Background : Clinic-based Care enrolled 1648 patients in 9 primary care clinics; Telehealth Care enrolled 1424 patient in 12 primary care clinics. Enrolled patients were, on average, 60 years old, and 53% were women. They were on a median of 2 antihypertensive medication classes. Blood pressure decreased significantly during 12 months of follow-up in both groups, from 157/93 mm Hg to 139/83 mm Hg in the Clinic-based Care patients (adjusted mean difference, ‒18/‒10 mm Hg) and 157/90 mm Hg to 139/80 mm Hg in the Telehealth Care patients (adjusted mean difference, ‒19/‒10 mm Hg). There was no significant difference in BP change between Telehealth Care and Clinic-based Care (‒0.8 mm Hg [95% CI, ‒2.84 to 1.32 mm Hg]). After 6 months of follow-up, Telehealth Care patients were significantly more likely than Clinic-based Care patients to report an increase in the frequency of home BP measurement twice or more per week vs less often (29% vs 28% at baseline, 44% vs 28% at 6 months; relative risk [RR], 1.55 [95% CI, 1.23-1.96]) and that the measurements were used to change their treatment (39% vs 40% at baseline, 57% vs 39% at 6 months; RR, 1.68 [95% CI, 1.37-2.06]). After 6 months of follow-up, patients in the Telehealth Care group were significantly more likely to rate their care more highly as 9 or 10 vs 0 through 8 (29% vs 28% at baseline, 40% vs 29% at 6 months; RR, 1.26 [95% CI, 1.07-1.47]) and were more likely to report that scheduling visits and time away from work or normal activities was not a problem for them. Although 81% of eligible patients were enrolled, reach and exposure to the interventions were limited by low rates of adherence to follow-up with the intended health care professional for BP assessment within 6 weeks: 32% in Clinic-based Care and 27% in Telehealth Care. Patient interviews showed that follow-up decisions were driven by personal health beliefs, rapport with their primary care professional (PCP), and logistical barriers. Adoption varied by PCP characteristics, with advanced practice clinicians, women, and younger PCPs more likely to enroll eligible patients. Implementation and maintenance of hypertension care best practices were similar and improved over time in all study clinics.
Conclusions : Telehealth and Clinic-based Care were similarly effective in lowering BP by 18/10 to 19/10 mm Hg. Several PROs were more favorable in the Telehealth Care group. Telehealth care that includes extended team care is an effective and safe alternative to clinic-based care for improving patient-centered care for hypertension.
Limitations : Patients and PCPs value choice in hypertension care; the research design preferentially directed Telehealth Care patients to follow up with a pharmacist and Clinic-based Care patients to follow up with a medical assistant, which limited adherence to protocol and exposure to the intended interventions : Approximately 1 in 3 American adults has hypertension. Lowering blood pressure (BP) to recommended levels has been shown to reduce the risk of future heart attacks and strokes, but fewer than half of people with hypertension have BP controlled to recommended levels. Research shows that a team approach is 1 of the most effective ways to care for patients with hypertension, but different models for organizing team-based care have not been compared directly.
Objectives : The objectives of this trial were to (1) compare the effects on BP and patient-reported outcomes (PROs) of 2 models of team-based care for uncontrolled hypertension (aim 1) and (2) study how the interventions were implemented in the real-world setting of a large health system (aim 2).
Methods : The design was a pragmatic, cluster-randomized trial comparing 2 interventions in adult patients with uncontrolled, moderately severe hypertension (BP ≥ 150/95 mm Hg at the 2 most recent office visits). The study population was drawn from patients cared for in 21 representative primary care clinics at HealthPartners, a large, integrated health care system. The interventions were (1) Clinic-based Care, which used recommended best practices and relied primarily on the physician-medical assistant duo and face-to face visits, and (2) Telehealth Care, which was adapted from a previously tested program. Telehealth Care included Clinic-based Care best practices but added home BP telemonitoring and home-based telehealth care coordinated by a clinical pharmacist or nurse practitioner. The primary outcome was change in systolic BP over 12 months. Secondary outcomes were change in PROs over 6 months, including medication side effects, experiences with hypertension care, self-monitoring rates, and confidence in self-care. Patient partners contributed extensively to the selection of the primary and secondary outcomes. Outcomes were collected over 24 months: PROs were measured by surveys, while BP and other clinical outcomes were ascertained from electronic health record data. Aim 1 hypotheses were tested by random coefficients models. Outcomes were estimated as a function of treatment group, follow-up time, and treatment by time. Treatment response heterogeneity was assessed by comparing the treatment by time effect between prespecified patient subgroups: age, race/ethnicity, socioeconomic status, and comorbidity. The aim 2 analysis evaluated reach, adoption, implementation, and maintenance of the 2 interventions using a mixed-methods approach supported by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.
Results