Influencing adherence among hypertensives. Electronic monitoring of adherence as a tool to improve blood pressure control. A randomized controlled trial. Pharmacist involvement in primary care improves hypertensive patient clinical outcomes. A controlled trial of health education in the physician's office. Nonpharmacologic intervention to reduce blood pressure in older patients with mild hypertension. Adherence to cardiovascular risk factor modification in patients with hypertension. Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial. Improving blood pressure control in diabetes: limitations of a clinical reminder in influencing physician behavior. Hypertension improvement project: randomized trial of quality improvement for physicians and lifestyle modification for patients.
In the treatment of hypertension, problems of nonadherence and consequent poor blood pressure control are particularly severe. Alternative intervention strategies were compared to explore means of improving adherence and lowering blood pressures. In a 3 x 4 repeated measures analysis of variance design, 115 patients were randomly selected and randomly assigned to one of three treatment modalities (routine clinic care, patient education, and contingency contracting) and were followed over four clinic visits. Subjects' knowledge about hypertension and its management, adherence to requests for regular medical follow-up, and blood pressure levels were measured. Patient education was not effective in lowering blood pressures; it produced an untoward outcome, a dropout rate higher than that for patients receiving only routine clinic care. However, contingency contracting was an effective intervention strategy for improving patient knowledge, F (1,59) = 51.32, p less than .0001; adherence to requests for regular medical care, Max L (2) = 25.9, p less than .0001; and decreasing diastolic blood pressures, F (2,49) = 3.39, p less than .05. Poor adherence to antihypertensive drug regimens is believed to be a major contributor to treatment failure. Electronic monitoring of adherence may improve adherence and allow differentiation between those who are nonadherent and those who are pharmacologically nonresponsive. This study was designed to evaluate the effectiveness of electronic monitoring of adherence in lowering blood pressure (BP) in comparison with usual care.
                A total of 258 patients with high BP despite use of antihypertensive medication were randomly assigned to either continuation of usual care (with adjustment in antihypertensive medication if necessary) or to the introduction of electronic monitoring. Adherence to antihypertensive medication was monitored for 2 months without medication changes. The primary outcome measure was the proportion of patients who reached target BP levels after a 5-month follow-up period.
                At 5 months, 50.6% of the patients in the usual care group reached adequate BP, v 53.7% in the electronic monitoring group (P = .73). The percentages of patients with drug additions or increases in dosage were higher in the usual care group compared with those in whom adherence was monitored (P < .01).
                These data show that electronic monitoring in comparison to usual care results in similar BP control but leads to fewer drug changes and less drug use. This result is likely to be achieved by improving adherence. Hence a strategy that includes electronic monitoring has the potential to prevent unnecessary treatment escalation in patients with poor adherence. The practice of pharmaceutical care in primary care settings in Thailand is currently not generally accepted.
                To evaluate the effect of pharmacist involvement in treatment with hypertensive patients in primary care settings.
                The treatment objective was to stabilize the blood pressure (BP) of hypertensive patients in accordance with the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure guidelines. Patients were randomly assigned to a pharmacist-involved group (treatment) or a group with no pharmacist involvement (control). Pre- and post-test BPs, tablet counts, lifestyle modifications, and pharmacists' recommendations were recorded. The 6-month study was carried out in Mahasarakham University pharmacy and 2 primary care units. Patients were monitored monthly by reviewing their medications and supported by providing pharmaceutical care and counseling.
                From a total of 235 patients, the treatment group (n = 118) had a significant reduction in both systolic (S) and diastolic (D) BP compared with the 117 patients of the control group (p = 0.037, 0.027, respectively). The 158 patients (76 treatment, 82 control) with BPs >or=140/90 mm Hg at the beginning of the study showed significant BP reductions (p = 0.002 SBP, 0.008 DBP). The proportion of 158 patients whose BP became stabilized was higher in the treatment group (p = 0.017). The treatment group showed significantly better adherence (p = 0.014) and exercise control (p = 0.012) at the end of the study. Physicians accepted 42.72% of medication modifications and 5.34% of the suggestions for additional investigations.
