Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertens

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Effectiveness of Home Blood Pressure Monitoring,
Web Communication, and Pharmacist Care on
Hypertension Control

• Brian Yoshio Laing, MD
• EBM Journal Club
• July 28, 2008

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The Article

• The Electronic Communications and Home Blood
  Pressure Monitoring Study (The e-BP study)
• Green BB, Cook AJ, Ralston JD, Fishman PA, Catz
  SL, Carlson J, Carrell D, Tyll L, Larson EB,
  Thompson RS. Effectiveness of home blood pressure
  monitoring, Web communication, and pharmacist
  care on hypertension control a randomized
  controlled trial. JAMA. 2008 Jun
  25299(24)2857-67.

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Background

• Almost 1 in 3 US adults has HTN
• (sustained BP of 140/90 or higher)
• Lowering BP with anti-HTN meds decreases
  mortality and major disability from
  cardiovascular and renal disease.
• HTN, however, remains inadequately treated in the
  majority of affected individuals.

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Effective methods to lower blood pressure include

• Involving patients with education and
  self-monitoring
• Adding a health care team member (nurse or
  pharmacist) to focus on HTN
• How should we implement these concepts in
  primary care?

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Can we treat HTN via internet?

• 75 of adults nationally have access to the
  internet and most want to communicate w/
  physicians, make appts, refill Rx receive lab
  results.
• No major studies show effectiveness of web
  services for chronic conditions.
• Group Health, non-profit health care system in
  Seattle, has a comprehensive EMR which integrates
  patient web access to all the above plus personal
  health profile, health education materials and
  clinic visit summaries.

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Hypothesis

• HTN could be improved asynchronously and remotely
  over the web without in-person clinic visits.

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Methods Study Design

• 3-group blinded randomized controlled trial.
• Conducted at 10 Group Health medical centers in
  WA 6/05 to 12/07
• 778 participants age 25 to 75 yrs with
  uncontrolled essential HTN on medication and with
  internet access.

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Methods Study Design

• Blinded randomized controlled trial comparing 2
  active intervention groups with usual care group.
• Conducted at 10 Group Health medical centers in
  WA 6/05 to 12/07

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Methods Study Design

• Included participants age 25 to 75 yrs with
  uncontrolled essential HTN on medication and with
  internet access.
• Patients with diabetes, heart disease or serious
  co-morbidities were excluded

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Methods Randomization

• Patients w/ uncontrolled HTN were randomly
  assigned to 3 groups
• Usual care
• Home BP monitoring w/ web services only
• Home BP monitoring with web services plus
  web-based pharmacist care management
• Intervention was based on the Chronic Care Model.

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Methods Patient Training

• Patients in all groups had access to the secure
  Group Health patient web services and received
  pamphlets on self-care for hypertension and for
  use of web services
• Patients assigned to active intervention groups
  were also provided with a home BP monitors,
  training on usage and web services training, and
  were instructed to measure BP at least twice per
  week.

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Methods Pharmacist Intervention

• 3 Group Health clinical pharmacists performed all
  pharmacy interventions.
• Pharmacists conducted 1 initial telephone visit
  per patient to introduce action plan then
  communicated via web every 2 weeks until BP was
  under 135/85.
• Patients reported BP, concerns about meds
  progress on lifestyle goals.
• Pharmacists responded with recommendations on med
  changes and action plans.

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Methods Outcome Measure

• Primary
• Change in systolic BP
• Change in diastolic BP
• of patients with controlled BP (lt140/90) at 12
  months
• Secondary (add)

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Methods Analysis

• Intention to treat
• Planned sub-group analyses for patients with
  systolic BP gt 160 vs lt 160

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Baseline Characteristics

• 778 participants
• 83 white
• 92 had some post-high school education
• 56 already had a home BP monitor
• Mean age 59.1
• Mean BP 151.9/89.1

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Results Primary Outcomes

• 730 of 778 (94) patients completed 1-year
  follow-up visit.
• Patients in home BP monitoring and web training
  only had no significant increase in control of BP
  v. usual care (36 v. 31, P .21)

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Results Primary Outcomes

• The group with web training plus web-based
  pharmacist care had significant increase in of
  patients with controlled BP v. usual care (56 v.
  31, P lt .001, RR 1.84).
• For subgroup with baseline SBP of 160 or higher,
  pharmacist care had 3.3 times more patients with
  BP control compared with usual care (RR 3.32,
  Plt.001).

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Results Secondary Results

• Pharmacist care group had
• increased mean number of classes of anti-HTN
  medication vs. web training only (P lt .01) and
  usual care groups (p lt .001).
• Increased mean number of web message threads
  (22.3) vs. web training only (3.3) vs. usual care
  (2.4).
• Same number of primary care visits as the 2 other
  groups (about 3 over 12 months).

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Results Secondary Results

• No significant differences between groups for
  inpatient, urgent care or ED use.
• Modest but significant decrease in of patients
  with specialist visit in pharmacist care group (P
  .04) vs. other groups.

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Discussion

• Study supports that web-based pharmacist care
  improves BP control especially for individuals
  with SBP gt 160.
• Confirms previous research demonstrating improved
  outcomes by combining care management and
  engaging patients in their own care.

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Discussion

• Appears that web training to help patients use an
  EMR with integrated provider communication and
  education resources is not sufficient to improve
  BP control.
• An ancillary provider is necessary to facilitate
  significant decrease in BP.

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• Pros

• Cons

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Study Limitations

• Patients required to have computer, email and
  internet access.
• Patients w/o computer access were more likely to
  be older, belong to racial/ethnic minority group
  and have less education.
• Study population was 83 white and 92 had a high
  school degree of higher.
• Unknown if BP control will be maintained after
  the end of pharmacist support.

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Study Strengths

• First large RCT of care management via web-based
  EMR shared by patients and providers.
• First large RCT to apply the Chronic Care Model
  to HTN.

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Should this change our practice?
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• Add graphics hamster wheel - animated? BP cuff?
  Randomization diagram
• Why I chose this article - Tom/Heather Treat to
  Target RCT, Chronic Care Model, Action Plan