title: Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months. The Impact of a Multidisciplinary Information Technology–Supported Program on Blood Pressure Control in Primary Care Hypertension outcomes through blood pressure monitoring and evaluation by pharmacists (HOME study) Improving primary care in rural Alabama with a pharmacy initiative. Intensified preventive care to reduce cardiovascular risk in healthcare centres located in deprived neighbourhoods: a randomized controlled trial Improving Blood Pressure Control: Results of Home-based Post-acute Care Interventions Implementation of case management to reduce cardiovascular disease risk in the Stanford and San Mateo Heart to Heart randomized controlled trial: study protocol and baseline characteristics Randomized Pilot Study of a Behavioral Feedback Intervention to Improve Medication Adherence in Older Adults With Hypertension Nurse management for hypertension. 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Description of pharmacist interventions during physician–pharmacist co-management of hypertension Effects of Nurse-Managed Telemonitoring on Blood Pressure at 12-Month Follow-Up Among Urban African Americans Medical Clinics Versus Usual Care for Patients With Both Diabetes and Hypertension Effect of an intensive nurse-managed medical care programme on ambulatory blood pressure in hypertensive patients. Efficacy of telephone and mail intervention in patient compliance with antihypertensive drugs in hypertension. ETECUM‐HTA study Community Outreach and Cardiovascular Health (COACH) Trial: A Randomized, Controlled Trial of Nurse Practitioner/Community Health Worker Cardiovascular Disease Risk Reduction in Urban Community Health Centers Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. A multimodal blood pressure control intervention in 3 healthcare systems. 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Educational outreach in diabetes to encourage practice nurses to use primary care hypertension and hyperlipidaemia guidelines (EDEN): a randomized controlled trial. Failure of computerized treatment suggestions to improve health outcomes of outpatients with uncomplicated hypertension: results of a randomized controlled trial. An RCT of the effect of motivational interviewing on medication adherence in hypertensive African Americans: rationale and design. The Take Control of Your Blood pressure (TCYB) study: study design and methodology. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial A practice-based trial of motivational interviewing and adherence in hypertensive African Americans. Nurse administered telephone intervention for blood pressure control: a patient-tailored multifactorial intervention. Pharmacist-physician comanagement of hypertension and reduction in 24-hour ambulatory blood pressures. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. Physician-pharmacist cooperation program for blood pressure control in patients with hypertension: a randomized-controlled trial. Sustained blood pressure control following discontinuation of a pharmacist intervention.
abstract: BACKGROUND African American men with hypertension in low socioeconomic urban population s achieve poor rates of hypertension control and suffer early from its complications . METHODS In a r and omized clinical trial with 309 hypertensive urban African American men aged 21 to 54 years , we evaluated the effectiveness of a more intensive comprehensive educational-behavioral-pharmacologic intervention by a nurse practitioner-community health worker-physician ( NP/CHW/MD ) team and a less intensive education and referral intervention in controlling blood pressure ( BP ) and minimizing progression of left ventricular hypertrophy ( LVH ) and renal insufficiency . Changes in BP , left ventricular mass ( LVM ) , and serum creatinine from baseline to 36 months were compared between groups . RESULTS At 36 months , the mean systolic BP/diastolic BP change from baseline was -7.5/-10.1 mm Hg for the more intensive group and + 3.4/-3.7 mm Hg for the less intensive group ( P = .001 and .005 for between-group differences in systolic BP and diastolic BP , respectively ) . The proportion of men with controlled BP ( < 140/90 mm Hg ) was 44 % in the more intensive group and 31 % in the less intensive group ( P = .045 ) . The LVM was significantly lower in the more intensive group than in the less intensive group ( more intensive , 274 g ; less intensive , 311 g ; P = .004 ) . There was a trend toward slowing of the progression of renal insufficiency ( incidence of 50 % increase in serum creatinine ) in the more intensive group compared to the less intensive group ( more intensive , 5.2 % ; less intensive , 8.0 % ; P = .08 ) . CONCLUSIONS During 36 months , the more intensive intervention led to a lower BP and decreased progression of LVH in a sample of hypertensive young African American men Background —Hypertension is a leading mortality risk factor yet inadequately controlled in most affected subjects . Effective programs to address this problem are lacking . We hypothesized that an information technology – supported management program could help improve blood pressure ( BP ) control . Methods and Results —This r and omized controlled trial included 223 primary care hypertensive subjects with mean 24-hour BP > 130/80 and daytime BP > 135/85 mm Hg measured with ambulatory monitoring ( ABPM ) . Intervention subjects received a BP monitor and access to an information technology – supported adherence and BP monitoring system providing nurses , pharmacists , and physicians with monthly reports . Control subjects received usual care . The mean ( ±SD ) follow-up was 348 ( ±78 ) and 349 ( ±84 ) days in the intervention and control group , respectively . The primary end point of the change in the mean 24-hour ambulatory BP was consistently greater in intervention subjects for both systolic ( −11.9 versus −7.1 mm Hg ; P<0.001 ) and diastolic BP ( −6.6 versus −4.5 mm Hg ; P=0.007 ) . The proportion of subjects that achieved Canadian Guideline target BP ( 46.0 % versus 28.6 % ) was also greater in the intervention group ( P=0.006 ) . We observed similar BP declines for ABPM and self-recorded home BP suggesting the latter could be an alternative for confirming BP control . The intervention was associated with more physician-driven antihypertensive dose adjustments or changes in agents ( P=0.03 ) , more antihypertensive classes at study end ( P=0.007 ) , and a trend toward improved adherence measured by prescription refills ( P=0.07 ) . Conclusions —This multidisciplinary information technology – supported program that provided feedback to patients and healthcare providers significantly improved blood pressure levels in a primary care setting OBJECTIVE : To evaluate the effectiveness of a community pharmacist-based home blood pressure ( BP ) monitoring program . DESIGN : Trial of a high-intensity ( HI ) versus low-intensity ( LI ) intervention r and omized in 12 community pharmacies . The HI intervention comprised 4 face-to-face visits with a trained pharmacist . Pharmacists provided patient-specific education about hypertension . Following the first and third visits , patients were provided with a home BP monitoring device and instructed to measure their BP at least once daily for the next month . Home BP readings were used by the pharmacists to develop treatment recommendations for the patient ’s physician . Recommendations were discussed with the physician and , if approved , implemented by the pharmacist . In the LI intervention , pharmacists measured patients BP in the pharmacy and referred them to their physician for evaluation . PARTICIPANTS : Patients with uncontrolled BP at baseline . MEASUREMENTS : The main outcomes were the differences in systolic and diastolic BP ( SBP and DBP ) from baseline to follow-up between the HI and LI patients . RESULTS : The study enrolled 125 patients , 64 in the HI and 61 in the LI group . From baseline , SBP declined 13.4 mmHg in the HI group and 9.0 mmHg in the LI group . At the final visit , the difference in SBP/DBP change between the HI and LI group was −4.5/−3.2 mmHg ( P=.12 for SBP and P=.03 for DBP ) . CONCLUSIONS : The HI intervention achieved a lower DBP and this model could be a strategy for patients with hypertension The effect of pharmaceutical care on the prevention , detection , and resolution of medication-related problems in high-risk patients in a rural community was studied . Adult patients who received care at clinics in a medically underserved area of Alabama and who were identified as being at high risk of medication-related adverse events were r and omly assigned to a control group or an intervention group . The control group received st and ard medical care , and the intervention group received pharmaceutical care , including a medical record review , a medication history review , pharmacotherapeutic evaluation , and patient medication education and monitoring over a one-year period .  A total of 69 patients completed the study ( 33 in the intervention group and 36 in the control group ) . The percentage of patients responding to hypertension , diabetes , dyslipidemia , and anticoagulation therapy increased significantly in the intervention group and declined in the control group . Ratings for inappropriate prescribing improved in all 10 domains evaluated in the intervention group but worsened in 5 domains in the control group . There were no significant differences between the groups at 12 months in health-related quality of life or medication misadventures . Medication compliance scores improved in the intervention group but not in the control group . Medication knowledge increased in the intervention group and decreased in the control group . Pharmaceutical care in a rural , community-based setting appeared to reduce inappropriate prescribing , enhance disease management , and improve medication compliance and knowledge without adversely affecting health-related quality of life Background We examined the effectiveness of a structured collaboration in general practice between a practice nurse , a peer health educator , the general practitioner ( GP ) and a GP assistant in providing intensified preventive care for patients at high risk of developing cardiovascular diseases . Design A r and omized controlled trial in three healthcare centres ( 18 GPs ) in deprived neighbourhoods of two major Dutch cities . Methods Two hundred seventy-five high-risk patients ( 30 - 70 years ) from various ethnic groups were r and omized to intervention ( n = 137 ) or usual care group ( n = 138 ) . We determined group differences in outcomes [ 10-year absolute risk ( Framingham risk equation ) , blood pressure , lipids and body mass index ] at 12-month follow-up . Results The 10-year absolute risk was reduced by 1.76 % ( st and ard error : 0.81 ) in intervention and by 2.27 % ( st and ard error : 0.69 ) in usual care group ; the difference in mean change was 0.88 % [ 95 % confidence interval : −1.16 to 2.93 ] . In both groups significant reductions were observed in the following individual risk factors : total cholesterol , total cholesterol/high-density lipoprotein cholesterol , and low-density lipoprotein cholesterol , with no relevance between group differences . Conclusion The cardiovascular risk profile of intervention and control patients improved after 1-year follow-up . However , no extra effect of the structured preventive care on the risk for cardiovascular diseases was achieved . Eur J Cardiovasc Prev Rehabil 15:488 - 493 © 2008 The European Society of Background Blood pressure ( BP ) control remains elusive for many Americans . Although home health nurses are uniquely positioned to help vulnerable individuals achieve BP control , hypertension ( HTN ) management has not been a high priority in post-acute care . Objective To examine the effects of two home-based interventions design ed to improve BP outcomes among high-risk African-American patients . Design Cluster r and omized controlled trial . Participants A total of 845 newly admitted patients with uncontrolled HTN ( JNC7 stages 1 or 2 ) . Interventions The “ basic ” intervention delivered key HTN information to clinicians and patients , and a home BP monitor to patients , while the patients received usual post-acute care . The “ augmented ” intervention provided more intensive and extensive HTN information , monitoring and feedback for 3 months beyond the index home care admission . Measures Primary : BP control . Secondary : reductions in mmHG SBP and DBP , improvements in proportions improving JNC7 stage or achieving clinical ly meaningful reductions in SBP and DBP . Methods Multivariate regression models . Key Results The basic intervention produced no significant BP improvements ; the augmented intervention significantly improved stage 2 patients ’ outcomes . Among stage 2 patients , the augmented intervention increased BP control by 8.7 percentage points relative to usual care ( 8.9 % vs. 17.6 % ; p = 0.01 ) , yielded an 8.3 mmHG relative reduction in SBP ( p = 0.01 ) , and increased the proportion achieving at least a 20 mmHG reduction in SBP by 16.4 percentage points ( p = 0.01 ) . Conclusion Among stage 2 patients , a nurse-led intervention providing additional HTN medication review and patient self-management support during the 3-month post-acute care period yielded significant improvements in 3-month BP control , plus improvements in secondary BP outcomes Background Case management has emerged as a promising alternative approach to supplement traditional one-on-one sessions between patients and doctors for improving the quality of care in chronic diseases such as coronary heart disease ( CHD ) . However , data are lacking in terms of its efficacy and cost-effectiveness when implemented in ethnic and low-income population s. Methods The Stanford and San Mateo Heart to Heart ( HTH ) project is a r and omized controlled clinical trial design ed to rigorously evaluate the efficacy and cost-effectiveness of a multi-risk cardiovascular case management program in low-income , primarily ethnic minority patients served by a local county health care system in California . R and omization occurred at the patient level . The primary outcome measure is the absolute CHD risk over 10 years . Secondary outcome measures include adherence to guidelines on CHD prevention practice . We documented the study design , methodology , and baseline sociodemographic , clinical and lifestyle characteristics of 419 participants . Results We achieved equal distributions of the sociodemographic , biophysical and lifestyle characteristics between the two r and omization groups . HTH participants had a mean age of 56 years , 63 % were Latinos/Hispanics , 65 % female , 61 % less educated , and 62 % were not employed . Twenty percent of participants reported having a prior  cardiovascular event . 