Blood Pressure-Visit Intensification for Successful Improvement of Treatment

摘要：高血压患者控制血压可降低心血管疾病的发病率和死亡率。然而，在高血压相关的诊所就诊中，血压得到控制的只有56%。黑人血压控制较差是造成心血管疾病种族差异的关键因素。第七届高血压诊断、预防和治疗全国联合委员会（JNC VII）讨论高血压管理。虽然临床医生对JNC VII指南的采用在BP治疗的开始和药物选择方面稳步提高，但临床医生在很大程度上未能实施JNC对未控制BP患者每月就诊的建议。这种转化差距代表了改进次优BP控制的潜在机会，同时也解决了BP控制的差异。本研究项目的主要目的是改善临床医生对血压未控制的高血压患者每月就诊的JNC指南的执行情况。我们的第二个目标是改善血压控制。我们建议在临床主任网络（一个由联邦合格医疗中心（fqhc）组成的基于实践的研究网络）内实施一种理论知情和循证的多模式质量改进干预措施，以实现这些目标。我们的中心假设是，针对临床医生的意识，态度，技能和惯例相关的建议将提高患者就诊频率。我们的第二个假设是，提高访问频率将改善BP控制。我们建议通过一项实用的随机试验来严格检验这些重要的假设，该试验在参与的fqhc中采用楔形分步干预。我们将通过从参与实践的电子病历中提取数据来评估就诊频率和BP。我们的具体目标是：目标1：实施JNC推荐的每月就诊的高血压患者不受控制的血压使用理论知情，经验基础，多模式气干预。目的2：通过月检改善血压控制，减少血压差异。目的3：评估干预的潜在调节者和调节者。研究结果对有效实施本指南的最佳战略具有国家意义。如果成功，实施每月检查代表了一种简单可行的方法来改善血压控制，并有可能解决血压控制中的种族差异。据我们所知，该项目将是第一个实施每月就诊以改善BP的随机试验。我们的团队包括高血压、实用试验、FQHC研究和临床患者沟通方面的专家，非常适合进行这项研究，并通过正式和非正式的网络传播研究结果。

DESCRIPTION (provided by applicant): Abstract Blood pressure (BP) control among hypertensive patients reduces cardiovascular morbidity and mortality. Yet, BP is controlled at only 56% of hypertension-related office visits. Worse control of BP among Blacks is a key contributor to racial disparities in cardiovascular disease. The Seventh Joint National Committee on the Diagnosis, Prevention and Treatment of Hypertension (JNC VII) address hypertension management. While clinician adoption of JNC VII guidelines has steadily improved relevant to initiation of BP treatment and medication selection, clinicians have largely failed to implement the JNC recommendation for monthly visits for patients with uncontrolled BP. This translational gap represents a potential opportunity to improve suboptimal BP control while also addressing disparities in BP control. The primary aim of this research project is to improve clinician implementation of the JNC guideline for monthly visits for hypertensive patients with uncontrolled BP. Our secondary aim is improved BP control. We propose to accomplish these aims using a theoretically informed and evidence-based multimodal quality improvement intervention implemented within the Clinical Directors Network, a practice based research network of federally qualified health centers (FQHCs). Our central hypothesis is that targeting clinician awareness, attitudes, skills and routines relevant to this recommendation will improve patient visit frequency. Our secondary hypothesis is that improving visit frequency will improve BP control. We propose to rigorously test these important hypotheses through a pragmatic randomized trial that uses a stepped wedge phase-in of the intervention in participating FQHCs. We will assess visit frequency and BP through abstraction of data from electronic medical records of participating practices. Our specific aims are: Aim 1: To implement the JNC recommendation for monthly visits for hypertensive patients with uncontrolled BP using a theoretically-informed, empirically grounded, multimodal QI intervention. Aim 2: To improve BP control and reduce disparity in BP through implementation of monthly visits. Aim 3: To assess potential mediators and moderators of the intervention. Findings have national implications for best strategies for effective implementation of this guideline. If successful, implementation of monthly visits represents a simple and feasible means for improving BP control, and potentially, for addressing racial disparities in BP control. To our knowledge, this project will be the first randomized trial of implementation of monthly visits to improve BP. Our team, which includes experts in hypertension, pragmatic trials, FQHC research, and clinician-patient communication, is well suited to undertake this study and disseminate findings through formal and informal networks.