Quality Improvement Strategies for Hypertension Management

Walsh, Judith M. E.; McDonald, Kathryn M; Shojania, Kaveh G; Sundaram, Vandana; Nayak, Smita; Lewis, Robyn; Owens, Douglas K; Goldstein, Mary K.

doi:10.1097/01.mlr.0000220260.30768.32

Cited by 293 publications

(304 citation statements)

References 57 publications

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“…There are several common reasons for therapeutic ineffectiveness in these groups that might be remedied by changing improvement targets 40. For instance, failure to change or increase therapy for patients who are not at goal (“therapeutic inertia”)41, 42 can be addressed by leveraging EHRs to implement treatment algorithms and protocols,16, 28, 38 utilizing clinical decision support tools embedded within EHRs including a 2‐week follow‐up process and patient reminders,19 and changes in team care 43, 44, 45, 46. Treatment‐resistant hypertension is related to age, patient factors, and medical causes of secondary hypertension47 and can be explored by implementing streamlined referral pathways35 and pushing EHR alerts to providers when the BP is elevated 30…”

Section: Discussionmentioning

confidence: 99%

Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control

Wozniak

Khan

Gillespie

et al. 2015

J of Clinical Hypertension

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Evidence‐based interventions differ for increasing hypertension awareness, treatment, and control and should be targeted for specific patient panels. This study developed a hypertension control cascade to identify patients with a usual source of care represented at each level of the cascade using the 2007–2012 National Health and Nutrition Examination Survey. Overall, 10.7 million adults in the United States were unaware of their condition, 3.8 million were aware but untreated, and 15.8 million were treated but uncontrolled. The results also suggest that failure to attain hypertension control because of lack of awareness or lack of treatment despite awareness occurs mainly among younger individuals and those with no annual healthcare visits, while the elderly and minorities are more likely to remain uncontrolled when aware and treated. Opportunities to leverage population health management functions in electronic health information systems to align the specific patient subgroups facing barriers to hypertension control at each level of the cascade with targeted hypertension management interventions are discussed.

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Section: Discussionmentioning

confidence: 99%

Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control

Wozniak

Khan

Gillespie

et al. 2015

J of Clinical Hypertension

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“…Interventions that engage ethnic minorities and those with suboptimal disease control to participate more fully in the health-care process are promising strategies to improve hypertension care. Examples of effective strategies include home BP monitoring; in-person, telephone, or web-based motivational strategies delivered by a nurse and/ or a pharmacist; collaborative management by primary carepharmacist teams; 60,61 and involvement of community health workers as members of the care team. 62 Physician-directed interventions such as continuing medical education, academic detailing, quality review and feedback, and computer decision support/reminders to change prescribing behaviors, when used alone, have not shown improvements in health outcomes, [63][64][65][66][67][68] and few studies have focused on communication skills training skills for providers.…”

Section: Discussionmentioning

confidence: 99%

The Effect of Patient Race and Blood Pressure Control on Patient-Physician Communication

et al. 2009

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BACKGROUND: Racial disparities in hypertension control contribute to higher rates of cardiovascular mortality among blacks. Patient-physician communication quality is associated with better health outcomes, including blood pressure (BP) control. Both race/ethnicity and BP control may adversely affect communication. OBJECTIVE:To determine whether being black and having poor BP control interact to adversely affect patient-physician communication more than either condition alone, a situation referred to as "double jeopardy." DESIGN, SETTINGS, AND PATIENTS:Cross-sectional study of enrollment data from a randomized controlled trial of interventions to enhance patient adherence to therapy for hypertension. Participants included 226 hypertensive patients and 39 physicians from 15 primary care practices in Baltimore, MD. MEASUREMENTS:Communication behaviors and visit length from coding of audiotapes. RESULTS:After controlling for patient and physician characteristics, blacks with uncontrolled BP have shorter visits (B=−3.9 min, p<0.01) with less biomedical (B=−24.0, p=0.05), psychosocial (B=−19.4, p< 0.01), and rapport-building (B=−19.5, p=0.01) statements than whites with controlled BP. Of all communication outcomes, blacks with uncontrolled BP are only in "double jeopardy" for a patient positive affect-coders give them lower ratings than all other patients. Blacks with controlled BP also experience shorter visits and less communication with physicians than whites with controlled BP. There are no significant communication differences between the visits of whites with uncontrolled versus controlled BP.CONCLUSIONS: This study reveals that patient race is associated with the quality of patient-physician communication to a greater extent than BP control. Interventions that improve patient-physician communication should be tested as a strategy to reduce racial disparities in hypertension care and outcomes.

