Journal of Cardiovascular Nursing
Vol. 31, No. 4, pp 291Y295 x Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
Examining the Feasibility of a Simple Intervention to Improve Blood Pressure Control for Primary Care Patients Giang T. Nguyen, MD, MPH, MSCE; Heather A. Klusaritz, PhD; Alison O’Donnell, BA; Elise M. Kaye, RN; Heather F. de Vries McClintock, PhD, MSW, MSPH; Zehra Hussain, MD; Hillary R. Bogner, MD, MSCE Background: Blood pressure control remains a challenge despite the availability of effective antihypertensive agents. Objective: This pilot study explored the feasibility of a simple, low-resource intervention to improve blood pressure control. Methods: A convenience sample was drawn of 56 patients with hypertension from a primary care clinic. A preintervention-postintervention delivered by medical assistants involved prompts to providers to address blood pressure control with a visual aid indicating patients’ current and target blood pressure in the context of a traffic light. Results: Patients showed a significant reduction in mean systolic blood pressure (preintervention, 141.5 mm Hg, vs postintervention, 133.0 mm Hg; P = .002) and mean diastolic blood pressure (preintervention, 83.4 mm Hg, vs postintervention, 80.4 mm Hg; P = .049). Conclusion: In this pilot study, we established the feasibility of a brief, simple intervention to improve blood pressure control implemented by existing primary care practice clinical support staff, and preliminary data show that it can be effective in improving blood pressure control. KEY WORDS:
H
health outcomes, health promotion, hypertension, primary healthcare, treatment
ypertension affects nearly one-third of adults and is a leading risk factor for cardiovascular and kidney
Giang T. Nguyen, MD, MPH, MSCE Assistant Professor, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia.
Heather A. Klusaritz, PhD Clinical Instructor, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia.
Alison O’Donnell, BA Master in Public Health Student, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia.
Elise M. Kaye, RN Midwifery Student, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia.
Heather F. de Vries McClintock, PhD, MSW, MSPH Postdoctoral Trainee, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia.
Zehra Hussain, MD Medical Resident, Department of Medicine, University of Pennsylvania, Philadelphia.
Hillary R. Bogner, MD, MSCE Associate Professor, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia. This work was supported by an American Heart Association Award 13GRNT17000021 and a Bach Fund Award. The authors have no conflicts of interest to disclose.
Correspondence Hillary R. Bogner, MD, MSCE, Perelman School of Medicine, Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania, 9 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104 ([email protected]). DOI: 10.1097/JCN.0000000000000254
disease.1 Studies have shown that well-controlled blood pressure reduces the risk of stroke by 31% to 45% and the risk of myocardial infarction by 8% to 23%.2 Despite the pervasiveness and prominence of hypertension, consistent blood pressure control remains a challenge.1 Many patients are not able to achieve blood pressure goals despite the availability of many effective antihypertensive agents.3 Other studies support that if all patients with diagnosed hypertension achieved blood pressure control within recommended current clinical guideline limits, nearly 46 000 deaths could potentially be prevented per year.4 Research into patient perspectives regarding hypertension reveals that a large proportion of patients believe that hypertension is caused by stress and is symptomatic.5 Moreover, many patients intentionally reduce or stop blood pressure treatment without consulting their provider, particularly when they are not having symptoms.5 Inadequate blood pressure control can be attributed to several factors, including limited provider time, the use of medical jargon, and low health literacy among some patients. In addition, providers who are distracted by other clinical concerns may not always identify times when targeted communication may be needed. Clinical inertia or failure to initiate therapy or of medical intensification contributes to poor blood pressure control.6 Previous investigators have examined whether expanding the role of ancillary health staff in the clinic, 291
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
292 Journal of Cardiovascular Nursing x July/August 2016 such as licensed practical nurses, medical assistants (MA), or healthcare assistants, modifies behavior (eg, medication adherence, smoking, drinking, exercise, diet) and/or improves health outcomes.7Y11 These studies have had varying degrees of success, with only 2 reporting statistically significant improvements in clinical outcomes when comparing the intervention with usual care.7,10 In the United States, Tsai and colleagues10 found that using MAs as weight loss counselors resulted in significant weight loss during the 6-month intervention period. In addition, Turner et al12 found that a peer coach and office staff (MA, licensed practical nurse, and chronic disease health educator) support intervention in African Americans with uncontrolled hypertension significantly reduced systolic blood pressure but not diastolic blood pressure. This current study differs from previous work by involving existing office staff taking on increasing roles in the treatment of chronic medical conditions in place of adding personnel to the structure of the practice. Like the providers