10-year CHD risk averaged 18 % in men and 13 % in women despite a modest low-density lipoprotein cholesterol level and a high on-treatment percentage at baseline . Sixty-three percent of participants were diagnosed with diabetes and an additional 22 % had metabolic syndrome . In addition , many participants had depressed high-density lipoprotein ( HDL ) cholesterol levels and elevated values of total cholesterol-to-HDL ratio , triglycerides , triglyceride-to-HDL ratio , and blood pressure . Furthermore , nearly 70 % of participants were obese , 45 % had a family history of CHD or stroke , and 16 % were current smokers . Conclusion We have recruited an ethnically diverse , low-income cohort in which to implement a case management approach and test its efficacy and cost-effectiveness . HTH will advance the scientific underst and ing of better strategies for CHD prevention among these priority sub population s and aid in guiding future practice that will reduce health disparities Background and Objectives : Older adults ' adherence to antihypertensive medications is far lower than what is considered necessary for clinical effectiveness , despite the risks for adverse cardiovascular events from uncontrolled blood pressure ( BP ) in the elderly . This pilot study tested a novel 8-week behavioral feedback intervention to improve antihypertensive medication adherence ( MA ) and BP control among older adults on existing treatment for hypertension . Methods : Adults 60 years old , or older taking at least 1 antihypertensive medication were r and omized to receive the nurse-delivered adherence intervention or usual care . Medication adherence was monitored continuously using electronic monitoring for 20 weeks . Intervention-group participants received biweekly MA and BP feedback , habit counseling , medication and disease education , a medication instruction card , and were given an electronic medication bottle cap with a digital display that provided daily adherence feedback during the 8-week intervention . Blood pressure was measured by a nurse at 12 and 20 weeks after r and omization . Adherence and BP outcomes were described using descriptive statistics and analyzed for between- and within-group differences using Mann-Whitney U tests . Results : Fifteen participants ( median age , 71 years ; 73 % female ) were eligible for r and omization . Participants took an average of 5.8 prescription medications and 2.93 over-the-counter medications per day . A nonsignificant difference was noted in baseline MA between groups . At the end of the intervention , the treatment group had better antihypertensive MA than did the control group ( median MA : 100 % vs 27.3 % , U = 5.00 , P = .013 ) . Systolic BP improved slightly in the intervention group during the study and was significantly different at week 12 ( median systolic BP : 130 vs 152 mm Hg ; U = 4.50 , P = .008 ) . Diastolic BP was largely unchanged over the course of the study . Conclusion : The results indicate that the intervention had a positive effect on MA . Additional testing is needed to further evaluate the intervention and its effect on adherence behavior and BP control BACKGROUND St and ard office-based approaches to controlling hypertension show limited success . Such suboptimal hypertension control reflects in part the absence of both an infrastructure for patient education and frequent , regular blood pressure ( BP ) monitoring . We tested the efficacy of a physician-directed , nurse-managed , home-based system for hypertension management with st and ardized algorithms to modulate drug therapy , based on patients ' reports of home BP . METHODS We r and omized out patients requiring drug therapy for hypertension according to the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure ( JNC VI ) criteria to receive usual medical care only ( UC , n = 76 ) or usual care plus nurse care management intervention ( INT , n = 74 ) over a 6-month period . RESULTS Patients receiving INT achieved greater reductions in office BP values at 6 months than those receiving UC : 14.2 + /- 18.1 versus 5.7 + /- 18.7 mm Hg systolic ( P < .01 ) and 6.5 + /- 10.0 versus 3.4 + /- 7.9 mm Hg diastolic , respectively ( P < .05 ) . At 6 months , we observed one or more changes in drug therapy in 97 % of INT patients versus 43 % of UC patients , and 70 % of INT patients received two or more drugs versus 46 % of UC . Average daily adherence to medication , measured by electronic drug event monitors , was superior among INT subjects ( mean + /- SD , 80.5 % + /- 23.0 % ) than among UC subjects ( 69.2 + /- 31.1 % ; t(113 ) = 2.199 , P = .03 ) . There were no significant adverse drug reactions in either group . CONCLUSIONS Telephone-mediated nurse management can successfully address many of the systems-related and patient-related issues that limit pharmacotherapeutic effectiveness for hypertension This pilot aims to better underst and the market for childcare in Saudi Arabia – both the supply and dem and sides – and to design a r and omized controlled experiment to test whether access to affordable day care ( in the form of subsidies , for example ) would incentivize Saudi mothers to search actively for employment and to remain employed once they are hired . In addition , the study seeks to underst and the degree to which employment early on in one ’s life impacts employment in later stages . The pilot will provide information on the groups of women the experiment should target , appropriate levels for the childcare subsidy , and the quality and current geographic locations of daycare sites . Expected Impact Determine the effects of facilitating childcare access on Saudi women ’s employment . PRINCIPAL INVESTIGATORS  Boston University Patricia Cortes  Harvard University Claudia Goldin  Swarthmore College Jennifer OBJECTIVE To evaluate the effect of a 9-month community pharmacy-based medication therapy management ( MTM ) program on quality of care in patients with diabetes and hypertension . DESIGN R and omized controlled trial . SETTING Tulsa , OK , between November 2005 and July 2007 . PATIENTS 52 patients with diabetes and hypertension who were enrolled in a managed care organization . INTERVENTION During monthly visits , intervention group participants received MTM services for hypertension and diabetes management . MAIN OUTCOME MEASURES Systolic blood pressure ( SBP ) , percentage at goal blood pressure ( < 130/80 mm Hg ) , and antihypertensive medication adherence . RESULTS The mean intervention group SBP decreased 17.32 mm Hg , whereas the mean control group SBP level increased 2.73 mm Hg ( P = 0.003 ) . The percentage of patients at goal blood pressure increased from 16.0 % to 48.0 % in the intervention group and decreased from 20.0 % to 6.67 % in the control group . Intervention group participants were 12.92 times more likely than control group participants to achieve goal blood pressure ( P = 0.021 ) . Although the mean adherence rate in the intervention group increased 7.0 % while remaining fairly constant in the control group ( -0.7 % ) , this group difference was not statistically significant . CONCLUSION A community pharmacy-based hypertension MTM program was effective in improving blood pressure control among managed care enrollees with diabetes and hypertension . Community pharmacists are strategically positioned to provide MTM services and effectively communicate with providers to improve quality of care for patients Hypertension is a major risk factor for developing cardiovascular disease and is more prevalent in African Americans compared with Caucasians . African Americans are often underrepresented in clinical trials . This study was composed of a largely urban African American cohort of hypertensive patients . This was a prospect i ve , 4-arm , r and omized controlled trial design ed to evaluate the comparative effectiveness of both physician and patient education ( PPE ) , patient education only ( PAE ) , and physician education only ( PHE ) vs usual care ( UC ) . Hypertension specialists gave a series of didactic lectures to the physicians , while a nurse educator performed the patient education . The mean adjusted difference in systolic blood pressure ( SBP ) from baseline in the PPE group was an average reduction of 12 mm Hg ( 95 % confidence interval [ CI ] , -4.5 to -19.4 ) at 6-months , followed by average reductions of 4.6 mm Hg ( 6.9 to -16.12 ) in the PAE group , 4.1 mm Hg ( 3.4 to -11.7 ) in the PHE group , and 2.6 mm Hg ( 3 to -8.2 ) in the UC group . The PPE group achieved a significantly better reduction in SBP compared with the UC group . Additional research should be conducted to evaluate whether the use of certified hypertension educators in collaboration with physicians will result in a similar blood pressure reduction African Americans have a higher prevalence of hypertension and poorer cardiovascular and renal outcomes than white Americans . The objective of this study was to determine whether a telephonic nurse disease management ( DM ) program design ed for African Americans is more effective than a home monitoring program alone to increase blood pressure ( BP ) control among African Americans enrolled in a national health plan . A prospect i ve r and omized controlled study ( March 2006-December 2007 ) was conducted , with 12 months of follow-up on each subject . A total of 5932 health plan members were r and omly selected from the population of self-identified African Americans , age 23 and older , in health maintenance organization plans , with hypertension ; 954 accepted , 638 completed initial assessment , and 485 completed follow-up assessment . The intervention consisted of telephonic nurse DM ( intervention group ) including educational material s , lifestyle and diet counseling , and home BP monitor vs. home BP monitor alone ( control group ) . Measurements included proportion with BP < 120/80 , mean systolic BP , mean diastolic BP , and frequency of BP self-monitoring . Results revealed that systolic BP was lower in the intervention group ( adjusted means 123.6 vs. 126.7 mm Hg , P = 0.03 ) ; there was no difference for diastolic BP . The intervention group was 50 % more likely to have BP in control ( odds ratio [ OR ] = 1.50 , 95 % confidence interval [ CI ] 0.997 - 2.27 , P = 0.052 ) and 46 % more likely to monitor BP at least weekly ( OR 1.46 , 95 % CI 1.07 - 2.00 , P = 0.02 ) than the control group . A nurse DM program tailored for African Americans was effective at decreasing systolic BP and increasing the frequency of self-monitoring of BP to a greater extent than home monitoring alone . Recruitment and program completion rates could be improved for maximal impact Purpose To assess whether VA MEDIC-E ( Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction[EM DASH ] Extended for 6 months ) , a pharmacist-led shared medical appointments program , could improve attainment of target goals for hypertension , hyperglycemia , hyperlipidemia , and tobacco use in patients with type 2 diabetes compared to st and ard primary care after 6 months of intervention . Methods A r and omized , controlled trial of VA MEDIC-E ( n = 50 ) versus st and ard primary care ( n = 49 ) in veterans with type 2 diabetes , hemoglobin A1c ( A1C ) > 7 % , blood pressure ( BP ) > 130/80 mmHg , and low density lipoprotein cholesterol ( LDL-C ) > 100mg/dl ( 2.59 mmol/l ) in the previous 6 months was conducted . The VA MEDIC-E intervention consisted of 4 weekly group sessions followed by 5 monthly booster group sessions . Each 2-hour session included 1 hour of multidisciplinary diabetes specific healthy lifestyle education and 1 hour of pharmacotherapeutic interventions performed by a clinical pharmacist . Evaluation measures included lab values of A1C , LDL cholesterol , BP , and goal attainment of these values , and diabetes self-care behavior question naires at 6 months . Results The r and omization groups were similar at baseline in all cardiovascular risk factors except for LDL , which was significantly lower in the MEDIC-E arm . At 6 months , significant improvements from baseline were found in the intervention arm for exercise , foot care , and goal attainment of A1C , LDL-C , and BP but not in the control arm . Conclusions The results of this study demonstrate that the pharmacist-led group intervention program for 6 months was an efficacious and sustainable collaborative care approach to managing diabetes and reducing associated cardiovascular risk CONTEXT Poor medication adherence diminishes the health benefits of pharmacotherapies . Elderly patients with coronary risk factors frequently require treatment with multiple medications , placing them at increased risk for nonadherence . OBJECTIVE To test the efficacy of a comprehensive pharmacy care program to improve medication adherence and its associated effects on blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) . DESIGN , SETTING , AND PATIENTS A multiphase , prospect i ve study with an observational phase and a r and omized controlled trial conducted at the Walter Reed Army Medical Center of 200 community-based patients aged 65 years or older taking at least 4 chronic medications . The study was conducted from June 2004 to August 2006 . INTERVENTION After a 2-month run-in phase ( measurement of baseline adherence , BP , and LDL-C ) , patients entered a 6-month intervention phase ( st and ardized medication education , regular follow-up by pharmacists , and medications dispensed in time-specific packs ) . Following the intervention phase , patients were r and omized to continued pharmacy care vs usual care for an additional 6 months . MAIN OUTCOME MEASURES Primary end point of the observation phase was change in the proportion of pills taken vs baseline ; secondary end points were the associated changes in BP and LDL-C. Primary end point of the r and omization phase was the between-group comparison of medication persistence . RESULTS A total of 200 elderly patients ( 77.1 % men ; mean [ SD ] age , 78 [ 8.3 ] years ) , taking a mean ( SD ) of 9 ( 3 ) chronic medications were enrolled . Coronary risk factors included drug-treated hypertension in 184 patients ( 91.5 % ) and drug-treated hyperlipidemia in 162 ( 80.6 % ) . Mean ( SD ) baseline medication adherence was 61.2 % ( 13.5 % ) . After 6 months of intervention , medication adherence increased to 96.9 % ( 5.2 % ; P<.001 ) and was associated with significant improvements in systolic BP ( 133.2 [ 14.9 ] to 129.9 [ 16.0 ] mm Hg ; P = .02 ) and LDL-C ( 91.7 [ 26.1 ] to 86.8 [ 23.4 ] mg/dL ; P = .001 ) . Six months after r and omization , the persistence of medication adherence decreased to 69.1 % ( 16.4 % ) among those patients assigned to usual care , whereas it was sustained at 95.5 % ( 7.7 % ) in pharmacy care ( P<.001 ) . This was associated with significant reductions in systolic BP in the pharmacy care group ( -6.9 mm Hg ; 95 % CI , -10.7 to -3.1 mm Hg ) vs the usual care group ( -1.0 mm Hg ; 95 % CI , -5.9 to 3.9 mm Hg ; P = .04 ) , but no significant between-group differences in LDL-C levels or reductions . CONCLUSIONS A pharmacy care program led to increases in medication adherence , medication persistence , and clinical ly meaningful reductions in BP , whereas discontinuation of the program was associated with decreased medication adherence and persistence . TRIAL REGISTRATION clinical trials.gov Identifier : Background Patient-shared electronic health records provide opportunities for care outside of office visits . However , those who might benefit may be unable to or choose not to use these re sources , while others might not need them . Objective Electronic Communications and Home Blood Pressure Monitoring ( e-BP ) was a r and omized trial that demonstrated that Web-based pharmacist care led to improved blood pressure ( BP ) control . During recruitment we attempted to contact all patients with hypertension from 10 clinics to determine whether they were eligible and willing to participate . We wanted to know whether particular subgroups , particularly those from vulnerable population s , were less willing to participate or unable to because they lacked computer access . Methods From 2005 to 2006 , we sent invitation letters to and attempted to recruit 9298 patients with hypertension . Eligibility to participate in the trial included access to a computer and the Internet , an email address  , and uncontrolled BP ( BP ≥ 140/90 mmHg ) . Generalized linear models within a modified Poisson regression framework were used to estimate the relative risk ( RR ) of in eligibility due to lack of computer access and of having uncontrolled BP . Results We were able to contact 95.1 % ( 8840/9298 ) of patients . Those refusing participation ( 3032/8840 , 34.3 % ) were significantly more likely ( P < .05 ) to be female , be nonwhite , have lower levels of education , and have Medicaid insurance . Among patients who answered survey questions , 22.8 % ( 1673/7354 ) did not have computer access . Older age , minority race , and lower levels of education were risk factors for lack of computer access , with education as the strongest predictor ( RR 2.63 , 95 % CI 2.30 - 3.01 for those with a high school degree compared to a college education ) . Among hypertensive patients with computer access who were willing to participate , African American race ( RR 1.22 , 95 % CI 1.06 - 1.40 ) , male sex ( RR 1.28 , 95 % CI 1.18 - 1.38 ) , and obesity ( RR 1.53 , 95 % CI 1.31 - 1.79 ) were risk factors for uncontrolled BP . Conclusion Older age , lower socioeconomic status , and lower levels of education were associated with decreased access to and willingness to participate in a Web-based intervention to improve hypertension control . Failure to ameliorate this may worsen health care disparities . Trial Registration Clinical trials.gov NCT00158639 ; http://www . clinical trials.gov/ct2/show/NCT00158639 ( Archived by WebCite at http://www.webcitation.org/5v1jnHaeo BACKGROUND Patients with depression and poorly controlled diabetes , coronary heart disease , or both have an increased risk of adverse outcomes and high health care costs . We conducted a study to determine whether coordinated care management of multiple conditions improves disease control in these patients . METHODS We conducted a single-blind , r and omized , controlled trial in 14 primary care clinics in an integrated health care system in Washington State , involving 214 participants with poorly controlled diabetes , coronary heart disease , or both and coexisting depression . Patients were r and omly assigned to the usual-care group or to the intervention group , in which a medically supervised nurse , working with each patient 's primary care physician , provided guideline -based , collaborative care management , with the goal of controlling risk factors associated with multiple diseases . The primary outcome was based on simultaneous modeling of glycated hemoglobin , low-density lipoprotein ( LDL ) cholesterol , and systolic blood-pressure levels and Symptom Checklist-20 ( SCL-20 ) depression outcomes at 12 months ; this modeling allowed estimation of a single overall treatment effect . RESULTS As compared with controls , patients in the intervention group had greater overall 12-month improvement across glycated hemoglobin levels ( difference , 0.58 % ) , LDL cholesterol levels ( difference , 6.9 mg per deciliter [ 0.2 mmol per liter ] ) , systolic blood pressure ( difference , 5.1 mm Hg ) , and SCL-20 depression scores ( difference , 0.40 points ) ( P<0.001 ) . Patients in the intervention group also were more likely to have one or more adjustments of insulin ( P=0.006 ) , antihypertensive medications ( P<0.001 ) , and antidepressant medications ( P<0.001 ) , and they had better quality of life ( P<0.001 ) and greater satisfaction with care for diabetes , coronary heart disease , or both ( P<0.001 ) and with care for depression ( P<0.001 ) . CONCLUSIONS As compared with usual care , an intervention involving nurses who provided guideline -based , patient-centered management of depression and chronic disease significantly improved control of medical disease and depression . ( Funded by the National Institute of Mental Health ; Clinical Trials.gov number , NCT00468676 . ) BACKGROUND Studies have demonstrated that blood pressure ( BP ) control can be improved when clinical pharmacists assist with patient management . The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control . METHODS This was a prospect i ve , cluster r and omized , controlled clinical trial with clinics r and omized to a control group ( n = 3 ) or to an intervention group ( n = 3 ) . The study enrolled 402 patients ( mean age , 58.3 years ) with uncontrolled hypertension .  