African American Blood Pressure Control

NHLBI African American Blood Pressure Control RCTs Tools and Resources for Dissemination

Project Background: African Americans suffer disproportionately higher rates of hypertension-related complications compared to whites. Practice-based approaches for hypertension control in African Americans are limited.

Objective:  To evaluate the effectiveness of a practice-based, multi-component intervention compared with usual care (UC), in improving blood pressure (BP) control among hypertensive African Americans.

Design: Cluster randomized controlled multicenter trial.

From research to practice, a need for a shift in focus
Although empirical evidence supports the efficacy of interventions designed to improve blood pressure (BP) control in treated hypertensive (HTN) patients, translation of these approaches to clinical practice is suboptimal especially among hypertensive African Americans. However, if these interventions cannot find a place in standard medical care, their impact on public health will be negligible.

This study emphasizes the translation of a series of empirically-validated interventions into clinical practice by focusing on their integration into standard practice in several C/MHCs that serve minority populations.

RFA: INTERVENTIONS TO IMPROVE HYPERTENSION CONTROL RATES IN AFRICAN AMERICANS

RFA-HL-04-007 (NHBLI)
URL RFA: http://grants.nih.gov/grants/guide/rfa-files/RFA-HL-04-007.html
Einhorn PT. National Heart, Lung, and Blood institute-initiated program interventions to improve hypertension control rates in African Americans: Background and implementation. Circ Cardiovasc Qual Outcomes 2009; 2(3): 236-40. PMC ID #: 20031843
Pubmed URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2798164/
Full Article URL: http://circoutcomes.ahajournals.org/content/2/3/236.full.pdf+html

Affiliation & Grant Number:

    • Baylor College of Medicine (TX) Grant No. R01 HL078589 (NHLBI)
    • New York University-Clinical Directors Network, Inc. (NY/NJ) Grant No. R01 HL078566 (NHLBI)
    • Visiting Nurse Service of New York (NY/NJ) Grant No. R01 HL078585 (NHLBI)
  • University of Wisconsin-Madison (Midwest) Grant No. R01 Hl078580 (NHLBI)

Research Study Components:

1. Meta-Analysis and Dissemination Webcast
presentations:

Tobin, J.N., Pavlik, V.N., Ogedegbe, G., Hyman, D.J., Feldman, P., Schwartz, J.E., Chan, W., Mcdonald, M., Svarstad, B.L., Cassells, A., Einhorn, P. “Multi-Level Interventions to Improve Hypertension Control for African-Americans: Lessons Learned and Tools from NHLBI-Funded Cluster Randomized Trials” Accepted for Presentation at ISHIB2015: The 28th Annual International Interdisciplinary Conference on Hypertension and Related Risk Factors in Ethnic Populations, New York, NY, May 14 – 15, 2015.

Multi-level Interventions to Improve Hypertension Control for African-Americans: Lessons Learned & Tools from NHLBI-funded Cluster Randomized Trials
Presented by: Paula Einhorn, MD, MS, Gbenga Ogedegbe, MD, MS, Penny Feldman, PhD, David Hyman, PhD, Bonnie L. Svarstad, PhD, Valory Pavlik, PhD, Jonathan N. Tobin, PhD

Tuesday, June 9, 2015, 12:00-1:30 PM EDT (CDN Webcast)

Click Here to View

► Archived Webcast

2. Methods

3. Baseline Results

4. Main Effects/Results

Other Papers/Publications

Baylor College of Medicine (TX) Grant No. R01 HL078589 (NHLBI)

New York University-Clinical Directors Network, Inc. (NY/NJ) Grant No. R01 HL078566 (NHLBI)

Visiting Nurse Service of New York (NY/NJ) Grant No. R01 HL078585 (NHLBI)

MANUAL OF OPERATIONS

Home Blood Pressure Monitoring Tools & Home Blood Pressure Log

PATIENT:

New York University-Clinical Directors Network, Inc. (NY/NJ) Grant No. R01 HL078566 (NHLBI)

PATIENT:

University of Wisconsin-Madison (Midwest) Grant No. R01 Hl078580 (NHLBI)

CLINICIAN:

New York University-Clinical Directors Network, Inc. (NY/NJ) Grant No. R01 HL078566 (NHLBI)

CLINICIAN:

University of Wisconsin-Madison (Midwest) Grant No. R01 Hl078580 (NHLBI)
Brief Medication Questionnaire-

CLINICIAN:

Visiting Nurse Service of New York (NY/NJ) Grant No. R01 HL078585 (NHLBI)

    • VNSNY Hypertension Study Intervention Contact and Management Protocol Review

VNSNY HYPERTENSION STUDY INTERVENTION CONTACTS AND MANAGEMENT PROTOCOL OVERVIEW

Phase 1: All patients receive bi-weekly contacts for the first 12 weeks after the initial home visit led by the study nurse who assesses medication effectiveness, monitor medication management & explore needed lifestyle modifications.
Phase 2: Patients move to a different intervention level if BP measurement information from 2 consecutive contacts indicates patient has reached an improved BP stage; or after 1 contact if the BP has increased and the patient moves to a more severe BP stage.