they work with, MAs in primary care practices often develop relationships with patients over many years and therefore have a unique understanding of patients’ healthcare needs. This study also differs by adding the use of visual aids to improve attention, recall, comprehension, and adherence to medication. The ‘‘picture-superiority effect’’ in psychology refers to the concept that humans prefer picture-based, rather than text-based, information and that information presented via pictures is more easily learned and recalled compared with information presented via text.13 Pictorial aids accompanying spoken and written language have been shown to improve attention, recall, comprehension, and adherence to medication.14 However, no studies used MAs to carry out a brief, simple intervention to address both the need for medical intensification and making blood pressure information more comprehensible for patients. The goal of the intervention, carried out by MAs, was 2-fold: (1) to provide a prompt for providers to address blood pressure control and (2) to provide a visual aid for patients indicating their current and target blood pressure in the context of a traffic light, a well-recognized and widely understood symbol. The main hypothesis of this study was that supplementing health communication with a medical assistant-administered visual aid coupled with prompts for providers to follow-up on MA-initiated counseling would be a simple, effective method to improve blood pressure control.
Institutional Review Board and all patients gave written informed consent before study participation. Patients were initially identified through an electronic medical record with the following inclusion criteria: (1) 18 years or older and (2) a diagnosis of hypertension or high blood pressure at visit. During primary care visits, a convenience sample of 67 patients was identified as potentially eligible and was approached for further screening. Hypertension is defined as a systolic blood pressure reading less than 140 mm Hg and a diastolic blood pressure reading less than 90 mm Hg without a diagnosis of type 2 diabetes mellitus (type 2 DM); goal systolic blood pressure reading less than 130 mm Hg and a diastolic blood pressure reading less than 80 mm Hg with a diagnosis of type 2 DM. All 67 patients approached provided oral consent for screening. However, 6 patients were excluded because they did not have a diagnosis of hypertension or a blood pressure reading level not at goal. The remaining 61 patients completed enrollment procedures and were given the intervention. Five patients had missed appointments, leaving 56 patients for this analysis. Intervention Training on how to indicate a patient’s current and target blood pressure on the visual aid in the context of a traffic light (Figure), as well as on placing the prompts for providers in the electronic medical record, was provided to MAs. The MAs were trained by the nurse manager
Methods Recruitment Procedures Patients who had high blood pressure were recruited from a large, community-based primary care practice serving low-income urban primarily minority patients from August 2012 to October 2012. The research protocols were approved by the University of Pennsylvania
FIGURE. Visual traffic light aid.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Improving BP Control for Primary Care Patients 293
on-site to ensure feasibility in primary care settings. Physicians were provided with an overview of the study and training on their role during an orientation session before study initiation. During an inpatient office visit, MAs identified eligible patients and proceeded to help them locate their specific systolic and diastolic blood pressures on the visual traffic light aid and the corresponding risk group they fell into: low, borderline, or high. Patients were given the traffic light visual aid to take home. The MA added blood pressure under the reason for visit in the electronic health record as a flag the chief complaint for provider action. Measurement Strategy At baseline, sociodemographic characteristics were assessed using standard questions. Blood pressure was assessed in accordance with American Heart Association Guidelines.15 Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters. Low-density lipoprotein cholesterol level was obtained using standard laboratory techniques in accordance with the American College of Cardiology and American Heart Association Guidelines.16 Data on lowdensity lipoprotein cholesterol levels and BMI were collected because of their importance as cardiovascular risk factors.1 Blood pressure medications were assessed at baseline and follow-up through lists of patients’ medications in the electronic health record. The mean (SD) length of follow-up was 10.5 (9.9) weeks and the range was 1 to 45 weeks. Analytic Strategy Descriptive statistics were first computed to characterize the study patients. Second, we compared systolic and diastolic blood pressure control of patients at baseline and postintervention using the paired t test. Five patients were excluded because the patients did not have a follow-up blood pressure, leaving a sample size of 56 for this analysis. Third, we examined whether changes in blood pressure medications occurred postintervention compared with baseline. Analysis was conducted using SPSS version 12.0 (SPSS, Chicago, Illinois). We used a level of statistical significance set at ! = .05, recognizing that tests of statistical significance are approximations that serve as aids to interpretation and inference.
