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TRH 01-038 – HSR&D Study

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TRH 01-038
Improving Hypertension Control: A Physician Intervention
Nancy R. Kressin PhD
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
Bedford, MA
Funding Period: April 2001 - March 2003

BACKGROUND/RATIONALE:
Hypertension affects nearly 50 million Americans, and is more frequent among African Americans than whites. Despite the importance of treating hypertension, studies have persistently shown that most patients with established hypertension have poorly controlled blood pressure, and that African Americans are disproportionately represented among this group.

OBJECTIVE(S):
In order to improve physician management of hypertension and to improve patients’ compliance with prescribed anti-hypertensive medication, we will conduct a three-armed facility based intervention trial. We will implement a computer-based reminder system identifying uncontrolled hypertensive patients for physicians and a proven intervention strategy teaching physicians to advise and counsel patients about hypertension control. We expect that improving hypertension care in general will improve the care provided to both white and African American patients, but as a secondary aim of this study we will examine whether such improvements will also decrease racial disparities in the three domains described below.

METHODS:
In one facility we will implement only the reminder system, in a second facility we will implement both the reminder system and the patient-centered counseling education program, and in the third (control group) we will only provide information about hypertension management through a grand rounds presentation. To assess outcomes in each site, we will assess the baseline (pre-intervention) blood pressure readings for hypertensive patients, and patient compliance with prescribed medications. Six and twelve months subsequent to the interventions, we will reassess each of these outcomes. Through exit interviews with a random sample of eligible patients, we will also assess physicians’ provision of advice and counseling about antihypertensive medications as well as self-reported medication compliance. In a small subsample of patients at each site, we will also audiotape interactions between patients and providers, to qualitatively examine patterns of communication.

FINDINGS/RESULTS:
Preliminary results from the pilot phase of this work suggest some interesting trends in racial differences regarding attitudes about antihypertensive medication and clinicians' counseling of patients regarding such therapies. For example, we found that African Americans (AA's) were more likely to report that they forgot their medications 2 or more days (10% AA's vs. 3% whites), and that they intentionally chose not to take medications (6% AA's vs. 0% whites). African American patients more often reported that their physician did not discuss their blood pressure (17% vs. 10%), but they also more often reported that their physicians did ask about problems taking blood pressure medications (54% vs. 35%), past efforts to get better at taking blood pressure medications (52% vs. 36%), barriers to taking such medications (34% vs. 21%), and strategies for improving medication adherence (45% vs. 33%). African Americans were less likely to say they agreed with their physicians regarding goals for taking blood pressure medications (53% vs. 63%), and physicians were less likely to tell African Americans to make a new appointment for blood pressure care (45% vs. 71%).

IMPACT:
Information gleaned from this study will help identify whether improving communication between patients and physicians will improve rates of hypertension control and medication adherence.

PUBLICATIONS:

Journal Articles

  1. Rose AJ, Shimada SL, Rothendler JA, Reisman JI, Glassman PA, Berlowitz DR, Kressin NR. The accuracy of clinician perceptions of "usual" blood pressure control. Journal of general internal medicine. 2008 Feb 1; 23(2):180-3.
  2. Rose AJ, Berlowitz DR, Orner MB, Kressin NR. Understanding uncontrolled hypertension: is it the patient or the provider? Journal of clinical hypertension (Greenwich, Conn.). 2007 Dec 1; 9(12):937-43.
  3. Kressin NR, Wang F, Long J, Bokhour BG, Orner MB, Rothendler JR, Clark C, Reddy S, Kozak W, Kroupa LP, Berlowitz DR. Hypertensive patients' race, health beliefs, process of care, and medication adherence. Journal of general internal medicine. 2007 Jun 1; 22(6):768-74.
  4. Bokhour BG, Berlowitz DR, Long JA, Kressin NR. How do providers assess antihypertensive medication adherence in medical encounters? Journal of general internal medicine. 2006 Jun 1; 21(6):577-83.
  5. Kressin NR, Chang BH, Hendricks A, Kazis LE. Agreement between administrative data and patients' self-reports of race/ethnicity. American journal of public health. 2003 Oct 1; 93(10):1734-9.
Conference Presentations

  1. Fix GM, Solomon J, Cortes D, Cohn ES, Bokhour BG. When I found out I had all the sickness, hypertensive patient experiences integrating management of co-occurring health conditions. Paper presented at: American Anthropological Association Society for Medical Anthropology International Conference; 2009 Aug 24; New Haven, CT.
  2. Rose AJ, Shimada SL, Rothendler JA, Reisman JI, Glassman PA, Berlowitz DR, Kressin NR. The Accuracy of Clinician Perceptions of "Usual" Blood Pressure Control. Paper presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD.
  3. Rose AJ, Berlowitz DR, Orner MB, Kressin NR. Understanding Uncontrolled Hypertension: Is it the Patient or the Provider? Poster session presented at: Society of General Internal Medicine Annual Meeting; 2007 Apr 1; Toronto, Canada.
  4. Kressin NR, Orner MD, Wang F, Long JA, Clark C, Reddy S, Kroupa L, Bokhour B, Rothendler J, Belowitz D. Racial differences in antihypertensive medication adherence, attitudes, beliefs, and experiences with blood pressure care. 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.


DRA: Health Systems
DRE: Technology Development and Assessment, Treatment - Observational
Keywords: Behavior (provider), Translation
MeSH Terms: none

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