hypertension self-management: the use of telemedicine as an intervention tool hayden bosworth, ph.d....
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Hypertension Hypertension Self-management: The use Self-management: The use
of Telemedicine as an of Telemedicine as an Intervention ToolIntervention ToolHayden Bosworth, Ph.D. Hayden Bosworth, Ph.D.
Center for Health Services Research in Center for Health Services Research in Primary Care, Durham VA Medical CenterPrimary Care, Durham VA Medical Center
Departments of Medicine, Psychiatry and Departments of Medicine, Psychiatry and School of NursingSchool of Nursing
Duke University Medical CenterDuke University Medical Center
Outline
Prevalence and Impact of Hypertension Chronic Disease Self-management: Barriers
and Facilitators Translation Studies
– Veterans Study to Improve The Control of Hypertension
(V-STITCH)– Hypertension Intervention Telemedicine Study (HINTS)
Take Home Messages Future Directions
Prevalence of HypertensionPrevalence of Hypertension
1 in 3 adult Americans 1 in 3 adult Americans
~ 65 million Americans ~ 65 million Americans ((JAMAJAMA 2003) 2003)
– ~45 million prehypertensive~45 million prehypertensive
~ 8 million veterans (37%) ~ 8 million veterans (37%) ((Med Care Res Rev 2003Med Care Res Rev 2003))
Lifetime risk for normotensive 55 Lifetime risk for normotensive 55 year old: 90% year old: 90% (JAMA (JAMA
2003)2003)
Hypertension Treatment FactsHypertension Treatment Facts
Life Style Matters– Weight Loss (any means)– DASH Diet– Low Na Diet– Exercise– Limited Alcohol
Medications Work– Nothing Better Than Thiazide Diuretics– Most Patients Require > 2 medications
Goal of HypertensionGoal of HypertensionSelf-management Self-management
Hypertension as a Model for Hypertension as a Model for Self-managementSelf-management
Complex, long-term, chronic diseaseComplex, long-term, chronic diseaseRequires initiation and maintenance Requires initiation and maintenance
of multiple behaviorsof multiple behaviorsRequires provider/patient Requires provider/patient
communicationcommunication
Significance of Self-management Significance of Self-management AdherenceAdherence
>80% of adults took at least 1 medication in the last week; 25% took at least five
Cost of medication non-adherence >$100 billion/year
~50% of patients non-adherent with medication
Rates of non-adherence higher in lifestyle recommendations
~50% of treatment failures are due to unrecognized patient non-adherence
Traditional Paradigms FailTraditional Paradigms Fail
clinical trial information alone does not result in adequate BP control
Specialist-based care not solutionPrimary care clinic based
management is not sufficient– Frequent contact with doctors in clinics
does not lead to BP control
Disease Management Disease Management Hypertension: EvidenceHypertension: Evidence
Cochrane review (2006)– 59 trials
• Reduces SBP (8-10 mm Hg))• Reduces DBP (4-7 mm Hg)• Improves all cause mortality
– Self-monitoring alone (17 trials)• Reduces DBP by 2 mm Hg
Health Decision Health Decision ModelModel
Social EnvironmentSocial Environment
TREATMENT ADHERENCE TREATMENT ADHERENCE
Provider CharacteristicsProvider Characteristics
Communication Communication StyleStyle
Medical EnvironmentMedical Environment
Bosworth HB, Olsen MK, Oddone EZ. Bosworth HB, Olsen MK, Oddone EZ. (2006). Am Heart J 149:795-803.l(2006). Am Heart J 149:795-803.lBosworth HB & Oddone EZ. (2002). Bosworth HB & Oddone EZ. (2002). J Nat Med Ass. 94; 236-248J Nat Med Ass. 94; 236-248
LiteracyLiteracy
PerceivedPerceived RisksRisks
Patient CharacteristicsPatient Characteristics
Coping & Coping & StressStress
Side EffectsSide EffectsComorbiditiesComorbidities
DepressionDepressionMental HealthMental Health
CognitionCognition Medication Medication RegimenRegimen
Treatment Treatment Guidelines Guidelines AdherenceAdherence
Intensity of Intensity of TherapyTherapy
BLOOD PRESSURE CONTROL BLOOD PRESSURE CONTROL
PolicyPolicy
Patient Characteristics RelatedPatient Characteristics Relatedto Self-managementto Self-management
1.1. Risk Perceptions / KnowledgeRisk Perceptions / Knowledge
2.2. Cognition Cognition • MemoryMemory• Inductive ReasoningInductive Reasoning• Verbal ComprehensionVerbal Comprehension
