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What was the research about?

Uncontrolled blood pressure, or BP, affects tens of millions of Americans. Lowering BP to recommended levels can reduce the risk of heart attack and stroke. Support from a medical team can help patients lower their BP, but questions remain about the best way to provide care.

In this study, the research team compared two ways of providing care:

• Clinic-based care, or CBC. In this group, patients had regular, in-person visits with a doctor or medical assistant.
• Telehealth. In this group, patients received home-based and telephone care from pharmacists or nurse practitioners who had special training to manage patients’ medicines.

What were the results?

After one year, the two groups didn’t differ in how much their BP changed. Both groups had lower BP.

After six months, compared with CBC, patients in the telehealth group:

• Were more satisfied with their care
• Reported that visits by phone were more convenient

The two groups didn’t differ in their confidence in self-care or side effects from BP medicine.

Who was in the study?

The study included 3,071 patients with uncontrolled BP. All received care at one of 21 clinics in Minnesota and Wisconsin. Among patients, 69 percent were White, 19 percent were Black, 7 percent were Asian, 1 percent were American Indian/Alaska Native, and 4 percent were another race; 2 percent were Hispanic. The average age was 60, and 53 percent were women.

What did the research team do?

The research team assigned 21 clinics by chance to one of the two groups. In CBC, patients had a BP checkup with a medical assistant in the clinic within two to four weeks. Patients then had regular, in-person follow-up visits until their BP was controlled.

In the telehealth group, doctors referred patients to have a one-hour, in-person visit within two to four weeks. At the visit, patients learned how to measure their BP. Patients then measured their BP at home six times per week. Pharmacists or nurse practitioners received a report with patients’ BP every two weeks and also got alerts if BP was too high or too low. Patients had regular visits with pharmacists or nurse practitioners by phone about how to make medicine and lifestyle changes.

The research team looked at patient BP at the start of the study and again 12 months later. Patients took surveys about their care at the start of the study and again 6 months later.

Patients, doctors, and health system administrators gave input during the study.

What were the limits of the study?

In both groups, only one in three patients had their follow-up visit within two to four weeks as planned. Also, in the telehealth group, pharmacists and nurse practitioners managed patients’ care. Results may have differed if more timely follow-up visits had occurred or if doctors or nurses had managed telehealth care.

Future research could examine telehealth care managed by other clinicians.

How can people use the results?

Patients and doctors can use the results when considering ways to help manage uncontrolled BP.

Objective

To compare the effectiveness of clinic-based care (CBC) versus telehealth in lowering blood pressure (BP) in adults with uncontrolled hypertension

Study Design

This pragmatic, cluster randomized trial compared the effect of two BP care approaches on improving patients’ systolic BP.

Researchers randomized primary care clinics to one of two groups:

• Clinic-based care. Clinicians referred eligible patients for a follow-up visit with a medical assistant within two to four weeks, including BP measurement. Patients then had regular follow-up visits until their BP was controlled. Clinicians and medical assistants followed best practices for hypertension care in the clinic setting.
• Telehealth care. Clinicians referred eligible patients for a one-hour, in-person visit within two to four weeks to learn from medication therapy management (MTM) pharmacists or nurse practitioners how to measure their BP at home. Patients measured their BP at home six times per week using BP monitors that automatically sent results to their health records. Pharmacists and nurse practitioners received alerts if BP was too high or too low and summary BP data every two weeks. Patients talked with pharmacists or nurse practitioners by phone every two to four weeks about adjusting medication and making lifestyle changes until BP was within recommended levels. Pharmacists and nurse practitioners followed best practices for hypertension care during telehealth visits.

The study included 3,071 adult patients with uncontrolled hypertension who visited one of 21 clinics in Minnesota or Wisconsin. Among patients, 69% were White, 19% were Black, 7% were Asian, 1% were American Indian/Alaska Native, and 4% were another race; 2% were Hispanic. The average age was 60, and 53% were female.

Researchers observed systolic BP at baseline and 12 months later. They surveyed patients about patient-reported secondary outcomes at baseline and 6 months later.

Patients, clinicians, and health system administrators provided input throughout the study.

Results

After 12 months, patients in the two groups did not differ significantly in change in systolic BP. In both groups, patients’ BP decreased by 18 to 19 mmHg on average.

At six-month follow-up, compared with the CBC group, patients in the telehealth group had significantly higher satisfaction with their care (relative risk [RR]=1.25; 95% confidence interval [CI]: 1.02, 1.52) and lower burden in scheduling visits (RR=0.70; 95% CI: 0.55, 0.89).

At six-month follow-up, patients in the two groups did not differ significantly in their confidence in self-care or medication side effects.

Limitations

In both groups, only a third of patients received follow-up visits within two to four weeks of their assignment to care, as planned. Results may have differed if patients had received timely follow-up visits. MTM pharmacists and nurse practitioners managed patients’ care using the telehealth care approach. Results may have differed if primary care physicians or registered nurses had managed the care.

Conclusions and Relevance

In this study, the CBC and telehealth care approach safely reduced systolic BP in patients with uncontrolled hypertension. Patients were more satisfied with telehealth care and its convenience.

Future Research Needs

Future research could examine telehealth BP management by primary care physicians or registered nurses.