Study Shows Sustained Improvement in Hypertension with Intervention Combining Behavioral and Medication Management

BACKGROUND:
The clinical and economic benefits of self-management (SM) interventions for the treatment of high blood pressure (BP) have been demonstrated in research studies, but whether these benefits persist after the trial has concluded remains largely untested. This study examined clinical and economic outcomes 18 months after completion of an 18-month hypertension SM randomized trial (conducted between 5/06 and 7/09) of 591 Veterans with hypertension who received treatment at one VAMC. The original trial evaluated three telephone-based interventions through a four-group design: 1) nurse-administered, physician-directed medication management intervention; 2) nurse-administered, behavioral management intervention; 3) combined behavioral management and medication management intervention; and 4) usual care. Investigators in the current study used modeling estimates to compare clinical and economic outcome trends between Veterans in the four groups 12 months before the intervention began, over the 18 months during the trial, and 18 months after the trial was completed. The primary clinical outcome from the original and follow-up study was BP control (≤140/90mmHg for patients without diabetes; ≤130/80mmHg for patients with diabetes). The secondary outcome was systolic BP.

FINDINGS:

• An intervention combining behavioral and medication management significantly improved BP control among Veterans with hypertension during an 18-month trial compared to usual care, and these improvements were sustained 18 months after trial completion, particularly for Veterans who had inadequate BP control at baseline.
• Eighteen months after trial completion, a statistically significant higher proportion of Veterans in the behavioral intervention (17%), the medication management intervention (20%), and the combined intervention (20%) had estimated BP improvements compared to usual care.
• Among Veterans with inadequate baseline BP control, estimated mean systolic BP was significantly lower in the combined intervention as compared to usual care during and after the 18-month trial.
• At baseline, at the end of the study, and at 18 months after study completion, the estimated probability of hospital admission was similar for Veterans in all four study groups. Estimated mean outpatient expenditures and estimated total expenditures also were similar for Veterans in the 18 months during the trial and the 18 months after trial completion.

LIMITATIONS:

• Study sample included Veterans at only one VAMC, so may not be generalizable to other Veterans.

AUTHOR/FUNDING INFORMATION:
This study was funded through VA/HSR&D's Quality Enhancement Research Initiative (QUERI; RRP 09-407); the original trial was funded through HSR&D (IIR 04-426); and Drs. Maciejewski and Bosworth are supported by HSR&D Research Career Scientist Awards. Drs. Maciejewski, Bosworth, and Olsen are part of HSR&D's Center for Health Services Research in Primary Care located in Durham, NC.

Maciejewski M, Bosworth H, Olsen M, et al. Do the Benefits of Participation in a Hypertension Self-Management Trial Persist after Patients Resume Usual Care? Circulation: Cardiovascular Quality and Outcomes March 2014;7(2):269-75.