Stakeholder Perspectives on Changes in Hypertension Care Under the Patient-Centered Medical Home.

INTRODUCTION: Hypertension is a major modifiable risk factor for cardiovascular and kidney disease, yet the proportion of adults whose hypertension is controlled is low. The patient-centered medical home (PCMH) is a model for care delivery that emphasizes patient-centered and team-based care and focuses on quality and safety. Our goal was to investigate changes in hypertension care under PCMH implementation in a large multipayer PCMH demonstration project that may have led to improvements in hypertension control. METHODS: The PCMH transformation initiative conducted 118 semistructured interviews at 17 primary care practices in southeastern Pennsylvania between January 2011 and January 2012. Clinicians (n = 47), medical assistants (n = 26), office administrators (n = 12), care managers (n = 11), front office staff (n = 7), patient educators (n = 4), nurses (n = 4), social workers (n = 4), and other administrators (n = 3) participated in interviews. Study personnel used thematic analysis to identify themes related to hypertension care. RESULTS: Clinicians described difficulties in expanding services under PCMH to meet the needs of the growing number of patients with hypertension as well as how perceptions of hypertension control differed from actual performance. Staff and office administrators discussed achieving patient-centered hypertension care through patient education and self-management support with personalized care plans. They indicated that patient report cards were helpful tools. Participants across all groups discussed a team- and systems-based approach to hypertension care. CONCLUSION: Practices undergoing PCMH transformation may consider stakeholder perspectives about patient-centered, team-based, and systems-based approaches as they work to optimize hypertension care.

Examining the Feasibility of a Simple Intervention to Improve Blood Pressure Control for Primary Care Patients.

BACKGROUND: Blood pressure control remains a challenge despite the availability of effective antihypertensive agents. OBJECTIVE: This pilot study explored the feasibility of a simple, low-resource intervention to improve blood pressure control. METHODS: A convenience sample was drawn of 56 patients with hypertension from a primary care clinic. A preintervention-postintervention delivered by medical assistants involved prompts to providers to address blood pressure control with a visual aid indicating patients' current and target blood pressure in the context of a traffic light. RESULTS: Patients showed a significant reduction in mean systolic blood pressure (preintervention, 141.5 mm Hg, vs postintervention, 133.0 mm Hg; P = .002) and mean diastolic blood pressure (preintervention, 83.4 mm Hg, vs postintervention, 80.4 mm Hg; P = .049). CONCLUSION: In this pilot study, we established the feasibility of a brief, simple intervention to improve blood pressure control implemented by existing primary care practice clinical support staff, and preliminary data show that it can be effective in improving blood pressure control.

Pilot trial of a licensed practical nurse intervention for hypertension and depression.

BACKGROUND AND OBJECTIVES: Depression is a risk factor for hypertension, and risk of depression is increased substantially in patients with hypertension. Our objective was to examine whether an intervention carried out by Licensed Practical Nurses (LPNs) integrating depression treatment into care for hypertension improved blood pressure control and depressive symptoms. METHODS: In all, 60 patients ages 41 to 92 years with hypertension and depressive symptoms at a large primary care practice in Philadelphia were randomly assigned to an integrated care intervention carried out by LPNs (n=30) or usual care (n=30). Intervention and control groups did not differ statistically on baseline measures. Outcomes assessed at baseline and 12 weeks included standard laboratory procedures to measure blood pressure control and the Patient Health Questionnaire (PHQ-9) to assess depression. RESULTS: Patients in the integrated care intervention had lower diastolic blood pressure (intervention 74.2 mmHg versus usual care 82.0 mmHg) and fewer depressive symptoms (PHQ-9 mean scores, intervention 2.4 versus usual care 7.1) compared with patients in the usual care group at 12 weeks after adjustment for baseline values. Patients in the integrated care intervention also had lower systolic blood pressure (intervention 130.0 mmHg versus usual care 140.6 mmHg) compared with patients in the usual care group at 12 weeks although the results approached but did not reach conventional levels of statistical significance. CONCLUSION: Training existing primary care practice office staff will facilitate implementation in real world practices with limited resources and competing demands.

Chronic medical conditions and reproducibility of self-reported age at menopause among community-dwelling women.

OBJECTIVE: The aim of this study was to examine the association between chronic medical conditions and reproducibility of self-reported age at menopause among community-dwelling women. METHODS: Age at menopause was assessed in a population-based longitudinal survey of 240 women twice, in 1993 and 2004. Women who recalled age at menopause in 2004 within 1 year or less of age at menopause recalled in 1993 (concordant) were compared with women who did not recall age at menopause in 2004 within 1 year of age at menopause recalled in 1993 (discordant). Type of menopause (surgical or natural) and chronic medical conditions were assessed by self-report. RESULTS: One hundred forty-three women (59.6%) reported surgical menopause, and 97 (40.4%) reported natural menopause. In all, 130 (54.2%) women recalled age at menopause in 2004 within 1 year or less of recalled age at menopause in 1994, whereas 110 (45.8%) women did not recall age at menopause in 2004 within 1 year or less of recalled age at menopause in 1994. Among the women with surgical menopause, the women with three or more medical conditions were less likely to have concordant recall of age at menopause than the women with less than three chronic medical conditions (adjusted odds ratio, 0.36; 95% CI, 0.15-0.91) in multivariate models controlling for potentially influential characteristics including cognition and years since menopause. CONCLUSIONS: Among women who underwent surgical menopause, the presence of three or more medical conditions is associated with decreased reproducibility of self-reported age at menopause.