Achieving 70% Hypertension Control: How Hard Can It Be?

      Background

      Although decades of research support hypertension treatment, studies guiding the successful implementation of programs to control blood pressure (BP) in real-world primary care settings are sparse.

      Methods

      In this study a multicomponent intervention was implemented, with the following goals: (1) achieve 70% control of hypertension within 18 months, (2) use the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to evaluate the implementation of the program, and (3) assess additional actions that could have been undertaken to achieve control among those who remained uncontrolled.

      Results

      Of 786 patients, 597 achieved BP control (75.9%; improvement of 20.9 percentage points). For RE-AIM outcomes, (1) staff performed outreach for all uncontrolled patients, with 75.3% making follow-up appointments, and 61.3% attending at least one appointment; (2) the proportion of faculty with at least 70% control increased from 26.7% to 87.5%, indicating significant physician adoption; (3) implementation outcomes were mixed, with four of six medical assistant BP training sessions completed, outreach calls performed in 16 of 18 months, but only 24 patients referred to the patient counseling and medication management program. For maintenance, 70% control was maintained for a 7-month observation period. The research team determined that 16.8% of those uncontrolled could have had additional actions taken to achieve control.

      Conclusion

      The goal of 70% control was achieved, improving control by 20.9 percentage points over 18 months. The RE-AIM framework evaluation demonstrated successful implementation and likely contributed to achievement of the target. The chart review findings revealed that a minority of patients could have additional interventions provided by the primary care practice.
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Joint Commission Journal on Quality and Patient Safety
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Whelton PK
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
        Hypertension. 2018; 71 (Erratum in: Hypertension. 2018;71:e140–e144): e13-e115
      1. Glynn LG, Murphy AW, Smith SM, Schroeder K and Fahey T. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. 2010 Mar 17:CD005182.

        • Merai R
        • et al.
        CDC grand rounds: a public health approach to detect and control hypertension.
        MMWR Morb Mortal Wkly Rep. 2016 Nov 18; 65: 1261-1264
        • Go AS
        • et al.
        An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention.
        J Am Coll Cardiol. 2014 Apr 1; 63: 1230-1238
        • Phillips LS
        • et al.
        Clinical inertia.
        Ann Intern Med. 2001 Nov 6; 135: 825-834
        • Okonofua EC
        • et al.
        Therapeutic inertia is an impediment to achieving the Healthy People 2010 blood pressure control goals.
        Hypertension. 2006; 47: 345-351
        • Yarnall KSH
        • et al.
        Primary care: is there enough time for prevention?.
        Am J Public Health. 2003; 93: 635-641
        • Yuguero O
        • et al.
        Occupational burnout and empathy influence blood pressure control in primary care physicians.
        BMC Fam Pract. 2017 May 12; 18: 63
        • Boonyasai RT
        • et al.
        Measure accurately, act rapidly, and partner with patients: an intuitive and practical three-part framework to guide efforts to improve hypertension control.
        J Clin Hypertens (Greenwich). 2017; 19: 684-694
        • Jaffe MG
        • et al.
        Improved blood pressure control associated with a large-scale hypertension program.
        JAMA. 2013 Aug 21; 310: 699-705
        • Choma NN
        • et al.
        Quality improvement initiatives improve hypertension care among veterans.
        Circ Cardiovasc Qual Outcomes. 2009; 2: 392-398
      2. Million Hearts. Home page. (Updated: Apr 7, 2020.) Accessed Apr 29, 2020. https://millionhearts.hhs.gov/.

      3. COPrevent. American Heart Association SouthWest Affiliate Releases RFP. Oct 8, 2015. Accessed Apr 29, 2020. http://www.coprevent.org/2015/10/american-heart-association-southwest.html.

      4. Target: BP™. Early Adopters: Celebrating One-Year Anniversary. 2016. Accessed Apr 29, 2020. https://targetbp.org/recognition-program/early-adopters/.

      5. Ivers N, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012 Jun 13:CD000259.

      6. Target: BP. 7 Simple Tips to Get an Accurate Blood Pressure Reading. (Updated: Dec 2016.) Accessed Apr 29, 2020. https://targetbp.org/wp-content/uploads/2017/02/Measuring-blood-pressure-new.pdf.

        • Rakotz MK
        • et al.
        Medical students and measuring blood pressure: results from the American Medical Association Blood Pressure Check Challenge.
        J Clin Hypertens (Greenwich). 2017; 19: 614-619
        • Garcia-Peña C
        • et al.
        Pragmatic randomized trial of home visits by a nurse to elderly people with hypertension in Mexico.
        Int J Epidemiol. 2001; 30: 1485-1491
        • Halme L
        • et al.
        Self-monitoring of blood pressure promotes achievement of blood pressure target in primary health care.
        Am J Hypertens. 2005; 18: 1415-1420
        • Haynes RB
        • et al.
        Improvement of medication compliance in uncontrolled hypertension.
        Lancet. 1976 Jun 12; 1: 1265-1268
        • Niiranen TJ
        • et al.
        Lack of impact of a comprehensive intervention on hypertension in the primary care setting.
        Am J Hypertens. 2014; 27: 489-496
        • Gaglio B
        • Shoup JA
        • Glasgow RE
        The RE-AIM framework: a systematic review of use over time.
        Am J Public Health. 2013; 103: e38-e46
        • James PA
        • et al.
        2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
        JAMA. 2014 Feb 5; 311: 507-520
        • Sacks FM
        • et al.
        Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH–Sodium Collaborative Research Group?.
        N Engl J Med. 2001 Jan 4; 344: 3-10
        • Tobe SW
        • et al.
        Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial.
        CMAJ. 2006 Apr 25; 174: 1267-1271
        • Glasgow RE
        • Vogt TM
        • Boles SM
        Evaluating the public health impact of health promotion interventions: the RE-AIM framework.
        Am J Public Health. 1999; 89: 1322-1327
      7. Centers for Disease Control and Prevention. Press Release: Million Hearts Recognizes the 2017 Hypertension Control Champions. Nov 7, 2017. Accessed Apr 29, 2020. https://www.cdc.gov/media/releases/2017/p1107-hypertension-control-champs.html.

      8. Million Hearts. About the Hypertension Control Champions. (Updated: Apr 24, 2020.) Accessed Apr 29, 2020. https://millionhearts.hhs.gov/partners-progress/champions/list.html#Champions.

      9. Centers for Disease Control and Prevention. Hypertension Prevalence and Control Among Adults: United States, 2015–2016. Fryar CD, et al. NCHS Data Brief, No. 289. Oct 2017. Accessed Apr 2p, 2020. https://www.cdc.gov/nchs/data/databriefs/db289.pdf.

        • Fontil V
        • et al.
        Adapting and evaluating a health system intervention from Kaiser Permanente to improve hypertension management and control in a large network of safety-net clinics.
        Circ Cardiovasc Qual Outcomes. 2018; 11: e004386