Clinical pharmacists made drug therapy recommendations to physicians based on national guidelines . Research nurses performed BP measurements and 24-hour BP monitoring . RESULTS The mean ( SD ) guideline adherence scores increased from 49.4 ( 19.3 ) at baseline to 53.4 ( 18.1 ) at 6 months ( 8.1 % increase ) in the control group and from 40.4 ( 22.6 ) at baseline to 62.8 ( 13.5 ) at 6 months ( 55.4 % increase ) in the intervention group ( P = .09 for adjusted between-group comparison ) . The mean BP decreased 6.8/4.5 mm Hg in the control group and 20.7/9.7 mm Hg in the intervention group ( P < .05 for between-group systolic BP comparison ) . The adjusted difference in systolic BP was -12.0 ( 95 % confidence interval [ CI ] , -24.0 to 0.0 ) mm Hg , while the adjusted difference in diastolic BP was -1.8 ( 95 % CI , -11.9 to 8.3 ) mm Hg . The 24-hour BP levels showed similar effect sizes . Blood pressure was controlled in 29.9 % of patients in the control group and in 63.9 % of patients in the intervention group ( adjusted odds ratio , 3.2 ; 95 % CI , 2.0 - 5.1 ; P < .001 ) . CONCLUSIONS A physician and pharmacist collaborative intervention achieved significantly better mean BP and overall BP control rates compared with a control group . Additional research should be conducted to evaluate efficient strategies to implement team-based chronic disease management . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00201019 OBJECTIVE To evaluate the effect of adding pharmacists to primary care teams on the management of hypertension and other cardiovascular risk factors  in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS We conducted a r and omized controlled trial with blinded ascertainment of outcomes within primary care clinics in Edmonton , Canada .  Pharmacists performed medication assessment s and limited history and physical examinations and provided guideline -concordant recommendations to optimize medication management . Follow-up contact was completed as necessary . Control patients received usual care . The primary outcome was a ≥10 % decrease in systolic blood pressure at 1 year . RESULTS A total of 260 patients were enrolled , 57 % were women , the mean age was 59 years , diabetes duration was 6 years , and blood pressure was 129/74 mmHg . Forty-eight of 131 ( 37 % ) intervention patients and 30 of 129 ( 23 % ) control patients achieved the primary outcome ( odds ratio 1.9 [ 95 % CI 1.1–3.3 ] ; P = 0.02 ) . Among 153 patients with inadequately controlled hypertension at baseline , intervention patients ( n = 82 ) were significantly more likely than control patients ( n = 71 ) to achieve the primary outcome ( 41 [ 50 % ] vs. 20 [ 28 % ] ; 2.6 [ 1.3–5.0 ] ; P = 0.007 ) and recommended blood pressure targets ( 44 [ 54 % ] vs. 21 [ 30 % ] ; 2.8 [ 1.4–5.4 ] ; P = 0.003 ) . The 10-year risk of cardiovascular disease , based on changes to the UK Prospect i ve Diabetes Study Risk Engine , were predicted to decrease by 3 % for intervention patients and 1 % for control patients ( P = 0.005 ) . CONCLUSIONS Significantly more patients with type 2 diabetes achieved better blood pressure control  when pharmacists were added to primary care teams , which suggests that pharmacists can make important contributions to the primary care of these patients ABSTRACT OBJECTIVE Evaluate the effectiveness of collaborative management of hypertension by primary care-pharmacist teams in community-based clinics . STUDY DESIGN A 12-month prospect i ve , single-blind , r and omized , controlled trial in the Providence Primary Care Research Network of patients with hypertension and uncontrolled blood pressure . METHODS As compared to usual primary care , intervention consisted of pharmacy practitioners participating in the active management of hypertension  in the primary care office according to established collaborative treatment protocol s. At baseline , there was no significant difference in blood pressure between groups . Primary outcome measures were the differences in mean systolic and diastolic blood pressures between arms at study end . Secondary measures included blood pressure goal attainment ( < 140/90 mmHg ) , hypertension-related knowledge , medication adherence , home blood pressure monitoring , re source utilization , quality of life , and satisfaction . RESULTS A total of 463 subjects were enrolled ( n = 233 control , n = 230 intervention ) . Subjects receiving the intervention achieved significantly lower systolic ( p = 0.007 ) and diastolic ( p = 0.002 ) blood pressures compared to control ( 137/75 mmHg vs. 143/78 mmHg ) . In addition , 62 % of intervention subjects achieved target blood pressure compared to 44 % of control subjects ( p = 0.003 ) . The intervention group received more total office visits ( 7.2 vs. 4.9 , p < 0.0001 ) , however had fewer physician visits ( 3.2 vs. 4.7 , p < 0.0001 ) compared to control . Intervention subjects were prescribed more antihypertensive medications ( 2.7 vs. 2.4 , p = 0.02 ) , but did not take more antihypertensive pills per day ( 2.4 vs. 2.5 , p = 0.87 ) . There were minimal differences between groups in hypertension-related knowledge , medication adherence , quality of life , or satisfaction . CONCLUSIONS Patients r and omized to collaborative primary care-pharmacist hypertension management achieved significantly better blood pressure control compared to usual care with no difference in quality of life or satisfaction Objective Studies have demonstrated that hypertension remains inadequately managed throughout the world , with lack of adherence to BP-lowering medication being a major factor . The aim of the present study was to evaluate if a pharmaceutical care program could improve antihypertensive medication adherence and blood pressure control . Setting This study was conducted in a secondary care hypertension/dyslipidemia outpatient clinic in the university teaching hospital of Cova da Beira Hospital Centre , Covilhã , located in the Eastern Central Region of Portugal . Method This report evaluates the pharmacist ’s interventions during a prospect i ve r and omised controlled trial , from July 2009 to June 2010 . Patients with diagnosis of essential hypertension attending the clinic for routine follow-up were r and omly allocated either to a control group ( no pharmaceutical care ) or to an intervention group ( quarterly follow-up by a hospital pharmacist during a 9-month period ) . The pharmacist interventions , aim ed to increase medication adherence and blood pressure control , involved educational interventions and counselling tips directed to the patient . Main outcome measure Systolic blood pressure , diastolic blood pressure and blood pressure control ( according to JNC 7 guidelines ) assessed at the baseline visit and at the end of pharmaceutical care were the main outcome measures . Blood pressure measurements were performed by blinded nurses . Medication adherence was also evaluated , using a vali date d question naire at baseline and at the end of investigation . Results A total of 197 hypertensive patients were r and omly assigned to the study ( 99 in the control group and 98 in the intervention group ) . Although there were no significant differences ( P > 0.05 ) in both groups concerning mean age , gender , body mass index , and antihypertensive pharmacotherapy , blood pressure control was higher in the intervention group ( P = 0.005 ) at the end of the study . Significant lower systolic blood pressure ( −6.8 mmHg , P = 0.006 ) and diastolic blood pressure ( −2.9 mmHg , P = 0.020 ) levels were observed in the intervention group . Medication adherence was also significantly higher in the intervention group at the end of the study ( 74.5 % vs. 57.6 % , P = 0.012 ) . Conclusion Pharmacist intervention can significantly improve medication adherence and blood pressure control in patients treated with antihypertensive agents BACKGROUND Blood pressure ( BP ) control in patients with diabetes mellitus is difficult to achieve and current patterns are suboptimal . Given increasing problems with access to primary care physicians , community pharmacists and nurses are well positioned to identify and observe these patients . This study aim ed to determine the efficacy of a community-based multidisciplinary intervention on BP control in patients with diabetes mellitus . METHODS We performed a r and omized controlled trial in 14 community pharmacies in Edmonton , Alberta , Canada , of patients with diabetes who had BPs higher than 130/80 mm Hg on 2 consecutive visits 2 weeks apart . Care from a pharmacist and nurse team included a wallet card with recorded BP measures , cardiovascular risk reduction education and counseling , a hypertension education pamphlet , referral to the patient 's primary care physician for further assessment or management , a 1-page local opinion leader-endorsed evidence summary sent to the physician reinforcing the guideline recommendations for the treatment of hypertension and diabetes , and 4 follow-up visits throughout 6 months .  Control-arm patients received a BP wallet card , a pamphlet on diabetes , general diabetes advice , and usual care by their physician . The primary outcome measure was the difference in change in systolic BP between the 2 groups at 6 months . RESULTS A total of 227 eligible patients were r and omized to intervention and control arms between May 5 , 2005 , and September 1 , 2006 . The mean ( SD ) patient age was 64.9 ( 12.1 ) years , 59.9 % were male , and the mean ( SD ) baseline systolic/diastolic BP was 141.2 (13.9)/77.3 ( 8.9 ) mm Hg at baseline . The intervention group had an adjusted mean ( SE ) greater reduction in systolic BP at 6 months of 5.6 ( 2.1 ) mm Hg compared with controls ( P = .008 ) . In the subgroup of patients with a systolic BP greater than 160 mm Hg at baseline , BP was reduced by an adjusted mean ( SE ) of 24.1 ( 1.9 ) mm Hg more in intervention patients than in controls ( P < .001 ) . CONCLUSION Even in patients who have diabetes and hypertension that are relatively well controlled , a pharmacist and nurse team-based intervention result ed in a clinical ly important improvement in BP . Trial Registration clinical trials.gov Identifier : NCT00374270 Background : First Nations people with diabetes mellitus and hypertension are at greater risk of renal and cardiovascular complications than are non-native patients because of barriers to health care services . We conducted this r and omized controlled trial to assess whether a community-based treatment strategy implemented by home care nurses would be effective in controlling hypertension in First Nations people with existing hypertension and type 2 diabetes . Methods : We compared 2 community-based strategies for controlling hypertension in First Nations people with existing hypertension and diabetes . In the intervention group , a home care nurse followed a predefined treatment algorithm of pharmacologic antihypertensive therapy . In the control group , treatment decisions were made by each subject 's primary care physician . The primary outcome measure was the difference between the 2 groups in the change in systolic blood pressure after 12 months . Secondary outcome measures were the change in diastolic blood pressure over time , the change in urine albumin status and the incidence of adverse events . Results : Both groups experienced a significant reduction in systolic blood pressure by the final visit ( by 24.0 [ st and ard deviation ( SD ) 13.5 ] mm Hg in the intervention group and by 17.0 [ SD 18.6 ] mm Hg in the control group ) ; p < 0.001 in each case ) . However , the difference between the 2 groups in this change was not significant . Patients in the intervention group had a larger decrease in diastolic blood pressure over time than did those in the control group ( by 11.6 [ SD 10.6 ] mm Hg v. 6.8 [ SD 11.1 ] mm Hg respectively ; p = 0.05 ) . The groups did not differ significantly in terms of changes in urine albumin excretion or incidence of adverse events . Interpretation : High rates of blood pressure control in the community were achieved in both groups in the DREAM 3 study . The addition of a home care nurse to implement a treatment strategy for blood pressure control was more effective in lowering diastolic than systolic blood pressure compared with home care visits for blood pressure monitoring alone and follow-up treatment by a family physician STUDY OBJECTIVE To measure the effectiveness of a multifaceted educational intervention to improve ambulatory hypertension control . DESIGN Cluster-r and omized trial . SETTING Academic health system using an ambulatory electronic medical record . SUBJECTS A total of 10,696 patients with a diagnosis of hypertension cared for by 93 primary care providers . INTERVENTION Academic detailing , provision of provider-specific data about hypertension control , provision of educational material s to the provider , and provision of educational and motivational material s to patients . MEASUREMENTS AND MAIN RESULTS The primary outcome was blood pressure control , defined as a blood pressure measurement below 140/90 mm Hg , and was ascertained from electronic medical records over 6 months of follow-up . We determined the adjusted odds ratio for the association between the intervention and the achievement of controlled blood pressure . When we accounted for clustering by provider , this adjusted odds ratio was 1.13 ( 95 % confidence interval 0.87 - 1.47 ) . Adjusted odds ratios were 1.03 ( 95 % confidence interval 0.78 - 1.36 ) in patients whose blood pressure was controlled at baseline and 1.25 ( 95 % confidence interval 0.94 - 1.65 ) in those whose blood pressure was not . These odds ratios were not significantly different ( p=0.11 ) . CONCLUSIONS These results were consistent with no effect or , at best , a relatively modest effect of the intervention among patients with hypertension . Had we not included a concurrent control group , the data would have provided an unduly optimistic view of the effectiveness of the program . The effectiveness of future interventions may be improved by focusing on patients whose blood pressure is uncontrolled at baseline STUDY OBJECTIVES To examine potential threats to internal and external study validity caused by differential patient withdrawal from a r and omized controlled trial evaluating pharmacist management of hypertension , to compare the characteristics of patients who withdrew with those of patients who completed the study , and to identify characteristics that predispose patients to withdraw from hypertension management . DESIGN Prospect i ve , r and omized , comparative study . SETTING Network of primary care clinics . PATIENTS Four hundred sixty-three patients with a diagnosis of hypertension and a last documented systolic blood pressure of 160 mm Hg or greater and /or diastolic blood pressure of 100 mm Hg or greater . INTERVENTION Patients were r and omly allocated to the pharmacist intervention or usual-care ( control ) group . Those in the pharmacist intervention group were collaboratively managed by a primary care clinical pharmacy specialist and their primary care provider .  Patients in the control group  received usual care from only their primary care provider . MEASUREMENTS AND MAIN RESULTS Of the 463 patients , 191 ( 41 % ) withdrew from the study after r and omization and 272 ( 59 % ) completed the study . Patients who withdrew from the pharmacist intervention group were similar to patients who withdrew from the usual-care group with respect to age , sex , insurance status , and chronic conditions . Patients who smoked or had commercial insurance were more likely to withdraw from the study than the other participants . However , multivariate analysis of all variables , when adjusted for the effect of the intervention , revealed that insurance status was the only variable associated with a heightened probability of withdrawal ( p=0.002 ) . CONCLUSION Although this study had a high withdrawal rate , between-group patient characteristics remained balanced . Therefore , internal validity was preserved , and outcomes from the study groups could be reliably compared . A lack of significant differences between patients who withdrew versus those who completed , with the exception of insurance status , suggests that external validity was not jeopardized Background Hypertension affects 29 % of the adult U.S. population and is a leading cause of heart disease , stroke , and kidney failure . Despite numerous effective treatments , only 53 % of people with hypertension are at goal blood pressure . The chronic care model suggests that blood pressure control can be achieved by improving how patients and physicians address patient self-care . Methods and design This paper describes the protocol of a nested 2 × 2 r and omized controlled trial to test the separate and combined effects on systolic blood pressure of a behavioral intervention for patients  and a  quality improvement-type intervention for physicians .  