Problem Addressed

• High prevalence: A Centers for Disease Control and Prevention analysis found that almost 29 percent of the U.S. population has hypertension; prevalence increases with age and is higher among women.²
• Largely uncontrolled: Hypertension in most individuals remains uncontrolled. An analysis based on Framingham Heart Study data found that only 38 percent of male and female hypertensive patients aged 60 years old or younger had their condition under control; comparable figures for those aged 60 to 79 years old were 36 percent in men and 28 percent in women, and for those 80 years and older were 38 percent in men and 23 percent in women.³
• Inadequate focus on hypertension during office visits: Due to time constraints and the presence of other higher priority acute and chronic conditions, many physicians do not focus adequately on BP control during office visits. Patient self-monitoring at home and the assignment of a health care team member (e.g., a nurse or pharmacist) to focus on hypertension management may lead to reductions in BP.⁴

Description of the Innovative Activity

• Target population: The program targeted patients with uncontrolled hypertension (i.e., above 140/90 mm Hg) between the ages of 25 and 75 years old who were taking antihypertensive medication and had access to the Internet and an e-mail address. Patients with more serious comorbidities, such as diabetes, renal disease, or cardiovascular disease, were excluded.
• Recruitment: In 2009, pharmacists began recruiting patients using lists generated from automated data of patients with hypertension on medications and with BP not controlled. Patients are contacted via mail and a followup phone call. Additionally, some patients are referred by physicians.
• Access to online patient portal: All Group Health Cooperative patients have access to Group Health Cooperative's online patient portal, called MyGroupHealth, which provides various secure Web services such as the ability to refill medications, make appointments, view portions of their electronic medical record, use secure messaging to contact clinicians, and access condition-specific educational information. For the randomized controlled trial, some patients were given training on how to use MyGroupHealth, receiving a tour of the different online services and instructions for their use.
• Home BP monitoring: Patients purchase an automated upper-arm BP monitor from pharmacies in the clinics or online through Group Health Cooperative, are trained to use it, and instructed to check their BP at least 2 days each week, taking two measurements each time. Patients used MyGroupHealth to send blood pressure readings and other related messages to the designated pharmacist (see below). BP monitors were given to patients for free during the trial period but must now be purchased for approximately $50.00.
• Pharmacist support: A pharmacist was assigned to work as part of the care team by offering ongoing hypertension care management to the patient, as outlined below:
  • Initial telephone call: The pharmacist called the patient to conduct an extensive medication history, discuss medication adherence issues, and suggest possible lifestyle changes that could help the patient better control his or her hypertension.
  • Protocol-driven prescription changes: Pharmacists used internally developed protocols (based on the Seventh Report of the Joint National Committee on Prevention Detection, Evaluation, and Treatment of High Blood Pressure protocols, also known as the JNC 7 protocols) for antihypertensive therapy. As long as pharmacists followed these protocols, they could write new or modified prescriptions without a physician's signature. (This discretion—called prescriptive authority—is allowed for licensed pharmacists in Washington State.)
  • Action plan: After the initial phone call, the pharmacist introduced the patient to an individualized action plan that incorporated a BP measurement schedule, a list of current medications, a description of agreed-to lifestyle changes (e.g., reducing salt intake or increasing physical activity), recommended changes in medications, and a followup plan. The action plan was sent electronically to the patient and his or her physician.
  • Ongoing pharmacist support: For the first 3 months or until BP was adequately controlled, the pharmacist contacted the patient approximately once every 2 weeks via the secure messaging system. Once adequate BP control was achieved, the frequency of contact was reduced to once every 3 months or as needed. During these exchanges, pharmacists offered specific recommendations in response to the BP measurements submitted by patients. In the adopted model at the additional centers, pharmacists provide collaborative support for 3 months and can continue depending on patient needs.
  • Physician involvement: Pharmacists contacted physicians via e-mail if they determined a need for a medication change that fell outside of the protocols, or if any clinical concerns arose.

