Impact of Computerized Decision Support on Blood Pressure Management and Control: A Randomized Controlled Trial

Abstract

BACKGROUND: We conducted a cluster randomized controlled trial to examine the effectiveness of computerized decision support (CDS) designed to improve hypertension care and outcomes in a racially diverse sample of primary care patients. METHODS:We randomized 2,027 adult patients receiving hypertension care in 14 primary care practices 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,) 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. INTRODUCTIONMeasuring and improving the quality of hypertension care has become a national priority in recent years. Prior studies have demonstrated substantial problems in the quality of hypertension treatment and low rates of blood pressure control, as well as racial and socioeconomic disparities. [1][2][3][4][5][6][7][8][9][10][11][12][13][14] Hypertension is particularly burdensome among racial/ethnic minority groups 7-14 and hypertension-related cardiovascular disease has been shown to be the greatest contributor to racial differences in mortality. 12 Several reviews have emphasized the importance of designing pragmatic interventions to improve care and reduce disparities in outcomes of chronic diseases [15][16][17] ; one such intervention may be the use of computerized decision support (CDS). In a prior randomized trial, we found that CDS for diabetes and coronary artery disease care were effective for improving provider adherence with recommended processes of care. 18 Other studies have also demonstrated that computer-based reminders are effective in improving measures of process of care, but intermediate clinical outcomes, such as blood pressure control, are rarely examined and when studied are frequently not improved. [19][20][21][22][2...

Effect of point-of-care computer reminders on physician behaviour: a systematic review

“…However, we were unable to identify any study characteristic or reminder feature that predicted larger effect sizes, except for a statistically significant increase in magnitude of effect seen in studies involving a well-developed, homegrown computer order entry system at Brigham and Women's Hospital. 26,31,37,40,46 A trend toward larger effects was also seen for reminders that required users to enter a response in order to proceed; however, this finding may have been confounded by the uneven distribution of studies from Brigham and Wo men's Hospital. Thus, we do not know if the success of computer reminders at this institution reflects the design of reminders requiring user responses, other features of the computer system or perhaps institutional culture.…”

The Effect of Patient Race and Blood Pressure Control on Patient-Physician Communication

“…Examples of effective strategies include home BP monitoring; in-person, telephone, or web-based motivational strategies delivered by a nurse and/ or a pharmacist; collaborative management by primary carepharmacist teams; 60,61 and involvement of community health workers as members of the care team. 62 Physician-directed interventions such as continuing medical education, academic detailing, quality review and feedback, and computer decision support/reminders to change prescribing behaviors, when used alone, have not shown improvements in health outcomes, [63][64][65][66][67][68] and few studies have focused on communication skills training skills for providers. 39,61 If shown to be effective in well-designed studies, integrating the best of these strategies will provide models that may be disseminated into practice to improve quality of care and reduce disparities in cardiovascular disease outcomes.…”

Changing Clinical Practice Through Patient Specific Reminders Available at the Time of the Clinical Encounter: Systematic Review and Meta-Analysis

“…The other 46 used length of hospital stay. Two papers reported clinical outcomes (control of blood pressure 24 and rate of venous thrombo-embolism) 29 and all the rest involved process outcomes. One paper 19 reported three different intervention arms and one control arm.…”