Primary care practice s were r and omly assigned to the physician intervention or to the physician control condition . Physician r and omization occurred at the clinic level . The physician intervention included training and performance monitoring . The training comprised 2 internet-based modules detailing both the JNC-7 hypertension guidelines and lifestyle modifications for hypertension . Performance data were collected for 18 months , and feedback was provided to physicians every 3 months . Patient participants in both intervention and control clinics were individually r and omized to the patient intervention or to usual care . The patient intervention consisted of a 6-month behavioral intervention conducted by trained interventionists in 20 group sessions , followed by 12 monthly phone contacts by community health advisors . Follow-up measurements were performed at 6 and 18 months . The primary outcome was the mean change in systolic blood pressure at 6 months . Secondary outcomes were diastolic blood pressure and the proportion of patients with adequate blood pressure control at 6 and 18 months . Discussion Overall , 8 practice s ( 4 per treatment group ) , 32 physicians ( 4 per practice ; 16 per treatment group ) , and 574 patients ( 289 control and 285 intervention ) were enrolled . Baseline characteristics of patients and providers and the challenges faced during study implementation are presented . The HIP interventions may improve blood pressure control and lower cardiovascular disease risk in a primary care practice setting by addressing key components of the chronic care model . The study design allows an assessment of the effectiveness and cost of physician and patient interventions separately , so that health care organizations can make informed decisions about implementation of 1 or both interventions in the context of local re sources .Trial registration Clinical Trials.gov identifier Background Patients with manifest vascular disease are at high risk of a new vascular event or death . Modification of classical risk factors is often not successful . We determined whether the extra care of a nurse practitioner could be beneficial to the cardiovascular risk profile of high-risk patients . Design We conducted a r and omized , controlled trial based on the Zelen design . Methods Two hundred and thirty-six patients with manifestations of a vascular disease and who had two or more modifiable vascular risk factors were pre-r and omized to receive treatment by a nurse practitioner plus usual care or usual care alone . After 1 year , risk factors were remeasured . The primary endpoint was achievement of treatment goals for blood pressure , lipid , glucose and homocysteine levels , body mass index , and smoking . Results Of the pre-r and omized patients , 95 of 119 ( 80 % ) in the intervention group and 80 of 117 ( 68 % ) in the control group participated in the study . After a mean follow-up of 14 months , the patients in the intervention group achieved significantly more treatment goals than did the patients in the control group ( systolic blood pressure 63 versus 37 % , total cholesterol 79 versus 61 % , low density lipoprotein-cholesterol 88 versus 67 % , and body mass index 38 versus 24 % ) . Medication use was increased in both groups and no differences were found in patients ' quality of life ( SF-36 ) at follow-up . Conclusion Treatment delivered by nurse practitioners , in addition to a vascular risk factor screening and prevention program , result ed in a better management of vascular risk factors than usual care alone in vascular patients after 1-year follow-up PURPOSE We wanted to examine whether integrating depression treatment into care for hypertension improved adherence to antidepressant and antihypertensive medications , depression outcomes , and blood pressure control among older primary care patients . METHODS Older adults prescribed pharmacotherapy for depression and hypertension from physicians at a large primary care practice in West Philadelphia were r and omly assigned to an integrated care intervention or usual care . Outcomes were assessed at baseline , 2 , 4 , and 6 weeks using the Center for Epidemiologic Studies Depression Scale ( CES-D ) to assess depression , an electronic monitor to measure blood pressure , and the Medication Event Monitoring System to assess adherence . RESULTS In all , 64 participants aged 50 to 80 years participated . Participants in the integrated care intervention had fewer depressive symptoms ( CES-D mean scores , intervention 9.9 vs usual care 19.3 ; P < .01 ) , lower systolic blood pressure ( intervention 127.3 mm Hg vs usual care 141.3 mm Hg ; P < .01 ) , and lower diastolic blood pressure ( intervention 75.8 mm Hg vs usual care 85.0 mm Hg ; P < .01 ) compared with participants in the usual care group at 6 weeks . Compared with the usual care group , the proportion of participants in the intervention group who had 80 % or greater adherence to an antidepressant medication  ( intervention 71.9 % vs usual care 31.3 % ; P < .01 ) and to an antihypertensive medication  ( intervention 78.1 % vs usual care 31.3 % ; P < .001 ) was greater at 6 weeks . CONCLUSION A pilot , r and omized controlled trial integrating depression and hypertension treatment was successful in improving patient outcomes . Integrated interventions may be more feasible and effective in real-world practice s , where there are competing dem and s for limited re sources PURPOSE To determine whether the type of health care provider ( i.e. , physician versus physician-nurse team ) affected the quality of hypertension care given to two groups of r and omly selected adult women . DATA SOURCES Three indicators measured the quality of hypertension care : blood pressure control level , knowledge of hypertension , and discussion about blood pressure medications with the health care provider(s ) .  Blood pressure readings were taken with a 24-hr ambulatory blood pressure monitor , and demographic data from survey results taken at orientation and research er-collected data on posttreatment knowledge of hypertension and cognitive representations of hypertension were gathered . Chi-square and t tests were used to analyze the data . CONCLUSIONS The group whose care was managed by a physician-nurse team demonstrated lower means for 24-hr systolic blood pressure and diastolic blood pressure ( systolic : M = 132 , SD = 14.9 ; diastolic : M = 75 , SD = 11.3 ) than the group whose care was managed only by one or more physicians ( systolic : M = 136 , SD = 13.4 ; diastolic : M = 79 , SD = 11.24 ) . Also , the group whose care was managed by a physician-nurse team revealed significantly higher scores for discussion of blood pressure medication than the group whose care was managed only by one or more physicians . There were no group differences for knowledge of hypertension . IMPLICATION S FOR PRACTICE Nurses qualified to assist with meeting the needs of hypertension clients in primary care setting s can positively affect clients ' knowledge about blood pressure medication and --perhaps as a result of this knowledge -- how well the clients control their blood pressure OBJECTIVE To determine whether nurse case management with a therapeutic algorithm could effectively improve rates of control for hypertension , hyperglycemia , and hyperlipidemia compared with usual care among veterans with diabetes . RESEARCH DESIGN AND METHODS A r and omized controlled trial of diabetic patients that had blood pressure ( BP ) > 140/90 mmHg , hemoglobin A1c ( HbA1c ) > 9.0 % , or LDL > 100 mg/dL. Intervention patients received case management ( n = 278 ) versus usual care ( n = 278 ) over a 1-year period . The primary outcome was the percentage of patients achieving simultaneous control of all three parameters ( defined by BP < 130/80 mmHg , HbA1c < 8.0 % , and LDL < 100 mg/dL ) at 1 year . Secondary outcomes included improvements within each individual component of the composite primary outcome . Differences between groups were analyzed using t tests , Pearson χ2 tests , and linear and logistic regression . RESULTS A greater number of individuals assigned to case management achieved the primary study outcome of having all three outcome measures under control ( 61 [ 21.9 % ] compared with 28 [ 10.1 % ] in the usual care group [ P < 0.01 ] ) . In addition , a greater number of individuals assigned to the intervention group achieved the individual treatment goals of HbA1c < 8.0 % ( 73.7 vs. 65.8 % , P = 0.04 ) and BP < 130/80 mmHg ( 45.0 vs. 25.4 % , P < 0.01 ) , but not for LDL < 100 mg/dL ( 57.6 vs. 55.4 % , P = 0.61 ) , compared with those in the usual care group . CONCLUSIONS In patients with diabetes , nurse case managers using a treatment algorithm can effectively improve the number of individuals with control of multiple cardiovascular risk factors at 1 year Background —Black subjects with a family history of premature coronary heart disease ( CHD ) have a marked excess risk , yet barriers prevent effective risk reduction . We tested a community-based multiple risk factor intervention ( community-based care [ CBC ] ) and compared it with “ enhanced ” primary care ( EPC ) to reduce CHD risk in high-risk black families . Methods and Results —Black 30- to 59-year-old siblings of a prob and with CHD aged < 60 years were r and omized for care of BP ≥140/90 mm Hg , LDL cholesterol ≥3.37 mmol/L , or current smoking to EPC ( n=168 ) or CBC ( n=196 ) and monitored for 1 year . EPC and CBC were design ed to eliminate barriers to care . The CBC group received care by a nurse practitioner and a community health worker in a community setting . The CBC group was 2 times more likely to achieve goal levels of LDL cholesterol and blood pressure compared with the EPC group ( 95 % CI , 1.11 to 4.20 and 1.39 to 3.88 , respectively ) with adjustment for baseline levels of age , sex , education , and baseline use of medications . The CBC group demonstrated a significant reduction in global CHD risk , whereas no reduction was seen in the EPC group ( P<0.0001 ) . Conclusions —Eliminating known barriers may not be sufficient to reduce CHD risk in primary care setting s. An alternative community care model that addresses barriers may be a more effective way to ameliorate CHD risk in high-risk black families Despite widely publicized hypertension treatment guidelines for physicians and lifestyle recommendations for patients , blood pressure control rates remain low . In community-based primary care clinics , we performed a nested , 2 × 2 r and omized , controlled trial of physician intervention versus control and /or patient intervention versus control . Physician intervention included internet-based training , self-monitoring , and quarterly feedback reports . Patient intervention included 20 weekly group sessions followed by 12 monthly telephone counseling contacts and focused on weight loss , Dietary Approaches to Stop Hypertension dietary pattern , exercise , and reduced sodium intake . The primary outcome was change in systolic blood pressure at 6 months . Eight primary care practice s ( 32 physicians ) were r and omized to physician intervention or control groups . Within those practice s , 574 patients were r and omized to patient intervention or control groups . Patient mean age was 60 years , 61 % were women , and 37 % were black . Blood pressure data were available for 91 % of patients at 6 months . The main effect of physician intervention  on systolic blood pressure at 6 months , adjusted for baseline pressure , was 0.3 mm Hg ( 95 % CI : −1.5 to 2.2 ; P=0.72 ) . The main effect of the patient intervention was −2.6 mm Hg ( 95 % CI : −4.4 to −0.7 ; P=0.01 ) . The interaction of the 2 interventions was significant ( P=0.03 ) ; the largest impact was observed with the combination of physician and patient intervention ( −9.7±12.7 mm Hg ) . Differences between treatment groups did not persist at 18 months . Combined physician and patient interventions  lowers blood pressure ; future research should focus on enhancing effectiveness and sustainability of these interventions PURPOSE The present study evaluated whether an intervention using a short message service ( SMS ) by cellular phone and Internet would improve blood pressure , weight control , and serum lipids of obese patients with hypertension during 8 weeks . METHODS This is a quasi-experimental design with pre- and follow-up tests . Participants were recruited from the family medicine outpatient department of tertiary care hospital located in an urban city of South Korea . Twenty-eight patients were assigned to an intervention group and 21 to a control group . The goal of intervention was to bring blood pressure , body weight , and serum lipids levels close to normal ranges . Patients in the intervention group were requested to record their blood pressure and body weight in a weekly web based diary through the Internet or by cellular phones . The research ers sent optimal recommendations as an intervention to each patient , by both cellular phone and Internet weekly . The intervention was applied for 8 weeks . RESULTS Systolic ( SBP ) and diastolic blood pressures ( DBP ) significantly decreased by 9.1 and 7.2 mmHg respectively at 8 weeks from the baseline in the intervention group ( p<0.05 ) . However , after 8 weeks from the baseline both SBP and DBP in the control group had not changed significantly . Yet , There were significant mean decreases in body weight and waist circumference by 1.6 kg ( p<0.05 ) and 2.8 cm ( p<0.05 ) in the intervention group , respectively . In the control group increases in body weight and waist circumference ( p<0.05 ) mean changes were also significant . High density lipoprotein cholesterol ( HDL-C ) significantly increased , with a mean change of 3.7 mg/dl at 8 weeks from baseline in the intervention group ( p<0.05 ) . The mean change of HDL-C in the control group was , however , not significant . CONCLUSION During 8 weeks using this web-based intervention by way of cellular phone and Internet SMS improved blood pressure , body weight , waist circumference , and HDL-C in patients with obese hypertension BACKGROUND Lack of medication adherence is a common reason for poor control of blood pressure in the community , increasing the risk of heart attacks and strokes . OBJECTIVE To evaluate the effect of nurse-led adherence support for people with uncontrolled high blood pressure compared with usual care . METHODS We recruited 245 women and men with uncontrolled hypertension ( > or = 150/90 mmHg ) from 21 general practice s in Bristol , UK . Participants were r and omized to receive  nurse-led adherence support  or usual care alone . Main outcome measures were  adherence to medication ( ' timing compliance ' ) and blood pressure . RESULTS Mean baseline timing compliance ( + /- SD ) was high in both the intervention ( 90.8 + /- 15.6 % ) and the control group ( 94.5 + /- 7.6 % ) . There was no evidence of an effect of the intervention on timing compliance at follow-up ( adjusted difference in means -1.0 % ; 95 % confidence interval ( CI ) -5.1 to 3.1 ) . There was also no difference at follow-up between the groups with regard to systolic blood pressure ( -2.7 mmHg ; 95 % CI -7.2 to 1.8 ) or diastolic blood pressure ( 0.2 mmHg ; 95 % CI -1.9 to 2.3 ) . Projected costs for the primary care sector per consultation were 6.60 pound sterling for the intervention compared with 5.08 pound sterling for usual care . CONCLUSION In this study , adherence to blood pressure medication was much higher than previously reported . There was no evidence of an effect of nurse-led adherence support on medication adherence or blood pressure compared with usual care . Nurse-led adherence support was also more expensive from a primary care perspective OBJECTIVES To determine the long-term effect of a community-based risk reduction intervention at five years after completion of a one-year r and omized clinical trial and to determine the sustainability of the beneficial effects seen one year after the intervention . METHODS 30- to 59- year-old African American siblings of prob and s with premature coronary heart disease ( CHD ) were r and omized for care of multiple CHD risk factors to either one year of community-based care ( CBC ) provided by a nurse practitioner/community health worker team or enhanced usual care ( EUC ) . At five years , 307 ( 84.6 % ) of the siblings returned for reevaluation . MAIN OUTCOME MEASURES Changes in and achievement of goal levels of low-density lipoprotein cholesterol ( LDL-C ) , systolic and diastolic blood pressure ( SBP and DBP , respectively ) , and smoking cessation at five years . RESULTS No significant differences were seen between groups in mean LDL-C , SBP , and DBP or in the overall percentages achieving goal LDL-C , blood pressure , or smoking status . Changes after completion of the intervention suggest that the CBC group lost the beneficial effects for mean LDL-C and for percentage at goal LDL-C , while the EUC group continued to improve . CBC was associated with greater sustainability and less refractoriness of one-year results for LDL-C and blood pressure goals . CONCLUSIONS Although no group differences were found in mean risk factor levels at five years , data indicate that CBC is both feasible and associated with earlier sustainability of positive risk factor changes compared with EUC This study investigated the effectiveness of a community-academic health center partnership , utilizing nurse-supervised indigenous community health workers , in decreasing the blood pressure in an urban African-American population . A four-year r and omized clinical trial was conducted in the S and town-Winchester community , which has an excess prevalence of high blood pressure , in order to test the effectiveness of 2 different levels of intervention intensity on increasing the control of high blood pressure .  