Adherence to blood pressure lowering medications is generally poor, due to problems that relate to patients, physicians and the medical care system in which they interact. These problems are generally worse among underserved populations. The proposed project tailors a nurse case management system (NCM) that has proven efficacious in clinical trials for hypertension and other chronic conditions, in various venues, to the medically underserved population of a publicly supported health plan. More than 80 percent of these individuals are ethnic minorities and many live in poverty: 90 percent are fluent in English, Spanish or Vietnamese. Patients needing blood pressure lowering drugs according to JNC VI criteria are randomized to receive usual care alone or usual care plus NCM. The latter consists of an initial face-to-face educational session with patients and their families followed by nurse-initiated phone contacts at specified intervals to reinforce the educational message and titrate drug therapy according to a standardized protocol. All patients receive electronic devices for measuring blood pressure and drug adherence at home. Periodic reports on blood pressure are mailed to patients and their physicians, but no drug adherence data are provided to physicians, patients or nurses. The treatment period is 6 months; blood pressure monitors are then withdrawn from all patients. During the subsequent 6-month post-treatment follow-up period, patients continue to monitor drug adherence. The primary hypothesis is: adherence to blood pressure medications is greater among patients receiving the combination of usual care and NCM than among those receiving usual care alone. The primary outcome measure is drug adherence measured by the electronic device. Secondary outcomes include blood pressure, health-related quality of life, program costs for providing the special intervention and patient and physician satisfaction. A total of 326 patients will be randomized, 163 to each of the two groups. Power calculations are based on detection of at least a 10 percent difference in drug adherence between the two groups. Demonstration of the efficacy of nurse case management of hypertension in the proposed project may facilitate the dissemination of this approach to underserved populations throughout the U.S.
