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157. Implementing Hypertension Guidelines: Randomized Trial of General versus Patient Specific Recommendation

MK Goldstein, VA Palo Alto Health Care System, Palo Alto, CA; Stanford University, Stanford, CA; BB Hoffman, VA Palo Alto Health Care System, Palo Alto, CA; Stanford University, Stanford, CA; P Lavori, VA Palo Alto Health Care System, Palo Alto, CA; Stanford University, Stanford, CA; RW Coleman, VA Palo Alto Health Care System, Palo Alto, CA; A Advani, Stanford University, Stanford, CA; P Gholami, VA Palo Alto Health Care System, Palo Alto, CA

Objectives: Guidelines are intended to improve quality of care, but little is known about the effects on patient care of implementing a guideline for management of chronic disease. Our aim was to determine whether a patient-specific intervention on drug choice for treatment of hypertension would improve concordance of drug regimens with guidelines without worsening blood pressure (BP).

Methods: We randomized 36 primary care clinicians in diverse primary care clinics to general (GEN) or GEN plus individualized (IND) intervention, and compared across the 2 groups by 2-sample t-tests, and before-after within groups by paired t-test. Unit of analysis is clinician and unit of ascertainment is the 4500 hypertensive patients in their panels using electronic medical record data. GEN included drug and BP education. IND added drug profiling for the clinicians, and a computer-generated patient-specific advisory at each clinic visit.

Results: The individualized intervention resulted in a change from baseline in guideline concordance more than twice that for the general intervention (10.9% versus 3.8%, t=2.796, p=0.008.) This improvement was significant in both groups by paired t-test: p<0.000 individualized and p=0.049 in general group. Average blood pressures decreased significantly in each group during the study: systolic blood pressure decreased 2.1 mmHg and 4.4; diastolic blood pressure decreased 2.9 and 3.4 in the individualized and general groups, respectively, by paired t-tests. The differences between the two groups were not significant. The proportion of patients with adequate control of blood pressure showed a trend toward improvement in the individualized group (+6.6%, p=0.088) and was unchanged in the general group (-0.1%, p=0.991); these changes were not significantly different between the two groups.

Conclusions: An individualized approach to implementation of guidelines for drug therapy of hypertension with clinicians in a large healthcare system was effective in changing clinician prescription behavior. In addition, a general intervention with all clinicians was associated with an improvement in the guideline concordance, and was also associated with a decrease in average blood pressure.

Impact: Patient-specific advisories for management of hypertension delivered at point-of-care were effective in changing physician behavior and were decreasing blood pressure. This method of guideline implementation has the potential to improve cardiovascular care for veterans.