Community health workers were trained and certified in blood pressure management , monitoring , education and counseling , social support mobilization , and community outreach and follow up . The primary results were a significant decrease in mean systolic and diastolic pressures after both levels of intervention , and a significant increase in the percentage of individuals with controlled high blood pressure . Surprisingly , no differences in results were observed between the 2 levels of intervention intensity . This study supports the use of community-based partnership efforts , and the utilization of indigenous health workers , to enhance the control of high blood pressure in a high-risk , African-American urban population BACKGROUND African American men with hypertension ( HTN ) in low socioeconomic urban environments continue to achieve poor rates of HTN control . METHODS In a 5-year r and omized clinical trial with 309 hypertensive urban African American men aged 21 to 54 years , the effectiveness of a more intensive educational/behavioral/pharmacologic intervention provided by a nurse practitioner/community health worker/physician team was compared to less intensive information and referral intervention . Changes in behavioral factors , health care utilization , blood pressure ( BP ) control , left ventricular hypertrophy ( LVH ) , and renal insufficiency were evaluated . RESULTS Follow-up rates exceeded 89 % of available men . The ranges of mean annual systolic BP/diastolic BP change from the baseline to each year follow-up were -3.7 to -10.1/-4.9 to -12.3 mm Hg for the more intensive group and + 3.4 to -3.0/-1.8 to -8.7 mm Hg for the less intensive group . The annual proportion of men with controlled BP ( < 140/90 mm Hg ) ranged from 17 % to 44 % in the more intensive group and 21 % to 36 % in the less intensive group . At 5 years the more intensive group had less LVH than the less intensive group and 17 % of the men were deceased primarily due to narcotic or alcohol intoxication ( 36 % ) and cardiovascular causes ( 19 % ) . CONCLUSIONS An appropriate educational/behavioral intervention significantly improved BP control and reduced some sequelae of HTN in a young African American male population . Improvement in risk factors other than HTN was limited and sustained control of HTN was difficult to maintain during 5 years BACKGROUND R and omized controlled trials have provided unequivocal evidence that treatment of hypertension decreases mortality and major disability from cardiovascular disease ; however , blood pressure remains inadequately treated in most affected individuals . This large gap continues despite the facts that more than 90 % of adults with hypertension have health insurance , and hypertension is the leading cause of visits to the doctor . New approaches are needed to improve hypertension care . OBJECTIVES The Electronic Communications and Home Blood Pressure Monitoring ( e-BP ) study is a three-arm r and omized controlled trial design ed to determine whether care based on the Chronic Care Model and delivered over the Internet improves hypertension care . The primary study outcomes are systolic , diastolic , and blood pressure control ; secondary outcomes are medication adherence , patient self-efficacy , satisfaction and quality of life , and healthcare utilization and costs . METHODS Hypertensive patients receiving care at Group Health medical centers are eligible if they have uncontrolled blood pressure on two screening visits and access to the Web and an e-mail address . Study participants are r and omly assigned to three intervention groups : ( a ) usual care ; ( b ) home blood pressure monitoring receipt and proficiency training on its use and the Group Health secure patient website ( with secure e-mail access to their healthcare provider , access to a shared medical record , prescription refill and other services ) ; or ( c ) this plus pharmacist care management ( collaborative care management between the patient , the pharmacist , and the patient 's physician via a secure patient website and the electronic medical record ) . CONCLUSION We will determine whether a new model of patient-centered care that leverages Web communications , self-monitoring , and collaborative care management improves hypertension control . If this model proves successful and cost-effective , similar interventions could be used to improve the care of large numbers of patients with uncontrolled hypertension This was a prospect i ve , cluster r and omized controlled trial in patients with uncontrolled hypertension aged 21 to 85 years ( mean , 61 years ) .  Pharmacists made recommendations to physicians for patients in the intervention clinics ( n=101 ) but not patients in the control clinics ( n=78 ) . The mean adjusted difference in systolic blood pressure ( BP ) between the control and intervention groups was 8.7 mm Hg ( 95 % confidence interval [ CI ] , 4.4 - 12.9 ) , while the difference in diastolic BP was 5.4 mm Hg ( CI , 2.8 - 8.0 ) at 9 months . The 24-hour BP levels showed similar effects , with a mean systolic BP level that was 8.8 mm Hg lower ( CI , 5.0 - 12.6 ) and a mean diastolic BP level that was 4.6 mm Hg ( CI , 2.4 - 6.8 ) lower in the intervention group . BP was controlled in 89.1 % of patients in the intervention group and 52.9 % in the control group ( adjusted odds ratio , 8.9 ; CI , 3.8 - 20.7 ; P<.001 ) . Physician/pharmacist collaboration achieved significantly better mean BP values and overall BP control rates , primarily by intensification of medication therapy and improving patient adherence BACKGROUND Less than one third of the 65 million Americans with hypertension have adequate blood pressure ( BP ) control . This study examined the effectiveness of 2 interventions for improving patient BP control . METHODS This was a 2-level ( primary care provider and patient ) cluster r and omized trial with 2-year follow-up occurring among patients with hypertension enrolled from a Veterans Affairs Medical Center primary care clinic . Primary care providers ( n = 17 ) in the intervention received computer-generated decision support design ed to improve guideline concordant medical therapy at each visit ; control providers ( n = 15 ) received a reminder at each visit . Patients received usual care or a bimonthly tailored nurse-delivered behavioral telephone intervention to improve hypertension treatment . The primary outcome was proportion of patients who achieved a BP < 140/90 mm Hg ( < 130/85 for diabetic patients ) over the 24-month intervention . RESULTS Of the 816 eligible patients contacted , 190 refused and 38 were excluded . The 588 enrolled patients had a mean age of 63 years , 43 % had adequate baseline BP control , and 482 ( 82 % ) completed the 24-month follow-up . There were no significant differences in amount of change in BP control in the 3 intervention groups as compared to the hypertension reminder control group . In secondary analyses , rates of BP control for all patients receiving the patient behavioral intervention ( n = 294 ) improved from 40.1 % to 54.4 % at 24 months ( P = .03 ) ; patients in the nonbehavioral intervention group improved from 38.2 % to 43.9 % ( P = .38 ) , but there was no between-group differences at the end of the study . CONCLUSION The brief behavioral intervention showed improved outcomes over time , but there were not significant between group differences Increasing dem and to deliver and document therapeutic and preventive care sharpens the need for disease management strategies that accomplish these goals efficiently while preserving quality of care . The purpose of this study was to compare selected outcomes for a new chronic disease management program involving a nurse practitioner - physician team with those of an existing model of care . One hundred fifty-seven patients with hypertension and diabetes mellitus were r and omly assigned to their primary care physician and a nurse practitioner or their primary care physician alone  . Costs for personnel directly involved in patient management , calculated from hourly rates and encounter time with patients , and pre- and post- study glycosylated hemoglobin ( HbA1c ) , high-density lipoprotein cholesterol ( HDL-c ) , satisfaction with care and health-related quality of life ( HRQoL ) were assessed . Although 1-year costs for personnel were higher in the team-treated group , participants experienced significant improvements in mean HbA1c ( − 0.7 % , p = 0.02 ) and HDL-c ( + 2.6 mg dL − 1 , p = 0.02 ) . Additionally , satisfaction with care improved significantly for team-treated subjects in several sub-scales whereas the mean change over time in HRQoL did not differ significantly between groups . This study demonstrates the value of a complementary team approach to chronic disease management in improving patient-derived and clinical outcomes at modest incremental costs BACKGROUND Few telemedicine programs have undergone cost analyses , impeding their implementation into practice . We report on the economic analysis of a nurse-administered intervention design ed to improve blood pressure control among hypertensive veterans . METHODS We r and omized hypertensive patients at the Durham Veterans Affairs Medical Center primary care clinic to behavioral ( n = 294 ) or nonbehavioral ( n = 294 ) interventions .  Behavioral intervention patients received tailored information bimonthly for 2 years via telephone . To calculate intervention cost , we microcosted the nurse 's labor cost and computer hardware and software costs , applied a direct-to-indirect cost ratio , and distributed the costs over an estimated cohort of patients . We analyzed data from the Veterans Affairs Decision Support System to assess whether the intervention impacted overall health care utilization and costs . We used life expectancy estimates from the literature to develop decision models to calculate cost per life-year saved . RESULTS The mean annual intervention cost was $ 112 ( range $ 61-$259 ) . During 2 years of follow-up , patients in the intervention group incurred $ 7,800 in inpatient costs and $ 9,741 in outpatient costs ; the nonintervention group incurred $ 6,866 in inpatient costs and $ 9,599 in outpatient costs . The total cost difference was not statistically significant ( P = .56 ) . Cost-effectiveness of the behavioral intervention ranged from $ 42,457 per life-year saved for normal-weight women to $ 87,300 per life-year saved for normal-weight men . CONCLUSIONS The study results suggest that a nurse-administered , tailored behavioral intervention can be implemented at nominal cost and be cost-effective ; however , there was no apparent lowering of health care utilization and costs during the 2 years of follow-up Few data exist on the effectiveness of cardiovascular disease ( CVD ) risk-reduction programs in patients with limited access to health care . The objective of this project was to evaluate a disease management approach to multifactor CVD risk reduction in patients with limited or no health insurance and low family income . Patients ( n = 148 ) were recruited from not-for-profit or free clinics and hospitals and r and omized to usual care or usual care plus team case management . Mean age was 59.3 years , 57 % were women , 50 % had less than a high school education , 57 % were Hispanic , and 64 % had no health insurance . All had > or = 1 increased risk factor for CVD , and 24.5 % had documented coronary artery disease . Follow-up measurements were obtained at 6 and 12 months . Primary outcomes were low-density lipoprotein cholesterol and systolic blood pressure . The disease management program was supervised by a physician , delivered by nurses and dietitians , and included comprehensive lifestyle changes and medications . Data were collected on 91 % of patients at 12 months . Disease management produced clinical ly important decreases in selected risk factors compared with usual care , including systolic blood pressure ( p < 0.01 ) and low-density lipoprotein cholesterol ( p < 0.03 ) . More patients with disease management than those with usual care moved from " high " and " very-high " risk to lower risk categories for selected risk factors . In conclusion , the disease management program had excellent retention and lower CVD risk factors and demonstrated the potential of such approaches for decreasing long-term disease burden in selected medically underserved population OBJECTIVE To determine the effectiveness of specialist nurse-led clinics for hypertension and hyperlipidemia provided for diabetic patients receiving hospital-based care . RESEARCH DESIGN AND METHODS This study was a r and omized controlled implementation trial at Hope Hospital , Salford , U.K. The subjects consisted of 1,407 subjects presenting for annual review with raised blood pressure(>or=140/80 mmHg ) , raised total cholesterol ( > or=5.0 mmol/l ) , or both . Individuals with diabetes were r and omized to usual care or usual care with subsequent invitation to attend  specialist nurse-led clinics . Nurses provided clinics for participants , with attendance every 4 - 6 weeks , until targets were achieved . Lifestyle advice and titration of drug therapies were provided according to the locally agreed upon guidelines . Patients with both conditions were eligible for enrollment in either or both clinics . At subsequent annual review , blood pressure and total cholesterol values were obtained from the Salford electronic diabetes register . Data relating to deaths were obtained from the national strategic tracing service . The primary outcome was the odds ratio of achieving targets in hypertension and hyperlipidemia , attributable to the  specialist nurse-led intervention . RESULTS Overall , specialist nurse-led clinics were associated with a significant improvement in patients achieving the target after 1 year ( odds ratio [ OR ] 1.37 [ 95 % CI 1.11 - 1.69 ] , P = 0.003 ) . This primary analysis revealed a borderline difference in effect between the two types of clinics ( test for interaction between groups : P = 0.06 ) . Secondary analysis , consistent with the prior beliefs of the health care professionals involved , suggested that targets were achieved more frequently in patients enrolled in the specialist nurse-led clinic for hyperlipidemia ( OR 1.69 [ 1.25 - 2.29 ] , P = 0.0007 ) than for hypertension ( OR 1.14 [ 0.86 - 1.51 ] , P = 0.37 ) . Intervention ( enrolled to either or both clinics ) was associated with a reduction in all-cause mortality ( OR 0.55 [ 0.32 - 0.92 ] , P = 0.02 ) . CONCLUSIONS This study provides good evidence to support the use of specialist nurse-led clinics as an effective adjunct to hospital-based care of patients with diabetes . If the st and ards of care recommended in the National Service Framework for Diabetes are to be achieved , then such proven methods for delivering care must be adopted Objective The aim of this study is to describe recommendations made by clinical pharmacists when co-managing hypertension with physicians . Setting Two family medicine clinics at a major teaching hospital in the mid-western United States . Method This report details the specific recommendations made by pharmacists during a prospect i ve r and omized controlled clinical trial . Patients with uncontrolled hypertension were enrolled in a 9-month intensive pharmacist – physician co-management study . Clinical pharmacists saw patients at baseline , 2 , 4 , 6 , and 8 month visits . Optional visits were allowed between required visits . Main outcome measure For this analysis , pharmacist recommendations were grouped . Physician acceptance of the