Behavioral Interventions to Improve Hypertension Control in the Veterans Affairs Healthcare System

Abstract

Hypertension is a common and costly disease among US veterans. The Veterans Affairs (VA) healthcare system is the largest integrated healthcare provider in the United States and reviewing hypertension interventions developed in the VA may inform interventions delivered in other integrated healthcare systems. This review describes behavioral interventions to improve hypertension control that have been conducted in the VA since 1970. The authors identified 27 articles representing 15 behavioral interventional trials.Studies were heterogeneous across patients, providers, interventionist, and intervention components. The VA bridges services related to diagnosis, treatment, medication management, and behavioral counseling in a unified approach that supports collaboration and provides infrastructure for hypertension management. J Clin Hypertens (Greenwich). 2014;16:827-837. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.In recent decades there has been improvement in hypertension care provided in the Veterans Affairs (VA) healthcare system, the largest integrated healthcare provider in the United States. From 2000 to 2010, blood pressure (BP) control improved in the VA from 43.0% to 76.6%.1 There is a need for innovative behavioral approaches to continue and improve BP control. Reviewing hypertension interventions developed in the VA may inform interventions delivered in other systems. We performed a literature review describing behavioral hypertension interventions administered in the VA and distilled commonalities among successful programs. We emphasize behavioral management interventions because the success of BP control ultimately depends on a patient's willingness and ability to modify and maintain certain behaviors (eg, proper diet, exercise, and medication adherence). Therefore, our objective was not to report on VA hypertension care in general, but, rather, to focus on behavioral hypertension management interventions. METHODSA literature search using the PubMed database was conducted. We identified articles containing MeSH and key words addressing intervention studies or clinical trials, veterans, and hypertension. Articles were limited to those published in English in the past 44 years. Studies need not be solely conducted in the VA. This initial search yielded 171 articles. We screened full articles for eligibility. Exclusion criteria included: (1) commentary or editorial; (2) observational or retrospective analysis; (3) review article or solely described a conceptual mode; (4) not focused on hypertension; or (5) not a patient-focused behavioral hypertension intervention. The Figure outlines the article identification process. Interventions were divided into only behavioral or behavioral/medication management. We made this distinction because medication management interventions generally require complex design, necessitating the involvement and/or oversight of a clinician or pharmacist. RESULTSWe identified 27 articles representing 15 unique trials. Approximatel...

The effect of a practice‐based multicomponent intervention that includes health coaching on medication adherence and blood pressure control in rural primary care

“…In this study, the investigators demonstrate that a practice‐based, multicomponent intervention, including monthly phone‐based health coaching delivered by local health coaches, in conjunction with home BP monitoring and practice improvement activities, improves medication adherence and produces modest reduction in BP over 2 years in rural African American and white patients with a history of uncontrolled HTN. These findings are consistent with prior investigators’ findings, but extend this work to include rural and minority patients with uncontrolled hypertension in a primary care anchored delivery model.…”

“…Many interventions have been tested to improve BP control in patients with HTN . The findings from randomized controlled trials (RCTs) have indicated that the use of antihypertensive drug therapy is one of the most effective ways to reduce both systolic and diastolic BP .…”

“…5 Many interventions have been tested to improve BP control in patients with HTN. [6][7][8][9][10][11][12] The findings from randomized controlled trials (RCTs) have indicated that the use of antihypertensive drug therapy is one of the most effective ways to reduce both systolic and diastolic BP. 6 Medication adherence is therefore critical to achieve and sustain BP control, 3,13 but barriers to optimal medication adherence are complex and multi-dimensional, 14 especially for rural patients.…”

A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops

“…One previous randomized trial showed slightly better blood-pressure reduction in black men when barbers checked blood pressure and urged patrons with elevated readings to make doctor appointments than when barbers only distributed hypertension pamphlets. 4 The marginal intervention effect (between-group difference of −2.5 mm Hg in systolic blood pressure and −0.9 mm Hg in diastolic blood pressure) appeared due in part to design issues but also to the fact that clinicians rarely intensified drug therapy for these men, 5 a reportedly common occurrence (with notable exceptions) 6,7 in busy primary care practices in which doctors, patients, and health care systems have shared responsibility. 8–11 …”