                Hypertensive patients who received pharmacist input achieved a significantly greater benefit in BP reduction, BP control, and improvement in adherence rate and lifestyle modification. Screening of 6,144 patients in a general practice clinic to assist physician case-finding uncovered 983 (16%) who were uncontrolled hypertensives. Following physician recommendation, 115 patients volunteered for a controlled trial to test the effectiveness of supplementary strategies to the pharmaceutical management of high blood pressure. A study of nonparticipants indicated that about 7% of the practice population was eligible for cardiovascular health education. One group received a health education program, a second was allocated to self-monitor their blood pressure for 6 months, a third group was allocated to both strategies, and the final group, acting as a control, continued to receive their usual care. Physician monitoring of patients continued for the duration of the study and blood pressures decreased in all patients. The study's most important outcome was the joint reduction of blood pressure and medication strength. These were assessed by a "blind" clinician before and after the interventions according to criteria set out in the "stepped-care" approach to management of high blood pressure. People allocated to a health education program conducted in the doctor's common room did twice as well on this measure as those who were not so educated. Daily self-monitoring of blood pressure for 6 months proved to be too much for the majority of those so instructed. It is concluded that the general practice setting remains an important place for health education to prevent cardiac disease and suggestions are made for incorporating this into everyday practice. Although nonpharmacologic interventions are widely recommended in the therapy of high blood pressure in older adults, surprisingly little data exist to confirm the efficacy of these interventions in older persons.
                We conducted a randomized, controlled clinical trial in persons aged 60 to 85 years with a diastolic blood pressure of 85 to 100 mm Hg. The experimental arm was a nonpharmacologic intervention combining weight reduction, sodium restriction, and increased physical activity. The nonpharmacologic intervention consisted of eight weekly group and two individual sessions during the intensive phase, followed by four monthly group sessions during the maintenance phase. The control group received no treatment during the study. Blood pressure was assessed by certified technicians (blinded to group assignment) using random zero sphygmomanometers.
                Of 56 participants randomized, 47 completed the entire 6-month trial (21 in the intervention group and 26 in the control group). Attendance at the intervention sessions was excellent. The intervention group lost more weight (-2.1 kg) over 6 months than the control group (+0.3 kg). Trends for decreasing 24-hour urine sodium excretion in both the intervention and control groups, with greater trend in the intervention group, were not statistically significant. The intervention group experienced more reduction in systolic and diastolic blood pressure than did the control group (mean differences between groups at 6 months, 4.2/4.9 mm Hg, respectively).
                Our data indicate that a nonpharmacologic intervention will lower systolic and diastolic blood pressure levels in older people with borderline or mild elevations of diastolic blood pressure. The effectiveness of the support of a healthcare practitioner and a family member in producing changes in cardiovascular risk factor modification was tested in a randomised, controlled trial in patients with hypertension.
                The primary outcome measured after the 24-week intervention was blood pressure change. Secondary outcomes included patients' adherence to the programme, their knowledge about hypertension, exercise capacity, body weight, self-reported ability to control stress, adherence to medication and salt restriction, as well as symptoms.
                There were no marked improvements in blood pressure regulation in either group. The differences between the experimental and control groups were 3 mmHg (CI -6.18-12.18) for systolic blood pressure and 4 mmHg (CI -1.48-9.48) for diastolic blood pressure. The estimated blood pressure effects were small increases in both diastolic and systolic blood pressure, due to larger changes in the control group. These small changes were of no clinical significance. This intervention was not successful in reducing blood pressure of hypertensive patients who participated in a lifestyle programme. Secondary outcomes did show positive changes as a result of the given intervention. The absolute difference in improvement between the two groups was significantly greater for the experimental group than for the control group for the following variables: 24% better adherence to the programme (p = 0.007); 10% higher mean percentage score of hypertension knowledge and its management (p = 0.04); 20% more patients could control their stress levels (p = 0.05); 26% more patients could control their salt ingestion (p = 0.02); and 20% had better adherence to their given medication regimen (p = 0.05). The experimental group had a statistically significant weight reduction of 1 (+/- 4) kg relative to the control group (p = 0.03). Both groups increased their exercise capacity during the trial (p = 0.03). On the completion of the intervention, significantly fewer patients in the experimental group than in the control complained of tiredness (p = 0.05). Patients who had a 75% adherence or more to the programme were found to have maintained their knowledge and their exercise capacity, but not their weight loss after a maintenance phase of 12 weeks, during which time there was no intervention.
                Patients in a supported environment such as the one in this study were able to modify their cardiovascular risk factors, even though there were non-significant changes in blood pressure reported in this study. Inadequate blood pressure control is a persistent gap in quality care.
                To evaluate provider and patient interventions to improve blood pressure control.
                Cluster randomized, controlled trial.
                2 hospital-based and 8 community-based clinics in the Veterans Affairs Tennessee Valley Healthcare System.