pharmacists ’ recommendations was also evaluated . Results Data from 101 patients were included and analyzed in this study . Changes in drug therapy were recommended 267 times for these 101 patients . Most recommendations for a change in treatment involved adding a new antihypertensive medication ( 46.4 % ) or increasing a dose ( 33.3 % ) . The majority of pharmacist recommendations to modify drug therapy were made at the baseline visit ( 41.6 % ) , with 76.8 % of recommendations made by the 2 month visit . Physicians accepted and implemented 95.9 % of the 267 pharmacist recommendations to modify drug therapy . Pharmacists recommended no change in the treatment plan 361 times , most often because the patient ’s blood pressure ( BP ) had achieved the goal . Average BP decreased from 153.1 ± 10.0/84.9 ± 12.0 mmHg ( average ± SD ) at baseline to 124.2 ± 9.7/74.7 ± 9.6 mmHg ( P < 0.001 ) at the end of 9 months , with 89.1 % ( P < 0.001 ) of patients reaching their BP goal . Conclusion Pharmacist recommendations for alterations in drug therapy generally occurred early in the course of the study and were largely to intensify therapy through higher dosages or additional medications . Pharmacist – physician co-management of BP is effective at reducing BP and improving BP control rates Background : Nearly one in three adults in the United States has hypertension . Hypertension is one of the largest risk factors for cardiovascular diseases , and it is growing in prevalence , especially among African Americans . Objectives : To test the hypothesis that individuals who participate in usual care ( UC ) plus blood pressure ( BP ) telemonitoring ( TM ) will have a greater reduction in BP from baseline to 12-month follow-up than would individuals who receive UC only . Methods : A two-group , experimental , longitudinal design with block stratified r and omization for antihypertensive medication use was used . African Americans with hypertension were recruited through free BP screenings offered in the community . Data were collected through a structured interview and brief physical exam . Cross tabs , repeated measures analysis of variance , and independent t tests were used to analyze the study 's hypothesis . Results : The TM intervention group had a greater reduction in systolic BP ( 13.0 mm Hg ) than the enhanced UC group ( 7.5 mm Hg ; t = −2.09 , p = .04 ) from baseline to the 12-month follow-up . Although the TM intervention group had a greater reduction in diastolic BP ( 6.3 mm Hg ) compared with the enhanced UC group ( 4.1 mm Hg ) , the differences were not statistically significant ( t = −1.56 , p = .12 ) . Discussion : Telemonitoring of BP result ed in clinical ly and statistically significant reductions in systolic BP over a 12-month period ; if maintained over a longer period of time , the reductions could improve care and outcomes significantly for African Americans with hypertension BACKGROUND Group medical clinics ( GMCs ) are widely used in the management of diabetes and hypertension , but data on their effectiveness are limited . OBJECTIVE To test the effectiveness of GMCs in the management of comorbid diabetes and hypertension . DESIGN R and omized , controlled trial . ( Clinical Trials.gov registration number : NCT00286741 ) SETTING 2 Veterans Affairs Medical Centers in North Carolina and Virginia . PATIENTS 239 patients with poorly controlled diabetes ( hemoglobin A(1c ) [ HbA(1c ) ] level > or = 7.5 % ) and hypertension ( systolic blood pressure > 140 mm Hg or diastolic blood pressure > 90 mm Hg ) . INTERVENTION Patients were r and omly assigned within each center to either attend a GMC or receive usual care . Clinics comprised 7 to 8 patients and a care team that consisted of a primary care general internist , a pharmacist , and a nurse or other certified diabetes educator . Each session included structured group interactions moderated by the educator . The pharmacist and physician adjusted medication to manage each patient 's HbA(1c ) level and blood pressure . MEASUREMENTS Hemoglobin A(1c ) level and systolic blood pressure , measured by blinded research personnel at baseline , study midpoint ( median , 6.8 months ) , and study completion ( median follow-up , 12.8 months ) . Linear mixed models , adjusted for clustering within GMCs , were used to compare HbA(1c ) levels and systolic blood pressure between the intervention and control groups . RESULTS Mean baseline systolic blood pressure and HbA(1c ) level were 152.9 mm Hg ( SD , 14.2 ) and 9.2 % ( SD , 1.4 ) , respectively . At the end of the study , mean systolic blood pressure improved by 13.7 mm Hg in the GMC group and 6.4 mm Hg in the usual care group ( P = 0.011 by linear mixed model ) , whereas mean HbA(1c ) level improved by 0.8 % in the GMC group and 0.5 % in the usual care group ( P = 0.159 ) . LIMITATION Measurements of effectiveness may have been limited by concomitant improvements in the usual care group that were due to co-intervention . CONCLUSION Group medical clinics are a potent strategy for improving blood pressure but not HbA(1c ) level in diabetic patients . PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs Health Services Research and Development Service BACKGROUND Uncontrolled hypertension is a major primary healthcare problem . AIM To investigate whether blood pressure ( BP ) control in primary care could be improved by nurses taking responsibility for managing hypertensive patients . METHODS R and omized trial with two groups : usual or intensive care .  Patients diagnosed previously as hypertensive and with a systolic office BP greater than 140mmHg were r and omized to an intensive care programme managed by trained nurses or to usual care . The intensive care programme included a visit every 6 weeks to the general practitioner 's office , with st and ardized BP measurement , self-measurement training , risk factor checks and advice on BP reduction . The intervention lasted for 1 year . The primary endpoints were systolic BP obtained by 24-hour ambulatory BP monitoring after 1 year and the change compared with baseline . RESULTS Two hundred patients from 19 physicians were enrolled ( 102 in the intensive care group ) . Data on ambulatory BP were available from 140 patients .  Systolic BP declined from 134.4+/-14.0 to 126.3+/-10.4mmHg in the intensive care group and from 132.4+/-13.5 to 128.2+/-13.0mmHg in the usual care group . There was no statistically significant difference in values after 1 year ( p=0.332 ) . The reduction in systolic BP was significantly greater in the intensive care group ( 7.6 vs 3.3mmHg in the usual care group ; p=0.036 ) . Similar results were observed for diastolic BP and day- and night-time measurements . CONCLUSIONS An intensive medical care programme in the office setting managed by trained nurses can improve BP control effectively . Nurses could take more responsibility for managing hypertensive patients Objective . To study the efficacy of telephone and mail intervention in therapeutic compliance among patients with mild to moderate hypertension . Design . A prospect i ve controlled multicenter clinical trial . Setting . Eighty‐five primary care centers in Spain , with a duration of 6 months . Patients . A total of 636 patients with newly diagnosed or uncontrolled hypertension were included . Interventions . The patients were r and omized and distributed between the following groups : ( i ) control ( CG ) – under routine clinical management ; ( ii ) mail intervention ( MIG ) – received a mailed message reinforcing compliance and reminding of the visits ( 15 days , 2 and 4 months ) ; ( iii ) telephone intervention ( TIG ) – received a telephone call at 15 days , then at 7 and 15 weeks . Main outcome measure . Five visits were scheduled , with the measurement of blood pressure and counting of tablets . Compliers were defined as subjects showing 80–110 % drug consumption . Calculations were made of mean percentage compliance ( MPC ) and compliers , mean blood pressure and percentage controlled subjects . Results . Five hundred and thirty‐eight patients completed the study ( 261 males ) ; 85.5 % were compliers ( CI = 82.5–88.5 ; n = 460 ) . The MPC was 95.1±19.6 % ( CI = 93.28–96.92 ) . The CG consisted of 182 individuals , MIG = 172 and TIG = 184 . Compliers represented 69.2 % of the CG ( CI 62.5–75.9 % ) , 91.3 % ( CI = 87.1–95.5 ) of the MIG ( p = 0.0001 ) and 96.2 % of the TIG ( CI 93.5–98.9 % ) ; the final MPC was 89.6%±15 in CG , 96.6%±12 in MIG and 99.1±26.8 in TIG ( p = 0.0001 ) . The percentage of controlled subjects was 47.2 % in CG ( CI = 40–54.4 ) , 61.3 % in MIG ( CI = 54.1–68.5 % ) and 63.3 % in TIG ( CI = 56.4–70.2 % ) ( p<0.05 ) . Conclusions . TIG and MIG are effective measures for improving patient compliance in hypertension Background —Despite well-publicized guidelines on the appropriate management of cardiovascular disease and type 2 diabetes , the implementation of risk-reducing practice s remains poor . This report describes the results of a r and omized , controlled clinical trial evaluating the effectiveness of a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner /community health worker ( NP/CHW ) teams versus enhanced usual care ( EUC ) to improve lipids , blood pressure , glycated hemoglobin ( HbA1c ) , and patient perceptions of the quality of their chronic illness care in patients in urban community health centers . Methods and Results —A total of 525 patients with documented cardiovascular disease , type 2 diabetes , hypercholesterolemia , or hypertension and levels of LDL cholesterol , blood pressure , or HbA1c that exceeded goals established by national guidelines were r and omly assigned to NP/CHW ( n=261 ) or EUC ( n=264 ) groups . The NP/CHW intervention included aggressive pharmacological management and tailored educational and behavioral counseling for lifestyle modification and problem solving to address barriers to adherence and control . Compared with EUC , patients in the NP/CHW group had significantly greater 12-month improvement in total cholesterol ( difference , 19.7 mg/dL ) , LDL cholesterol ( difference,15.9 mg/dL ) , triglycerides ( difference , 16.3 mg/dL ) , systolic blood pressure ( difference , 6.2 mm Hg ) , diastolic blood pressure ( difference , 3.1 mm Hg ) , HbA1c ( difference , 0.5 % ) , and perceptions of the quality of their chronic illness care ( difference , 1.2 points ) . Conclusions —An intervention delivered by an NP/CHW team using individualized treatment regimens based on treat-to-target algorithms can be an effective approach to improve risk factor status and perceptions of chronic illness care in high-risk patients . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT00241904 BACKGROUND To determine which of 3 interventions was most effective in improving  blood pressure ( BP ) control , we performed a 4-arm r and omized trial with 18-month follow-up at the primary care clinics at a Veterans Affairs Medical Center . METHODS Eligible patients were r and omized to either usual care or 1 of 3 telephone-based intervention groups : ( 1 ) nurse-administered behavioral management , ( 2 ) nurse- and physician-administered medication management , or ( 3 ) a combination of both . Of the 1551 eligible patients , 593 individuals were r and omized ; 48 % were African American . The intervention telephone calls were triggered based on home BP values transmitted via telemonitoring devices . Behavioral management involved promotion of health behaviors . Medication management involved adjustment of medications by a study physician and nurse based on hypertension treatment guidelines . RESULTS The primary outcome was change in BP control measured at 6-month intervals over 18 months . Both the behavioral management and medication management alone showed significant improvements at 12 months-12.8 % ( 95 % confidence interval [ CI ] , 1.6%-24.1 % ) and 12.5 % ( 95 % CI , 1.3%-23.6 % ) , respectively-but not at 18 months . In subgroup analyses , among those with poor baseline BP control , systolic BP decreased in the combined intervention group by 14.8 mm Hg ( 95 % CI , -21.8 to -7.8 mm Hg ) at 12 months and 8.0 mm Hg ( 95 % CI , -15.5 to -0.5 mm Hg ) at 18 months , relative to usual care . CONCLUSIONS Overall intervention effects were moderate , but among individuals with poor BP control at baseline , the effects were larger . This study indicates the importance of identifying individuals most likely to benefit from potentially re source intensive programs . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00237692 OBJECTIVE To determine if a multimodal intervention composed of patient education , home blood pressure ( BP ) monitoring , BP measurement reporting to an interactive voice response ( IVR ) phone system , and clinical pharmacist follow-up improves BP control compared with usual care . STUDY DESIGN Prospect i ve study with patient enrollment , medication consultation and adjustment , remote BP monitoring , and follow-up at 6 months . METHODS This r and omized controlled trial was conducted at 3 healthcare systems in Denver , Colorado , including a large health maintenance organization , a Veterans Affairs medical center , and a county hospital . At each site , patients with uncontrolled BP were r and omized to the multimodal intervention vs usual care for 6 months , with the primary end point of BP reduction . RESULTS Of 338 patients r and omized , 283 ( 84 % ) completed the study , including 138 intervention patients and 145 usual care patients .  Baseline BP was higher in the intervention group vs the usual care group ( 150.5/89.4 vs 143.8/85.3 mm Hg ) . At 6 months , BPs were similar in the intervention group vs the usual care group ( 137.4 vs 136.7 mm Hg , P = .85 for systolic ; 82.9 vs 81.1 mm Hg , P = .14 for diastolic ) . However , BP reductions were greater in the intervention group vs the usual care group ( −13.1 vs −7.1 mm Hg , P = .006 for systolic ; −6.5 vs −4.2 mm Hg , P = .07 for diastolic ) . Adherence to medications was similar between the 2 groups , but intervention patients had a greater increase in medication regimen intensity . CONCLUSIONS A multimodal intervention of patient education , home BP monitoring , BP measurement reporting to an IVR system , and clinical pharmacist follow-up achieved greater reductions in BP compared with usual care Electronic interactive technology is being used in medical care to enhance communication between the patient and health care provider , as well as the patient ’s performance of appropriate health behaviors . Research has demonstrated the value of technology in enhancing medication-taking behavior , capturing medicationtaking events , and generating reports to health care providers.1–4 These devices can capture other patient-specific information such as blood pressure , presence of symptoms , and functional status in “ real time ” rather than depending on patient recall at a later date . What is lacking in these studies is a clear view of how medication management devices fit with existing patient monitoring and feedback processes , which depend on the interaction between patients and their health care providers . Clinical endpoints are also lacking . We had the opportunity to conduct a pilot study of a medication management system that used patient-specific information to tailor the electronic interactive technology to each individual patient ’s needs and behaviors OBJECTIVE Concurrent peer review visits are structured office visits conducted by clinician peers of the primary care clinician that are specifically design ed to reduce competing dem and s , clinical inertia , and bias . We assessed whether a single concurrent peer review visit reduced clinical inertia and improved control of hypertension , hyperlipidemia , and diabetes control among underserved patients . METHODS We conducted a r and omized encouragement trial to evaluate concurrent peer review visits with a community health center . Seven hundred twenty-seven patients with hypertension , hyperlipidemia , and /or diabetes who were not at goal for systolic blood pressure ( SBP ) , low-density lipoprotein cholesterol ( LDL-C ) , and /or glycated hemoglobin ( A1c ) were r and omly assigned to an invitation to participate in a concurrent peer review visit or to usual care . We compared change in these measures using mixed models and rates of therapeutic intensification during concurrent peer review visits with control visits . RESULTS One hundred seventy-one patients completed a concurrent peer review visit .  SBP improved significantly ( p < .01 ) more among those completing concurrent peer review visits than among those who failed to respond to a concurrent peer review invitation or those r and omized to usual care . There were no differences seen for changes in LDL-C or A1c .  