AJH 2004; 17:921–927

Nurse Management for Hypertension

A Systems Approach
Peter Rudd, Nancy Houston Miller, Judy Kaufman, Helena C. Kraemer,
Albert Bandura, George Greenwald, and Robert F. Debusk

Background: Standard office-based approaches to UC: 14.2 ⫾ 18.1 versus 5.7 ⫾ 18.7 mm Hg systolic (P ⬍
controlling hypertension show limited success. Such sub- .01) and 6.5 ⫾ 10.0 versus 3.4 ⫾ 7.9 mm Hg diastolic,
optimal hypertension control reflects in part the absence of respectively (P ⬍ .05). At 6 months, we observed one or
both an infrastructure for patient education and frequent, more changes in drug therapy in 97% of INT patients
regular blood pressure (BP) monitoring. We tested the versus 43% of UC patients, and 70% of INT patients
efficacy of a physician-directed, nurse-managed, home- received two or more drugs versus 46% of UC. Average
based system for hypertension management with standard- daily adherence to medication, measured by electronic
ized algorithms to modulate drug therapy, based on drug event monitors, was superior among INT subjects
patients’ reports of home BP. (mean ⫾ SD, 80.5% ⫾ 23.0%) than among UC subjects
(69.2 ⫾ 31.1%; t113 ⫽ 2.199, P ⫽ .03). There were no
Methods: We randomized outpatients requiring drug
significant adverse drug reactions in either group.
therapy for hypertension according to the Joint National
Committee on Prevention, Detection, Evaluation, and Conclusions: Telephone-mediated nurse management
Treatment of High Blood Pressure (JNC VI) criteria to can successfully address many of the systems-related and
receive usual medical care only (UC, n ⫽ 76) or usual care patient-related issues that limit pharmacotherapeutic effec-
plus nurse care management intervention (INT, n ⫽ 74) tiveness for hypertension. Am J Hypertens 2004;17:
over a 6-month period. 921–927 © 2004 American Journal of Hypertension, Ltd.
Results: Patients receiving INT achieved greater reduc- Key Words: Hypertension, nurse management, home-
tions in office BP values at 6 months than those receiving based management.

T
he control of blood pressure (BP) remains a major evaluate, and refine systems for guiding individual and
challenge in clinical practice. Only half of those groups of patients. Specialized hypertension clinics staffed
individuals with hypertension receive the diagno- by nurses have shown significant improvements in hyper-
sis, and only half of these achieve BP goals established by tension control compared with usual care.4 – 6 The present
the Joint National Committee on Prevention, Detection, study extends the model of nurse management to home-
Evaluation and Treatment of High Blood Pressure (JNC based treatment.
VI) and other scientific organizations.1,2 Contributing fac-
tors for the failure to achieve goal BP cluster as patient
related, provider related, and system related. Patient fac- Methods
tors include medication side effects, drug regimen com- Study Population
plexity, and unawareness of the need for long term We conducted a randomized controlled trial in which
therapy.3 Physician-linked issues may involve timely ac- patients received either usual care alone (UC) or usual care
cess to relevant clinical data, ignorance of evidence-based supplemented by nurse management for hypertension
management guidelines, and sense of nonaccountability (INT). For initial screening purposes we defined hyperten-
for patient outcomes. The system-related factors reflect sion as BP ⱖ140 mm Hg systolic or ⱖ90 mm Hg diastolic,
little if any attention or resources to design, implement, recorded in the medical record at least once in the previous

Received February 8, 2004. First decision June 2, 2004. Accepted June Supported by a grant to Stanford University from CorSolutions, Inc.
3, 2004. (Buffalo Grove, IL).
From Department of Medicine, Stanford University (PR, NHM, JK,
HCK, AB, RFDB), Stanford, California, and Urgent Care Department, Address correspondence and reprint requests to Dr. Robert F. De-
Kaiser Permanente Medical Care Program (GG), Mountain View, Cali- Busk, Stanford Cardiac Rehabilitation Program, 780 Welch Road, Suite
fornia. 106, Palo Alto, CA 94304-5735; e-mail: debusk@stanford.edu.