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“…It might be possible that patients on their own could improve their hypertension care by using home blood pressure monitors and communicating these by e-mail directly to their healthcare team; and as noted above, self-monitoring of blood pressure studies improved blood pressure control [78]. In a recent meta-analysis, while home blood pressure monitoring and patient education strategies positively influenced blood pressure control, adding a healthcare team member to focus specifically on hypertension resulted in greater changes, particularly if the assigned person managed medication adjustments [28]. Methods for integration of the team member into routine care and the costs of this care were less certain.…”

Section: Discussionmentioning

confidence: 99%

“…Pharmacists could provide most care without directly involving the physician: Communication was routine, and collaboration occurred for any clinical concerns, but the physician did not have to respond or place orders. Based on our review of the literature and later the Walsh meta-analysis [28], we hypothesized that family physicians often are too busy to do the iterative work required for ongoing management of blood pressure; and pharmacist focus and autonomy (within the guidelines of a protocol) would lead to increased hypertensive medication adjustment and improve blood pressure control. Additionally, as care was delivered over the Internet, we wanted to assure safety before testing more complex scenarios.…”

Section: Discussionmentioning

confidence: 99%

“…The benefits of self-management (including self-monitoring of blood pressure) and self-management support have been less certain for hypertension [27]. In a recent meta-analysis by Walsh et al, the largest improvement in hypertension control came from adding a healthcare team member other than a physician, e.g., a nurse or pharmacist, to focus on hypertension care [28].…”

Section: Introductionmentioning

confidence: 99%

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Electronic Communications and Home Blood Pressure Monitoring (e-BP) study: Design, delivery, and evaluation framework

Green¹,

Ralston²,

Fishman³

et al. 2008

Contemporary Clinical Trials

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Background-Randomized controlled trials have provided unequivocal evidence that treatment of hypertension decreases mortality and major disability from cardiovascular disease; however, blood pressure remains inadequately treated in most affected individuals. This large gap continues despite the facts that more than 90% of adults with hypertension have health insurance, and hypertension is the leading cause of visits to the doctor. New approaches are needed to improve hypertension care. Objectives-The Electronic Communications and Home Blood PressureMonitoring (e-BP) study is a three-arm randomized controlled trial designed to determine whether care based on the Chronic Care Model and delivered over the Internet improves hypertension care. The primary study outcomes are systolic, diastolic, and blood pressure control; secondary outcomes are medication adherence, patient self-efficacy, satisfaction and quality of life, and healthcare utilization and costs.Methods-Hypertensive patients receiving care at Group Health medical centers are eligible if they have uncontrolled blood pressure on two screening visits and access to the Web and an e-mail address. Study participants are randomly assigned to three intervention groups: (a) usual care; (b) home blood pressure monitoring receipt and proficiency training on its use and the Group Health secure patient website (with secure e-mail access to their healthcare provider, access to a shared medical record, prescription refill and other services); or (c) this plus pharmacist care management (collaborative care management between the patient, the pharmacist, and the patient's physician via a secure patient website and the electronic medical record).Conclusion-We will determine whether a new model of patient-centered care that leverages Web communications, self-monitoring, and collaborative care management improves hypertension control. If this model proves successful and cost-effective, similar interventions could be used to improve the care of large numbers of patients with uncontrolled hypertension.

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Quality Improvement Strategies for Hypertension Management

Abstract: QI strategies are associated with improved hypertension control. A focus on hypertension by someone in addition to the patient's physician was associated with substantial improvement. Future research should examine the contributions of individual QI strategies and their relative costs.

Cited by 293 publications

References 57 publications

Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control

Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control

The Effect of Patient Race and Blood Pressure Control on Patient-Physician Communication

Electronic Communications and Home Blood Pressure Monitoring (e-BP) study: Design, delivery, and evaluation framework

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