TY - JOUR
AU - Peterson, Eric D.
AB - Hypertension is the most common reversible cardiovascular disease risk factor in the United States and around the world. By 2025, it is predicted that more than 1.5 billion individuals worldwide will have hypertension, accounting for up to 50% of heart disease risk and 75% of stroke risk.1,2 Yet the ravages of hypertension are potentially preventable. For several decades, it has been well known that lowering blood pressure (BP) with lifestyle modification, medications, or both can substantially reduce a patient's subsequent risk for disease.3 For each 10-mm Hg decrease in systolic BP, the average risk of heart disease mortality and cerebrovascular disease mortality decreases by 30% and 40%, respectively.4 Despite effective therapies and proven benefits, only about one-third of patients with hypertension in the United States have their BP lowered to target goals. While control rates have increased slightly over time from 23% in 1999 to 35% in 2004,5 it is unlikely that current management strategies will achieve the Healthy People 2010 modest goal of 50%.6 Both patient and physician factors contribute to the inability to control BP. Prominent on the physician side is clinical inertia, defined as the clinician's “failure to increase therapy when the treatment goals are unmet.”6,7 Patients also have their own issues of inertia and denial when dealing with this silent disorder, manifest by failing to adhere to prescribed therapies or to return for follow-up. Improving patient-physician feedback and information exchange has been suggested as a means of overcoming both forms of inertia.7 A method should be available to allow patients and clinicians to routinely evaluate patients’ responses to therapies and progress toward target goals. Yet, due to time limitations, costs, and other factors, such close follow-up is practically impossible in today's busy clinic setting. In this issue of JAMA, Green and colleagues8 explore whether 2 non–clinic-based interventions could facilitate a collaborative model of care management and thereby lead to improved hypertension control. The first intervention involved providing patients with uncontrolled BP with a home BP monitor and use of a secure Web service (for exchange of information with clinicians). The second intervention gave patients the use of the Web service and a home BP monitor plus the services of a personal clinical pharmacist. The use of the Internet by these investigators was certainly novel, yet their interventions share commonalities with many disease management strategies. The interventions were designed to encourage frequent home measurement, and thus engaged the patient in his or her care. The interventions also encouraged closer communication between the patient and his or her clinician or clinician representative, and generally relied on guideline-driven care algorithms and treatment plans. How successful were these interventions? By 1 year, target BP control had increased to 36% among those randomized to the group receiving the Web service and BP monitoring; yet this control rate was not significantly higher than that seen among those receiving usual clinic care (31%); and was significantly lower than that achieved by those receiving the Web service and home BP monitoring plus pharmacist care (56%).8 The study has several strengths. The evaluation was tested under a rigorous randomized design to ensure balance among the 3 treatment groups. Assessment of the primary outcome of 1-year BP was performed in a blinded fashion to limit observer measurement bias. The study also carefully monitored multiple secondary end points including changes in medication regimens, health-related quality of life, adverse events, resource use, and patient satisfaction. In addition, and perhaps most important, the investigators measured the degree to which the interventions affected patient-clinician communications (e-mail message threads) during the follow-up period. This later information turned out to be key to understanding the reason(s) for the varied success of the interventions. While the study is internally valid, certain aspects of the study population and setting make external extrapolation of the study findings challenging. The patients enrolled were atypical relative to many US patients with hypertension: being younger (average age of 59 years), with fewer blacks (<10%), and a majority with post–high school education, Internet access, and full-time employment. As such, it remains unclear whether the study's Web-based interventions would have similar applicability if offered to older, less educated, or less Internet-savvy patients. Study patients also had health insurance and prescription coverage, thus eliminating financial constraints that can seriously affect treatment options among many patients with hypertension. Moreover, the study was conducted within a closed, integrated health system that facilitated care coordination, a feature lacking in typical community practice. As a reflection of these special conditions, more than 60% of the plan's patients with hypertension who were screened for the study had controlled BP at baseline (almost twice the national average). Why did the Web service and BP monitoring system fail to significantly improve BP control beyond usual care? There are several potential explanations. First, up to half of the patients with uncontrolled BP enrolled in the study already owned a BP monitor. Thus, the study enrolled a population for whom home monitoring had, in effect, previously failed. Second, the Web service and BP monitoring was compared with a usual care group, yet this comparator also experienced marked improvement in BP during the follow-up period. This improvement likely represents the well-known Hawthorne effect, in which patients and their physicians respond differently when informed that BP control would be carefully evaluated over time. Third, and perhaps most noteworthy, the Web-based intervention appeared to lack “stickiness,”9 the ability of an application to be consistently used over time. While a prime goal of the Web site was to facilitate communication, those randomized to the Web service and home BP monitoring group had only slightly more annual patient-clinician message threads than the control (3.3 vs 2.4 threads). Because the Web service and BP monitoring failed to augment active patient-clinician dialog, it was not surprising that it also had limited incremental benefit on BP control. Possibilities for why the Web intervention lacked stickiness may be due to 1 or more of the following: ineffective patient or clinician Web training, a nonintuitive Web site, limited perceived Web application benefits, the ease of traditional communication options (ie, telephone), or a failure of clinicians to provide timely responses to patient e-mail (ie, communication requires 2-way exchange). In contrast, why did the addition of a pharmacist markedly improve BP control? One reason may be the pharmacist's expertise in formulating and implementing evidence-based