BP Stage* SBP/DBP MMHG* Nurse Intervention Health Educator Intervention Physician Contact Medication Management/Lifestyle Modification
Normal and Prehypertension < 135/<85 Phase 1 : Weeks 1-12
Biweekly Contacts

Phase 2: Weeks 13-52
No contact 		Phase 2 : Weeks 13-52

Quarterly phone follow-up 		NONE
  • Quarterly calls by health educator include collection of BP measurements.
  • Focus is on promoting good lifestyle habits and medication adherence.
Stage 1
Mild to Moderately Elevated 		Phase 1: Weeks 1-12
Biweekly Contacts


Phase 2: Weeks 13-52
No contact 		Phase 2:Weeks 13-52

Monthly phone follow-up
  • Patient initiated
  • Study Staff: Study Nurse may call physician with medication concerns
  • If patient has adherence issues, RN works with patient to explore and address issues and concerns.
  • RN consults study protocol recommendations on medication management and determines recommendations.
  • RN recommends patient schedule an office visit with his/her doctor after four weeks of BP in Stage 1 range; RN may suggest that the patient talk to his/her MD regarding simplifying medication regimen if patient having trouble management regimen.
  • At the end of Phase I, a letter is sent to the patient and to his/her physician that includes a chart of BP progress and the JNC guideline recommendations.
  • HE works with patient on lifestyle management and contacts physician every 2 months after the initial contact for patients who remain in Stage 1.
AGES 21-69 135-159/85-99
Ages 70+ 135-169/85-99
Stage 2
Extremely Elevated 		Phase 1:Weeks 1-12
Biweekly Contacts

Phase 2:Weeks 13-52
Monthly Contacts 		Phase 2:Weeks 13-52

Weekly phone follow-up
  • Patient initiated
  • Phone contact by study staff
  • Follow-up contacts by mail or fax
  • Recommend patient to HTN specialist, if appropriate
  • RN to consult study protocol recommendations (including evaluation of whether patient is on maximum dose of medication, as appropriate) and contact patient’s physician with BP data and recommendations.
  • RN and HE make recommendations to patient to schedule office visits with his/her physician.
  • If a patient’s BP remains in Stage 2 for eight weeks after the patient’s primary care doctor has been contacted, RN refers to a hypertension specialist
AGES 21-69 >160/100
Ages 70+ >170/100

NOTES: *BP measurements and classifications have been modified from the JNC7. The range base starts 5 points lower than those identified in JNC7 because the measurements will be taken in a home setting by the patient. Also, age subcategories were created within each stage for this study. We will collect 14 days of BP readings from patient and average the readings to determine patient stage. Protocol implemented 2006-2009.

PRACTICE:

Baylor College of Medicine (TX) Grant No. R01 HL078589 (NHLBI)

  • Blood Pressure Monitoring Tool
  • Hypertension Monitoring and Tracking Form

PRACTICE:

New York University-Clinical Directors Network, Inc. (NY/NJ) Grant No. R01 HL078566 (NHLBI)

  • Clinician Chart Audit

PRACTICE:

University of Wisconsin-Madison (Midwest) Grant No. R01 Hl078580 (NHLBI)

CME Education

CDN CAATCH Project – Hypertension and Heart Failure/span>
Presented by: Gbenga Ogedegbe, MD, MPH, MS

ALLHAT Clinical Trial Results
Presented by: Michael Alderman, MD

Improving Blood Pressure Treatment in the Community: How the JNC7 Recommendations and ALLHAT Trial Results Relate to Your Practice
Presented by: M. Monica Sweeney, MD, MPH

Blood Pressure Control in Hispanic Participants in ALLHAT
Presented by: Karen Margolis, MD, MPH

Role of Lifestyle Changes in the Treatment of Hypertension: When and How?
Presented by: Lawrence Appel, MD

Management of Hypertension in Chronic Kidney Disease: A Report from the ALLHAT Study
Presented by: Mahboob Rahman, MD, MS

Outcomes in Hypertensive Black and Non-Black Patients Treated with Chlorthalidone, Amlodipine and Lisinopril
Presented by: Jackson Wright, MD, PhD

Publications:

1. Pavlik, V.N., Chan, W., Hyman, D.J., Feldman, P., Ogedegbe, G., Schwartz, J.E., McDonald, M., Einhorn, P., Tobin, J.N., “Evaluating Health-Systems Level Hypertension Control Interventions for African-Americans: Lessons from a Pooled Analysis of Three Cluster Randomized Trials.” Current Hypertension Reviews (In Press, 2015).PMC ID#: 25808682
Pubmed URL: http://www.ncbi.nlm.nih.gov/pubmed/25808682

Number Topic Source Version Used in BP visit study
1 Blood pressure NIH>NHLBI English & Spanish
2 Consequences of HTN AHA English & Spanish
3 Add-steps-your day University of Wisconsin System English Yes
4 Blood pressure Tracker log AHA English Yes
5 Consumer ED HBP (Facts about BP) CDC English
6 HBP rainbow chart (BP. Categories) AHA English
7 HNBP wallet NIH/NHLBI U.S DHHS English
8 HBP lowering guide NIH/NHLBI U.S DHHS English CAATCH
9 High blood pressure-sheet Preventive cardiovascular nurses association English & Spanish Yes
10 Dash eating plan 2007, B.L. Svarstad, Ph.D. (University of Wisconsin System) English Yes
11 Ucm_Medicine chart AHA English Yes
12 Blood pressure monitoring 1. High Blood Pressure – It’s in your court! Health Bulletin – NYC DOHMH; Vol 6, No 4
2. Understanding Task Force Recommendations – U.S. Preventive Services Task Force, Oct 2015		 English Yes
13 Tip sheet_hcp_medadherence Millions Hearts English CAATCH
14 Do you know the facts about taking your medication? NYC DOH English & Spanish
15 HBP med. Adherence NYC DOH&MH English
16 Medicine list AHRQ English
17 Medicine list -patient reminder card AHRQ English
18 Pe hbp blood pressure tracker AHA English