TABLE
Results Baseline Participant Characteristics This was a predominantly African American (96.4%), middle-aged (mean [SD] age, 56.8 [13.9] years), female (66.1%), obese (mean [SD] BMI, 32.9 [9.1] kg/m2) and hypertensive population. Smoking, current (19.6%) or former (33.9%), was common, as was diabetes (48.2%). On average, patients were on 2.1 blood pressure medications, with over 60.7% taking 2 or more medications. Posttest Outcomes Posttest data were collected on 56 patients. Sociodemographic characteristics of patients did not differ from those for whom no follow-up data was available (n = 5). Preintervention and postintervention blood pressure measurements are presented in the Table. Patients showed a significant reduction in mean systolic blood pressure (preintervention, 141.5 mm Hg vs postintervention, 133.0 mm Hg; P = .002) and mean diastolic blood pressure (preintervention, 83.4 mm Hg vs postintervention, 80.4 mm Hg; P = .049). In all, 2 (3.6%) patients had a change in the dosage of 1 of their blood pressure medications, and 10 (17.9%) patients had an additional blood pressure medication added to their regimen.
Discussion The primary goal of this pilot study was to explore the feasibility and test in a preliminary fashion whether a simple, low-resource intervention carried out by medical assistants improved blood pressure control among primary care patients. The reasons for blood pressure control are complex and variable but reflect a myriad of influences on patients and providers. Therefore, our intervention included both visual aids for patients and prompts for providers. The results of the blood pressure readings postintervention showed significantly lower systolic and diastolic blood pressures. After the intervention, more than 20% of the patients had a change in the dosage of 1 of their blood pressure medications or an additional blood pressure medication added to their regimen. Primary care visits have multiple competing demands including prevention, acute care, and chronic care, as well as addressing the psychosocial needs of patients. Our results offer support for the usefulness of an MA
Preintervention and Postintervention Systolic and Diastolic Blood Pressure (n = 56)
Systolic BP, mean (SD), mm Hg Diastolic BP, mean (SD), mm Hg
Preintervention
Postintervention
Test Statistic
P
141.5 (19.9) 83.4 (12.9)
133.0 (17.4) 80.4 (11.9)
t55 = 3.18 t55 = 2.01
.002 .049
P values represent comparisons according to paired t tests. Abbreviation: BP, blood pressure.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
294 Journal of Cardiovascular Nursing x July/August 2016
What’s New and Important h Poor control of blood pressure is a major public health problem. h A brief, simple pilot intervention to improve blood pressure control implemented by existing primary care practice clinical support staff was feasible and effective. h Practice incorporated interventions carried out by nonprovider staff as part of the primary care team may be more possible and efficient in real world practices with competing demands for limited resources and fewer primary care providers.
