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Research Letter |

Blood Pressure 1 Year After Completion of Web-Based Pharmacist Care FREE

Beverly B. Green, MD, MPH1,2,3; Melissa L. Anderson, MS2; James D. Ralston, MD, MPH1,2,4; Sheryl L. Catz, PhD2; Andrea J. Cook, PhD2,5
[+] Author Affiliations
1Group Health Cooperative, Seattle, Washington
2Group Health Research Institute, Seattle, Washington
3Department of Family Medicine, University of Washington Medical School, Seattle
4Department of Health Services University of Washington School of Public Health, Seattle
5Department of Biostatistics, University of Washington School of Public Health, Seattle
JAMA Intern Med. 2013;173(13):1250-1252. doi:10.1001/jamainternmed.2013.1037.
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Published online

Meta-analyses provide strong evidence that blood pressure (BP) control improves with “team-based” hypertension care provided by a health professional such as a pharmacist or nurse, separate from physician care.1 Few studies have analyzed whether team care leads to sustained BP reductions after the end of an intervention.

In the Electronic Communications and Home Blood Pressure Trial (e-BP),2 patients with uncontrolled BP were registered to use an existing patient website (with a patient-shared electronic health record [EHR] and secure e-mail) and randomly assigned to receive the following interventions: (1) usual care (UC), (2) home BP monitoring (BPM) and website training, or (3) BPM and website training plus pharmacist team-care delivered via the website (Pharm). At the end of the 1-year intervention, Pharm patients were twice as likely to have controlled BP.2 Our objective was to determine if BP reductions were sustained after the intervention ended.

Details of the study design3 and main study results2 have been previously published. The Group Health institutional review board approved all study procedures.

We collected all BPs available in the EHR from participants’ primary care visits between 18 and 30 months after randomization (approximately 6 to 18 months after completion of all interventions). If more than 1 BP was available, the BP closest to 24 months (defined as 1-year after intervention) was used. Primary outcomes included change in baseline systolic BP (SBP) and diastolic BP (DBP) and BP control at 1 year after intervention. Secondary outcomes, including number (by class)2 and adherence to4 antihypertensive medications and utilization of health care services, were calculated using automated data. Preplanned subanalyses included assessments of the patients with a baseline SBP of 160 mm Hg or higher.

Analysis was limited to trial participants with a BP measurement in the EHR from a primary care visit in the defined period (N = 618, after 160 were excluded). Linear regression models were used to evaluate changes in BP from baseline. A modified Poisson regression approach, using generalized linear models with a log-link linear and a robust sandwich variance estimator, was used to estimate the relative risk (RR) of BP control5 (SBP <140 mm Hg and DBP <90 mm Hg). Regression models were adjusted for baseline BP, sex, prestudy home BP monitoring use, clinic, and time between the end of the intervention and the EHR BP measurement. To protect against multiple comparisons, the Fisher protected least significant difference approach was used; pairwise comparisons were made between intervention groups only if the overall omnibus test result was significant.6 Analyses of secondary outcomes were unadjusted. All analyses used Stata statistical software, version 12.0 (StataCorp).

Of the 778 patients enrolled in the trial, 725 (93%) remained enrolled in Group Health (49 had disenrolled and 4 had died) and 618 (79%) had a BP measurement recorded in the EHR 1-year after intervention. Characteristics of the 618 patients with BPs were comparable across randomization groups and were similar to those excluded, except for less prestudy home BP monitoring prior to the study in those excluded.

At 1-year after intervention, all 3 groups had lower SBP and DBP compared with baseline (Table), with the Pharm group having significantly larger decreases in SBP than UC and BPM (difference in adjusted mean change, −3.6 mm Hg [P = .02], and −6.8 mm Hg [P < .001], respectively). Change in DBP did not differ between groups. The Pharm group had higher rates of BP control compared with the UC group (P = .11) and had significantly higher rates of BP control compared with the BPM group (P = .01) (UC, 52%; BPM, 48%; and Pharm, 60%).

Table Graphic Jump LocationTable.  Blood Pressure (BP) Outcomes 1 Year After Interventions1

In patients with a BP of 160 mm Hg or higher at baseline, BP control was 34%, 23%, and 56% in the UC, BPM, and Pharm groups (adjusted relative risk of controlled BP [Pharm vs UC], 1.87 [95% CI, 1.06 to 3.17]), with an adjusted difference in mean change in SBP of −10.5 (95% CI, −18.3 to −2.7 mm Hg) (Pharm vs UC).

The mean number of antihypertensive classes was significantly higher in the Pharm and BPM groups compared with the UC group. Adherence was high for all groups but significantly higher in the Pharm and BPM groups than in the UC group (eTable in Supplement). Primary care and hospital utilization did not differ by group (eTable in Supplement).

Web-delivered pharmacy team care resulted in greater reductions in SBP and improved BP control 6 to 18 months after the completion of interventions. Similar to Wentzlaff et al7 and Carter et al,8 the control group (UC) continued to improve, and differences between groups narrowed. In our study team care, BP benefits occurred mainly in those with more severe hypertension at baseline, with Web-based pharmacist team patients almost twice as likely to have controlled BP. Limitations included reliance on a single EHR BP measurement9 and no EHR BP measurement recorded in 21% of study participants. However, significant differences in BP persisted in sensitivity analyses that assumed that BP remained unchanged from baseline for those without EHR BP measurements. More studies are needed to assess BP and clinical outcomes at longer intervals and whether team-care booster interventions improve these outcomes.

