Nurse-led disease management for hypertension control in a diverse urban community: a randomized trial

Abstract

Background: Treated but uncontrolled hypertension is highly prevalent in African American and Hispanic communities.

Objective: To test the effectiveness on blood pressure of home blood pressure monitors alone or in combination with follow-up by a nurse manager.

Design: Randomized controlled effectiveness trial.

Patients: Four hundred and sixteen African American or Hispanic patients with a history of uncontrolled hypertension. Patients with blood pressure ≥150/95, or ≥140/85 for patients with diabetes or renal disease, at enrollment were recruited from one community clinic and four hospital outpatient clinics in East and Central Harlem, New York City.

Intervention: Patients were randomized to receive usual care or a home blood pressure monitor plus one in-person counseling session and 9 months of telephone follow-up with a registered nurse. During the trial, the home monitor alone arm was added.

Main measures: Change in systolic and diastolic blood pressure at 9 and 18 months.

Key results: Changes from baseline to 9 months in systolic blood pressure relative to usual care was -7.0 mm Hg (Confidence Interval [CI], -13.4 to -0.6) in the nurse management plus home blood pressure monitor arm, and +1.1 mm Hg (95% CI, -5.5 to 7.8) in the home blood pressure monitor only arm. No statistically significant differences in systolic blood pressure were observed among treatment arms at 18 months. No statistically significant improvements in diastolic blood pressure were found across treatment arms at 9 or 18 months. Changes in prescribing practices did not explain the decrease in blood pressure in the nurse management arm.

Conclusions: A nurse management intervention combining an in-person visit, periodic phone calls, and home blood pressure monitoring over 9 months was associated with a statistically significant reduction in systolic, but not diastolic, blood pressure compared to usual care in a high risk population. Home blood pressure monitoring alone was no more effective than usual care.

Figure 1.

Study flow chart. Legend: Patients were recruited in three phases. In the first, recruitment was restricted to usual care and nurse management arms. In the second, the home blood pressure monitor arm was added and patients were recruited to all three arms. After the 120th patient was assigned to the nurse management arm, the third phase was initiated in which all subsequent patients were randomized to either the home blood pressure monitor arm or usual care group.

Figure 2.

Systolic blood pressure at baseline, 9 and 18 months for patients in the usual care and nurse management groups (top panel) and usual care versus home BP monitor groups (bottom panel), by whether the blood pressure improved or worsened between baseline and 9 months. Lighter lines represent individual blood pressures at baseline, 9 and 18 months. Darker lines represent group mean blood pressures at those months.

Figure 3.

Percentage of patients who had changes in medication prescribed from baseline to termination of intervention at 9 months, usual care versus intervention groups. Legend: none.