BACKGROUND/RATIONALE:
Despite the impact of hypertension and the availability of well-defined therapies and widely accepted target values for blood pressure (BP), interventions to improve BP control have had limited success.

OBJECTIVE(S):
The study is one of the first to compare three interventions designed to improve BP control: a behavioral educational intervention, an evidence-based medication management intervention, and combined intervention for patients with poor BP control defined by home BP monitoring. We received an 11 month extension to evaluate 3 key components of the study (sustainability of BP effects, qualitative evaluation of the intervention, evaluation of the supporting materials used to ensure literacy levels and cultural sensitivity.)

METHODS:
A 4-arm randomized trial with 18-month follow-up. Patents were selected from primary care clinics at the Durham VA Medical Center. Of the 1551 eligible patients, 591 individuals were randomized to either usual care or one of three telephone-based intervention groups. The intervention phone calls were triggered based on home BP values transmitted via telemonitoring devices. Patients were instructed to take their BP three times a week and transmit to study team. Behavioral management involved promoting health behaviors. Medication management involved adjustment of hypertension medications by a study physician and nurse based on hypertension treatment guidelines. The primary outcome was changes in BP control measured at six-month intervals over 18 months. For the sustainability extension of the study, in additional to collection of BP values, we will use qualitative analysis to examine the audio interviews.

FINDINGS/RESULTS:
We enrolled 591 participants and randomized 147 to usual care, 148 to behavioral intervention, 159 to a medication management intervention, and 147 to a combined behavioral medication management intervention. The average age was 61 years (SD=12); 49% were African American; 38% had limited health literacy. Baseline systolic and diastolic BP was 129/77. 503 (85%) completed the 18-month follow-up. Both the behavioral management and medication management alone showed significant improvement, 13.3% (95% CI: 2.0%, 24.5%) and 13.5% (95% CI: 2.4% 24.6%), respectively at 12 months All intervention groups improved in systolic BP at 12 months relative to usual care, but only the combined group was significant -4.3 mm Hg (95% -8.5 to -0.2). By 18 months, there were no statistically significant differences in either BP control or systolic BP for the intervention groups compared to usual care.

We enrolled 42 participants in the sustainability phase of the study. Primary themes suggest that awareness of BP values, understanding of diet, exercise, weight, smoking, education about hypertension and consistency of nurse calls influenced behavioral change.

IMPACT:
Each intervention group demonstrated improvements in BP control or systolic BP at 12 months, but the improvements were not sustained at 18 months. None of the intervention groups increased health care use and the cost of the interventions was approximately $1,200 per patient over 18 months. Further work is required to identify individuals who will likely most benefit from this more intensive model of behavioral and medication management interventions in non-clinical settings.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Crowley MJ, Olsen MK, Woolson SL, King HA, Oddone EZ, Bosworth HB. Baseline Antihypertensive Drug Count and Patient Response to Hypertension Medication Management. Journal of clinical hypertension (Greenwich, Conn.). 2016 Apr 1; 18(4):322-8. [view]
2. Bowen ME, Bosworth HB, Roumie CL. Blood pressure control in a hypertension telemedicine intervention: does distance to primary care matter? Journal of clinical hypertension (Greenwich, Conn.). 2013 Oct 1; 15(10):723-30. [view]
3. Wang V, Smith VA, Bosworth HB, Oddone EZ, Olsen MK, McCant F, Powers BJ, Van Houtven CH. Economic evaluation of telephone self-management interventions for blood pressure control. American heart journal. 2012 Jun 1; 163(6):980-6. [view]
4. Crowley MJ, Grubber JM, Olsen MK, Bosworth HB. Factors associated with non-adherence to three hypertension self-management behaviors: preliminary data for a new instrument. Journal of general internal medicine. 2013 Jan 1; 28(1):99-106. [view]
5. McCant F, McKoy G, Grubber J, Olsen MK, Oddone E, Powers B, Bosworth HB. Feasibility of blood pressure telemonitoring in patients with poor blood pressure control. Journal of telemedicine and telecare. 2009 Jan 1; 15(6):281-5. [view]
6. Bosworth HB, Powers BJ, Olsen MK, McCant F, Grubber J, Smith V, Gentry PW, Rose C, Van Houtven C, Wang V, Goldstein MK, Oddone EZ. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Archives of internal medicine. 2011 Jul 11; 171(13):1173-80. [view]
7. Bosworth HB, Olsen MK, McCant F, Harrelson M, Gentry P, Rose C, Goldstein MK, Hoffman BB, Powers B, Oddone EZ. Hypertension Intervention Nurse Telemedicine Study (HINTS): testing a multifactorial tailored behavioral/educational and a medication management intervention for blood pressure control. American heart journal. 2007 Jun 1; 153(6):918-24. [view]
8. Powers BJ, Olsen MK, Smith VA, Woolson RF, Bosworth HB, Oddone EZ. Measuring blood pressure for decision making and quality reporting: where and how many measures? Annals of internal medicine. 2011 Jun 21; 154(12):781-8, W-289-90. [view]
9. 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]
10. Jackson GL, Oddone EZ, Olsen MK, Powers BJ, Grubber JM, McCant F, Bosworth HB. Racial differences in the effect of a telephone-delivered hypertension disease management program. Journal of general internal medicine. 2012 Dec 1; 27(12):1682-9. [view]
11. Powers BJ, Danus S, Grubber JM, Olsen MK, Oddone EZ, Bosworth HB. The effectiveness of personalized coronary heart disease and stroke risk communication. American heart journal. 2011 Apr 1; 161(4):673-80. [view]
12. Zullig LL, Melnyk SD, Goldstein K, Shaw RJ, Bosworth HB. The role of home blood pressure telemonitoring in managing hypertensive populations. Current Hypertension Reports. 2013 Aug 1; 15(4):346-55. [view]
13. Crowley MJ, Smith VA, Olsen MK, Danus S, Oddone EZ, Bosworth HB, Powers BJ. Treatment intensification in a hypertension telemanagement trial: clinical inertia or good clinical judgment? Hypertension. 2011 Oct 1; 58(4):552-8. [view]