approach to extend the primary care team’s ability to improve outcomes for hypertension. Before considering the implications of the findings for our future work, the limitations require discussion. First, our results were obtained from patients who receive care at 1 primary care site that might not be representative of most primary care practices. However, this practice was community based and probably similar to other primary care practices in the area. Second, the sample size achieved was fairly small. The small sample size of the study limits the generalizability of study results, and findings should be applied with caution to other populations. Third, the absence of a control arm and lack of randomization make it unclear as to the extent to which the intervention may have contributed to improvements in blood pressure. Therefore, results must be interpreted with caution but set the stage for a larger clinical trial to fully test the efficacy of the intervention. Fourth, our intervention would require additional training of MAs in primary care settings. However, we have designed a simple intervention and training existing primary care practice office staff will facilitate future implementation and dissemination. Fifth, recently new blood pressure guidelines have been released from the Eighth Joint National Committee.17 However, the visual aid could be easily adapted to new guidelines with minimal changes. Sixth, there was variability of time between blood pressure readings among participants, thus limiting our ability to draw inferences based on the interval for follow-up. Seventh, this study was only short-term. Further work should assess longer durations of follow-up to evaluate whether the success of the intervention can be maintained. Finally, the Hawthorne effect may have influenced patient behavior making patients more likely to adhere to blood pressure guidelines than they would if they were not participating in the study.18 However, even with careful monitoring in the study setting, blood pressure control has been shown to be poor in numerous settings.1 Despite the limitations of this study, our results deserve attention because our intervention is simple, effective, and easily adaptable to various settings (subspecialists’
office, emergency department, home nurses). The lack of implementation of previous trials in practice is indicative of a lack of feasibility in daily practice operations of interventions. Our intervention caused no disruption to workflow in our busy practice and did not require increased resources or personnel. The intervention is widely adaptable for management of other chronic health conditions, such as type 2 DM and hyperlipidemia. The study was conducted under real-world conditions, thus making the results more generalizable. Consistent with our hypothesis, patients who received the intervention had lower systolic blood pressure and lower diastolic blood pressure postintervention in comparison with baseline blood pressures. Of note, this intervention had many patients who were willing to enroll, and once enrolled, the patients all had a high rate of study completion. Participants in the sample received medical care on a regular basis and findings may not be generalizable to community members who are less engaged in treatment. The MAs’ relationships with patients and all clinicians developed over many years may have played a role in our high retention rate. Because of limited resources in primary care, simple and brief interventions are not only more acceptable to patients but also are needed to achieve cost containment. Redefining the roles of nonprovider staff such as MAs is a promising alternative and allows clinicians to focus on issues specifically requiring their knowledge and skills. Poor control of blood pressure is a major public health problem. Our study intervention may provide a feasible solution that can be implemented in primary care for patients being treated for hypertension. We carried out a preliminary analysis of a relatively brief pilot trial conducted by MAs with a focus on the management of hypertension. Increasing and redefining the roles of nonprovider staff in a community-based practice successfully improved clinical outcomes and support an expanded role for non-provider staff. We designed our study carefully in order not to place excessive demands on a community-based primary care practice. Practiceincorporated interventions carried out by nonprovider staff as part of the primary care team may be more possible and efficient in real-world practices with competing demands for limited resources and fewer primary care providers.19 Further research is necessary to evaluate this intervention in a larger, more representative sample population, with a longer follow-up trajectory. In addition, implications of recently released blood pressure guidelines from panel members of the Eighth Joint National Committee17 should be considered when planning future work in this area.
REFERENCES 1. CDC. High blood pressure facts. 2014. http://www.cdc.gov/ bloodpressure/facts.htm. Accessed December 15, 2014.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Improving BP Control for Primary Care Patients 295 2. Collins R, MacMahon S. Blood pressure, antihypertensive drug treatment and the risks of stroke and of coronary heart disease. Br Med Bull. 1994;50(2):272Y298. 3. Bramlage P. Fixed combination of irbesartan and hydrochlorothiazide in the management of hypertension. Vasc Health Risk Manag. 2009;5(1):213Y224. 4. Farley TA, Dalal MA, Mostashari F, Frieden TR. Deaths preventable in the U.S. by improvements in use of clinical preventive services. Am J Prev Med. 2010;38(6):600Y609. 5. Marshall IJ, Wolfe CD, McKevitt C. Lay perspectives on hypertension and drug adherence: systematic review of qualitative research. BMJ. 2012;345:e3953. 6. Aujoulat I, Jacquemin P, Rietzschel E, et al. Factors associated with clinical inertia: an integrative review. Adv Med Educ Pract. 2014;5:141Y147. 7. Gensichen J, von Korff M, Peitz M, et al. Case management for depression by health care assistants in small primary care practices: a cluster randomized trial. Ann Intern Med. 2009;151(6):369Y378. 8. Ferrer RL, Mody-Bailey P, Jaen CR, Gott S, Araujo S. A medical assistant-based program to promote healthy behaviors in primary care. Ann Fam Med. 2009;7(6):504Y512. 9. Ruggiero L, Moadsiri A, Butler P, et al. Supporting diabetes selfcare in underserved populations: a randomized pilot study using medical assistant coaches. Diabetes Educ. 2010;36(1):127Y131. 10. Tsai AG, Wadden TA, Rogers MA, Day SC, Moore RH, Islam BJ. A primary care intervention for weight loss: results of a randomized controlled pilot study. Obesity (Silver Spring). 2010;18(8):1614Y1618. 11. Baker AN, Parsons M, Donnelly SM, et al. Improving colon cancer screening rates in primary care: a pilot study emphasising
12.
