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2011 HSR&D National Meeting Abstract

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2011 National Meeting

1037 — Blood Pressure Lowering among Eligible Patients Immediately and Up to Six Months after the Adherence and Intensification of Medications (AIM) Program

Heisler M (Ann Arbor HSR&D COE), Hofer TP (Ann Arbor HSR&D COE), Schmittdiel J (Division of Research, Kaiser Permanente Northern California), Klamerus ML (Ann Arbor HSR&D COE), Holleman R (Ann Arbor HSR&D COE), Bosworth H (Center for Health Services Research in Primary Care, Durham VA), Kerr EA (Ann Arbor HSR&D COE)

Objectives:
We designed the Adherence and Intensification of Medications (AIM) Program to combine proactive identification, adherence counseling, and medication intensification - all hypothesized to be essential elements to achieve optimal levels of blood pressure (BP) control for high cardiovascular disease (CVD)-risk patients. We tested the effectiveness of this intervention at the team level to examine the program as it would typically be implemented within a clinic setting, including how it integrates with other elements of care.

Methods:
AIM was a cluster-randomized implementation study in which 16 primary care teams consisting of 5-28 PCPs, their staff, and diabetes patients, within 3 VA facilities and 2 Kaiser Permanente facilities, were randomized to one of two conditions: proactive case identification followed by adherence counseling and medication management delivered by a clinical pharmacist trained in Motivational Interviewing or to usual care. We collected data during a 14-month intervention period (August 2008 to September 2009). Clinical pharmacists were supported by clinical information systems that enabled proactive identification of, and outreach, to eligible patients identified on the basis of persistent poor BP control and either medication refill gaps or lack of recent medication intensification. The primary outcome was the relative change in systolic blood pressure (SBP) measurements over time between patients in the intervention teams compared with patients in the control teams. Using multi-level mixed-effects linear regression models, we examined longitudinal differences in differences between SBP among eligible participants immediately after receiving the intervention and up to six months after the intervention.

Results:
1797 eligible patients in intervention teams and 2303 patients in the control teams were included in these analyses, although only 53% of these eligible intervention team patients received the AIM intervention. Mean SBP of intervention team patients one month prior to the intervention was 151 mm Hg compared to 150 in control teams (p = .33) Changes in mean SBP immediately after the intervention were -4.4 mm Hg among intervention team patients compared with -1.9 among eligible control team patients (P < .001). By six months after the intervention, however, mean SBP was approximately 145 mm Hg among both intervention and control team patients.

Implications:
Eligible intervention team patients achieved improved SBP control more quickly than control team patients, but by six months after the intervention control team patients had achieved similar levels of better SBP control. The AIM intervention, however, only reached 53% of eligible intervention patients and did not provide maintenance support for patients once they had been discharged from the program.

Impacts:
The AIM program was successful in more rapidly lowering BP for “resistant” hypertensive patients – those with adherence problems or who lacked prior intensification—than usual care. This was true even in settings that already have high levels of BP control, and in which improving BP control was a high priority during the study period. Future applications of AIM will require greater penetration and maintenance to spread and sustain the improved BP effect.


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