Community self-check program results in better hypertension control

Lowering blood pressure might be as simple as encouraging hypertensive patients to check in. In a study published online Oct. 28 in Circulation: Cardiovascular Quality and Outcomes, a community-outreach program improved hypertensive blood pressure after six weeks using web portals and personalized care.

Kevin L. Thomas, MD, of the department of medicine at Duke University in Durham, N.C., and colleagues developed the community-based quality improvement program called Check It, Change It to access a wider range of patients than in prior studies on self-measured blood pressure management.

Patients were enrolled from eight diverse ambulatory clinics from across Durham County, including primary care, cardiac and nephrology, safety net and free clinics. Through the program, patients had access to a web-based portal for longitudinal blood pressure monitoring, blood pressure monitoring kiosks and computer terminals, physician assistants and community health coaches in addition to the patient’s own healthcare provider to varying degrees.

Using a tiered approach, patients were assigned to one of three groups based on blood pressure control: tiers zero, one and two. Patients in tier zero had blood pressure control of less than 140/90 mmHg and had access to the web-portal and automated reminders. Patients in tiers one and two had blood pressure between 140-159/90-99 mmHg and greater than 159/99 mmHg, respectively. Beyond web-portal access, physician assistants assisted these patients, providing behavioral and lifestyle counseling, medication assessments, and adjusted medical therapy as needed. Patients in tier two also had home visits from a community health coach to assess nonmedical barriers to blood pressure control.

Kiosks and portals for self-monitoring were placed in frequently visited locations, such as places of worship, community centers and libraries, among others.

Patients were assessed for tier assignment over the course of six weeks and followed for six months thereafter. Thomas et al sought to determine if intensive community-based follow-up would work as well in a population with a broader socioeconomic span.

Overall, mean systolic and diastolic blood pressure dropped by 4.6 mmHg and 2.8 mmHg, respectively, from baseline at six months. The percentage of patients with optimal blood pressure control rose from 51 percent to 63 percent. Thomas et al noted that by six months, 69 percent of patients had either blood pressure below 140/90 mmHg or had a 10 mmHg or more decrease in systolic blood pressure by the final reading. Tier one patients had a mean decrease of 8.8/5.0 mmHg, while tier two patients saw mean declines of 23.7/10.1 mmHg.

Hypertensive black patients with poor blood pressure control had a mean decline of 15/7.2 mmHg, resulting in a net increase in black patients with controlled blood pressure from 49.2 percent to 62.2 percent.

Thomas et al noted that Medicaid and uninsured patients improved systolic blood pressure by 13.2 and 15.2 mmHg, respectively, over the course of the intervention.

Though largely successful, on average, 42 percent of patients entered only one result into the web portal. In exit interviews, Thomas et al learned that for many participants, lack of personal computers, knowledge of public portal locations or personal computing experience inhibited reporting. Based on this, the research team noted that increased marketing and an automated telephone system would have improved use. They also found that providing blood pressure cuffs to high-risk patients assisted them in self-monitoring, when they couldn’t reach or find kiosks.