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.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Bosworth HB, Oddone EZ. A model of psychosocial and cultural antecedents of blood pressure control. Journal of the National Medical Association. 2002 Apr 1; 94(4):236-48. [view]
2. Steinman MA, Fischer MA, Shlipak MG, Bosworth HB, Oddone EZ, Hoffman BB, Goldstein MK. Clinician awareness of adherence to hypertension guidelines. The American journal of medicine. 2004 Nov 15; 117(10):747-54. [view]
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 (Greenwich, Conn.). 2007 May 1; 9(5):330-6. [view]
4. Datta SK, Oddone EZ, Olsen MK, Orr M, McCant F, Gentry P, Bosworth HB. Economic analysis of a tailored behavioral intervention to improve blood pressure control for primary care patients. American heart journal. 2010 Aug 1; 160(2):257-63. [view]
5. 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 Sep 1; 11(Pt 1):125-9. [view]
6. Lin ND, Martins SB, Chan AS, Coleman RW, Bosworth HB, Oddone EZ, Shankar RD, Musen MA, Hoffman BB, Goldstein MK. Identifying barriers to hypertension guideline adherence using clinician feedback at the point of care. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2006 Jan 1; 494-8. [view]
7. Walsh JM, Sundaram V, McDonald K, Owens DK, Goldstein MK. Implementing effective hypertension quality improvement strategies: barriers and potential solutions. Journal of clinical hypertension (Greenwich, Conn.). 2008 Apr 1; 10(4):311-6. [view]
8. Lowry KP, Dudley TK, Oddone EZ, Bosworth HB. Intentional and unintentional nonadherence to antihypertensive medication. The Annals of pharmacotherapy. 2005 Jul 1; 39(7-8):1198-203. [view]
9. Powers BJ, Olsen MK, Oddone EZ, Thorpe CT, Bosworth HB. Literacy and blood pressure--do healthcare systems influence this relationship? A cross-sectional study. BMC health services research. 2008 Oct 23; 8:219. [view]
10. Thorpe CT, Bryson CL, Maciejewski ML, Bosworth HB. Medication acquisition and self-reported adherence in veterans with hypertension. Medical care. 2009 Apr 1; 47(4):474-81. [view]
11. 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 Apr 1; 57(1):5-14. [view]
12. Bosworth HB, Olsen MK, Dudley T, Orr M, Goldstein MK, Datta SK, McCant F, Gentry P, Simel DL, Oddone EZ. Patient education and provider decision support to control blood pressure in primary care: a cluster randomized trial. American heart journal. 2009 Mar 1; 157(3):450-6. [view]
13. Powers BJ, Oddone EZ, Grubber JM, Olsen MK, Bosworth HB. Perceived and actual stroke risk among men with hypertension. Journal of clinical hypertension (Greenwich, Conn.). 2008 Apr 1; 10(4):287-94. [view]
14. Bosworth HB, Dudley T, Olsen MK, Voils CI, Powers B, Goldstein MK, Oddone EZ. Racial differences in blood pressure control: potential explanatory factors. The American journal of medicine. 2006 Jan 1; 119(1):70.e9-15. [view]
15. Olsen MK, Delong ER, Oddone EZ, Bosworth HB. Strategies for analyzing multilevel cluster-randomized studies with binary outcomes collected at varying intervals of time. Statistics in medicine. 2008 Dec 20; 27(29):6055-71. [view]
16. 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 Oct 1; 17(5):592-608. [view]
17. Powers BJ, Olsen MK, Oddone EZ, Bosworth HB. The effect of a hypertension self-management intervention on diabetes and cholesterol control. The American journal of medicine. 2009 Jul 1; 122(7):639-46. [view]
18. 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 Apr 1; 26(2):155-68. [view]

Book Chapters

1. Bosworth HB. Hypertension and Blood Pressure Control. In: Miller JR, Lerner RM, Schiamberg LB, Anderson PM, editors. The Encyclopedia of Human Ecology. Vol. 1 ed. Santa Barbara, CA: ABC-Clio; 2003. 388-391 p. [view]