13.
14.
15. 16.
17.
18.
19.
the role of the medical assistant. Qual Saf Health Care. 2009; 18(5):355Y359. Turner BJ, Hollenbeak CS, Liang Y, Pandit K, Joseph S, Weiner MG. A randomized trial of peer coach and office staff support to reduce coronary heart disease risk in AfricanAmericans with uncontrolled hypertension. J Gen Intern Med. 2012;27(10):1258Y1264. Brady TF, Konkle T, Alvarez GA, Oliva A. Visual long-term memory has a massive storage capacity for object details. Proc Natl Acad Sci USA. 2008;105(38):14325Y14329. Katz MG, Kripalani S, Weiss BD. Use of pictorial aids in medication instructions: a review of the literature. Am J Health Syst Pharm. 2006;63(23):2391Y2397. American Heart Association. Blood pressure testing and assessment. www.americanheart.org. Accessed April 4, 2012. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013; 311:507Y520. James PA, Oparil S, Carter BL, 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. 2013. McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: new concepts are needed to study research participation effects. J Clin Epidemiol. 2014;67(3): 267Y277. Petterson SM, Liaw WR, Phillips RL Jr, Rabin DL, Meyers DS, Bazemore AW. Projecting US primary care physician workforce needs: 2010Y2025. Ann Fam Med. 2012;10(6):503Y509.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Vol. 31, No. 4, pp 291Y295 x Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
Examining the Feasibility of a Simple Intervention to Improve Blood Pressure Control for Primary Care Patients Giang T. Nguyen, MD, MPH, MSCE; Heather A. Klusaritz, PhD; Alison O’Donnell, BA; Elise M. Kaye, RN; Heather F. de Vries McClintock, PhD, MSW, MSPH; Zehra Hussain, MD; Hillary R. Bogner, MD, MSCE Background: Blood pressure control remains a challenge despite the availability of effective antihypertensive agents. Objective: This pilot study explored the feasibility of a simple, low-resource intervention to improve blood pressure control. Methods: A convenience sample was drawn of 56 patients with hypertension from a primary care clinic. A preintervention-postintervention delivered by medical assistants involved prompts to providers to address blood pressure control with a visual aid indicating patients’ current and target blood pressure in the context of a traffic light. Results: Patients showed a significant reduction in mean systolic blood pressure (preintervention, 141.5 mm Hg, vs postintervention, 133.0 mm Hg; P = .002) and mean diastolic blood pressure (preintervention, 83.4 mm Hg, vs postintervention, 80.4 mm Hg; P = .049). Conclusion: In this pilot study, we established the feasibility of a brief, simple intervention to improve blood pressure control implemented by existing primary care practice clinical support staff, and preliminary data show that it can be effective in improving blood pressure control. KEY WORDS:
H
health outcomes, health promotion, hypertension, primary healthcare, treatment
ypertension affects nearly one-third of adults and is a leading risk factor for cardiovascular and kidney
Giang T. Nguyen, MD, MPH, MSCE Assistant Professor, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia.
Heather A. Klusaritz, PhD Clinical Instructor, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia.
Alison O’Donnell, BA Master in Public Health Student, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia.
Elise M. Kaye, RN Midwifery Student, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia.
Heather F. de Vries McClintock, PhD, MSW, MSPH Postdoctoral Trainee, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia.
Zehra Hussain, MD Medical Resident, Department of Medicine, University of Pennsylvania, Philadelphia.
Hillary R. Bogner, MD, MSCE Associate Professor, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia. This work was supported by an American Heart Association Award 13GRNT17000021 and a Bach Fund Award. The authors have no conflicts of interest to disclose.