3.3. Literacy / NumeracyLiteracy / Numeracy
4.4. Coping / Stress Coping / Stress • AvoidanceAvoidance• Daily hassleDaily hassle• StigmaStigma
Patient Characteristics RelatedPatient Characteristics Relatedto Self-managementto Self-management
5.5. ComorbiditiesComorbidities
6.6. Medication Side EffectsMedication Side Effects
7.7. Depression/mental healthDepression/mental health
Social Characteristics RelatedSocial Characteristics Relatedto Self-managementto Self-management
1.1. Social NetworkSocial Network
2.2. Social SupportSocial Support• Tangible/instrumentalTangible/instrumental• EmotionalEmotional
3.3. CultureCulture
Medical Environment Related Medical Environment Related to Self-managementto Self-management
Access and BarriersAccess and Barriers
1.1. Insurance (i.e., co-payments, deductibles)Insurance (i.e., co-payments, deductibles)
2.2. TransportationTransportation
3.3. Organization and staffingOrganization and staffing
Provider Characteristics Related Provider Characteristics Related to Self-managementto Self-management
1.1. Evidence-based Guideline Evidence-based Guideline ComplianceCompliance
• Medication ComplexityMedication Complexity
• Medication IntensityMedication Intensity
2.2. Provider CommunicationProvider Communication
Provider Factors: Clinical Provider Factors: Clinical InertiaInertia
Failure of providers to initiate or intensify therapy when indicated
Reasons:– Overestimation of care provided– “Soft” reasons to avoid intensification– Lack of education, training or practice
organization – Lack of belief of efficacy
Phillips, et al. Ann Intern Med; 2001
Issues in Patient-Provider Issues in Patient-Provider CommunicationCommunication
Poor patient-physician communication is common– Physicians do >60% of talking during a visit
• Instrumental and biomedically focused• Rarely address psychosocial issues
– ~50% of the time physicians do not name the medicine or give dosing instructions
– Many patients reluctant to express• Expectations or medication preferences • Misunderstandings about the regimen
Poor patient-provider communication may contribute to health disparities in minority populations
How do you translate this How do you translate this information into an intervention? information into an intervention?
Veterans Study to Improve TheVeterans Study to Improve The
Control of HypertensionControl of Hypertension
VA Health Services ResearchVA Health Services Research
Investigator Initiated Award, 2001-06Investigator Initiated Award, 2001-06
The V-STITCH StudyThe V-STITCH Study
The V-STITCH The V-STITCH StudyStudy
A randomized controlled trial testing two A randomized controlled trial testing two interventions designed to improve BP controlinterventions designed to improve BP control
– Patient Intervention: Self-ManagementPatient Intervention: Self-Management
– Provider Intervention: Decision Support Provider Intervention: Decision Support
Durham VAMC General Medicine ClinicsDurham VAMC General Medicine Clinics
Patients with hypertension on medicationsPatients with hypertension on medications
24 month intervention and follow-up24 month intervention and follow-up
The V-STITCH Study The V-STITCH Study DesignDesign
Providers RandomlyAssigned (clusters)
R 1
ProviderIntervention
Provider Reminder
PatientIntervention
N = 150
PatientUsual Care
N = 151
PatientIntervention
N = 144
PatientUsual Care
N = 143
R 2 R 2
Patient Patient InterventionIntervention
Patient Patient InterventionIntervention
1.1. Hypertension KnowledgeHypertension Knowledge• African AmericanAfrican American• DiabetesDiabetes• Family historyFamily history
2.2. LiteracyLiteracy
3.3. MemoryMemory
4.4. Patient’s Relationship with Primary Care ProviderPatient’s Relationship with Primary Care Provider
5.5. Social SupportSocial Support
6.6. Side EffectsSide Effects
7.7. Lifestyle Factors (smoking, alcohol, exercise, diet, Lifestyle Factors (smoking, alcohol, exercise, diet, stress)stress)
8.8. Missed AppointmentsMissed Appointments
9.9. Pill RefillPill Refill
Tailored Behavioral Delivered via TelephoneTailored Behavioral Delivered via Telephone
Patient Patient InterventionIntervention