Concurrent peer review visits were associated with statistically significant greater clinician intensification of blood pressure ( p < .001 ) , lipid ( p < .001 ) , and diabetes ( p < .005 ) treatment than either for control visits for patients in either the nonresponse group or usual care group . CONCLUSIONS Concurrent peer review visits represent a promising strategy for improving blood pressure control and improving therapeutic intensification in community health centers BACKGROUND Increased emphasis is being placed on the critical need to control hypertension ( HTN ) in patients with diabetes . OBJECTIVE The objective of this study was to evaluate the efficacy of a nurse-managed home telehealth intervention to improve outcomes in veterans with comorbid diabetes and HTN . DESIGN A single-center , r and omized , controlled clinical trial design comparing two remote monitoring intensity levels and usual care in patients with type 2 diabetes and HTN being treated in primary care was used . MEASUREMENTS Primary outcomes were hemoglobin A1c and systolic blood pressure ( SBP ) ; secondary outcome was adherence . RESULTS Intervention subjects experienced decreased A1c during the 6-month intervention period compared with the control group , but 6 months after the intervention was withdrawn , the intervention groups were comparable with the control group . For SBP , the high-intensity subjects had a significant decrease in SBP compared with the other groups at 6 months and this pattern was maintained at 12 months . Adherence improved over time for all groups , but there were no differences among the three groups . LIMITATIONS Subjects had relatively good baseline control for A1c and SBP ; minorities and women were underrepresented . CONCLUSIONS Home telehealth provides an innovative and pragmatic approach to enhance earlier detection of key clinical symptoms requiring intervention . Transmission of education and advice to the patient on an ongoing basis with close surveillance by nurses can improve clinical outcomes in patients with comorbid chronic illness BACKGROUND We conducted a cluster r and omized controlled trial to examine the effectiveness of computerized decision support ( CDS ) design ed to improve hypertension care and outcomes in a racially diverse sample of primary care patients . METHODS We r and omized 2,027 adult patients receiving hypertension care in 14 primary care practice s to either 18 months of their physicians receiving CDS for each hypertensive patient or to usual care without computerized support for the control group .  We assessed prescribing of guideline -recommended drug therapy and levels of blood pressure control for patients in each group and examined if the effects of the intervention differed by patients ’ race/ethnicity using interaction terms . MEASUREMENTS AND MAIN RESULTS Rates of blood pressure control were 42 % at baseline and 46 % at the outcome visit with no significant differences between groups . After adjustment for patients ’ demographic and clinical characteristics , number of prior visits , and levels of baseline blood pressure control , there were no differences between intervention groups in the odds of outcome blood pressure control . The use of CDS to providers significantly improved Joint National Committee ( JNC ) guideline adherent medication prescribing compared to usual care ( 7 % versus 5 % , P < 0.001 ) ; the effects of the intervention remained after multivariable adjustment ( odds ratio [ OR ] 1.39 [ CI , 1.13–1.72 ] ) and the effects of the intervention did not differ by patients ’ race and ethnicity . CONCLUSIONS CDS improved appropriate medication prescribing with no improvement in disparities in care and overall blood pressure control . Future work focusing on improvement of these interventions and the study of other practical interventions to reduce disparities in hypertension-related outcomes is needed BACKGROUND Most patient chronic disease  self-management interventions target single-disease outcomes . We evaluated the effect of a tailored hypertension self-management intervention on the unintended targets of glycosylated hemoglobin ( HbA1c ) and low-density lipoprotein cholesterol ( LDL-C ) . METHODS We evaluated patients from the Veterans Study to Improve the Control of Hypertension , a 2-year r and omized controlled trial . Patients received either a hypertension self-management intervention delivered by a nurse over the telephone or usual care . Although the study focused on hypertension self-management , we compared changes in HbA1c among a subgroup of 216 patients with diabetes and LDL-C among 528 patients with measurements during the study period . Changes in these laboratory values over time were compared between the 2 treatment groups using linear mixed-effects models . RESULTS For the patients with diabetes , the hypertension self-management intervention result ed in a 0.46 % reduction in HbA1c over 2 years compared with usual care ( 95 % confidence interval , 0.04%-0.89 % ; P = .03 ) . For LDL-C , there was a minimal 0.9 mg/dL between-group difference that was not statistically significant ( 95 % confidence interval , -7.3 - 5.6 mg/dL ; P = .79 ) . CONCLUSIONS There was a significant effect of the self-management intervention on the unintended target of HbA1c , but not LDL-C. Chronic disease self-management interventions might have " spill-over " effects on patients ' comorbid chronic conditions M eeting the complex needs of patients with chronic illness or impairment is the single greatest challenge facing organized medical practice . Usual care is not doing the job ; dozens of surveys and audits have revealed that sizable proportions of chronically ill patients are not receiving effective therapy , have poor disease con- trol , and are unhappy with their care ( 1 ) . Results of r and omized trials also show that effective disease management programs can achieve substantially better outcomes than usual care , the control intervention . These trials , along with the ideas and efforts for improvement discussed in this issue , show that we can improve care and outcomes . As the articles suggest , these improvements will not come easily . If we are to improve care for most patients with chronic illness , the evidence strongly suggests that we reshape our ambulatory care systems for this purpose . Pri- mary care practice was largely design ed to provide ready access and care to patients with acute , varied problems , with an emphasis on triage and patient flow ; short appointments ; diagnosis and treatment of symptoms and signs ; reliance on laborato- ry investigations and prescriptions ; brief , didactic patient education ; and patient- initiated follow-up . Patients and families struggling with chronic illness have differ- ent needs , and these needs are unlikely to be met by an acute care organization and culture . They require planned , regular interactions with their caregivers , with a focus on function and prevention of exacerbations and complications . This interac- tion includes systematic assessment s , attention to treatment guidelines , and behav- iorally sophisticated support for the patient 's role as self-manager . These interactions must be linked through time by clinical ly relevant information systems and continu- ing follow-up initiated by the medical practice . Comprehensive System Purpose : In developing our Patient-Centered Team CareSM ( PCTC ) program , we design ed a Plan-of-Care ( POC ) tool to facilitate the physician-patient discussion for setting health goals . This study aim ed to determine the effectiveness of the POC tool in improving clinical outcomes . Methods : We compared baseline and 6-month or greater follow-up values for hemoglobin A1c ( HbA1c ) , low-density lipoprotein ( LDL ) , systolic blood pressure ( SP ) , diastolic blood pressure ( DP ) , and weight for  PCTC patients ( intervention group ) and non-PCTC patients ( control group ) . For the intervention group , we also compared POC tool completeness scores ( 1 , low and 8 , high ) . Results : Of 1366 patients , 1110 ( 593 intervention , 517 control ) had baseline and follow-up clinical measures for analysis . After adjusting for demographics , significant effects occurred in the intervention group for HbA1c ( P = .0067 ) , LDL ( P = .012 ) , and DP ( P = .091 ) . For completeness of POC , a significant association occurred between more fully completed forms ( scores , 5 - 8 ) and change in HbA1c ( P < .001 ) and SP ( P = .011 ) . Conclusion : Patients receiving a POC showed significant improvement in 3 of 5 clinical outcomes compared with those without the tool , and those with more fully completed forms had significant improvement in 2 of 5 clinical outcomes compared with those with partially completed forms BACKGROUND Only 31 % of Americans with hypertension have their blood pressure ( BP ) under effective control . We describe a study that tests 3 different interventions in a r and omized controlled trial using home BP telemedicine monitoring . METHODS A sample of hypertensive patients with poor BP control at baseline ( N = 600 ) are r and omized to 1 of 4 arms : ( 1 ) control group -- a group of hypertensive patients who receive usual care ; ( 2 ) nurse-administered tailored behavioral intervention ; ( 3 ) nurse-administered medication management according to a hypertension decision support system ; ( 4 ) combination of the 2 interventions . The interventions are triggered based on home BP values transmitted via telemonitoring devices over st and ard telephone lines . The tailored behavioral intervention involves promoting adherence with medication and health behaviors . Patients r and omized to the medication management or the combined arm have their hypertension regimen changed by the study team using a vali date d hypertension decision support system based on evidence -based hypertension treatment guidelines and individualized to patients ' comorbid illnesses . The primary outcome is BP control : < or = 140/90 mm Hg ( nondiabetic ) and < or = 130/80 mm Hg ( diabetics ) measured at 6-month intervals over 18 months ( 4 total measurements ) . CONCLUSIONS Given the increasing prevalence of hypertension and our inability to achieve adequate BP control using traditional models of care , testing novel interventions in patients ' homes may improve access , quality , and outcomes OBJECTIVE To determine the effectiveness of specialist nurse delivered education in primary care to improve control of hypertension and hyperlipidaemia in patients with diabetes . DESIGN AND SETTING Practice -level r and omized controlled trial , Salford , Engl and . SUBJECTS From 44 practice s , 10 303 subjects presenting in general practice with raised blood pressure (= 140/80 mmHg ) , raised total cholesterol (= 5.0 mmol/l ) or both . INTERVENTIONS Practice s were r and omized to receive either the intervention for hyperlipidaemia or for hypertension ; practice s acted as control for the intervention not received . Specialist nurses arranged a schedule of visits with general practitioners and general practice nurses , reminding them of diabetes protocol s and clinical targets . They provided educational material s and protocol s used in secondary care for nurse and doctor interventions including stepping up pharmacotherapy when necessary . Practice s received a list of patients in their practice who were poorly controlled at their last annual review ; new and recalled patients were targeted . OUTCOME MEASURES At subsequent annual review , blood pressure and total cholesterol values were obtained from the Salford electronic diabetes register for patients from participating practice s. RESULTS Overall , specialist nurse-led educational outreach to primary care was associated with no improvement in patients achieving target after 1 year-odds ratio ( OR ) : 1.03 ( 95 % CI 0.95 - 1.11 ; P = 0.52 ) . Similar results were achieved with hyperlipidaemia OR : 1.04 ( 95 % CI 0.88 - 1.23 ; P = 0.62 ) and hypertension OR : 1.01 ( 95 % CI 0.80 - 1.27 ; P = 0.93 ) . CONCLUSION This study provides evidence that the use of specialist nurses to perform educational outreach to improve target adherence to patients with diabetes in primary care is not effective STUDY OBJECTIVE To assess the effects of evidence -based treatment suggestions for hypertension made to physicians and pharmacists using a comprehensive electronic medical record system . DESIGN R and omized controlled trial with a 2 x 2 factorial design of physician and pharmacist interventions , which result ed in four groups of patients :  physician intervention only , pharmacist intervention only , intervention by physician and pharmacist , and intervention by neither physician nor pharmacist ( control ) . SETTING Academic primary care internal medicine practice . SUBJECTS Seven hundred twelve patients with uncomplicated hypertension . MEASUREMENTS AND MAIN RESULTS Suggestions were displayed to physicians on computer workstations used to write outpatient orders and to pharmacists when filling prescriptions . The primary end point was generic health-related quality of life . Secondary end points were symptom profile and side effects from antihypertensive drugs , number of emergency department visits and hospitalizations , blood pressure measurements , patient satisfaction with physicians and pharmacists , drug therapy compliance , and health care charges . In the control group , implementation of care changes in accordance with treatment suggestions was observed in 26 % of patients . In the intervention groups , compliance with suggestions was poor , with treatment suggestions implemented in 25 % of patients for whom suggestions were displayed only to pharmacists , 29 % of those for whom suggestions were displayed only to physicians , and 35 % of the group for whom both physicians and pharmacists received suggestions ( p=0.13 ) . Intergroup differences were neither statistically significant nor clinical ly relevant for generic health-related quality of life , symptom and side-effect profiles , number of emergency department visits and hospitalizations , blood pressure measurements , charges , or drug therapy compliance . CONCLUSION Computer-based intervention using a sophisticated electronic physician order-entry system failed to improve compliance with treatment suggestions or outcomes of patients with uncomplicated hypertension BACKGROUND Hypertension disproportionately affects African Americans compared to whites , and it is the single most common explanation for the disparity in mortality between African Americans and whites . Adherence with antihypertensive medications can help reduce risk of negative hypertension-related outcomes . Motivational interviewing is a promising patient-centered approach for improving adherence in patients with chronic diseases . In this paper we describe the rationale and design of an ongoing r and omized controlled trial testing the effectiveness of motivational interviewing versus usual care in improving medication adherence among 190 African American uncontrolled hypertensive patients , who receive care in a primary care setting . METHODS The usual care group receives st and ard medical care , while those in the intervention group receive st and ard care plus four sessions of motivational interviewing at 3-month intervals for a period of 1 year . This technique consists of brief , patient-driven counseling sessions to facilitate initiation and maintenance of behavior change . The primary outcome is adherence to prescribed antihypertensive medication , assessed with the electronic medication events monitoring system ( MEMS ) and the Morisky self-report adherence question naire . Secondary outcomes are within-patient changes in blood pressure , self-efficacy , and intrinsic motivation between baseline and 12 months . We report the baseline sociodemographic and clinical characteristics of the participants . CONCLUSIONS Despite the potential utility of motivational interviewing , little is known about its effectiveness in improving medication adherence among hypertensive patients , especially African Americans . In addition to the baseline data this study has generated , this trial should provide data with which we can assess the effectiveness of this approach as a behavioral intervention BACKGROUND Among the 65 million Americans with hypertension , only approximately 31 % have their blood pressure under control ( < 140/90 mm/Hg ) . Despite the damaging impact of hypertension and the availability of evidence -based target values for blood pressure , interventions to improve blood pressure control have had limited success . OBJECTIVES A r and omized controlled health services intervention trial with a two by two design is being conducted to improve blood pressure control . This five-year trial evaluates two patient-directed interventions design ed to improve blood pressure control among patients diagnosed with hypertension in a community-based primary care setting . METHODS Patients are r and omized to one of four groups :  usual care , home blood pressure monitoring , tailored behavioral self-management intervention that is administered via telephone by a nurse , or a combination of the home blood pressure monitoring and tailored behavioral intervention . Patients receiving the home blood pressure monitoring are trained in the use of an electronic blood pressure measurement device , are asked to measure their blood pressure 3 times/week , and send in two-month blood pressure recordings throughout the 24-month study duration . The behavioral intervention incorporates patients ' need assessment s and involves tailored behavioral and