                1341 veterans with essential hypertension cared for by 182 providers. Eligible patients had 2 or more blood pressure measurements greater than 140/90 mm Hg in a 6-month period and were taking a single antihypertensive agent.
                Providers who cared for eligible patients were randomly assigned to receive an e-mail with a Web-based link to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) guidelines (provider education); provider education and a patient-specific hypertension computerized alert (provider education and alert); or provider education, hypertension alert, and patient education, in which patients were sent a letter advocating drug adherence, lifestyle modification, and conversations with providers (patient education).
                Proportion of patients with a systolic blood pressure less than 140 mm Hg at 6 months; intensification of antihypertensive medication.
                Mean baseline blood pressure was 157/83 mm Hg with no differences between groups (P = 0.105). Six-month follow-up data were available for 975 patients (73%). Patients of providers who were randomly assigned to the patient education group had better blood pressure control (138/75 mm Hg) than those in the provider education and alert or provider education alone groups (146/76 mm Hg and 145/78 mm Hg, respectively). More patients in the patient education group had a systolic blood pressure of 140 mm Hg or less compared with those in the provider education or provider education and alert groups (adjusted relative risk for the patient education group compared with the provider education alone group, 1.31 [95% CI, 1.06 to 1.62]; P = 0.012).
                Follow-up blood pressure measurements were missing for 27% of study patients. The study could not detect a mechanism by which patient education improved blood pressure control.
                A multifactorial intervention including patient education improved blood pressure control compared with provider education alone. Hypertension should be aggressively treated, especially in diabetic patients. But studies of physician prescribing habits reveal that physicians often delay making medication changes or initiating antihypertensive therapy. A chart-based reminder was designed to improve physician medication prescribing in this clinical situation.
                A randomized controlled trial was conducted at the Veterans Affairs Medical Center in Richmond, Virginia. Patients with diabetes and hypertension were selected. A highly visible chart reminder was applied to the front of outpatient charts in the intervention group practice. A chart review was conducted to assess physician-directed medication changes. A successful outcome was defined as any antihypertensive medication increase or addition at that same visit.
                Physicians were more likely to intensify antihypertensive medication as the blood pressure increased regardless of the reminder. Overall, only 33% of visits resulted in a medication change, even though 93% of patients had elevations over target blood pressure at the follow-up visit. Physicians in the intervention and control groups made changes to medication at similar rates (chi 2 = 0.621, p = .511).
                In this study, a chart reminder failed to improve physician compliance with the clinical guideline for hypertension management in diabetics, Sixth Report of the Joint National Committee on the Detection, Evaluation, Prevention and Treatment of High Blood Pressure. To inform the design of effective intervention strategies, further research should explore specific barriers to guideline adherence in this clinical situation. Despite widely publicized hypertension treatment guidelines for physicians and lifestyle recommendations for patients, blood pressure control rates remain low. In community-based primary care clinics, we performed a nested, 2 x 2 randomized, controlled trial of physician intervention versus control and/or patient intervention versus control. Physician intervention included internet-based training, self-monitoring, and quarterly feedback reports. Patient intervention included 20 weekly group sessions followed by 12 monthly telephone counseling contacts and focused on weight loss, Dietary Approaches to Stop Hypertension dietary pattern, exercise, and reduced sodium intake. The primary outcome was change in systolic blood pressure at 6 months. Eight primary care practices (32 physicians) were randomized to physician intervention or control groups. Within those practices, 574 patients were randomized to patient intervention or control groups. Patient mean age was 60 years, 61% were women, and 37% were black. Blood pressure data were available for 91% of patients at 6 months. The main effect of physician intervention on systolic blood pressure at 6 months, adjusted for baseline pressure, was 0.3 mm Hg (95% CI: 1.5 to 2.2; P=0.72). The main effect of the patient intervention was 2.6 mm Hg (95% CI: 4.4 to 0.7; P=0.01). The interaction of the 2 interventions was significant (P=0.03); the largest impact was observed with the combination of physician and patient intervention (9.7 +/- 12.7 mm Hg). Differences between treatment groups did not persist at 18 months. Combined physician and patient interventions lowers blood pressure; future research should focus on enhancing effectiveness and sustainability of these interventions.
Reducing the number of daily doses appears to be effective in increasing adherence to blood pressure lowering medication and should be tried as a first line strategy, although there is less evidence of an effect on blood pressure reduction. Some motivational strategies and complex interventions appear promising, but we need more evidence on their effect through carefully designed RCTs.