A large literature suggests that the majority of """"""""uncontrolled"""""""" hypertensives are under medical care, and that lack of control is largely explained by physicians not intensifying treatment to achieve the blood pressure targets recommended in the national guidelines. Traditional physician education, feedback, and reminders have a limited effect in promoting a rapid rate of guideline implementation. The theoretical framework of diffusion of innovations suggests that providing physicians with tools to reduce uncertainty about the attributes of a guideline may accelerate the adoption process. The presumed barriers to treatment intensification for uncontrolled hypertension are: 1) uncertainty over the patient's """"""""true"""""""" blood pressure; 2) uncertainty over whether the patient is adherent to medications already prescribed; and 3) uncertainty over the benefits of adding medications when patients express preference for lifestyle modification. We will conduct a cluster randomized trial in 10 primary care clinics (5 intervention and 5 control) to test the hypothesis that an intervention based on diffusion of innovations theory, and targeting provider treatment actions, will increase the prevalence of blood pressure control to JNC 7- recommended levels in African- American patients (< 140/90 mm Hg or < 130/80 mmHg if the patient has diabetes). The uncertainty reduction tools in the proposed """"""""Uncertainty Reduction to Accelerate Diffusion (URAD)"""""""" practices will include: 24-hour ambulatory blood pressure monitoring, electronic bottle-cap monitoring of medication adherence, and medication and lifestyle counseling. The """"""""Usual Practice (UP)"""""""" physicians will receive education about the guidelines and a """"""""placebo"""""""" chart form indicating the patient is being followed in a blood 3ressure control study. The 10 participating clinics represent a large, multi-site private group practice and a 3ublic health care system. Sixty-seven patients per clinic (670 total) will be enrolled when the intervention is initiated, and their blood pressure and self-reported medication and lifestyle adherence will be monitored for two years. Sixty percent of the sample will be African-American, and the study will have 90% power to detect a difference of 20% in the prevalence of hypertension control in the African-Americans as a result of the intervention (50% control in URAD clinics vs. 30% control UP clinics). Secondary endpoints will include blood pressure measurements by study staff under standardized conditions, physician treatment intensification actions, patient adherence, characteristics of doctor-patient communication associated with treatment action, use of the URAD components, and physician knowledge and beliefs about the JNC 7 guidelines and their relationship to blood pressure control. Analysis of secondary endpoints will include race. The research team has collaborated with both health systems in previous studies, and is experienced in conducting hypertension control and behavioral intervention studies in the target population.

Agency
National Institute of Health (NIH)
Institute
National Heart, Lung, and Blood Institute (NHLBI)
Type
Research Project (R01)
Project #
5R01HL078589-05
Application #
7458971
Study Section
Special Emphasis Panel (ZHL1-CSR-B (S1))
Program Officer
Einhorn, Paula
Project Start
2004-09-30
Project End
2012-06-30
Budget Start
2008-07-01
Budget End
2012-06-30
Support Year
5
Fiscal Year
2008
Total Cost
$675,729
Indirect Cost
Name
Baylor College of Medicine
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
051113330
City
Houston
State
TX
Country
United States
Zip Code
77030
Pavlik, Valory N; Chan, Wenyaw; Hyman, David J et al. (2015) Designing and evaluating health systems level hypertension control interventions for African-Americans: lessons from a pooled analysis of three cluster randomized trials. Curr Hypertens Rev 11:123-31
Grigoryan, Larissa; Pavlik, Valory N; Hyman, David J (2013) Characteristics, drug combinations and dosages of primary care patients with uncontrolled ambulatory blood pressure and high medication adherence. J Am Soc Hypertens 7:471-6
Grigoryan, Larissa; Pavlik, Valory N; Hyman, David J (2013) Patterns of nonadherence to antihypertensive therapy in primary care. J Clin Hypertens (Greenwich) 15:107-11
Grigoryan, Larissa; Pavlik, Valory N; Hyman, David J (2012) Predictors of antihypertensive medication adherence in two urban health-care systems. Am J Hypertens 25:735-8
Hyman, David J; Pavlik, Valory N; Greisinger, Anthony J et al. (2012) Effect of a physician uncertainty reduction intervention on blood pressure in uncontrolled hypertensives--a cluster randomized trial. J Gen Intern Med 27:413-9
Pavlik, Valory N; Greisinger, Anthony J; Pool, James et al. (2009) Does reducing physician uncertainty improve hypertension control?: rationale and methods. Circ Cardiovasc Qual Outcomes 2:257-63
Naik, Aanand D; Teal, Cayla R; Pavlik, Valory N et al. (2008) Conceptual challenges and practical approaches to screening capacity for self-care and protection in vulnerable older adults. J Am Geriatr Soc 56 Suppl 2:S266-70
Kelly, P Adam; Dyer, Carmel B; Pavlik, Valory et al. (2008) Exploring self-neglect in older adults: preliminary findings of the self-neglect severity scale and next steps. J Am Geriatr Soc 56 Suppl 2:S253-60