© 2004 by the American Journal of Hypertension, Ltd. 0895-7061/04/$30.00
Published by Elsevier Inc. doi:10.1016/j.amjhyper.2004.06.006

Every 2 weeks. The calls averaged 10 min in duration. During Baseline BP Measurement phone contacts. Stanford University Medical Center in California. Printed materials ex- drug therapy. the nurse increased drug dosage to the maximal level recommended for each drug The same research staff implemented the same protocol for or added one or more additional drugs in accordance with screening and enrollment of patients at each of two par. Patients recorded BP twice-daily at the same times each nine. Sampling The nurse care manager implemented a management al- We screened a total of 1580 patients. a the BP device to the nurse care manager. 2. display of BP values. and patients confirmed their ability for hypertension: 150 mm Hg systolic. the nurse made no further changes in drug therapy.8. These measurements guided day. glucose. the medication dosage and any problems experienced since nurse care manager measured BP with a mercury sphyg. and potassium. 17. or both. on two screening visits conducted on separate days at least Changes in drug therapy were categorized as either an 1 week apart. creati. the device puter-generated assignment. or a family history of premature cardiovascular The nurse care manager conducted baseline counseling on disease or target organ damage. age ⬎60 Nurse Management Protocol years. zero mercury sphygmomanometer. According to JNC VI intervention (INT) patients’ correct use of the automated criteria. (UA 751. We used the same semiautomated portable device to mea- lish their medical eligibility and willingness to participate sure BP at home and during each clinic visits. BP readings achieved this treatment goal. taken 5 min later. 10 6 months. the nurse asked INT patients about each During the baseline clinic visit. we chose a treatment Hg systolic or 95 mm Hg diastolic. We ended with 150 goal of 130/85 mm Hg. who used these research assistant blinded to group assignment measured BP data to guide drug therapy. 95 mm Hg dia- to operate the BP device. regular return of the automatically printed BP greater than 140 to 159 mm Hg systolic and/or 90 to 99 reports. the previous contact. We identified patients by physician referral or review of med- ical records. CA). subjects permission to initiate any new BP drug but did not contact needed the mean of two BP values to be ⱖ150/95 mm Hg physicians regarding changes in medication dosage. clinic BP and interviewed patients about medications In addition. The nurse initiated follow up stolic. and BP measurements. to The nurse care manager contacted physicians to obtain establish the mean baseline BP. patients mailed the values printed by drug therapy. Milpitas. specified by the JNC VI or had major medical comorbid. From prior studies. finding 743 (47%) gorithm based on patients’ current medications. and diastolic pressures are approx- mean baseline BP values below the criterion of 150 mm imately 5 mm Hg less. patients had to be eligible for hypertensive taken since the previous visit. drug therapy according to JNC VI criteria. NO. A&D. and recogni- mm Hg diastolic are considered eligible for BP lowering tion of potential drug side effects. systolic pressures measured at ity. validated with a random After establishing eligibility. patients gave written in. All patients provided baseline generated a printed report of up to 14 measurements. At 3 and 6 months after randomization. At the end of each week. The project cardiologist consulted by phone ticipating medical clinics.10 provided a digital formed consent and underwent randomization using com. Research staff telephoned patients to estab. The nurse also encouraged patients to momanometer using the arm with the higher reading as the telephone anytime during regular hours with questions or “reference” arm for all subsequent BP recordings. laboratory who were ineligible because they lacked the risk factors values. Patients received a postcard indicating their Measurements of BP physician’s knowledge of the study and inviting study participation. This device in the study. dyslipidemia. the protocol. nurse used a second BP measurement. as measured with the home BP patients.922 HOME-BASED MANAGEMENT OF HYPERTENSION AJH–October 2004 –VOL. and 84 (5%) had measured in the office. and 4 months. phone contacts at 1 week and at 1. An additional 603 (40%) either could not be contacted home generally run about 10 mm Hg lower than those or refused participation after contact. or 40 min in all.2 Clinical risk criteria assessed the presence of coronary risk factors (smoking. tips for enhancing drug adherence. We adopted a more stringent BP threshold tended this instruction. or diabetes mellitus). for device over a 2-week period. For study entry. When ⬍80% of mea- Recruitment and Randomization surements met this criterion. measurements of nonfasting blood urea nitrogen. increase (a drug added or dose of drug increased) or as a decrease (a drug withdrawn or dose of drug decreased).9 When 80% of the home randomization. the Kaiser Permanente Moun- with the nurse care manager about problematic cases as tain View Clinic and the Primary Care Clinics of the needed. . before randomization. representing 10% of the screened population.7 Accordingly. The concerns. or a history of drug treatment for hypertension.2 only patients with elevation of BP to levels BP device.