hypertension care plans. Yet an alternative explanation is that frequent patient contacts with a pharmacist stimulated patient engagement. As proof, the patients receiving the Web service and BP monitoring plus pharmacist care had significantly more Web interchanges with their clinicians (an average of 22 e-mail threads annually) relative to the other 2 groups. It remains to be seen whether a human content expert is required for the system's success or whether less costly, programmed reminder e-mail or electronic exception management prompts could have achieved similar degrees of BP control. Another important consideration raised by the study by Green et al8 is a financial one. While the authors did not explicitly measure resource use, they did report a modest reduction in office visits for those randomized to the Web service and BP monitoring plus pharmacist care group. It would be interesting to know whether the intervention could be demonstrated to be cost neutral or even cost saving from a societal perspective had the reductions in physician office visits offset the costs of the Web service and the pharmacists. Even if so, any Web-based patient management strategy would still face some real financial dilemmas in the current US fee-for-service environment. For example, if a physician implemented the Web and BP monitoring tool with or without pharmacist assistance, his or her patients may benefit from significantly better BP control. Yet physicians would face a triple financial whammy of paying to integrate the Web system into their practice, paying for the pharmacist's time, and then receiving less reimbursement due to fewer patient office visits. If care partnerships such as these are to flourish, the reimbursement system needs to be redesigned to provide appropriate incentives. The study by Green et al8 is an important demonstration of both the promise of nontraditional, nonclinic models for hypertension management. Yet like many evaluations of first-generation technologies, it has raised more questions than it fully answers. Can the next generation of Web-based disease management systems be sticky enough to encourage durable patient engagement? Will technology-driven online health services be simple enough for widespread adoption (just as online banking and product purchasing have become)? Or will these strategies leave certain socioeconomic strata behind and further widen existing disparities in preventive care? Will physicians be willing to accept this new model of shared control with nonphysician clinicians as well as with patients themselves? If so, will the major insurers adapt payment policies to encourage these interactions? The world will not have to wait long for these questions to be addressed. A recent scientific statement10 recommended that home BP monitoring should become a routine component of BP management for most patients with hypertension, and also recommended that reimbursement should be provided for this approach. In addition, online health information and intervention applications are being touted as the “next big thing in medical care.”11 As one example, the American Heart Association is currently developing a Blood Pressure Management Center, which will allow patients to automatically upload BP data from their home BP monitors, integrate this with other personal health data including diet, body weight, exercise, and pharmacy records, and provide patients with the option of directly sharing this information with their caregivers.12 Such novel systems have the potential to rapidly evaluate and implement these new care models on a national scale. In conclusion, it is clear that the current office-based, physician-centric model for BP treatment has not achieved desired rates for BP control. The study by Green and colleagues8 demonstrates that even early versions of Web and home BP monitoring technologies can facilitate better BP control if and when they are integrated with receptive clinical personnel. While certainly more work will be needed to refine these models, the future of BP management has taken a significant turn for the better. By finding new tools, ensuring appropriate use by patients and clinicians, and integrating these systems into clinical practice, it will be possible to achieve more effective and cost-effective BP control, and ultimately to save lives. Back to top Article Information Corresponding Author: Eric D. Peterson, MD, MPH, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715 (peter016@mc.duke.edu). Financial Disclosures: None reported. Disclaimer: The views expressed in this letter are those of the authors and do not necessarily reflect the official policy or position of the American Heart Association. Editorials represent the opinions of the authors and JAMA and not those of the American Medical Association. This article was corrected online for typographical errors on 6/24/2008. References 1. Kearney PM, Welton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455):217-22315652604PubMedGoogle Scholar 2. World Health Organization. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva, Switzerland: World Health Organization; 2002 3. Chobanian AV, Bakris GL, Black HR, et al; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [published ahead of print December 1, 2003]. Hypertension. 2003;42(6):1206-125214656957PubMedGoogle ScholarCrossref 4. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349):1903-191312493255PubMedGoogle ScholarCrossref 5. US Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey. http://www.cdc.gov/nchs/nhanes.htm. Accessed May 29, 2008 6. Okonofua EC, Simpson KN, Jesri A, Rehman SU, Durkalski VL, Egan BM. Therapeutic inertia is an impediment to achieving the Healthy People 2010 blood pressure control goals. Hypertension. 2006;47(3):345-35116432045PubMedGoogle ScholarCrossref 7. Phillips LS, Branch WT Jr, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135(9):825-84311694107PubMedGoogle ScholarCrossref 8. Green BB, Cook AJ, Ralston JD, et al. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. JAMA. 2008;299(24):2857-2867Google ScholarCrossref 9. Peterson ED. Is information the answer for hypertension control? Arch Intern Med. 2008;168(3):259-26018268163PubMedGoogle ScholarCrossref 10. Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D. Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association [published online ahead of print May 22, 2008]. Hypertension18497370PubMedGoogle Scholar 11. Steinbrook R. Personally controlled online health data—the next big thing in medical care? N Engl J Med. 2008;358(16):1653-165618420496PubMedGoogle ScholarCrossref 12. American Heart Association. Blood pressure management center. https://www.bpmc.heart.org. Accessed May 29, 2008
TI - Improving Hypertension Control Rates: Technology, People, or Systems?
JF - JAMA
DO - 10.1001/jama.299.24.2896
DA - 2008-06-25
UR - https://www.deepdyve.com/lp/american-medical-association/improving-hypertension-control-rates-technology-people-or-systems-45FRWc0ZqJ
SP - 2896
EP - 2898
VL - 299
IS - 24
DP - DeepDyve
ER -