1st & 13th months Physician Interaction, Memory, Literacy, Side effects
3rd & 15th months Hypertension knowledge, Memory, Literacy, Side effects, Missed appointments, Pill refills
5th & 17th months Lifestyle, Memory, Literacy, Side effects, Missed appointments, Pill refills
7th & 19th months Social Support, Memory, Literacy, Side effects, Missed appointments, Pill Refills
9th & 21st months Physician Interaction, Memory, Literacy, Side effects, Missed appointments, Pill Refills
11th & 23rd months Memory, Literacy, Side effects, Missed appointments, Pill Refills
Any month Patient initiated
Frequency of Nurse-base calls
Patient Patient InterventionIntervention
Use of TelephoneUse of Telephone Telephone contact has been shown to be Telephone contact has been shown to be
effective in changing patient behavior effective in changing patient behavior ((Am J Am J HypertensHypertens 1996, 1996, Am J Prev MedAm J Prev Med 2002) 2002)
Allow reaching more patientsAllow reaching more patients Tend to be more acceptable and Tend to be more acceptable and
convenient than in-person interventions.convenient than in-person interventions. Most U.S. homes have phones (>97%) – Most U.S. homes have phones (>97%) –
useful tool to deliver an intervention useful tool to deliver an intervention (U.S. (U.S. Bureau of Census, 2003)Bureau of Census, 2003)
May enhance the interventions’ cost-May enhance the interventions’ cost-effectiveness, due to reduced intervention effectiveness, due to reduced intervention costs and reduced visit rates.costs and reduced visit rates.
Mode of AdministrationMode of Administration
Provider Provider InterventionIntervention
Displayed at point-of-care
Summarized the hypertension-relevant information from clinical record
Individualized for the patient
Educated as well as reminded Displayed reasons / explanations
Provided continuous quality improvement - quarterly
Automated Treatment for Automated Treatment for Hypertension:Hypertension:
EvideNce-based Advice (ATHENA)EvideNce-based Advice (ATHENA)
ATHENA: BP - Prescription ATHENA: BP - Prescription GraphsGraphs
Displayed patient's most recent BPDisplayed patient's most recent BP
Displayed patient’s current antihypertensive Displayed patient’s current antihypertensive drug regimendrug regimen
Provided opportunity to update BP Provided opportunity to update BP
Offered no advisories or recommendations Offered no advisories or recommendations for medication managementfor medication management
Simply a reminder for hypertensionSimply a reminder for hypertension
Provider Control GroupProvider Control Group
Primary Care Providers Primary Care Providers
24 Attending Physicians24 Attending Physicians 6 Physician Assistants6 Physician Assistants 2 Registered Nurse Practioners2 Registered Nurse Practioners
17 intervention providers received full 17 intervention providers received full decision support tailored to specific decision support tailored to specific patientpatient
15 control providers received display 15 control providers received display with most recent BPwith most recent BP
Patient Identification Patient Identification
816 816 Contacted either by Contacted either by
Telephone or In-personTelephone or In-person
588 588 EnrolledEnrolled • 76% participation 76% participation raterate
190 190 RefusedRefused
3838 Excluded Excluded
• Hospitalized last 3 months Hospitalized last 3 months • Dementia diagnosisDementia diagnosis• Resident in nursing home Resident in nursing home • Severely impaired hearing Severely impaired hearing or speech or speech
4017 4017 ICD code for Hypertension ICD code for Hypertension
Hypertensive MedicationHypertensive MedicationEnrolled Durham VAEnrolled Durham VA
• 85% 24 month 85% 24 month retention rateretention rate
Patient CharacteristicsPatient Characteristics (N=588)(N=588)
MaleMale 98%98%
Mean ageMean age 63 years 63 years (21-87)(21-87)
MarriedMarried 68%68%
Live aloneLive alone 22%22%
WhiteWhite 57%57%
African AmericanAfrican American 40%40%
High school or lessHigh school or less 51%51%
Inadequate incomeInadequate income 23%23%
Patient Patient CharacteristicsCharacteristics
Taking BP meds for > 5 yearsTaking BP meds for > 5 years 64%64%
