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Effect of a Physician Uncertainty Reduction Intervention on Blood Pressure in Uncontrolled Hypertensives—A Cluster Randomized Trial

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Abstract

BACKGROUND

Clinical inertia, provider failure to appropriately intensify treatment, is a major contributor to uncontrolled blood pressure (BP). Some clinical inertia may result from physician uncertainty over the patient’s usual BP, adherence, or value of continuing efforts to control BP through lifestyle changes.

OBJECTIVE

To test the hypothesis that providing physicians with uncertainty reduction tools, including 24-h ambulatory BP monitoring, electronic bottle cap monitoring, and lifestyle assessment and counseling, will lead to improved BP control.

DESIGN

Cluster randomized trial with five intervention clinics (IC) and five usual care clinics (UCC).

SETTING

Six public and 4 private primary care clinics.

PARTICIPANTS

A total of 665 patients (63 percent African American) with uncontrolled hypertension (BP ≥140 mmHg/90 mmHg or ≥130/80 mmHg if diabetic).

INTERVENTIONS

An order form for uncertainty reduction tools was placed in the IC participants’ charts before each visit and results fed back to the provider.

OUTCOME MEASURES

Percent with controlled BP at last visit. Secondary outcome was BP changes from baseline.

RESULTS

Median follow-up time was 24 months. IC physicians intensified treatment in 81% of IC patients compared to 67% in UCC (p < 0.001); 35.0% of IC patients and 31.9% of UCC patients achieved control at the last recorded visit (p > 0.05). Multi-level mixed effects longitudinal regression modeling of SBP and DBP indicated a significant, non-linear slope difference favoring IC (p time × group interaction = 0.048 for SBP and p = 0.001 for DBP). The model-predicted difference attributable to intervention was −2.8 mmHg for both SBP and DBP by month 24, and −6.5 mmHg for both SBP and DBP by month 36.

CONCLUSIONS

The uncertainty reduction intervention did not achieve the pre-specified dichotomous outcome, but led to lower measured BP in IC patients.

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Acknowledgements

The study was funded by the National Heart Lungs and Blood Institute (1 RO1 HL078589). The sponsor did not participate in the design, analysis, or interpretation of study results.

Conflicts of Interest

Dr. Victor Simms was on the speaker panels of Novartis and Forest pharmaceuticals. These relationships were terminated at the beginning of 2011.

Author information

Authors and Affiliations

  1. Baylor College of Medicine, Houston, TX, USA

    David J. Hyman MD, Valory N. Pavlik PhD & James Pool MD

  2. Kelsey-Seybold Clinic, Houston, TX, USA

    Anthony J. Greisinger PhD

  3. UT Health Science Center at Houston, Houston, TX, USA

    Wenyaw Chan PhD & Victor Simms MD

  4. UT Health Science Center at Houston Medical School, Houston, TX, USA

    Jose Bayona MD

  5. Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA

    Valory N. Pavlik PhD

  6. Old Dominion University, Norfolk, VA, USA

    Carol Mansyur PhD

Authors
  1. David J. Hyman MD
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  2. Valory N. Pavlik PhD
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  4. Wenyaw Chan PhD
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  5. Jose Bayona MD
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  6. Carol Mansyur PhD
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  7. Victor Simms MD
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  8. James Pool MD
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Corresponding author

Correspondence to Valory N. Pavlik PhD.

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Hyman, D.J., Pavlik, V.N., Greisinger, A.J. et al. Effect of a Physician Uncertainty Reduction Intervention on Blood Pressure in Uncontrolled Hypertensives—A Cluster Randomized Trial. J GEN INTERN MED 27, 413–419 (2012). https://doi.org/10.1007/s11606-011-1888-1

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  • DOI: https://doi.org/10.1007/s11606-011-1888-1

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