Correspondence Hillary R. Bogner, MD, MSCE, Perelman School of Medicine, Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania, 9 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104 ([email protected]). DOI: 10.1097/JCN.0000000000000254
disease.1 Studies have shown that well-controlled blood pressure reduces the risk of stroke by 31% to 45% and the risk of myocardial infarction by 8% to 23%.2 Despite the pervasiveness and prominence of hypertension, consistent blood pressure control remains a challenge.1 Many patients are not able to achieve blood pressure goals despite the availability of many effective antihypertensive agents.3 Other studies support that if all patients with diagnosed hypertension achieved blood pressure control within recommended current clinical guideline limits, nearly 46 000 deaths could potentially be prevented per year.4 Research into patient perspectives regarding hypertension reveals that a large proportion of patients believe that hypertension is caused by stress and is symptomatic.5 Moreover, many patients intentionally reduce or stop blood pressure treatment without consulting their provider, particularly when they are not having symptoms.5 Inadequate blood pressure control can be attributed to several factors, including limited provider time, the use of medical jargon, and low health literacy among some patients. In addition, providers who are distracted by other clinical concerns may not always identify times when targeted communication may be needed. Clinical inertia or failure to initiate therapy or of medical intensification contributes to poor blood pressure control.6 Previous investigators have examined whether expanding the role of ancillary health staff in the clinic, 291
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
292 Journal of Cardiovascular Nursing x July/August 2016 such as licensed practical nurses, medical assistants (MA), or healthcare assistants, modifies behavior (eg, medication adherence, smoking, drinking, exercise, diet) and/or improves health outcomes.7Y11 These studies have had varying degrees of success, with only 2 reporting statistically significant improvements in clinical outcomes when comparing the intervention with usual care.7,10 In the United States, Tsai and colleagues10 found that using MAs as weight loss counselors resulted in significant weight loss during the 6-month intervention period. In addition, Turner et al12 found that a peer coach and office staff (MA, licensed practical nurse, and chronic disease health educator) support intervention in African Americans with uncontrolled hypertension significantly reduced systolic blood pressure but not diastolic blood pressure. This current study differs from previous work by involving existing office staff taking on increasing roles in the treatment of chronic medical conditions in place of adding personnel to the structure of the practice. Like the providers they work with, MAs in primary care practices often develop relationships with patients over many years and therefore have a unique understanding of patients’ healthcare needs. This study also differs by adding the use of visual aids to improve attention, recall, comprehension, and adherence to medication. The ‘‘picture-superiority effect’’ in psychology refers to the concept that humans prefer picture-based, rather than text-based, information and that information presented via pictures is more easily learned and recalled compared with information presented via text.13 Pictorial aids accompanying spoken and written language have been shown to improve attention, recall, comprehension, and adherence to medication.14 However, no studies used MAs to carry out a brief, simple intervention to address both the need for medical intensification and making blood pressure information more comprehensible for patients. The goal of the intervention, carried out by MAs, was 2-fold: (1) to provide a prompt for providers to address blood pressure control and (2) to provide a visual aid for patients indicating their current and target blood pressure in the context of a traffic light, a well-recognized and widely understood symbol. The main hypothesis of this study was that supplementing health communication with a medical assistant-administered visual aid coupled with prompts for providers to follow-up on MA-initiated counseling would be a simple, effective method to improve blood pressure control.