Close relative with hypertensionClose relative with hypertension
65%65%
No exerciseNo exercise 44%44%
SmokeSmoke 30%30%
DiabeticDiabetic 40%40%
BP in control at Baseline:BP in control at Baseline:42%42%< 130 / 85 mm/Hg diabetic< 130 / 85 mm/Hg diabetic< 140 / 90 mm/Hg non-diabetic < 140 / 90 mm/Hg non-diabetic
Mean Systolic BP 138.4 (SD=18)Mean Systolic BP 138.4 (SD=18)Mean Diastolic BP 75.5 (SD=11)Mean Diastolic BP 75.5 (SD=11)
Primary OutcomePrimary OutcomeBlood pressure control at every primary Blood pressure control at every primary care provider clinic visit over 24 monthscare provider clinic visit over 24 months
time in weekstime in weeks
bp
co
ntr
ol
bp
co
ntr
ol
00 1010 2020 3030 4040 5050 6060
nono
yesyes
patient 1patient 1
time in weekstime in weeks
bp
co
ntr
ol
bp
co
ntr
ol
00 1010 2020 3030 4040 5050 6060
nono
yesyes
patient 2patient 2
time in weekstime in weeks
bp
co
ntr
ol
bp
co
ntr
ol
00 1010 2020 3030 4040 5050 6060
nono
yesyes
patient 3patient 3
time in weekstime in weeks
bp
co
ntr
ol
bp
co
ntr
ol
00 1010 2020 3030 4040 5050 6060
nono
yesyes
patient 4patient 4
Time in Months
BP
Co
ntr
ol
0.2
0.3
0.4
0.5
0.6
0.7
0 6 12 18 24
Blood Pressure Control RatesPrimary Analysis
ReminderReminder N=143N=143
BehavioralBehavioral N=144N=144
Decision Decision SupportSupport N=151N=151
CombinedCombined N=150N=150
Time Effect: P=.01 Group*Time Effect: P=.11
Nurse Behavioral Intervention vs. NoneNurse Behavioral Intervention vs. NoneSecondary AnalysisSecondary Analysis
Time in MonthsTime in Months
BP
Co
ntr
ol
BP
Co
ntr
ol
0.40
0.40
0.50
0.50
0.60
0.60
0.70
0.70
00 66 1212 1818 2424
RN BehavioralRN BehavioralN=294N=294
No RNNo RNN=294N=294
P=0.03P=0.03
Compliance with Nurse Compliance with Nurse Telephone InterventionTelephone Intervention
Patients completing all 12 scheduled study calls: 85%
Average length of call:
3 minutes (SD 2.5 min)
Primary Care VisitsPrimary Care VisitsDuring Study (24 During Study (24
Months)Months)
Mean SD
Usual Care 7.7 4.7
Behavior only 7.3 3.6
Decision Support
7.4 3.6
Combined 7.1 3.5
Two-Year Outpatient CostsTwo-Year Outpatient Costs
Cost Category Total cost Average cost per Subject
Behavioral intervention (n=294)
$2,863,775 $9,741
Non-Behavioral
(N=294)
$2,822,215 $9,599
Average Behavioral Intervention Average Behavioral Intervention Costs Per Patient over 24 monthsCosts Per Patient over 24 months
Cost Category
Patients Overseen by Nurse
Number of Patients
1120 840 560
Direct Costs/per patient
$70
($61-81)
$94
($82-$109)
$141
($123-$163)
Average min/per patient
15 20 30
Provider Intervention Provider Intervention ResultsResults
ATHENA displayed at 68% of visits ATHENA displayed at 68% of visits (929/1370)(929/1370)
• Among displayed, providers Among displayed, providers interacted with intervention 57% of interacted with intervention 57% of time (38.5% overall)time (38.5% overall)
• 54% BP control when provider 54% BP control when provider interacted versus 45% when provider interacted versus 45% when provider did not interactdid not interact
Provider Intervention Provider Intervention ResultsResults
Most common reasons for Most common reasons for disregarding recommendationsdisregarding recommendations
• 68% inadequate BP control 68% inadequate BP control due to med non-adherencedue to med non-adherence
• 68% concern that an 68% concern that an inaccurate BP reading was used inaccurate BP reading was used to generate recommendationsto generate recommendations
• 46% insufficient time46% insufficient time
SummarSummaryy
Brief telephone intervention improved Brief telephone intervention improved BP control by 21% at 24 monthsBP control by 21% at 24 months
• 12.6% improvement compared to the 12.6% improvement compared to the non-behavioral groupnon-behavioral group
No increase in clinic utilizationNo increase in clinic utilization
Cost effectiveCost effective
Computer Decision Support did not Computer Decision Support did not significantly improve BP control rates at significantly improve BP control rates at 24 months24 months
Next Next StudyStudy
How can we overcome provider How can we overcome provider inertia with a stronger medication inertia with a stronger medication management intervention?management intervention?
