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CPG 97-006 – HSR&D Study

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CPG 97-006
Guidelines for Drug Therapy of Hypertension: Closing the Loop
Mary K. Goldstein MD MS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: January 1998 - September 2000

BACKGROUND/RATIONALE:
Hypertension is a major risk factor for heart disease and stroke. Evidence-based guidelines support the use of specific drugs for patients with specific comorbidities to maximize the decrease in cardiovascular risk; yet, many physicians do not follow these guidelines in choosing drug therapy.

OBJECTIVE(S):
The goal of this project was to evaluate methods of implementing clinical practice guidelines, using hypertension as a model. We hypothesized that providing patient-specific recommendations to clinicians at the time of clinic contact with hypertensive patients would substantially improve guideline concordance of drug therapy without adversely affecting (possibly improving) blood pressure control. Our long-term goal is to develop and evaluate methods of implementing clinical practice guidelines that build on current knowledge about the most effective approaches to changing clinician behavior, and to extend those methods to other cardiovascular diseases.

METHODS:
This project, known as ATHENA, included two major components: (1) We conducted a randomized controlled trial of patient-specific recommendations about drug therapy for hypertension, delivered to primary care clinicians at the time of primary care clinic visits. The recommendations were based on VA Hypertension Guidelines. The trial included 36 clinicians and 4500 hypertensive patients enrolled in primary care clinics at VA Palo Alto Health Care System. We compared a general intervention to an individualized intervention. Both the general and the intervention groups of clinicians received extensive guideline education, as part of a VISN-mandated hypertension guideline implementation. Clinicians randomized to the individualized intervention received, in addition, computer-generated patient-specific recommendations about drug therapy of hypertension, delivered to the clinics with the encounter forms for each visit. (2) In the 2nd major component of the study, we collaborated with Stanford Medical Informatics to develop a hypertension decision support system (ATHENA DSS). ATHENA DSS combines detailed patient information from the VA electronic medical record (VistA) with hypertension guideline knowledge based on the VA and JNC 6 hypertension guidelines. A special feature of ATHENA DSS is that the knowledge in the system can be easily browsed and updated by clinician-managers, so that knowledge can be kept up to date with emerging clinical trial findings about best treatments. We developed an infrastructure to implement the system in a pop-up window in the CPRS-GUI in the primary care clinics at VA Palo Alto. We also conducted an offline test of the program logic by comparing the ATHENA DSS recommendations with those made by a physician for 100 randomly selected VA patients.

FINDINGS/RESULTS:
(1) In the randomized trial, we found that both study groups of clinicians had a significant increase in rate of guideline-concordant therapy as compared with baseline, and that the individualized intervention group had a statistically significantly greater improvement than the general group (10.8% vs 4%, p=0.01). Average blood pressure of hypertensives patients decreased significantly in both groups. (2) ATHENA DSS was successfully implemented in the clinics at VA Palo Alto. Offline testing of 100 cases detected no errors in program logic, and identified some areas for refinement of the knowledge that have since been made. ATHENA DSS is now ready for use as the source of recommendations in a multisite VA trial of hypertension guideline implementation.

IMPACT:
Our hypertension guideline implementation using patient-specific recommendations sent to primary care clinicians improved drug choice for treatment of hypertension, which potentially can improve cardiovascular outcomes. The guideline implementation was also associated with improved control of blood pressure, which is important for lowering the risk of cardiovascular disease. These findings support the value of patient-specific recommendations to clinicians as a method of guideline implementation to improve patient care. The ATHENA decision support system we have developed can potentially be used throughout the VA as a source of guideline recommendations for hypertension, and it can be extended to other diseases. Because it can be easily updated, it can generate recommendations that provide the most current evidence-based information about effective clinical management.

PUBLICATIONS:

Journal Articles

  1. Tu SW, Hrabak KM, Campbell JR, Glasgow J, Nyman MA, McClure R, McClay J, Abarbanel R, Mansfield JG, Martins SM, Goldstein MK, Musen MA. Use of declarative statements in creating and maintaining computer-interpretable knowledge bases for guideline-based care. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2006 Nov 1; 784-8.
  2. 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.
  3. Goldstein MK, Lavori P, Coleman R, Advani A, Hoffman BB. Improving adherence to guidelines for hypertension drug prescribing: cluster-randomized controlled trial of general versus patient-specific recommendations. The American journal of managed care. 2005 Nov 1; 11(11):677-85.
  4. Advani A, Goldstein M, Musen MA. A framework for evidence-adaptive quality assessment that unifies guideline-based and performance-indicator approaches. Proc AMIA Symp. 2002 Nov 1; 2-6.
  5. Shankar RD, Martins SB, Tu SW, Goldstein MK, Musen MA. Building an explanation function for a hypertension decision-support system. Medinfo. 2001 Oct 1; 10(Pt 1):538-42.
  6. Goldstein MK, Hoffman BB, Coleman RW, Tu SW, Shankar RD, O'Connor M, Martins S, Martins S, Advani A, Musen MA. Patient safety in guideline-based decision support for hypertension management: ATHENA DSS. Proc AMIA Symp. 2001 Jan 1; 214-8.
  7. Shankar RD, Tu SW, Martins SB, Fagan LM, Goldstein MK, Musen MA. Integration of textual guideline documents with formal guideline knowledge bases. Proc AMIA Symp. 2001 Jan 1; 617-21.
  8. Goldstein MK, Hoffman BB, Coleman RW, Musen MA, Tu SW, Advani A, Shankar R, O'Connor M. Implementing clinical practice guidelines while taking account of changing evidence: ATHENA DSS, an easily modifiable decision-support system for managing hypertension in primary care. Proc AMIA Symp. 2000 Jan 1; 300-4.
  9. Advani A, Tu S, O'Connor M, Coleman R, Goldstein MK, Musen M. Integrating a modern knowledge-based system architecture with a legacy VA database: the ATHENA and EON projects at Stanford. Proc AMIA Symp. 1999 Nov 1; 653-7.
Conference Presentations

  1. Goldstein MK, Miller DE, Davies S, Garber AM. Quality of life assessment software for computer-inexperienced older adults: multimedia utility elicitation for activities of daily living. Paper presented at: American Medical Informatics Association Annual Symposium; 2002 Jul 12; San Antonio, TX.
  2. Coleman R, Goldstein M, Hoffman B, Musen M. Athena: A decision support system for hypertension. Paper presented at: VA Information Technology Annual Conference; 2000 Aug 7; Austin, TX.
  3. Goldstein MK, Coleman RW, Munroe P, Gholami P, Hoffman B. Impact of hypertension guideline implementation on patients. Paper presented at: VA HSR&D National Meeting; 2000 Mar 22; Washington, DC.
  4. Goldstein MK, Coleman R, Advani A, Munroe P, Gholami P, Lavori PW. Implementing practice guidelines for hypertension: Effect of computer generated patient-specific recommendations for drug therapy. Paper presented at: Society for Medical Decision Making Annual Meeting; 1999 Oct 1; Reno, NV.


DRA: Health Systems
DRE: none
Keywords: Clinical practice guidelines, Decision support, Primary care
MeSH Terms: Primary Health Care