Institutional Review Board and all patients gave written informed consent before study participation. Patients were initially identified through an electronic medical record with the following inclusion criteria: (1) 18 years or older and (2) a diagnosis of hypertension or high blood pressure at visit. During primary care visits, a convenience sample of 67 patients was identified as potentially eligible and was approached for further screening. Hypertension is defined as a systolic blood pressure reading less than 140 mm Hg and a diastolic blood pressure reading less than 90 mm Hg without a diagnosis of type 2 diabetes mellitus (type 2 DM); goal systolic blood pressure reading less than 130 mm Hg and a diastolic blood pressure reading less than 80 mm Hg with a diagnosis of type 2 DM. All 67 patients approached provided oral consent for screening. However, 6 patients were excluded because they did not have a diagnosis of hypertension or a blood pressure reading level not at goal. The remaining 61 patients completed enrollment procedures and were given the intervention. Five patients had missed appointments, leaving 56 patients for this analysis. Intervention Training on how to indicate a patient’s current and target blood pressure on the visual aid in the context of a traffic light (Figure), as well as on placing the prompts for providers in the electronic medical record, was provided to MAs. The MAs were trained by the nurse manager
Methods Recruitment Procedures Patients who had high blood pressure were recruited from a large, community-based primary care practice serving low-income urban primarily minority patients from August 2012 to October 2012. The research protocols were approved by the University of Pennsylvania
FIGURE. Visual traffic light aid.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Improving BP Control for Primary Care Patients 293
on-site to ensure feasibility in primary care settings. Physicians were provided with an overview of the study and training on their role during an orientation session before study initiation. During an inpatient office visit, MAs identified eligible patients and proceeded to help them locate their specific systolic and diastolic blood pressures on the visual traffic light aid and the corresponding risk group they fell into: low, borderline, or high. Patients were given the traffic light visual aid to take home. The MA added blood pressure under the reason for visit in the electronic health record as a flag the chief complaint for provider action. Measurement Strategy At baseline, sociodemographic characteristics were assessed using standard questions. Blood pressure was assessed in accordance with American Heart Association Guidelines.15 Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters. Low-density lipoprotein cholesterol level was obtained using standard laboratory techniques in accordance with the American College of Cardiology and American Heart Association Guidelines.16 Data on lowdensity lipoprotein cholesterol levels and BMI were collected because of their importance as cardiovascular risk factors.1 Blood pressure medications were assessed at baseline and follow-up through lists of patients’ medications in the electronic health record. The mean (SD) length of follow-up was 10.5 (9.9) weeks and the range was 1 to 45 weeks. Analytic Strategy Descriptive statistics were first computed to characterize the study patients. Second, we compared systolic and diastolic blood pressure control of patients at baseline and postintervention using the paired t test. Five patients were excluded because the patients did not have a follow-up blood pressure, leaving a sample size of 56 for this analysis. Third, we examined whether changes in blood pressure medications occurred postintervention compared with baseline. Analysis was conducted using SPSS version 12.0 (SPSS, Chicago, Illinois). We used a level of statistical significance set at ! = .05, recognizing that tests of statistical significance are approximations that serve as aids to interpretation and inference.
TABLE
Results Baseline Participant Characteristics This was a predominantly African American (96.4%), middle-aged (mean [SD] age, 56.8 [13.9] years), female (66.1%), obese (mean [SD] BMI, 32.9 [9.1] kg/m2) and hypertensive population. Smoking, current (19.6%) or former (33.9%), was common, as was diabetes (48.2%). On average, patients were on 2.1 blood pressure medications, with over 60.7% taking 2 or more medications. Posttest Outcomes Posttest data were collected on 56 patients. Sociodemographic characteristics of patients did not differ from those for whom no follow-up data was available (n = 5). Preintervention and postintervention blood pressure measurements are presented in the Table. Patients showed a significant reduction in mean systolic blood pressure (preintervention, 141.5 mm Hg vs postintervention, 133.0 mm Hg; P = .002) and mean diastolic blood pressure (preintervention, 83.4 mm Hg vs postintervention, 80.4 mm Hg; P = .049). In all, 2 (3.6%) patients had a change in the dosage of 1 of their blood pressure medications, and 10 (17.9%) patients had an additional blood pressure medication added to their regimen.
Discussion The primary goal of this pilot study was to explore the feasibility and test in a preliminary fashion whether a simple, low-resource intervention carried out by medical assistants improved blood pressure control among primary care patients. The reasons for blood pressure control are complex and variable but reflect a myriad of influences on patients and providers. Therefore, our intervention included both visual aids for patients and prompts for providers. The results of the blood pressure readings postintervention showed significantly lower systolic and diastolic blood pressures. After the intervention, more than 20% of the patients had a change in the dosage of 1 of their blood pressure medications or an additional blood pressure medication added to their regimen. Primary care visits have multiple competing demands including prevention, acute care, and chronic care, as well as addressing the psychosocial needs of patients. Our results offer support for the usefulness of an MA
Preintervention and Postintervention Systolic and Diastolic Blood Pressure (n = 56)
Systolic BP, mean (SD), mm Hg Diastolic BP, mean (SD), mm Hg
Preintervention
Postintervention
Test Statistic
P
141.5 (19.9) 83.4 (12.9)
133.0 (17.4) 80.4 (11.9)
t55 = 3.18 t55 = 2.01
.002 .049
P values represent comparisons according to paired t tests. Abbreviation: BP, blood pressure.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
294 Journal of Cardiovascular Nursing x July/August 2016
What’s New and Important h Poor control of blood pressure is a major public health problem. h A brief, simple pilot intervention to improve blood pressure control implemented by existing primary care practice clinical support staff was feasible and effective. h Practice incorporated interventions carried out by nonprovider staff as part of the primary care team may be more possible and efficient in real world practices with competing demands for limited resources and fewer primary care providers.
