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Care management shows benefits

A recent study could provide a look into the future of care management.

Rather than using the regular call center–based care management program, “Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control,” published in the June 25 Journal of American Medical Association, analyzed a program delivered through secure Web communication and found that the program improved BP in hypertension patients.

The study involved more than 700 hypertension patients in the Group Health plan in Seattle who did not have a comorbidity such as diabetes or heart failure.

The results found that a Web-based care program nearly doubled the percentage of hypertension patients whose BP was controlled.

“Those with the most severe hypertension had such significant drops to their blood pressure,” says Beverly Green, MD, MPH, a family physician and investigator at Group Health who coauthored the study.

“They had more room to go, but it was pretty dramatic. It made me think … that there are just things that are falling through the cracks that are not hard to fix if you’re paying attention,” she adds.

The study outcomes showed that:

Web-based pharmacist care, in addition to home BP monitoring and Web training, resulted in 25% more patients with controlled BP than the control group and 20% more patients with controlled BP compared to the home BP monitoring and Web training–only group.

The home BP monitoring and Web training–only group had a significant improvement and a modest reduction in systolic BP.

Compared to the usual care group, the home BP monitoring and Web training plus pharmacist care group was 1.8 times more likely to control its BP. Those in the home BP monitoring and Web training group were 1.2 times more likely to control their BP than the usual care group.

Improvements in the number of classes of antihypertensive medications, aspirin use, body mass index, physical activity, health-related quality of life, satisfaction with the health plan, and use of the healthcare services from baseline until the 12-month follow-up.

For more results, see the charts on MDM pp. 2–3 of the PDF of this issue.

“Our study findings support previous research that demonstrates encouraging patients to participate more actively in their own care, combined with care management, including assisted patient review of paper medical records, leads to improved health outcomes. Our intervention extends this work by connecting patients and care managers through a shared [electronic medical record (EMR)] over the Web. In our study, providing home BP monitors and Web training alone did not significantly improve BP control, despite trends in that direction,” the study authors wrote.

Green says having a Web connection to patients is important because much of the day-to-day care for chronic conditions, such as hypertension, is done at home. “The Web is a very convenient way to provide support that is required for self-management and also for improving care,” she says.

Green says researchers tackled the issue of hypertension because it is one of the most common diagnoses at primary care visits. In fact, almost one in three U.S. adults has hypertension, which is considered a sustained systolic and diastolic BP of 140 and 90 mm Hg or higher, respectively, according to the study.

Successful strategies to lower BP include educating patients and encouraging self-monitoring or adding a healthcare team member to focus on hypertension. The Group Health program took the plan’s existing EMRs and secure patient Web site so patients could view portions of their medical record, access healthcare services, and communicate with their healthcare team online, according to the study.

The study authors noted that a Web-based solution to the hypertension epidemic could be successful because more than 75% of U.S. adults have Internet access, most people want to use that technology to contact physicians and receive laboratory results, and the at-home system allows physicians to measure BP longitudinally. Self-monitored BP devices are accurate and less expensive than usual care and provide direct feedback for hypertension patients, according to the study.

Existing Web portal

Green says the program used an existing Group Health Web portal, and the hypertension program encouraged more care coordination between the patient and the care team. “The pharmacists were the glue to make sure that happened,” says Green, adding that Group Health’s pharmacists already perform some care management roles.

Adding pharmacist care to the program “allowed the Chronic Care Model to be integrated with further increases in securing messaging, more antihypertensive medical classes being added, and larger reductions in both systolic and diastolic BP,” according to the study.

The Chronic Care Model uses seven domains: self-management, clinical information systems, delivery system redesign, decision support, healthcare organization, community resources, and care partnership support.

“We believe the pharmacists were successful because they provided planned care to a defined population, consistently applied stepped medical protocols, and used comprehensive information systems, a patient-shared EMR, and Web communications to collaborate with patients and their physicians,” according to the study. Pharmacists communicated with the patients’ physicians at the start of the program and then only if there was a clinical concern. Program organizers wanted to limit the amount of communication with physicians because they are already bombarded with information, says Green.

Care management through the Internet will become more common as more people become accustomed to computers, Green says. “Once patients are used to it and they use the Internet, they seem to adapt very quickly. I have been amazed at some patients I thought would never expect to be able to use it,” she says.

Green says people living with chronic disease find health Web access helpful for their daily care. “Why shouldn’t it be part of medical care? It’s just a natural thing that needs to happen because it does improve care. We know it and this has helped prove it,” says Green.

The study’s coauthors acknowledged there were limitations to the study, most notably that the hypertension patients needed Internet and e-mail access. The researchers are going to investigate how factors such as not having computer skills played into the results, Green says, adding that she thinks computer barrier issues will subside.

“That won’t be a problem in a few years because middle-age people who are already using it at work will be 65 pretty soon,” says Green about the computer literacy of baby boomers.

Patients separated into three groups

“Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control,” published in the June 25 Journal of American Medical Association, is the first large randomized controlled trial to test the use of care management over the Web and the first randomized controlled trial that applied the Chronic Care Model to hypertension.

The patients in the trial were from 10 medical centers within Seattle-based Group Health, which provides coverage and care to more than 540,000 residents of Washington state and Idaho. Patients were separated into the following three groups:

Usual care

Training for home BP monitoring and patient Web site

Home BP monitoring and Web training plus pharmacist care intervention

All patients were given access to an electronic medical record (EMR) and patient Web site at the beginning of the study. Group Health’s Web services allow patients to refill medications, make appointments, view portions of their EMR (which includes laboratory results, immunizations, current health conditions, and medications), and communicate with members of the healthcare team. After the first randomization, the people assigned to the usual care group were told their BP was not under control and encouraged to speak with their physicians to improve the numbers. Patients received the following additional interventions depending on their group:

Patient training for home BP monitoring and Web site. Patients were given a home BP monitor, trained on its use, and told to check their BP at least two days per week and enter the numbers into their online record. They were also trained on how to use the Web site, including using its secure e-mail, refilling medications, viewing portions of the medical record, and finding links to resources for lifestyle and behavioral change.

Patient training for home BP monitoring and Web training plus pharmacist care intervention. Patients in this group were assigned a Group Health pharmacist to assist with team-based care management activities, including collaborating with the patient’s physician. After an initial phone call to obtain a detailed medical history, the pharmacists and patients with high BP communicated every two weeks via the EMR until the BP was under control. The pharmacists also received two half days of additional training on evidence-based care of hypertension, medical protocols, and patient-centered techniques for addressing behavioral issues related to adherence and lifestyle change.