Study to Lower Veterans Blood Pressure: Patient/Physician Intervention
Hayden B. Bosworth PhD
VA Medical Center
Durham, NC
Funding Period: October 2001 - March 2006

BACKGROUND/RATIONALE:
There are 65 million Americans and over 8.5 million veterans who have been diagnosed with hypertension, yet only 31% have their blood pressure (BP) under effective control. Uncontrolled hypertension greatly increases the risk of stroke, CAD, renal failure, CHF, and mortality.

OBJECTIVE(S):
This four year study evaluated simultaneously both a patient and a provider intervention in a primary care setting among diagnosed hypertensive veterans. The two primary hypotheses were: 1) the proportion of veterans with BP control who receive either the provider-directed decision support or the patient behavioral/education intervention will be increased by 10% as compared to usual care; and 2) the proportion of veterans with BP control who receive both the provider-directed decision support and the patient health education and behavioral intervention will be increased by 25% as compared to usual care.

METHODS:
This was a randomized controlled trial with a split-plot design. Thirty primary care providers in the Durham VAMC Primary Care Clinic were randomly assigned to receive either the provider intervention or basic patient information; 588 of their hypertensive patients were randomized to the patient intervention or usual care. The provider intervention (ATHENA study (IIR 99-275) included an electronically generated hypertension decision support system (DSS) delivered to the provider at each hypertensive patient's visit. The provider intervention was designed to improve guideline concordant therapy. The patient intervention was a tailored behavioral/education intervention administered at periodic telephone contacts. The intervention included support and reminders, information on hypertension and on health behaviors. Patients received feedback about their recent BP values, continuous patient education, and were monitored and supported to enhance adherence. The control group was usual care.

FINDINGS/RESULTS:
We completed enrollment of 588 participants ahead of schedule and surpassed our projected enrollment level by 10%. Our recruitment rate was 76%. Our 24-month retention rate was 84%. The patients' mean age was 63 years, 98% were male, 41% were African-American, and 57% were white. Using JNC VI cut-offs, 43% of the sample had their BP under control at baseline. There were no significant differences between treatment groups over the 24-months for either SBP (p=0.71) or BP control (p=0.18). The behavioral, combined, and usual care group improved in BP control over the 24 months, the provider intervention did not. Among the 294 randomized to the overall patient intervention (patient intervention and combined), BP control improved from a base rate of 44% to 65% over the 24 months. The absolute improvement in BP control relative to the non-behavioral group was 12.6% (p<0.03) at 24-months. The average behavioral intervention phone call was 3.2 minutes. The total incremental cost of the behavioral intervention was $8,613, or an average cost of $29.29 per patient in 2005 costs. There were no significant differences in the median number of primary care visits over the 24 months.

IMPACT:
Despite the known risk of poor BP control, a majority of adults still do not have their BP under effective control. A tailored, brief behavioral intervention concentrating on patient behaviors to enhance adherence with prescribed hypertension regimen can improve BP control among veterans in the primary care setting. Focusing on patient behavior interventions may have larger effects on BP control than provider interventions. This study is an important step in testing the effectiveness of a patient and provider intervention to improve BP control among veterans.

PUBLICATIONS:

Journal Articles

1. Powers BJ, Oddone EZ, Grubber JM, Olsen MK, Bosworth HB. Perceived and actual stroke risk among men with hypertension. Journal of Clinical Hypertension. 2008; 10(4): 287-94.
2. Walsh JM, Sundaram V, McDonald K, Owens DK, Goldstein MK. Implementing effective hypertension quality improvement strategies: barriers and potential solutions. Journal of Clinical Hypertension. 2008; 10(4): 311-6.
3. Cho AH, Voils CI, Yancy WS, Oddone EZ, Bosworth HB. Does participatory decision making improve hypertension self-care behaviors and outcomes? Journal of Clinical Hypertension. 2007; 9(5): 330-6.
4. Hong TB, Oddone EZ, Dudley TK, Bosworth HB. Subjective and objective evaluations of health among middle-aged and older veterans with hypertension. Journal of Aging and Health. 2005; 17(5): 592-608.
5. Lowry KP, Dudley TK, Oddone EZ, Bosworth HB. Intentional and unintentional nonadherence to antihypertensive medication. Annals of Pharmacotherapy. 2005; 39(7-8): 1198-203.
6. Bosworth HB, Olsen MK, Gentry P, Orr M, Dudley T, McCant F, Oddone EZ. Nurse administered telephone intervention for blood pressure control: a patient-tailored multifactorial intervention. Patient Education and Counseling. 2005; 57(1): 5-14.
7. Bosworth HB, Olsen MK, Goldstein MK, Orr M, Dudley T, McCant F, Gentry P, Oddone EZ. The veterans' study to improve the control of hypertension (V-STITCH): design and methodology. Contemporary Clinical Trials. 2005; 26(2): 155-68.
8. Steinman MA, Fischer MA, Shlipak MG, Bosworth HB, Oddone EZ, Hoffman BB, Goldstein MK. Clinician awareness of adherence to hypertension guidelines. American Journal of Medicine. 2004; 117(10): 747-54.
9. Chan AS, Coleman RW, Martins SB, Advani A, Musen MA, Bosworth HB, Oddone EZ, Shlipak MG, Hoffman BB, Goldstein MK. Evaluating provider adherence in a trial of a guideline-based decision support system for hypertension. Medinfo. 2004; 11(Pt 1): 125-9.
10. Bosworth HB, Oddone EZ. A model of psychosocial and cultural antecedents of blood pressure control. Journal of The National Medical Association. 2002; 94(4): 236-48.

DRA: Chronic Diseases, Health Services and Systems
DRE: Prevention, Quality of Care, Resource Use and Cost
Keywords: Cardiovasc’r disease, Education (patient), Hypertension, Decision support
MeSH Terms: Behavior and Behavior Mechanisms, Intervention Studies