based on the JNC VI report. mean ⫾ SD) 60 ⫾ 9 59 ⫾ 10 The Stanford University institutional review board re. Results Patterns of BP Population Characteristics The UC and INT groups displayed similar patterns of The two patient samples. nificant changes among UC patients. Five of the eight dropouts in the UC group mm Hg in the intervention group (95% CI ⫺8. high educational status. Patients in both College degree 31 27 groups received instruction in the use of the electronic Postdoctoral degree 22 27 drug event monitor (eDEM. 55% had elevation of systolic pressure sociodemographic and clinical characteristics. systolic BP fell by 14. * P ⬍ . continued participation. Sex After the 6-month clinic visit. were pooled (Table 1). The level of experienced difficulty in using the BP device and declined significance was a two-sided probability value of P ⬍ .3.01) and diastolic BP cept for higher rates of married status and dyslipidemia (F212 ⫽ 6. which were performed by Some college 23 24 study staff blinded to group assignment.05 by ␹2 analysis. A total of 13 patients (9%).AJH–October 2004 –VOL. Two of the INT patients ence to medication with the Student t test.2 age.05. three moved out of the area.5 dropouts. We performed secondary analyses moved out of the area. At 3.01) among INT patients but nonsig- among usual care patients.and 6-month clinic visits. Age (y.01).22.12 to dispense the BP medication used most fre. frequency of drug changes. diastolic BP fell by 6. The usual care only (UC) and 5.1) . P ⬍ usual care plus nurse care management intervention (INT) .8 to ⫺4. Patients were typically of middle Between baseline and 6 months. nometer. the 6-month follow-up visit. project staff Retired 32 32 Other 6 8 downloaded the data from the electronic drug event mon- Coronary risk factors (%) itor but provided no feedback on drug adherence to pa. White 72 76 tients randomized to nurse management received portable African American 8 11 BP monitors. the remainder declined to return for of BP medication. exhibited similar stolic pressure. One-way ANOVA confirmed significant decreases in randomization successfully produced similar groups ex. Only pa. Dyslipidemia* 30 16 tients. Divorced 8 15 Usual care patients in both groups continued to receive Separated 2 5 the routine care that they had received before the study. and modest rates of cardio. Study Population Before the study. 10 HOME-BASED MANAGEMENT OF HYPERTENSION 923 Physician Review of Protocol Table 1. Occupational status (%) Full time 51 49 CA).2 to ⫺1. Union City. Each monitor contained a microchip in the pill bottle Part time 7 7 lid11. NO. so data only.30. mm Hg in the INT group (95% CI ⫺18.0) and by vascular comorbidities. representative of hypertensive baseline BP: 36% had elevation of both systolic and dia- patients in the two participating clinics. all physicians received a Female (% of total) 56 50 final report of their patients’ medications and BP values. P ⬍ . The primary statistical analysis was a two-sam- ple t test comparing the change in BP measured between baseline and 6 months. and adher. changes in office-based systolic BP. Marital status* (%) Married 80 60 viewed and approved the project protocol. the investigators met with the medical Usual Inter- staffs at the two sites to discuss the study protocol and Care vention management algorithm. physicians. Figure 1 depicts eight in the UC group and five in the intervention group. and 9% had elevation of diastolic pressure only.1 to ⫺10. both systolic (F212 ⫽ 17. 17. No Widowed 4 3 attempt was made to alter the frequency of office visits or Single 6 17 Ethnicity (%) any other aspect of doctor-patient interactions. Current smoker 2 4 Diabetes 14 14 Statistical Analysis Family history of CAD 18 22 CAD 4 8 The primary outcome measure was change in BP from Cerebrovascular Disease 5 10 baseline to 6-month visit. or nurse care managers. AARDEX-USA. did not return for the 6-month visit and were classified as Between baseline and 6 months.7 mm Hg in the UC group (95% CI ⫺10. considering both systolic and CAD ⫽ coronary artery disease.2 that (n ⴝ 76) (n ⴝ 74) were used by the nurse care manager for INT patients. Asian American 4 4 Hispanic 8 1 Other 8 8 Patient Monitoring Educational status (%) Patients in both groups returned to the clinic at 3 and 6 Some high school 5 5 High school graduate 19 17 months for BP measurements. diastolic BP and using a wall-mounted clinic sphygmoma. Disabled or unemployed 4 4 quently. P ⬍ .

