doi: 10.1161/HYPERTENSIONAHA.109.134874
(Hypertension. 2009;54:1226.)
© 2009 American Heart Association, Inc.
Original Articles |
Hypertension Improvement Project
Randomized Trial of Quality Improvement for Physicians and Lifestyle Modification for Patients
From the Department of Medicine (L.P.S., W.S.Y., R.J.D., B.C.B., G.S., D.B.M., P.-H.L.), Duke Hypertension Center (L.P.S., B.C.B., P.-H.L.), Sarah W. Stedman Nutrition and Metabolism Center (L.P.S., P.-H.L.), Department of Community and Family Medicine (K.I.P.), Cancer Prevention, Detection, and Control Research Program (K.I.P., D.B.M.), Center for Health Policy Research (G.S.), and Department of Biostatistics and Bioinformatics (G.S.), Duke University Medical Center, Durham, N.C.; Program in Health Services Research (D.B.M.), Duke-National University of Singapore Graduate Medical School, Singapore.
Correspondence to Laura P. Svetkey, Stedman Building, Center for Living Campus, 3475 Erwin Rd, Suite 100, Durham, NC 27705. E-mail svetk001{at}mc.duke.edu
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, 2x2 randomized, 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 practices (32 physicians) were randomized to physician intervention or control groups. Within those practices, 574 patients were randomized 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.
Key Words: hypertension • blood pressure • behavioral intervention • quality improvement • lifestyle • DASH dietary pattern
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