Focus intensive interventions on Focus intensive interventions on those at greater risk (i.e., out of those at greater risk (i.e., out of control)control)
Can we monitor and treat blood Can we monitor and treat blood pressure outside of clinic? pressure outside of clinic?
Hypertension Intervention Hypertension Intervention
Telemedicine StudyTelemedicine Study((HINTS)HINTS)
Department of Veterans Affairs, Grant IIR 04-426 (2005-2008)
Established Investigator Award, American Heart Association (2006-2011)
Hypertension Intervention Nurse Hypertension Intervention Nurse
Telemedicine Study (HINTS)Telemedicine Study (HINTS)600 primary care veterans with poor BP 600 primary care veterans with poor BP
control control
Home BP tele-monitoring used to Home BP tele-monitoring used to activate interventionsactivate interventions
Nurse-administered via telephone for Nurse-administered via telephone for 18 months18 months
HINTS Study: DesignFour Group DesignFour Group Design
Usual CareUsual Care PCP drive management, no special programPCP drive management, no special program
Tailored Behavioral Phone InterventionTailored Behavioral Phone Intervention Home BP monitoring evaluated by nurseHome BP monitoring evaluated by nurse Tailored behavioral modulesTailored behavioral modules
Medication Management (ATHENA) Phone InterventionMedication Management (ATHENA) Phone Intervention Home BP monitoring evaluated by nurseHome BP monitoring evaluated by nurse Medication management implemented by study MD/RNMedication management implemented by study MD/RN
Combined InterventionCombined Intervention Home BP monitoring evaluated by nurseHome BP monitoring evaluated by nurse Medication management/tailored behavioral modulesMedication management/tailored behavioral modules
Why BP Monitors as Interventions?Why BP Monitors as Interventions?
• Improve BP controlImprove BP control
• Self-monitoring programs are used in Self-monitoring programs are used in clinical practice to assist PCP in treating clinical practice to assist PCP in treating their patientstheir patients
• Encourage patients to monitor their Encourage patients to monitor their diseasedisease
• Provide objective information to Provide objective information to motivate patients to control their health motivate patients to control their health conditioncondition
Case for TelemedicineCase for Telemedicine
Effective use of home BP monitoring Effective use of home BP monitoring improve hypertension outcomes improve hypertension outcomes
Treating at home may avert visits and Treating at home may avert visits and result in better BP controlresult in better BP control
Alternative way to integrate home BP Alternative way to integrate home BP monitoring into primary caremonitoring into primary care
HINTS Study: Telemedicine
Baseline Patient CharacteristicsBaseline Patient Characteristics
546 subjects enrolled546 subjects enrolled
MinorityMinority 51%51%
Low LiterateLow Literate 38%38%
DiabeticDiabetic 44%44%
MalesMales 98%98%
Summary of Summary of InterventionIntervention
• Safety alert activatedSafety alert activated
(2 values within 12 hours (2 values within 12 hours >175 systolic, >105 diastolic,
pulse <40 or >110)
144 times, 51 unique pts144 times, 51 unique pts• Intervention activatedIntervention activated
687 times, 241 unique pts687 times, 241 unique pts• Praise alert activatedPraise alert activated
74 times, 68 unique pts74 times, 68 unique pts
Summary of Summary of InterventionIntervention
• Technicals activatedTechnicals activated
634 times, 220 unique pts634 times, 220 unique pts
7% Did not understand how to set up or 7% Did not understand how to set up or
use equipmentuse equipment
66% nonadherence66% nonadherence
27% technical problems with equipment27% technical problems with equipment
Home Readings: Console ViewHome Readings: Console View
RN:MD Dialogue for Medication RN:MD Dialogue for Medication ChangeChange
OutcomeOutcomess
BP control BP control – 0, 6, 12, 18 months0, 6, 12, 18 months
Health-related quality of life (SF-12)Health-related quality of life (SF-12) Hypertension knowledgeHypertension knowledge Adherence to hypertension regimen Adherence to hypertension regimen Cost-effectiveness of both interventionsCost-effectiveness of both interventions
