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Collaborative Management of Hypertension Results in Greater Control of BP

Authors

Tori Socha

Sixty-five million people in the United States have hypertension, putting them at increased risk for stroke, myocardial infarction, and heart failure. Among patients with hypertension, blood pressure (BP) control is below national targets. Researchers have hypothesized that the lack of effective BP control is due to barriers such as access to care and clinical inertia, rather than to a lack of effective antihypertensive medications. Previous studies have found that comanagement of BP by a pharmacist and a physician improves office BPs. Researchers recently conducted a trial to assess the effect of a comanagement model on 24-hour ambulatory BP. They reported results of the current study in Archives of Internal Medicine [2010;170(18):1634-1639]. The current trial was a prospective, cluster-randomized controlled clinical trial that included 179 patients with uncontrolled hypertension from 5 primary care clinics in Iowa City, Iowa. Inclusion criteria were age 28 to 85 years, treatment with 0 to 3 antihypertensive agents with no changes in regimen in the previous 4 weeks, and clinic systolic blood pressure (SBP) value between 145 and 179 mm Hg or a diastolic blood pressure (DBP) of 95 to 109 mm Hg (for patients without diabetes) or clinic SBP readings of 135 to 179 mm Hg or DBP readings of 85 to 109 mm Hg (for patients with diabetes). Exclusion criteria included serious renal or hepatic disease and recent myocardial infarction or stroke, or New York Heart Association class III or IV congestive heart failure. Patients were randomized to an intervention group (n=101) or a control group (n=78). Those in the intervention group received pharmacist–physician collaborative hypertension management for more than 9 months. Those in the control group received usual care for the 9-month study period. Of the 179 patients enrolled, 10 from the control group and 9 from the intervention group withdrew from the study. At baseline, 24 ambulatory BP profiles were obtained for 100 patients in the intervention group and 75 in the control group. At the conclusion of the study, ambulatory BP data were collected for 92 patients in the intervention group and 64 in the control group. Mean age was 59.6 years for the intervention group and 61.9 for the control group. In the control group, 7.7% of patients had a history of coronary artery bypass grafting, compared with 1.1% in the intervention group (P=.04). There were no other significant differences between the 2 groups. At the end of the study, the mean number of antihypertensive medications increased from 1.4 to 2.4 in the intervention group and from 1.4 to 1.9 in the control group (P<.01 for the comparison). In the intervention group, mean office SBP decreased by 28.9 mm Hg, compared with a decrease of 17.3 mm Hg in the control group (P<.001 for the between-group difference). The reductions in SBP were significantly greater in the intervention group compared with the control group for daytime, nighttime, and overall 24-hour period (both groups began the study with similar BP readings). In the intervention group, the overall 24-hour mean SBP was reduced from 135.5 mm Hg to 121.4 mm Hg, compared with a reduction in the control group from 136.0 mm Hg to 130.5 mm Hg (P<.001 for intervention vs control). At baseline, the percentages of patients at goal for BP control were similar. At the end of the 9-month study period, a greater percentage of patients in the intervention group had their BP controlled as defined by overall 24-hour ambulatory BP monitoring, compared with the control group (75.0% vs 50.7%; P<.001). In conclusion, the researchers summarized their findings by stating that “pharmacist-physician collaborative management of hypertension achieved consistent and significantly greater reduction in 24-hour BP and a high rate of BP control.”

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