Improving Blood Pressure Control through Provider Education, Provider Alerts, and Patient Education

A Cluster Randomized Trial

1 August 2006 | Volume 145 Issue 3 | Pages 165-175

Background: Inadequate blood pressure control is a persistent gap in quality care.

Objective: To evaluate provider and patient interventions to improve blood pressure control.

Design: Cluster randomized, controlled trial.

Setting: 2 hospital-based and 8 community-based clinics in the Veterans Affairs Tennessee Valley Healthcare System.

Patients: 1341 veterans with essential hypertension cared for by 182 providers. Eligible patients had 2 or more blood pressure measurements greater than 140/90 mm Hg in a 6-month period and were taking a single antihypertensive agent.

Intervention: Providers who cared for eligible patients were randomly assigned to receive an e-mail with a Web-based link to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) guidelines (provider education); provider education and a patient-specific hypertension computerized alert (provider education and alert); or provider education, hypertension alert, and patient education, in which patients were sent a letter advocating drug adherence, lifestyle modification, and conversations with providers (patient education).

Measurements: Proportion of patients with a systolic blood pressure less than 140 mm Hg at 6 months; intensification of antihypertensive medication.

Results: Mean baseline blood pressure was 157/83 mm Hg with no differences between groups (P = 0.105). Six-month follow-up data were available for 975 patients (73%). Patients of providers who were randomly assigned to the patient education group had better blood pressure control (138/75 mm Hg) than those in the provider education and alert or provider education alone groups (146/76 mm Hg and 145/78 mm Hg, respectively). More patients in the patient education group had a systolic blood pressure of 140 mm Hg or less compared with those in the provider education or provider education and alert groups (adjusted relative risk for the patient education group compared with the provider education alone group, 1.31 [95% CI, 1.06 to 1.62]; P = 0.012).

Limitations: Follow-up blood pressure measurements were missing for 27% of study patients. The study could not detect a mechanism by which patient education improved blood pressure control.

Conclusions: A multifactorial intervention including patient education improved blood pressure control compared with provider education alone.

Editors' Notes Context Despite evidence showing that even mild elevation of blood pressure above 140/90 mm Hg puts patients at risk for cardiovascular complications, many patients who are treated for hypertension still have high blood pressure. Contribution The authors sought to improve the blood pressure of patients using a health systems approach. They randomly assigned providers caring for hypertensive patients to receive a Web link to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; the Web link and a computer alert notifying them of the patient's blood pressure; or the Web link, computer alert, and a letter educating the patient about ways to control his or her blood pressure. Patients of providers randomly assigned to the third group had greater decreases in blood pressure and were more likely to have a systolic blood pressure less than 140 mm Hg. Cautions The study took place in a Veterans Affairs setting, follow-up blood pressure measures were missing for many patients, and the study was not designed to detect a mechanism for any observed changes. Implications A health systems approach that gave providers feedback about their patients' blood pressure and that gave patients information about ways to control it improved blood pressure control compared with provider education alone. —The Editors

 

Author and Article Information

From Tennessee Valley Healthcare System, Vanderbilt University, and the Veterans Administration Medical Center, Nashville, Tennessee.

Grant Support: By the Veterans Affairs Clinical Research Center of Excellence (Drs. Roumie, Elasy, Greevy, Griffin, Dittus, and Speroff); VA Career Development Award 04-342-2 (Dr. Roumie); HSR&D Targeted Research Enhancement Program Center for Patient Healthcare Behavior TRP 03-073 (Drs. Roumie, Elasy, Greevy, Griffin, Wallston, Dittus, Alvarez, and Speroff and Ms. Cobb); Geriatric Research Education and Clinical Center, Veterans Affairs, Tennessee Valley Healthcare, Nashville, Tennessee (Drs. Roumie, Elasy, Griffin, Wallston, Dittus, and Speroff); and Health Services Research–VISN Cooperative Grant for Improving Implementation of Best Practices (IMV 04-091-1) (Drs. Roumie, Wallston, Alvarez, and Speroff and Ms. Cobb).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Christianne L. Roumie, MD, MPH, Tennessee Valley Healthcare System, 1310 24th Avenue South, GRECC 4A120, Nashville, TN 37212; e-mail, christianne.roumie{at}vanderbilt.edu.

Current Author Addresses: Drs. Roumie, Elasy, Griffin, Stone, Alvarez, and Speroff and Ms. Cobb: Tennessee Valley Healthcare System, 1310 24th Avenue South, GRECC 4A120, Nashville, TN 37212.

Drs. Greevy and Liu: Vanderbilt University, 1161 21st Avenue South, S-2323 MCN, Nashville, TN 37232.

Dr. Wallston: Vanderbilt University, 421 Godchuk Hall, Nashville, TN 37240.

Dr. Dittus: Vanderbilt University, 1215 21st Avenue South, Suite 6000, Medical Center East, Nashville, TN 37232.

Author Contributions: Conception and design: C.L. Roumie, T.A. Elasy, M.R. Griffin, W.J. Stone, K.A. Wallston, R.S. Dittus, V. Alvarez, J. Cobb, T. Speroff.

Analysis and interpretation of the data: C.L. Roumie, T.A. Elasy, R. Greevy, M.R. Griffin, X. Liu, K.A. Wallston, R.S. Dittus, T. Speroff.

Drafting of the article: C.L. Roumie, R. Greevy.

Critical revision of the article for important intellectual content: C.L. Roumie, T.A. Elasy, R. Greevy, M.R. Griffin, X. Liu, W.J. Stone, K.A. Wallston, R.S. Dittus, V. Alvarez, J. Cobb, T. Speroff.

Final approval of the article: C.L. Roumie, T.A. Elasy, R. Greevy, M.R. Griffin, X. Liu, W.J. Stone, K.A. Wallston, R.S. Dittus, V. Alvarez, J. Cobb, T. Speroff.

Provision of study materials or patients: V. Alvarez, J. Cobb.

Statistical expertise: R. Greevy, X. Liu, T. Speroff.

Obtaining of funding: T.A. Elasy, M.R. Griffin, R.S. Dittus, T. Speroff.

Administrative, technical, or logistic support: T.A. Elasy, M.R. Griffin, W.J. Stone, R.S. Dittus, V. Alvarez, J. Cobb, T. Speroff.

Collection and assembly of data: C.L. Roumie, V. Alvarez, J. Cobb.

Clinicaltrials.gov Identifier: NCT00265044

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Comments on importance of drug therapy for hypertension

Munir E Nassar

Annals Online, 3 Aug 2006 [Full text]