Summary Summary
Need to considerNeed to consider• Alternative methods of implementing Alternative methods of implementing
interventionsinterventions
• Telemedicine not panacea for allTelemedicine not panacea for all
• Cost of implementing interventionsCost of implementing interventions
• Methods of reimbursementMethods of reimbursement
• Not just initiating, but maintaining Not just initiating, but maintaining multiple health behaviorsmultiple health behaviors
• Both patient/provider and possibly Both patient/provider and possibly systemsystem
RecommendationsRecommendations
• Self-management adherence-enhancing strategies Self-management adherence-enhancing strategies need to occur:need to occur:
Introduction of treatmentIntroduction of treatmentLater in the course (remediation)Later in the course (remediation)Maintenance (less attention) Maintenance (less attention)
• Strategies include:Strategies include:
•Social SupportSocial Support•Educational InterventionsEducational Interventions (written and/or verbal (written and/or verbal
instructions delivered individually, group,instructions delivered individually, group,telephone, or audiovisually) telephone, or audiovisually)
•Behavioral StrategiesBehavioral Strategies (self-monitoring, positive (self-monitoring, positive reinforcement, goal setting, cueing, reinforcement, goal setting, cueing,
chaining)chaining)
RecommendationsRecommendations
Educational InterventionsEducational Interventions
• Knowledge alone will not change behavior Knowledge alone will not change behavior
• Establish what is known before offering new Establish what is known before offering new knowledge knowledge
• Use concrete examplesUse concrete examples
RecommendationsRecommendations
Ways of Presenting Written InformationWays of Presenting Written Information
• Instructions should be clear and structuredInstructions should be clear and structured
• Picture charts, color-coded medication Picture charts, color-coded medication schedules and large print schedules and large print
RecommendationsRecommendations
Behavioral InterventionsBehavioral Interventions
Strategies include:Strategies include:
• Developing prompts and reminder systemsDeveloping prompts and reminder systems
• Identifying a potential relapse into old behaviorIdentifying a potential relapse into old behavior
• Setting appropriate and realistic goalsSetting appropriate and realistic goals
• Simplifying regimens to once or twice dailySimplifying regimens to once or twice daily
•Use opportunities to model behaviorUse opportunities to model behavior
•Reinforce positive behaviorsReinforce positive behaviors
RecommendationsRecommendations
Clinical IssuesClinical Issues
• Key validated question “Have you missed any Key validated question “Have you missed any pills in the past week?” pills in the past week?”
Sensitivity > 50% of those with low adherenceSensitivity > 50% of those with low adherence Specificity of 87%Specificity of 87%
• Common misperceptions should be anticipated Common misperceptions should be anticipated and avoided and avoided
i.e., medication can be stopped when the i.e., medication can be stopped when the prescription runs out or symptoms are guides to prescription runs out or symptoms are guides to
when to take the medicationwhen to take the medication
RecommendationsRecommendations
Clinical Issues (continued)Clinical Issues (continued)
• Missing appointments is correlated with Missing appointments is correlated with lower adherence rates - first sign of dropping lower adherence rates - first sign of dropping out of care entirely, the most severe form of out of care entirely, the most severe form of nonadherence. nonadherence.
• Telephone or appointment reminders provide Telephone or appointment reminders provide relatively easy method to overcome relatively easy method to overcome nonadherence.nonadherence.
RecommendationsRecommendations
Effective, Effective, collaborativecollaborative provider- provider-patient communication should be the patient communication should be the foundation of all clinical interventions foundation of all clinical interventions designed to improve patient self-designed to improve patient self-management.management.