education modules to promote medication adherence and improve specific health behaviors . A nurse delivers all behavioral self-management modules over the telephone bi-monthly for 24 months . The primary outcome is the proportion of patients who achieve control of their blood pressure based on evidence -based guidelines ( for patients without diabetes < 140/90 mm/Hg , for patients with diabetes < 130/80 mm/Hg ) evaluated at six-month intervals over 24 months ( five measurements ) using a r and om-zero sphygmomanometer . CONCLUSION Despite the known risk of poor blood pressure control , and the wide availability of effective treatment strategies , a majority of adults still do not have their blood pressure controlled . This study will be an important step in defining two explicit interventions to improve blood pressure control . To our knowledge , this study is the first to combine both a tailored behavioral self-management intervention and self-monitoring home blood pressure intervention to improve blood pressure control among patients in a primary care setting BACKGROUND Our aim was to investigate whether a nurse-coordinated multidisciplinary , family-based preventive cardiology programme could improve st and ards of preventive care in routine clinical practice . METHODS In a matched , cluster-r and omised , controlled trial in eight European countries , six pairs of hospitals and six pairs of general practice s were assigned to an intervention programme ( INT ) or usual care ( UC ) for patients with coronary heart disease or those at high risk of developing cardiovascular disease . The primary endpoints-measured at 1 year-were family-based lifestyle change ; management of blood pressure , lipids , and blood glucose to target concentrations ; and prescription of cardioprotective drugs . Analysis was by intention to treat . The trial is registered as IS RCT N 71715857 . FINDINGS 1589 and 1499 patients with coronary heart disease in hospitals and 1189 and 1128 at high risk were assigned to INT and UC , respectively . In patients with coronary heart disease who smoked in the month before the event , 136 ( 58 % ) in the INT and 154 ( 47 % ) in the UC groups did not smoke 1 year afterwards ( difference in change 10.4 % , 95 % CI -0.3 to 21.2 , p=0.06 ) . Reduced consumption of saturated fat ( 196 [ 55 % ] vs 168 [ 40 % ] ; 17.3 % , 6.4 to 28.2 , p=0.009 ) , and increased consumption of fruit and vegetables  ( 680 [ 72 % ] vs 349 [ 35 % ] ; 37.3 % , 18.1 to 56.5 , p=0.004 ) , and  oily fish  ( 156 [ 17 % ] vs 81 [ 8 % ] ; 8.9 % , 0.3 to 17.5 , p=0.04 ) at 1 year were greatest in the INT group . High-risk individuals and partners showed changes only for fruit and vegetables ( p=0.005 ) . Blood-pressure target of less than 140/90 mm Hg was attained by both coronary ( 615 [ 65 % ] vs 547 [ 55 % ] ; 10.4 % , 0.6 to 20.2 , p=0.04 ) and high-risk ( 586 [ 58 % ] vs 407 [ 41 % ] ; 16.9 % , 2.0 to 31.8 , p=0.03 ) patients in the INT groups . Achievement of total cholesterol of less than 5 mmol/L did not differ between groups , but in high-risk patients the difference in change from baseline to 1 year was 12.7 % ( 2.4 to 23.0 , p=0.02 ) in favour of INT . In the hospital group , prescriptions for statins  were higher in the INT group ( 810 [ 86 % ] vs 794 [ 80 % ] ; 6.0 % , -0.5 to 11.5 , p=0.04 ) . In general practice s in the intervention groups ,  angiotensin-converting enzyme inhibitors  ( 297 [ 29 % ] INT vs 196 [ 20 % ] UC ; 8.5 % , 1.8 to 15.2 , p=0.02 ) and  statins  ( 381 [ 37 % ] INT vs 232 [ 22 % ] UC ; 14.6 % , 2.5 to 26.7 , p=0.03 ) were more frequently prescribed . INTERPRETATION To achieve the potential for cardiovascular prevention , we need local preventive cardiology programmes adapted to individual countries , which are accessible by all hospitals and general practice s caring for coronary and high-risk patients BACKGROUND Poor medication adherence is a significant problem in hypertensive African Americans . Although motivational interviewing ( MINT ) is effective for adoption and maintenance of health behaviors in patients with chronic diseases , its effect on medication adherence remains untested in this population . METHODS This r and omized controlled trial tested the effect of a practice -based MINT counseling vs. usual care ( UC ) on medication adherence and blood pressure ( BP ) in 190 hypertensive African Americans ( 88 % women ; mean age 54 years ) . Patients were recruited from two community-based primary care practice s in New York City . The primary outcome was adherence measured by electronic pill monitors ; the secondary outcome was within-patient change in office BP from baseline to 12 months . RESULTS Baseline adherence was similar in both groups ( 56.2 and 56.6 % for MINT and UC , respectively , P = 0.94 ) . Based on intent-to-treat analysis using mixed-effects regression , a significant time x group interaction with model-predicted posttreatment adherence rates of 43 and 57 % were found in the UC and MINT groups , respectively ( P = 0.027 ) , with a between-group difference of 14 % ( 95 % confidence interval , -0.2 to -27 % ) . The between-group difference in systolic and diastolic BP was -6.1 mm Hg ( P = 0.065 ) and -1.4 mm Hg ( P = 0.465 ) , respectively , in favor of the MINT group . CONCLUSIONS A practice -based MINT counseling led to steady maintenance of medication adherence over time , compared to significant decline in adherence for UC patients . This effect was associated with a modest , nonsignificant trend toward a net reduction in systolic BP in favor of the MINT group OBJECTIVES A r and omized controlled trial involving a nurse administered patient-tailored intervention is being conducted to improve blood pressure ( BP ) control . METHODS Veterans with hypertension from an outpatient primary care clinic completed a baseline assessment and were r and omly allocated to either a nurse administered intervention or to usual care . In this ongoing study , intervention patients receive the tailored intervention bi-monthly for 2 years via telephone ; the goal of the intervention is to promote adherence with medication and improve health behaviors . Patient factors targeted for intervention include perceived risk of hypertension , memory , literacy , social support , patients ' relationship with their health care provider , side effects of therapy , pill refill , missed appointments , and health behaviors . RESULTS The sample r and omized to the nurse intervention  consisted of 294 veterans with hypertension ( average age = 63 years ; 41 % African-American ) . A comparable sample of veterans was assigned to usual care ( n = 294 ) . We have maintained a 97 % retention rate for the first 12 months of the study . The average phone call has lasted 3.7 min ranging from less than 1 to 40 min . At 6-month post-enrollment , individuals receiving the nurse intervention had a greater increase in confidence with following hypertension treatment ( P < 0.007 ) than the usual care group . DISCUSSION The intervention is easily implemented and is design ed to enhance adherence with prescribed hypertension regimen . The study includes both general and patient-tailored information based upon need assessment . The study design ensures internal validity as well as the ability to generalize study findings to the clinic setting BACKGROUND Pharmacist-physician comanagement of hypertension has been shown to improve office blood pressures ( BPs ) . We sought to describe the effect of such a model on 24-hour ambulatory BPs . METHODS We performed a prospect i ve , cluster-r and omized , controlled clinical trial , enrolling 179 patients with uncontrolled hypertension from 5 primary care clinics in Iowa City , Iowa . Patients were r and omized by clinic to receive pharmacist-physician collaborative management of hypertension ( intervention ) or  usual care ( control ) for a 9-month period . In the intervention group , pharmacists helped patients to identify barriers to BP control , counseled on lifestyle and dietary modifications , and adjusted antihypertensive therapy in collaboration with the patients ' primary care providers . Patients were seen by pharmacists a minimum of every 2 months . Ambulatory BP was measured at baseline and at study end . RESULTS Baseline and end-of- study ambulatory BP profiles were evaluated for 175 patients . Mean ( SD ) ambulatory systolic BPs ( SBPs ) , reported in millimeters of mercury , were reduced more in the intervention group than in the control group : daytime change in ( Δ ) SBP , 15.2 ( 11.5 ) vs 5.5 ( 13.5 ) ( P < .001 ) ; nighttime ΔSBP , 12.2 ( 14.8 ) vs 3.4 ( 13.3 ) ( P < .001 ) ; and 24-hour ΔSBP , 14.1 ( 11.3 ) vs 5.5 ( 12.5 ) ( P < .001 ) . More patients in the intervention group than in the control group had their BP controlled at the end of the study ( 75.0 % vs 50.7 % ) ( P < .001 ) , as defined by overall 24-hour ambulatory BP monitoring . CONCLUSION Pharmacist-physician collaborative management of hypertension achieved consistent and significantly greater reduction in 24-hour BP and a high rate of BP control . Trial Registration clinical trials.gov Identifier : NCT00201045 CONTEXT Treating hypertension decreases mortality and disability from cardiovascular disease , but most hypertension remains inadequately controlled . OBJECTIVE To determine if a new model of care that uses patient Web services , home blood pressure ( BP ) monitoring , and pharmacist-assisted care improves BP control . DESIGN , SETTING , AND PARTICIPANTS A 3-group r and omized controlled trial , the Electronic Communications and Home Blood Pressure Monitoring study was based on the Chronic Care Model . The trial was conducted at an integrated group practice in Washington state , enrolling 778 participants aged 25 to 75 years with uncontrolled essential hypertension and Internet access . Care was delivered over a secure patient Web site from June 2005 to December 2007 . INTERVENTIONS Participants were r and omly assigned to usual care , home BP monitoring and secure patient Web site training only , or home BP monitoring and secure patient Web site training plus pharmacist care management delivered through Web communications . MAIN OUTCOME MEASURES Percentage of patients with controlled BP ( < 140/90 mm Hg ) and changes in systolic and diastolic BP at 12 months . RESULTS Of 778 patients , 730 ( 94 % ) completed the 1-year follow-up visit . Patients assigned to the home BP monitoring and Web training only group had a nonsignificant increase in the percentage of patients with controlled BP ( < 140/90 mm Hg ) compared with usual care ( 36 % [ 95 % confidence interval { CI } , 30%-42 % ] vs 31 % [ 95 % CI , 25%-37 % ] ; P = .21 ) . Adding Web-based pharmacist care to home BP monitoring and Web training significantly increased the percentage of patients with controlled BP ( 56 % ; 95 % CI , 49%-62 % ) compared with usual care ( P < .001 ) and home BP monitoring and Web training only ( P < .001 ) . Systolic BP was decreased stepwise from usual care to home BP monitoring and Web training only to home BP monitoring and Web training plus pharmacist care . Diastolic BP was decreased only in the pharmacist care group compared with both the usual care and home BP monitoring and Web training only groups . Compared with usual care , the patients who had baseline systolic BP of 160 mm Hg or higher and received home BP monitoring and Web training plus pharmacist care had a greater net reduction in systolic BP ( -13.2 mm Hg [ 95 % CI , -19.2 to -7.1 ] ; P < .001 ) and diastolic BP ( -4.6 mm Hg [ 95 % CI , -8.0 to -1.2 ] ; P < .001 ) , and improved BP control ( relative risk , 3.32 [ 95 % CI , 1.86 to 5.94 ] ; P<.001 ) . CONCLUSION Pharmacist care management delivered through secure patient Web communications improved BP control  in patients with hypertension . Trial Registration clinical trials.gov Identifier : NCT00158639 BACKGROUND The aim of the trial was to evaluate the effectiveness of a program of cooperation between physician and pharmacist to reduce cardiovascular risk factors in patients with mild to moderate hypertension by promoting better blood pressure ( BP ) control , appropriate changes in antihypertensive medications , and beneficial changes in lifestyle . METHODS The 132 subjects in this r and omized , controlled trial were in the age range of 40 - 79 years . The inclusion criteria were : systolic BP ( SBP ) ranging from 140 - 179 mm Hg and /or diastolic BP ( DBP ) ranging from 90 - 99 mm Hg and treatment-naive ( untreated for hypertension ) ; or on a regimen of medication for hypertension . Of these 132 subjects , 124 ( 94 % ) were already receiving treatment with antihypertensive medications . Equal numbers of subjects were r and omly assigned to one of two groups : a physician-pharmacist intervention group ( n = 66 ) and a control group ( n = 66 ) . RESULTS The 6-month follow-up rate was 97 % in both groups . At 6 months , the mean decrease in SBP/DBP , as measured at home in the morning , was 2.9/3.3 mm Hg in the intervention group relative to baseline ( P = 0.02 and P < 0.0001 for SBP and DBP , respectively ) . The mean decrease in home morning SBP in the intervention group was not significantly greater than in the control group . However , the DBP decline was significantly greater in the intervention than control groups , which showed a mean decrease of 2.8 mm Hg ( confidence interval : -5.5 to -0.1 ; P = 0.04 ) . The percentage of patients in whom control of home morning BP was achieved was 53 % in the intervention group and 47 % in the control group ( P = 0.40 ) . A higher percentage of patients in the intervention group , relative to the control group , were able to reduce the use of antihypertensive medications ( 31 vs. 8 % , P < 0.0001 ) , and fewer patients in this group required additional medications or increases in dosage relative to the controls ( 11 vs. 28 % , P = 0.03 ) . Patients of the intervention group were more likely to show reduction in body mass index and sodium intake and to stop smoking , as compared with the control group . CONCLUSIONS A program of cooperation between physician and pharmacist was successful in reducing cardiovascular risk factors in patients with mild to moderate hypertension by promoting better blood pressure ( BP ) control , appropriate changes in antihypertensive medications , and beneficial changes in lifestyle Team-based care can improve  hypertension control . The purpose of the present study was to evaluate blood pressure ( BP ) control 18 months following the discontinuation of a physician-pharmacist collaborative intervention . This was a retrospective analysis of patients who had previously participated in a prospect i ve , cluster r and omized , controlled clinical trial . Six community-based family medicine offices were r and omized to control or intervention groups . Research nurses measured BPs using an automated device during the prospect i ve trial . The research nurses then abstract ed data from medical records , including BPs , medications , changes in therapy , and laboratory values for 18 months following the discontinuation of the 6-month prospect i ve trial . The study included 228 patients in the control ( n = 146 ) or intervention ( n = 82 ) groups . The control group contained more patients with diabetes or chronic kidney disease ( P < .013 ) , were older ( P = .047 ) , and had more coexisting conditions ( P < .001 ) than the intervention group . Systolic BP 9 months following discontinuation of the physician-pharmacist intervention was 137.2 ± 18.2 mm Hg and 129.8 ± 13.3 mm Hg in the control and intervention groups , respectively ( P = .0015 ) . BP control was maintained in 61 ( 41.8 % ) control patients and 55 ( 67.1 % ) intervention patients ( P = .0003 ) . At 18 months post-intervention , systolic BP was 138.1 ± 20.4 mm Hg and 130.0 ± 16.0 mm Hg in the control and intervention groups , respectively ( P = .023 ) . BP control was maintained in 53 ( 36.3 % ) control patients and 55 ( 67.1 % ) intervention patients at 18 months post-intervention ( P < .0001 ) . A sensitivity analysis was conducted to address the uneven distribution of patients with diabetes or chronic kidney disease , and the differences between groups were still significant . BP control rates remained significantly higher following a physician-pharmacist intervention compared with usual care for 18 months after discontinuation of the intervention . This model has the potential value as a useful long-term strategy to benefit patients with hypertension
target: Team-based care increased the proportion of people with controlled BP  and reduced both systolic and diastolic BP , especially when pharmacists and nurses were part of the team .
background: CONTEXT Uncontrolled hypertension remains a widely prevalent cardiovascular risk factor in the U.S. team-based care , established by adding new staff or changing the roles of existing staff such as nurses and pharmacists to work with a primary care provider and the patient .
  Team-based care has the potential to improve the quality of hypertension management .
  The goal of this Community Guide systematic review was to examine the effectiveness of team-based care in improving blood pressure ( BP ) outcomes .