References/Related Articles

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Results

• Increase in percentage of patients with controlled hypertension: Among those patients receiving all program elements, 56 percent were able to achieve sustained control of their hypertension (with readings consistently below 140/90 mm Hg), compared with just 36 percent of those receiving home BP monitoring and education/training on the Web-based portal, and 31 percent of those receiving usual care.
• Reduction in BP, especially for severely hypertensive patients: Patients receiving all program elements had a reduction in systolic BP of 14.2 mm Hg, compared with a reduction of 8.2 mm Hg in patients receiving home monitoring and Web training and a reduction of 5.3 mm Hg in patients receiving usual care. Patients with severe hypertension (baseline systolic BP of >160 mm Hg) had a reduction in systolic BP of 27.6 mm Hg when they received all program elements, compared with reductions of 17.8 mm Hg in those receiving home monitoring and Web training and 14.4 mm Hg in usual care patients.
• Increased medication use: At baseline, the average number of antihypertensive medication classes used by all patients was 1.6. At 12 months, this number increased to 2.16 in those patients receiving all three program elements, compared with 1.94 in those receiving home monitoring and education/training on the Web-based portal, and 1.69 in those receiving usual care. Use of aspirin also increased more in those receiving all program elements (to 1.3 times the rate of use achieved in the other groups).
• No change in utilization: The number of primary care visits, hospitalizations, urgent care visits, and emergency department visits did not vary significantly among the three groups.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Obtaining grant funding: The researchers submitted grant proposals and ultimately obtained funding from the National Heart, Lung, and Blood Institute (NHLBI).
• Developing and refining the intervention model: Investigators piloted the new model using frontline pharmacists but found that these pharmacists could not devote adequate time to the program. In June of 2005, the program was reintroduced using Group Health Cooperative-employed pharmacists who already had "protected time" for other population management activities.
• Preparing the pharmacists: Pharmacists received 2 half-days of training on evidence-based care of hypertension, including medication protocols and patient-centered techniques (e.g., motivational interviewing) for addressing behavioral change. They also received care guidelines for hypertension management, a protocol for hypertension medical therapy, and instructions regarding when to contact the patient's physician.

Resources Used and Skills Needed

• Staffing: Three pharmacists employed by Group Health Cooperative incorporate the program into their daily routines, although their workload was reduced somewhat to accommodate these responsibilities. Each pharmacist spends roughly 2 to 8 hours per week on program activities.
• Costs: The costs of the program include providing pharmacists with protected time through workload reductions (estimates for this cost are unavailable) and providing BP monitors to patients (at a cost of $35 each).

Funding Sources

• Patterns of BP and hypertension control over time
• Patterns of antihypertensive medication intensification and adherence over time
• Long-term changes in health services utilization and costs, and
• Long-term incremental cost-effectiveness of each intervention arm

Tools and Other Resources

Getting Started with This Innovation

• Leverage existing infrastructure: Group Health Cooperative already had a number of components in place that facilitated program adoption, including the Web-based portal and pharmacist involvement in population-based management.
• Train pharmacists: Pharmacists must work proactively with patients on chronic disease management, which is not typically part of their job description.
• Have a system in place for identifying and managing patients with elevated blood pressure: Elements of such a system might include the following:
  • Ensure that blood pressure measurements are taken using validated monitors that are regularly checked.
  • Provide medical staff who measure blood pressure with proficiency training. Periodically observe their process for blood pressure measurement.
  • Have processes in place to identify patients who have elevated blood pressure at the time of a clinic visit or prescription refill.
  • If there is a question as to whether blood pressure is truly elevated, obtain additional blood pressure measurements (at the clinic and at home) and ensure that followup occurs.
  • If "white coat hypertension" (elevated blood pressure due to the anxiety of a medical visit), conduct 24-hour blood pressure ambulatory monitoring.
  • Consider cardiovascular risk in those with borderline elevated blood pressure; those patients at higher risk particularly benefit from keeping their blood pressure consistently below thresholds.
  • Once a patient is identified as having uncontrolled blood pressure, have a process in place for handoffs to a nurse or pharmacist. A brief intervention may be all that is needed.
  • Most people with hypertension need to maintain blood pressure at about 5 points lower than threshold (if not lower) to always be at target. Home blood pressure thresholds are 135/85 mg/dL, so the target should be about 130/80 mg/dL.
  • Exercise caution in lowering diastolic blood pressure below 70 in patients with symptomatic coronary artery disease, smokers, and the elderly with wide pulse pressures (these patients should be checked for postural hypotension).
  • Consider having pharmacists and nurses work with a hypertension specialist to facilitate coordination of optimal care. The American Society of Hypertension has a program for training and certifying physicians (all types) as hypertension specialists.

Sustaining This Innovation

• Strive for efficiency: Many chronic care needs can be met outside of the physician office visit through telephone or Web-based initiatives.
• Patient referral: Physician referral may be an easier way to engage patients.
• Leadership commitment: Leadership from pharmacy and primary care sectors of the organization are integral to success of the program.
• Alignment with patient-centered medical home concept: The success of the program likely will depend on its ability to align with the "Medical Home Model" Group Health is implementing and will probably expand so pharmacists can also provide collaborative care and virtual visits for patients with other chronic conditions.