Future Directions & Future Directions & ConclusionsConclusions
Examining tailoring of intervention mode to needs and intensity of intervention (Stepped level care)
Disseminating and sustaining interventions in the community
Expanding behavioral interventions to multiple chronic diseases
Translating evidence into practice
Acknowledgements
Research Team
Alice Neary Melinda Orr Maren OlsenMike Harrelson Felicia McCant Kelly DealPam Gentry Laura Svetkey Mary GoldsteinRowena Dolor Tara Dudley Laurie MarbreyMartha Adams Shelby Reed Santanu DattaLaurie Leeson Anthony Goodin Gwen McKoyCourtney Van Houtven Ben Powers Cindy RoseSharon Hooker Tina Hong David SimelJanet Grubber
Relevant Publications1.1. Bosworth HB, Olsen MK, McCant F, et al. Hypertension Intervention Bosworth HB, Olsen MK, McCant F, et al. Hypertension Intervention
Nurse Telemedicine Nurse Telemedicine Study (HINTS). Study (HINTS). Am Heart JAm Heart J 2007;153(6):918-24. 2007;153(6):918-24.2. Bosworth HB, Olsen MK, Goldstein MK, et al. The veterans' study to 2. Bosworth HB, Olsen MK, Goldstein MK, et al. The veterans' study to
improve the control improve the control of hypertension (V-STITCH): design and methodology. of hypertension (V-STITCH): design and methodology. Contemp Clin TrialsContemp Clin Trials
2005;26:155-68.2005;26:155-68.3. Chan AS, Coleman RW, Martins SB, et al. Evaluating provider adherence 3. Chan AS, Coleman RW, Martins SB, et al. Evaluating provider adherence
in a trial of a in a trial of a guideline-based decision support system for hypertension. guideline-based decision support system for hypertension. MedinfoMedinfo
2004;11(Pt 1):125-9.2004;11(Pt 1):125-9.4. Goldstein MK, Coleman RW, Tu SW, et al. Translating research into 4. Goldstein MK, Coleman RW, Tu SW, et al. Translating research into
practice: practice: organizational issues in implementing automated decision support for organizational issues in implementing automated decision support for
hypertension in hypertension in three medical centers. three medical centers. J Am Med Inform AssocJ Am Med Inform Assoc 2004;11(5):368-76. 2004;11(5):368-76.5. Goldstein MK, Hoffman BB, Coleman RW, et al. Implementing clinical 5. Goldstein MK, Hoffman BB, Coleman RW, et al. Implementing clinical
practice guidelines practice guidelines while taking account of changing evidence. while taking account of changing evidence. Proc AMIA SympProc AMIA Symp 2000:300-4. 2000:300-4.6. Goldstein MK, Hoffman BB, Coleman RW, et al. Patient safety in 6. Goldstein MK, Hoffman BB, Coleman RW, et al. Patient safety in
guideline-based decision guideline-based decision support for hypertension management: ATHENA DSS. support for hypertension management: ATHENA DSS. Proc AMIA SympProc AMIA Symp
2001:214-8.2001:214-8.
Relevant Publications7. Lin ND, Martins SB, Chan AS, et al. Identifying barriers to hypertension 7. Lin ND, Martins SB, Chan AS, et al. Identifying barriers to hypertension
guideline guideline adherence using clinician feedback at the point of care. adherence using clinician feedback at the point of care. AMIA Annu Symp AMIA Annu Symp
ProcProc 2006:494-8. 2006:494-8.8. Bosworth HB, Oddone EZ. Telemedicine and Hypertension. 8. Bosworth HB, Oddone EZ. Telemedicine and Hypertension. J Clin J Clin
Outcomes ManagementOutcomes Management 2004;11(8):517-522. 2004;11(8):517-522.9. Bosworth HB, Oddone EZ, Weinberger M. Patient treatment adherence: 9. Bosworth HB, Oddone EZ, Weinberger M. Patient treatment adherence:
ConceptsConceptsinterventions, and measurement. Mahwah, NJ: Lawrence Erlbaum interventions, and measurement. Mahwah, NJ: Lawrence Erlbaum
Associates, 2006.Associates, 2006.10. Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood 10. Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood
pressure control: pressure control: potential explanatory factors. potential explanatory factors. Am J MedAm J Med 2006;119(1):70. 2006;119(1):70.11. Bosworth HB, Oddone EZ. A model of psychosocial and cultural 11. Bosworth HB, Oddone EZ. A model of psychosocial and cultural
antecedents of antecedents of blood pressure control. blood pressure control. Journal of the National Medical AssociationJournal of the National Medical Association
2002;94:236-248.2002;94:236-248.12. Bosworth HB, Olsen MK, Gentry P, et al. Nurse administered telephone 12. Bosworth HB, Olsen MK, Gentry P, et al. Nurse administered telephone
intervention for intervention for blood pressure control. blood pressure control. Patient Educ Couns Patient Educ Couns 2005;57(1):5-14.2005;57(1):5-14.13. Bosworth HB, Olsen MK, Oddone EZ. Improving blood pressure control 13. Bosworth HB, Olsen MK, Oddone EZ. Improving blood pressure control
by tailored by tailored feedback to patients and clinicians. feedback to patients and clinicians. Am Heart JAm Heart J 2005;149(5):795-803. 2005;149(5):795-803.