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The Use of Telemedicine to Improve Access and Quality Care in the VHA: Case Studies

Bosworth HB. The Use of Telemedicine to Improve Access and Quality Care in the VHA: Case Studies. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA.


Background: Hypertension affects 65 million US adults and another 45 million have above-optimal levels of blood pressure (BP) - now termed "prehypertension". Despite the rising incidence of many hypertension-related diseases, and the availability of respected evidence-based guidelines for effective pharmacologic and non pharmacologic treatments, only a third of all U.S. hypertensive patients have their BP under adequate control. Interventions delivered in patients homes may improve control. Methods: Design: A 4-arm randomized trial with 18-month follow-up. Eligible patients were randomized to one of four groups: 1) Control group - a group of hypertensive patients who receive usual primary care ; 2) Nurse-administered tailored behavioral intervention; 3) Nurse and physician-administered medication management according to a hypertension clinical decision support system (CDS); 4) combined behavioral and medication management intervention. Setting: Durham, NC VAMC primary care clinics. Patients: Of the 1542 potentially eligible patients with inadequate BP control in year prior to enrollment who met our inclusion/exclusion criteria, 593 individuals consented. The average age was 61 years (SD = 12); 49% were African American; 27% were functionally illiterate (REALM < 60). Mean baseline systolic BP was 125 mm hg (SD = 18) and diastolic BP was 71 mm hg (SD = 11). Interventions: The interventions were triggered based on home BP values transmitted via telemonitoring devices over standard telephone lines. The tailored behavioral intervention involved promoting adherence with medication and health behaviors. Patients randomized to the medication management or the combined arm had their hypertension medications managed by a study physician and nurse supported by a validated hypertension CDS that relied on evidence-based hypertension treatment guidelines individualized to patients' comorbid illnesses. Measurements: The primary outcome was changes in systolic BP measured at six-month intervals over 18 months (4 total measurements). Results: 518 (87%) completed the 18-month BP follow-up. All intervention groups improved in systolic BP at 12 months, but only the combined arm was significant -4.33 mm hg (95% -8.49 to -0.17); medication arm -2.49 mm hg, behavior -2.1 mm hg). The effect was sustained only in the combined arm at 18 months (-3.61 mm hg; 95% -8.06 to .84), but was no longer significant. Conclusions: Medication management combined with a telephone tailored-behavioral intervention resulted in modest improvements in systolic BP that declined over time. Patients' low baseline BP values, despite a clinical history of inadequate control, may have thwarted our ability to show significant changes.

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