VA Cyberseminars

1. Goldstein MK. ATHENA Clinical Decision Support System: Aspects of Design and Implementation. [Cyberseminar]. 2010 Feb 18. [view]

Conference Presentations

1. Crowley M, Grubber J, Olsen MK, Bosworth HB. A simple instrument for evaluating the likelihood of medication, diet, and exercise non-adherence in Veterans with hypertension. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD. [view]
2. Bosworth HB. Defining and measuring adherence outcomes. Paper presented at: VA Optimizing Adherence Summit; 2010 Jul 15; Chicago, IL. [view]
3. Datta SK, Oddone EZ, Olsen MK, Orr M, McCant F, Gentry P, Simel DL, Bosworth HB. Economic analysis of a tailored behavioral intervention to improve blood pressure control in a Veterans Primary Care sample. Poster session presented at: AcademyHealth Annual Research Meeting; 2007 Jun 4; Orlando, FL. [view]
4. Goldstein MK. From Evidence to Patient Care: Decision Support with Actionable Guidelines. Paper presented at: Agency for Healthcare Research and Quality Annual Conference; 2009 Nov 12; Rockville, MD. [view]
5. Bosworth HB. Hypertension Intervention Nurse Telemedicine Study (HINTS). Paper presented at: Future of Telehealth: Essential Tools and Technologies for Clinical Research and Care Conference; 2009 Jun 23; Bethesda, MD. [view]
6. Bosworth HB, Powers BJ, Olsen MK, Grubber J, Gentry PW, Rose CM, Goldstein MK, Oddone EZ. Hypertension Intervention Nurse Telemedicine Study (HINTS): Testing a multifactorial tailored behavioral/educational and a medication management intervention for blood pressure control. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 29; Minneapolis, MN. [view]
7. McCant FA, Olsen MK, Powers BJ, Oddone EZ, Bosworth HB. Is Telemonitoring a Panacea for Chronic Care? Feasibility of Blood pressure telemonitoring in patients with poor blood pressure control. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD. [view]
8. Crowley M, Smith V, Danus SM, Oddone EZ, Bosworth HB, Powers BJ. Lack of Treatment Intensification in a Trial of Home Telemonitoring and Medication Management: Clinical Inertia or Good Clinical Judgment? Paper presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD. [view]
9. Powers BJ, Olsen MK, Smith V, Woolson RF, Bosworth HB, Oddone EZ. Measuring Blood Pressure for Decision Making and Quality Reporting: Where and How Many Measures? Paper presented at: Society of General Internal Medicine Annual Meeting; 2011 May 6; Phoenix, AZ. [view]
10. Muir KW, Bosworth HB. Progression of Diabetic Retinopathy in the Hypertension Intervention Nurse Telemedicine Study. Poster session presented at: VA Durham VAMC Annual Research Week; 2013 May 15; Durham, NC. [view]
11. Bosworth HB, Olsen MK, Grubber J, Powers BJ, Oddone EZ. Racial differences in two self-management hypertension interventions. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 29; Minneapolis, MN. [view]
12. Bosworth HB, Allen KD, Edelman D, Oddone EZ. Self-Management Interventions for Patients with Chronic Illness. Paper presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA. [view]
13. Thorpe CT, Powers, Oddone, Bosworth. The effect of emotional health status on multiple illness self-management behaviors in veterans with hypertension. Poster session presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2008 May 1; San Diego, CA. [view]
14. Crowley M, Olsen MK, King HA, Powers BJ, Oddone EZ, Bosworth HB. The impact of baseline antihypertensive burden on response to medication and behavior management interventions for hypertension. Poster session presented at: VA Durham VAMC Annual Research Week; 2014 May 13; Durham, NC. [view]
15. Bosworth HB. The Use of Telemedicine to Improve Access and Quality Care in the VHA: Case Studies. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA. [view]
16. Simmons D, Bosworth HB. Understanding contributors to racial differences in varying levels of blood pressure control in Durham, North Carolina. Poster session presented at: VA Clinical and Translational Science Awards Annual Meeting; 2011 Apr 27; Washington, DC. [view]

DRA: Health Systems
DRE: Treatment - Observational
Keywords: Behavior (patient), Hypertension, Telemedicine
MeSH Terms: none