Corresponding Author: Beverly B. Green, MD, MPH, Group Health Research Institute, Metropolitan Park East, 1730 Minor Ave, Ste 1600, Seattle, WA 98101 (green.b@ghc.org).

Published Online: May 20, 2013. doi:10.1001/jamainternmed.2013.1037.

Author Contributions: Ms Anderson and Dr Cook had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Green, Ralston, Catz, and Cook.

Acquisition of data: Green.

Analysis and interpretation of data: Green, Anderson, Ralston, Catz, and Cook.

Drafting of the manuscript: Green and Anderson.

Critical revision of the manuscript for important intellectual content: Green, Anderson, Ralston, Catz, and Cook.

Statistical analysis: Green, Anderson, and Cook.

Obtained funding: Ralston.

Administrative, technical, and material support: Green.

Study supervision: Green.

Conflict of Interest Disclosures: Dr Ralston has received grant funding from sanofi-aventis.

Funding/Support: This research was funded by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health (Electronic Communications and Blood Pressure Monitoring [e-BP]: grant R01-HL075263).

Role of the Sponsor: The funding agency had no role in the study design, analysis, or interpretation of data; decision regarding publication; or preparation of this article.

Trial Registration: clinicaltrials.gov Identifier:NCT00158639

Additional Contributions: Robert S. Thompson, MD (emeritus director, Group Health Department of Preventive Medicine) contributed to the study design; Paul Fishman, PhD (senior investigator, health services and economics) contributed to the study design and analysis; and Jim Carlson, PharmD, Danette Feuling, RPh, Shannon Clarke, PharmD, and Jilene Winther, PharmD, assisted in the study as clinical pharmacists.

Task Force on Community Preventive Services. The community guide: Cardiovascular disease prevention and control: team-based care to improve blood pressure control. http://www.thecommunityguide.org/cvd/teambasedcare.html. Accessed December 30, 2012.
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):2857-2867.
PubMed   |  Link to Article
Green  BB, Ralston  JD, Fishman  PA,  et al.  Electronic communications and home blood pressure monitoring (e-BP) study: design, delivery, and evaluation framework. Contemp Clin Trials. 2008;29(3):376-395.
PubMed   |  Link to Article
Karter  AJ, Parker  MM, Moffet  HH, Ahmed  AT, Schmittdiel  JA, Selby  JV.  New prescription medication gaps: a comprehensive measure of adherence to new prescriptions. Health Serv Res. 2009;44(5 Pt 1):1640-1661.
PubMed   |  Link to Article
Zou  G.  A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702-706.
PubMed   |  Link to Article
Levin  J, Serlin  R, Seaman  MA.  A controlled, powerful multiple-comparison strategy for several situations. Psychol Bull. 1994;115(1):153-159.
Link to Article
Wentzlaff  DM, Carter  BL, Ardery  G,  et al.  Sustained blood pressure control following discontinuation of a pharmacist intervention. J Clin Hypertens (Greenwich). 2011;13(6):431-437.
PubMed   |  Link to Article
Carter  BL, Doucette  WR, Franciscus  CL, Ardery  G, Kluesner  KM, Chrischilles  EA.  Deterioration of blood pressure control after discontinuation of a physician-pharmacist collaborative intervention. Pharmacotherapy. 2010;30(3):228-235.
PubMed   |  Link to Article
Fishman  PA, Anderson  ML, Cook  AJ,  et al.  Accuracy of blood pressure measurements reported in an electronic medical record during routine primary care visits. J Clin Hypertens (Greenwich). 2011;13(11):821-828.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable.  Blood Pressure (BP) Outcomes 1 Year After Interventions1

References

Task Force on Community Preventive Services. The community guide: Cardiovascular disease prevention and control: team-based care to improve blood pressure control. http://www.thecommunityguide.org/cvd/teambasedcare.html. Accessed December 30, 2012.
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):2857-2867.
PubMed   |  Link to Article
Green  BB, Ralston  JD, Fishman  PA,  et al.  Electronic communications and home blood pressure monitoring (e-BP) study: design, delivery, and evaluation framework. Contemp Clin Trials. 2008;29(3):376-395.
PubMed   |  Link to Article
Karter  AJ, Parker  MM, Moffet  HH, Ahmed  AT, Schmittdiel  JA, Selby  JV.  New prescription medication gaps: a comprehensive measure of adherence to new prescriptions. Health Serv Res. 2009;44(5 Pt 1):1640-1661.
PubMed   |  Link to Article
Zou  G.  A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702-706.
PubMed   |  Link to Article
Levin  J, Serlin  R, Seaman  MA.  A controlled, powerful multiple-comparison strategy for several situations. Psychol Bull. 1994;115(1):153-159.
Link to Article
Wentzlaff  DM, Carter  BL, Ardery  G,  et al.  Sustained blood pressure control following discontinuation of a pharmacist intervention. J Clin Hypertens (Greenwich). 2011;13(6):431-437.
PubMed   |  Link to Article
Carter  BL, Doucette  WR, Franciscus  CL, Ardery  G, Kluesner  KM, Chrischilles  EA.  Deterioration of blood pressure control after discontinuation of a physician-pharmacist collaborative intervention. Pharmacotherapy. 2010;30(3):228-235.
PubMed   |  Link to Article
Fishman  PA, Anderson  ML, Cook  AJ,  et al.  Accuracy of blood pressure measurements reported in an electronic medical record during routine primary care visits. J Clin Hypertens (Greenwich). 2011;13(11):821-828.
PubMed   |  Link to Article

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eTable. Antihypertensive Medication Use and Utilization 1 Year Post-Intervention

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