approach to extend the primary care team’s ability to improve outcomes for hypertension. Before considering the implications of the findings for our future work, the limitations require discussion. First, our results were obtained from patients who receive care at 1 primary care site that might not be representative of most primary care practices. However, this practice was community based and probably similar to other primary care practices in the area. Second, the sample size achieved was fairly small. The small sample size of the study limits the generalizability of study results, and findings should be applied with caution to other populations. Third, the absence of a control arm and lack of randomization make it unclear as to the extent to which the intervention may have contributed to improvements in blood pressure. Therefore, results must be interpreted with caution but set the stage for a larger clinical trial to fully test the efficacy of the intervention. Fourth, our intervention would require additional training of MAs in primary care settings. However, we have designed a simple intervention and training existing primary care practice office staff will facilitate future implementation and dissemination. Fifth, recently new blood pressure guidelines have been released from the Eighth Joint National Committee.17 However, the visual aid could be easily adapted to new guidelines with minimal changes. Sixth, there was variability of time between blood pressure readings among participants, thus limiting our ability to draw inferences based on the interval for follow-up. Seventh, this study was only short-term. Further work should assess longer durations of follow-up to evaluate whether the success of the intervention can be maintained. Finally, the Hawthorne effect may have influenced patient behavior making patients more likely to adhere to blood pressure guidelines than they would if they were not participating in the study.18 However, even with careful monitoring in the study setting, blood pressure control has been shown to be poor in numerous settings.1 Despite the limitations of this study, our results deserve attention because our intervention is simple, effective, and easily adaptable to various settings (subspecialists’
office, emergency department, home nurses). The lack of implementation of previous trials in practice is indicative of a lack of feasibility in daily practice operations of interventions. Our intervention caused no disruption to workflow in our busy practice and did not require increased resources or personnel. The intervention is widely adaptable for management of other chronic health conditions, such as type 2 DM and hyperlipidemia. The study was conducted under real-world conditions, thus making the results more generalizable. Consistent with our hypothesis, patients who received the intervention had lower systolic blood pressure and lower diastolic blood pressure postintervention in comparison with baseline blood pressures. Of note, this intervention had many patients who were willing to enroll, and once enrolled, the patients all had a high rate of study completion. Participants in the sample received medical care on a regular basis and findings may not be generalizable to community members who are less engaged in treatment. The MAs’ relationships with patients and all clinicians developed over many years may have played a role in our high retention rate. Because of limited resources in primary care, simple and brief interventions are not only more acceptable to patients but also are needed to achieve cost containment. Redefining the roles of nonprovider staff such as MAs is a promising alternative and allows clinicians to focus on issues specifically requiring their knowledge and skills. Poor control of blood pressure is a major public health problem. Our study intervention may provide a feasible solution that can be implemented in primary care for patients being treated for hypertension. We carried out a preliminary analysis of a relatively brief pilot trial conducted by MAs with a focus on the management of hypertension. Increasing and redefining the roles of nonprovider staff in a community-based practice successfully improved clinical outcomes and support an expanded role for non-provider staff. We designed our study carefully in order not to place excessive demands on a community-based primary care practice. Practiceincorporated interventions carried out by nonprovider staff as part of the primary care team may be more possible and efficient in real-world practices with competing demands for limited resources and fewer primary care providers.19 Further research is necessary to evaluate this intervention in a larger, more representative sample population, with a longer follow-up trajectory. In addition, implications of recently released blood pressure guidelines from panel members of the Eighth Joint National Committee17 should be considered when planning future work in this area.
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