Do the Benefits of Participation in a Hypertension Self-Management Trial Persist After Patients Resume Usual Care?

Abstract

Interventions that combine self-management (SM) support and individualized medical management theoretically represent a potentially sustainable intervention for patients with hypertension if they retain and apply skills learned in such interventions after returning to usual care. The longer-term clinical and economic benefits of SM interventions remain largely untested because only 5 prior studies tracked clinical outcomes after completion of SM trials in patients with hypertension. Results from the United Kingdom Prospective Diabetes Study (UKPDS) 1 found that the clinical benefits of tight blood pressure (BP) control were not sustained ≤10 years after trial completion. Editorial see p 205The Steno-2 2 follow-up study of patients with diabetes mellitus and microalbuminuria and 3 follow-up studies of pharmacist interventions for patients with hypertension suggested that SM interventions had long-lasting effects.3-5 These long-term clinical benefits may translate into reductions in healthcare utilization and costs, but no prior trial has reported long-term economic outcomes once patients return to usual care.The purpose of this article is to examine clinical and economic outcomes 18 months after completion of an 18-month Background-Hypertension self-management has been shown to improve systolic blood pressure (BP) control, but longerterm economic and clinical impacts are unknown. The purpose of this article is to examine clinical and economic outcomes 18 months after completion of a hypertension self-management trial. Methods and Results-This study is a follow-up analysis of an 18-month, 4-arm, hypertension self-management trial of 591 veterans with hypertension who were randomized to usual care or 1 of 3 interventions. Clinic-derived systolic blood pressure obtained before, during, and after the trial were estimated using linear mixed models. Inpatient admissions, outpatient expenditures, and total expenditures were estimated using generalized estimating equations. The 3 telephonebased interventions were nurse-administered health behavior promotion, provider-administered medication adjustments based on hypertension treatment guidelines, or a combination of both. Intervention calls were triggered by home BP values transmitted via telemonitoring devices. Clinical and economic outcomes were examined 12 months before, 18 months during, and 18 months after trial completion. Compared with usual care, patients randomized to the combined arm had greater improvement in proportion of BP control during and after the 18-month trial and estimated proportion of BP control improved 18 months after trial completion for patients in the behavioral and medication management arms. Among the patients with inadequate baseline BP control, estimated mean systolic BP was significantly lower in the combined arm as compared with usual care during and after the 18-month trial. Utilization and expenditure trends were similar for patients in all 4 arms. Conclusions-Behavioral and medication management can generate systolic BP improvements ...

Open-label randomized trial of titrated disease management for patients with hypertension: Study design and baseline sample characteristics

“…However, we recently evaluated clinical benefits of calls similar to those in the TDM Trial and home BP monitoring after the trial concluded. The positive effect of the intervention, which did not include titration of resource intensity, was sustained 18 months following study conclusion 50 Finally, we were not able to maintain our original goal of only including patients who had uncontrolled SBP at baseline. In the final sample, 23.4% of patients had blood pressure under control based on measurements collected at the baseline study visit.…”

Hypertension Self-Management

“…The study by Maciejewski et al 12 provides further evidence supporting this approach. The Hypertension Intervention Nurse Telemedicine Study (HINTS) was a randomized trial of patients who received care at Durham Veterans Affairs Medical Center primary care clinics.…”

“…13 This report by Maciejewski et. al 12 adds to the growing evidence that HSM is safe and effective. Indeed, HSM is being implemented in integrated and capitated healthcare systems because it improves BP control and patient satisfaction while preserving office visits for patients who need an in-person assessment.…”

“…Lack of Medicare coverage is a major impediment to the diffusion of HSM in fee-for-service practice because most private payers follow CMS guidance in determining coverage for health services. 14 The results of the study by Maciejewski et al 12 offer a new opportunity for CMS to review its coverage policy. As with many national coverage determinations, there are additional factors to consider.…”

Models of Intervention, Which Are Applied by the Nurse and Aimed at Changing the Behavior of Hypertensives-Review

“…In comparison to the usual care, the patients who had been randomized on the combined intervention, had had a great improvement in blood pressure control. The conclusions made, are that the behavioral changes and medicaments can generate improvements in systolic blood pressure, which have been kept 18 months after the intervention was finished (Maciejewski ML., et al, 2014). The patients with high blood pressure frequently do not succeed in fulfilling the goals of treatmenta state defined as an "uncontrolled" hypertension.…”