). A negative association was noted between diabetes distress and self-care, but a positive effect on provider recommendations was found. The model demonstrated good fit [CFI=0.94, and Root Mean Square Error of Approximation (RMSEA) =0.05]. Conclusions: To enhance diabetes self-care, providers should consistently provide education on self-care behaviors as well as partner with them to address diabetes distress.
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Purpose of Review Hypertension represents the most important cardiovascular risk factor, affecting over 4.06 billion adults worldwide. In this review, we will discuss potential barriers and their solutions to improve prevention, detection, and management of hypertension. Recent Findings The prevalence of hypertension has been increasing in low- and middle-income countries, requiring new strategies to improve its recognition and proper management. The World Heart Federation (WHF) developed a roadmap for hypertension, advising health system policies and clinical practices as part of its commitment to improving global cardiovascular health. The World Health Organization (WHO) has published in 2021 practical guidelines for the pharmacological treatment of hypertension in adults. Summary Identifying potential roadblocks and solutions deserves high priority to improve the detection, management, and control of hypertension.
1. To gain knowledge of the cardiovascular (CV) risks associated with chronic kidney disease (CKD). 2. To evaluate and understand how CV risk can be reduced and managed in patients with CKD. 3. To highlight the important role of nurses in cardiovascular disease (CVD) management in patients with CKD.
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Background: The number of African immigrants in the United States grew 40-fold between 1960 and 2007, from 35 355 to 1.4 million, with a large majority from West Africa. This study sought to examine the prevalence of cardiovascular disease (CVD) risk factors and global CVD risk and to identify independent predictors of increased CVD risk among West African immigrants in the United States. Methods and results: This cross-sectional study assessed West African (Ghanaian and Nigerian) immigrants aged 35-74 years in the Baltimore-Washington metropolitan area. The mean age of participants was 49.5±9.2 years, and 58% were female. The majority (95%) had ≥1 of the 6 CVD risk factors. Smoking was least prevalent, and overweight or obesity was most prevalent, with 88% having a body mass index (in kg/m(2)) ≥25; 16% had a prior diagnosis of diabetes or had fasting blood glucose levels ≥126 mg/dL. In addition, 44% were physically inactive. Among women, employment and health insurance were associated with odds of 0.09 (95% CI 0.033-0.29) and 0.25 (95% CI 0.09-0.67), respectively, of having a Pooled Cohort Equations estimate ≥7.5% in the multivariable logistic regression analysis. Among men, higher social support was associated with 0.90 (95% CI 0.83-0.98) lower odds of having ≥3 CVD risk factors but not with having a Pooled Cohort Equations estimate ≥7.5%. Conclusions: The prevalence of CVD risk factors among West African immigrants was particularly high. Being employed and having health insurance were associated with lower CVD risk in women, but only higher social support was associated with lower CVD risk in men.
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Cardiovascular disease (CVD) remains the leading cause of death in the United States (US). Africandescent populations bear a disproportionate burden of CVD risk factors. With the increase in the number of West African immigrants (WAIs) to the US over the past decades, it is imperative to specifically study this new and substantial subset of the African-descent population and how acculturation impacts their CVD risk. The Afro-Cardiac study, a community-based cross-sectional study of adult WAIs in the Baltimore–Washington metropolis. Guided by the PRECEDE– PROCEED model, we used a modification of the World Health Organization Steps survey to collect data on demographics, socioeconomic status, migration-related factors and behaviors. We obtained physical, biochemical, acculturation measurements as well as a socio-demographic and health history. Our study provides critical data on the CVD risk of WAIs. The framework used is valuable for future epidemiological studies addressing CVD risk and acculturation among immigrants.
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In the 20th century, Africans in Sub-Saharan Africa had lower rates of cardiometabolic disease than Africans who migrated. However, in the 21st century, beyond infectious diseases, the triple epidemics of obesity, diabetes and hypertension have taken hold in Africa. Therefore, Africans are acquiring these chronic diseases at different rates and different intensity prior to migration. To ensure optimal care and health outcomes, the United States practice of grouping all African-descent populations into the “Black/African American” category without regard to country of origin masks socioeconomic and cultural differences and needs re-evaluation. Overall, research on African-descent populations would benefit from a shift from a racial to an ethnic perspective. To demonstrate the value of disaggregating data on African-descent populations, the epidemiologic transition, social, economic, and health characteristics of African immigrants are presented.
Behaviors critical to hypertensive patients' achieving therapeutic control and assuming active responsibility for their own care were defined by an interdisciplinary group brought together by the National High Blood Pressure Education Program. The report focused on the achievement and maintenance of long-term control through drug therapy and concentrated on the patient-physician interaction as a critical factor. The basic hypothesis that active participation by the patient favors successful management of hypertension identifies the physician, the prime diagnostician and initiator of the subsequent interaction, as the promoter of that important collaboration. The working group views the patient as the decision-maker and problemsolver, with the professional functioning as advisor and guide. This synthesis of available theory and practice in therapy adherence includes knowledge, attitudes, and skills defined under four major behaviors: making the decision for control, taking medication, monitoring progress, and problem solving.
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.
• Objective: To describe results of a multifaceted improvement intervention to improve Wood pressure control among patients in a primary care group practice. • Methods: We implemented a multifactorial intervention that included performance reporting, clinical and patient education, and financial performance incentives. Blood pressure control was assessed and compared with levels recommended in national guidelines. • Results: In 2008, the overall level of blood pressure control to < 140/90 mm Hg was 66% of patients. Among patients with diabetes, 65% were controlled; among patients with chronic kidney disease, 40% were controlled. Among patients with congestive heart failure, 52% were controlled to the American College of Cardiology target of < 120/80 mm Hg. Control of blood pressure was 74% and 61% among patients of internal medicine physicians and family practice physicians, respectively (x2 = 14.185, P< 0.001). • Conclusion: Following a multifaceted educational and quality improvement intervention, we found that levels of Wood pressure control improved in average-risk patients. In addition, subpopulations of patients with diabetes, chronic kidney disease, and congestive heart failure had favorable levels of control. This approach is easily exportable to other physician organizations to improve outcomes by reducing cardiovascular disease morbidity and mortality.
![Figure][1] ![Figure][1] ![Figure][1] ![Figure][1] Cardiovascular disease (CVD) is a major cause of morbidity and premature mortality in women and men worldwide. During the past 2 decades, the prevalence of CVD and stroke has increased and accelerated in low- and