Home Blood Pressure Telemonitoring and Case Management to Control Hypertension

描述(申请人提供)：只有1/3的高血压患者的血压(BP)被控制在推荐水平，而且自20世纪80年代末以来几乎没有改善，尽管有证据表明积极控制高血压，以及许多新的有效降压药物的可用。很明显，高血压控制的有意义和持续的改善可能需要从根本上改变目前以医生为中心的以办公室访问为基础的高血压护理模式。在这个项目中，我们开发和实施了一种干预措施，利用新的护理技术和团队模式来改进血压测量和控制，解决了限制病例管理方法应用于高血压护理改进的问题。这项研究将在不同的成人高血压人群中进行，这些人在现实世界的初级保健环境中得到护理。远程监测干预(TI)集成了两个创新组件：首先，家庭BP测量使用最先进的调制解调器启用的自动化设备，在内部存储BP数据，并通过简单的按键电话连接到安全的网站以电子方式传输BP数据。其次，药剂师病例经理通过共同使用的电子病历(EMR)和处方集与初级保健团队集成，根据与医生的合作实践协议，使用经批准的书面协议调整抗高血压治疗。治疗决定基于家庭BP数据，并在电话访问中与药剂师病例经理讨论并传达给患者。药剂师案例经理和患者的初级保健团队之间的双向沟通通过使用共享的电子病历和将每次药剂师接触的结果安全地发送给初级保健团队来确保。为了评估TI对高血压控制、患者满意度和护理成本的影响，我们将进行一项整群随机试验，将16家初级保健诊所和450名无控制高血压的嵌套患者分配到普通护理(UC)对照组或TI。两组的血压结果将在基线、6个月、12个月和18个月时以相同的盲法在独立于患者接受医疗护理的临床环境的研究诊所中进行测定。我们假设来自TI诊所的超过60%的患者将在6个月后实现指导血压控制，并将其维持在12个月，而在UC诊所的患者中，这一比例为40%。我们将比较TI组和UC组的护理满意度和成本。TI有可能改善数百万患者的高血压控制，并可以根据在这项随机试验中的表现在不同的和大量的患者群体中广泛实施。该项目的结果将对未来改善向约2000万美国高血压患者中许多人提供的护理具有重要影响。公共卫生相关性：在这个项目中，我们开发和实施了一种干预措施，以改善初级保健环境中的高血压控制，利用新技术(家庭血压远程监测)和团队护理模式(药剂师病例管理)。该项目的结果将对未来改善向约2000万美国高血压患者中许多人提供的护理具有重要影响。

DESCRIPTION (provided by applicant): Blood pressure (BP) is controlled to recommended levels in only 1 in 3 people with hypertension, and there has been little improvement since the late 1980s, despite advances in evidence to support aggressive hypertension control, and availability of many new and effective antihypertensive drugs. It is clear that meaningful and sustained improvement in hypertension control will likely require fundamental changes in the current physician-centered office-visit based model of caring for hypertension. In this project we develop and implement an intervention that takes advantage of new technology and team models of care to improve BP measurement and control, solving the problems that have limited the application of case management approaches to hypertension care improvement. The study will take place in a diverse population of adults with hypertension cared for in a real-world primary care setting. The Telemonitoring Intervention (TI) integrates 2 innovative components: First, home BP measures are done using state-of-the-art modem-enabled automated equipment that internally stores and electronically transmits BP data through a simple touch-tone telephone connection to a secure web site. Second, a pharmacist case manager integrated with the primary care team through a jointly used electronic medical record (EMR) and formulary adjusts antihypertensive therapy using an approved written protocol, under a collaborative practice agreement with physicians. Treatment decisions are based on home BP data and are discussed and communicated to patients in telephone visits with the pharmacist case manager. Two-way communication between the pharmacist case manager and the patient's primary care team is assured by using a shared EMR and by additional secure messaging of the results of every pharmacist encounter to the primary care team. To assess the impact of the TI on hypertension control, patient satisfaction, and costs of care, we will conduct a cluster-randomized trial, assigning 16 primary care clinics and 450 of their nested patients with uncontrolled hypertension to either a Usual Care (UC) control group or TI. Blood pressure outcomes in both groups will be determined at baseline, 6, 12 and 18 months in an identical and blinded fashion in a research clinic separate from the clinical setting where patients received their medical care. We hypothesize that guideline BP control will be achieved at 6 months and maintained at 12 months in more than 60% of patients from TI clinics, compared to < 40% in patients from UC clinics. We will compare satisfaction with care and costs in the TI and UC groups. The TI has the potential to improve hypertension control for millions of patients, and could be implemented widely in diverse and large patient populations based on performance in this randomized trial. The results of the project will have important implications for future efforts to improve care provided to many of the estimated 20 million Americans with uncontrolled hypertension. PUBLIC HEALTH RELEVANCE: In this project we develop and implement an intervention to improve hypertension control in a primary care setting that takes advantage of new technology (home blood pressure telemonitoring) and team models of care (pharmacist case management). The results of the project will have important implications for future efforts to improve care provided to many of the estimated 20 million Americans with uncontrolled hypertension.