Technology-supported apprenticeship in the management of hypertension
According to the National Center for Disease Control and Prevention 30% of the American adult population has a diagnosis of hypertension. Of these 52%, or approximately 35 million adults are uncontrolled. The cost of managing this care is estimated at 47.5 billion a year and rising1.
A growing body of research indicates that patients can greatly reduce or prevent chronic diseases through education and behavioral changes2. New models of disease management include the use of primary care based certified Nurse Coaches to partner with patients in establishing and reaching goals set by patients3. This relationship focuses on empowering the patient toward the achievement of maximizing their health and creating self-efficacy. Barriers to the success of such models include the general lack of information technology tools that allow adequate communication within an appropriate span of time.
This study investigates the effectiveness of the remote (home-base) use of a software platform for collaborative hypertension management coupled with Nurse Coaching in controlling hypertension. The primary outcomes evaluated were: the achievement of blood pressure to goal, patient experience, and cost effectiveness.
At the Ambulatory Practice of the Future, a primary care practice at Massachusetts General Hospital in Boston, MA, patients were recruited into a 3month, IRB-approved randomized controlled trial. All patients had a diagnosis of uncontrolled hypertension (HTN) and were on no more than one medication. Subjects were randomized to either a control group, that received standard Nurse Coach care through office visits, virtual (phone) appointments, or email messaging; or to an intervention group that utilized a collaborative HTN management software platform (Collaborhythm) along with a Nurse Coach. The intervention group was provided with electronic mobile tablets loaded with the Collaborhythm application and a blood pressure cuff that wirelessly connected to the software. All subjects had a thirty minute orientation office visit upon recruitment. In contrast to the control group, patients in the intervention group tracked their pressures and medication adherence daily. This information, along with any individual lifestyle changes, were collected and shared remotely with the Nurse Coach. Unlike the control group, patients in the intervention group were limited only to remote care visits around the management of their hypertension throughout this 12 week trial.
42 of the 44 subjects completed the study. Intervention subjects achieved a greater decrease in SBP at 12 weeks than control subjects (26.3mmHG vs 16.0 mmHg, p=0.009). A greater percentage of patients in the intervention group achieved a goal SBP < 130mmHg (80.0% vs 45.5%, p=0.03), and rated a higher scale of satisfaction with their care (8.9 vs 7.6 out of 10, p=0.12). Intervention patients required more nurse coaching time than controls (0.85 hours vs 0.57 hours, p=0.15), but this corresponded to less than 1/5 of the clinician cost of standard care ($42.50 vs $248) for optimal outcomes (100% < 140/90 at 3 months).
Technology-supported nurse coaching may serve as a new, cost-effective paradigm in the management of hypertension. The success of this trial warrants its study of scalability (across larger populations) as well as its use across a broader spectrum of chronic disease management.
1. “Recent Trends in the Prevalence of High Blood Pressure and its Treatment and Control,” National Center for Health Statistics, Hyattsville,Maryland,2010.
2. Synderman R, Dinan MA. Improving Health by Taking It Personally. JAMA 2010;303(4):363-364.
3. Margolius D, Bodenheimer T. Controlling Hypertension Requires a New Primary Care Model. AM J Manag Care. 2010;16(9):648-650.