Predictors of blood pressure control among hypertensives in community health centers.

BACKGROUND: The correlates of blood pressure (BP) control among hypertensive individuals who have access to care in community-based health-care settings are poorly characterized, particularly among minority and immigrant populations. METHODS: Using data extracted from electronic medical records in four federally qualified health centers in New York, we investigated correlates of hypertension (HTN) control in cross-sectional analyses. The sample consisted of adult, nonobstetric patients with a diagnosis of HTN and a clinic visit between June 2007 and October 2008 (n = 2,585). RESULTS: Forty-nine percent of hypertensive patients had controlled BP at their last visit. Blacks had a higher prevalence of HTN (B, 32.8%; W, 16.2%; H, 11.5%) and were less likely to have controlled BP (B, 42.2%; W, 50.9%; H, 50.8%) compared with Hispanics and whites. Medication intensification did not differ by race/ethnicity. In multivariate analyses higher body mass index (BMI), black race, diabetes, fewer clinical encounters, and male gender were associated with poor BP control. However, when we applied the Seventh Report of the Joint National Committee (JNC 7) definition for BP control for nondiabetic patients (systolic blood pressure (SBP) <140, diastolic blood pressure (DBP) <90) to all patients with HTN, we found no difference in BP control between those with and without diabetes. CONCLUSIONS: Blacks had poorer HTN control compared with whites and Hispanics. Significant discrepancies in BP control between hypertensive patients with and without diabetes may be related to a lack of provider adherence to JNC 7 guidelines that define BP control in this population as <130/80. Further research is needed to understand racial disparities in BP control as well as factors influencing clinician's management of BP among patients with diabetes.

Technology-driven intervention to improve hypertension outcomes in community health centers.

OBJECTIVES: To assess the impact of an electronic medical record (EMR) with clinical decision support (CDS) and performance feedback on provider adherence to guideline-recommended care and blood pressure (BP) control compared with a standard EMR alone. STUDY DESIGN: Quasi-experimental with repeated measures. METHODS: The study was conducted in a 4-site, federally qualified health center, Open Door Family Medical Centers, located in New York. The research team, Open Door leadership, providers, and staff developed and implemented a tailored multicomponent CDS system, which included a BP alert, a hypertension (HTN) order set, an HTN template, and clinical reminders. We extracted patient-level data for each encounter 17 months prior to implementation of the intervention (June 2007-October 2008) and 15 months post-intervention (April 2009-June 2010), from the EMR's data tables for all adult nonobstetric patients with a diagnosis of HTN (N = 3636). RESULTS: Rates of HTN control were significantly greater in the post-intervention period compared with the baseline period (50.9% vs 60.8%; P <.001). Process measures, derived from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Guidelines, also improved significantly. Logistic regression with generalized estimating equations showed that patients were 1.5 times more likely to have controlled BP post-intervention than pre-intervention. Correlates of poor BP control were black race, higher body mass index, diabetes, female gender, income, and a greater number of prescribed antihypertensive medications. CONCLUSIONS: Our findings suggest that health information technology that is implemented as part of a multicomponent quality improvement initiative can lead to improvements in HTN care and outcomes.

Qualitative evaluation to explain success of multifaceted technology-driven hypertension intervention.

OBJECTIVES: This study sought to examine the implementation of an electronic health record-based intervention to improve quality of hypertension care in community health centers. The primary goal was to use qualitative analysis to explain how different components of the intervention contributed to positive patient-level outcomes. STUDY DESIGN: Qualitative process evaluation. METHODS: The intervention included alerts, order sets, templates, clinical reminder algorithms, and provider performance feedback. Semi-structured interviews were conducted with primary care providers before (n = 16) and after (n = 16) intervention, and with key staff and leadership involved in the implementation (n = 6). The research team applied an iterative systematic qualitative coding process to identify salient themes. Several constructs from IT implementation theories guided the analysis. RESULTS: The analysis focused on: (1) satisfaction and perceived usefulness of intervention components, (2) perceived proximal changes resulting from intervention, and (3) perceived facilitators of change. Different participants found different components useful. Proximal impact manifested in multiple ways (eg, more aggressive follow-up appointments and prescribing) and in increased overall attention to hypertension. Facilitators of success included leadership, organizational culture, provider engagement, rigorous implementation process, framing of intervention as quality improvement (QI), and health center capacity to process data. CONCLUSIONS: We attribute the success of the intervention to a multifaceted approach where the combination of multiple intervention components resulted in across the-board change in hypertension care practices. In contrast with research that attempts to isolate the impact of circumscribed health information technology (HIT) tools, our experience suggests that HIT can achieve success in patient outcomes when rigorously implemented as a multifaceted intervention and framed as QI activity.