Conference Presentations

1. Bosworth HB, Olsen MK, Dudley TK, Goldstein KM, Orr MM, Oddone EZ. Antihypertensive medication adherence: Racial, clinical and psychological factors. Paper presented at: VA HSR&D National Meeting; 2004 Mar 1; Washington, DC. [view]
2. Chan AS, Martins SB, Coleman RW, Shlipak MG, Bosworth HB, Oddone EZ, Hoffman BB, Goldstein KM. Barriers to clinician hypertension guideline adherence identified from clinician comments entered into an automated decision support system. Paper presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2004 May 1; Washington, DC. [view]
3. Chan AS, Steinman MA, Fischer MA, Shlipak MG, Bosworth HB, Oddone EZ, Martins SB, Coleman RW, Hoffman BB, Goldstein KM. Clinician experience with the Athena DSS Hypertension Management System: Facilitators and Barriers to Guideline compliance. Paper presented at: American Heart Association Compliance in Healthcare and Research Scientific Annual Conference; 2004 May 1; Washington, DC. [view]
4. Chan AS, Martins S, Bosworth HB, Oddone EZ, Schlipak MG, Goldstein KM. Clinician feedback of a guideline-based decision support systems and identification of areas for improvement in patient safety and quality of clinical information. Paper presented at: Society for Medical Decision Making Annual Meeting; 2003 Oct 1; Chicago, IL. [view]
5. Jackson GL, Bosworth HB, Powers BJ, Maciejewski ML, Edelman D. Do the Economic Benefits of Participation in Disease Management Trials Persist After Trial Completion? Paper presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA. [view]
6. Goldstein KM, Chan AS, Martins SB, Coleman RW, Shlipak MG, Bosworth HB, Oddone EZ, Musen MA, EON Investigators, Hoffman BB. Innovation in Practice: ATHENA DSS hypertension management system. Paper presented at: Society of General Internal Medicine Annual Meeting; 2004 May 1; Chicago, IL. [view]
7. Maciejewski, Thorpe, Bryson, Bosworth. Medication Acquisition and Blood Pressure Control in Older Veterans with Hypertension. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 7; Washington, DC. [view]
8. Bosworth HB, Olsen MK, Gentry P, Orr MM, Dudley TK, McCant FA, Oddone EZ. Nurse Administered Telephone Intervention for Blood Pressure Control: A Patient-Tailored Multifactorial Intervention. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2004 Nov 15; Washington, DC. [view]
9. Bosworth HB, Olsen MK, Dudley T, Goldstein M, Orr M, Gentry P, McCant F, Oddone EZ. Nurse administered, patient-tailored, telephone intervention for blood pressure control. Paper presented at: AcademyHealth Annual Research Meeting; 2005 Jun 2; Boston, MA. [view]
10. Bosworth HB, Bartash RM, Olsen MK, Steffens DC. The relationship between depression and hypertension among older adults. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2003 Nov 1; San Diego, CA. [view]
11. Bosworth HB, Olsen M, Dudley T, Orr M, Goldstein MK, Datta S, McMcant F, Gentry P, Simel D, Oddone E. The Veterans' Study to Improve the Control of Hypertension (V-STITCH): A patient and provide intervention to improve blood pressure control. Paper presented at: VA HSR&D National Meeting; 2007 Feb 15; Arlington, VA. [view]
12. Olsen M. Using Mixed Effects Logistic Regression Models for the Analysis of Blood Pressure Control in a Clustered and Longitudinal Trial. Paper presented at: VA HSR&D National Meeting; 2007 Feb 15; Arlington, VA. [view]
13. Chan AS, Steinman MA, Fischer MA, Shlipak MG, Bosworth HB, Oddone EZ, Hoffman BB, Goldstein KM. Will physicians accept a decision support system for hypertension management (ATHENA DSS). Paper presented at: Society of General Internal Medicine Annual Meeting; 2004 May 1; Chicago, IL. [view]
14. Goldstein KM, Shlipak MG, Oddone EZ, Bosworth HB, Martins S, Yiu H, Musen MA, Tu S, Shankar R, Hoffman BB. Will primary care clinicians use automated decision support? Paper presented at: Society for Medical Decision Making Annual Meeting; 2003 Oct 1; Chicago, IL. [view]

DRA: Health Systems
DRE: Epidemiology, Prevention
Keywords: Cardiovasc’r disease, Decision support, Education (patient), Hypertension
MeSH Terms: Intervention Studies, Behavior and Behavior Mechanisms