— Drug info sheets alone raised BP, adding nurse-led education didn't help
A medication management intervention not only failed to improve the adherence of hypertensive patients to their complex medication regimens, but also left their blood pressure worse off, a trial showed.
At Chicago federally-qualified health centers that were randomized to provide hypertensive patients medication management tools delivered through an electronic health record (EHR) for a year -- namely medication review sheets at visit check-in and medication information sheets printed after visits -- systolic blood pressures averaged 3.6 mm Hg higher at 12 months than seen with usual care at similar centers (P=0.03).
Centers randomized to provide EHR tools plus nurse-led education interventions for a year (given after office visits and by telephone every 3-6 months) reduced systolic blood pressures by a non-significant 2.0 mm Hg at 12 months versus the usual care group, Stephen Persell, MD, MPH, of Northwestern University in Chicago, and colleagues reported online in JAMA Internal Medicine
Where EHR-alone and EHR-plus-education interventions did show a benefit was in hypertension medication reconciliation, though only patients that got the nurse-led education intervention showed better understanding of medication instructions and dosing than did the usual care arm at 1 year.
Importantly, neither intervention improved hypertension medication adherence or knowledge of chronic drug indications, Persell and colleagues found.
"Even with the combined intervention, self-administration errors, medication discrepancies, and incomplete adherence were common, leaving much room for improvement," they said.
It is possible that the interventions didn't work for the most part because they were "too low intensity," the authors suggested. The patients didn't receive more intensive treatment just because of the EHR- and nurse-based interventions; nurse educators were "focused on reducing medication errors and improving self-management" instead.
Nurses also weren't able to engage participants as frequently as intended. Among those assigned to the education intervention, 30.9% had only one session and 13.3% had none. Additionally, office visits were required for exposure to the EHR tools
such that people who rarely visited these clinics were unlikely to be influenced by the interventions, according to the investigators.
What was "unexpected," however, was that the group receiving EHR tools alone ended up with higher blood pressure, Persell's group said.
"We speculate that medication information sheets (which contain some information on adverse drug effects) may have led some patients to stop or reduce antihypertensive therapy," they suggested. "This unexpected finding highlights the importance of testing system-level changes and checking for unintended effects."
The study randomized 12 federally qualified health centers in Chicago to EHR-based medication management, EHR-based tools plus nurse-led education, or usual care. All centers used the same EHR system, EpicCare.
Persell and colleagues originally wanted 1,260 patients enrolled and ended up with 794, leaving them underpowered to detect a 4-mm Hg difference in systolic blood pressure.
The individuals they managed to recruit were English-speaking patients with hypertension who said they were on three or more medications of any kind. It was a group that was two-thirds women and 87.2% black, with a mean age of 52.7 years.
The study was supported by a grant from the National Institute of Nursing Research.
Persell reported receiving unrelated research support from Omron Healthcare and previously receiving unrelated research support from Pfizer.
JAMA Internal Medicine
Source Reference: Persell SD, et al "Effect of electronic health record-based medication support and nurse-led medication therapy management on hypertension and medication self-management: a randomized clinical trial" JAMA Intern Med 2018; DOI: 10.1001/jamainternmed.2018.2372.
Read the original article on Medpage Today: Hypertension Program Backfires at Community Clinics