1.05).3 to ⫺1. .4 mm Hg in the UC group (95% CI of ⫺5. Figure 2 depicts changes in office-based diastolic manometer during clinic visits averaged 1 to 2 mm Hg BP. 90 88 86 Diastolic Blood Pressure (mm Hg) 84 DBP INT 82 DBP UC 80 * 78 76 74 Baseline 3 month 6 month FIG. Change in office-based diastolic blood pressure (DBP). Blood pressure measured with the mercury sphygmo- P ⬍ . 10 160 155 Systolic Blood Pressure (mm Hg) 150 SBP INT 145 SBP UC * 140 135 130 Baseline 3 month 6 month FIG. 2.5. UC ⫽ usual care only. Change in office-based systolic blood pressure (SBP). and 3. higher than that measured with the semiautomated device.924 HOME-BASED MANAGEMENT OF HYPERTENSION AJH–October 2004 –VOL. UC ⫽ usual care only. 17. INT ⫽ usual care plus nurse care management intervention. NO. INT ⫽ usual care plus nurse care management intervention.

P ⬍ . the rate of patients report- ing changes in drug therapy was more than doubled (97%) FIG. among INT and UC subjects (P ⬍ . The maximal dose of each individual medication was similar Discussion in the two groups. were taking no BP medications (NS).AJH–October 2004 –VOL. statistical significance.13 Pill-taking adherence by the electronic drug event monitor remained high in both groups but reached statistically higher levels among INT subjects. Figure 3 summarizes differences between office versus home-based systolic BP.01). In this randomized controlled trial. and the progressive medication adjustment contributed to the su- perior INT outcomes. tively. Similarly. P ⫽ . At baseline. 20%. The variety of antihypertensive medications. changes among INT patients arose from scheduled phone contacts. The INT subjects performed Medication Adherence most scheduled home BP measurements (range 89% to Drug adherence. In contrast. and 15% at the three assessment points.0% (mean ⫾ SD.1% (25th and 75th percentile values 50% to 93%.01). ␤ -blockers. Less than mm Hg lower than that measured with the same device 5% of treatment decisions made by the nurse care manager during clinic visits. no con- sistent standards for antihypertensive management. The number of medication changes (mean ⫾ SD) reported by UC patients was 52 ⫾ 1 (mean 0. The distribution of medications re- proved superior in BP control to standard office-based management among eligible hypertensive patients by JNC VI criteria. 17. respec. The INT patients noted 223 ⫾ 6 medication using the semiautomated device was approximately 10 changes (mean 2. INT In both groups. Most hypertension management studies reflect ambula- tory settings. The INT patients’ rate of daily adherence during the 6-month study period was 80. The proportion respective adherence rates were 82% ⫾ 28% and 75% ⫾ of patients reporting two or more drugs at 6 months was 27% for once-daily dosing and 69% ⫾ 34% and 49% ⫾ 70% and 46%. Ber- . the proportion of patients reporting no INT and UC groups.14 –16 Inauspicious characteristics include large numbers of patients. Most therapy vention patients only. with 25th and 75th percentile values Patients in both INT and UC groups reported similar 77% to 95%). The greater variety of BP drugs. None of these differences reached drug therapy at 6 months was 4% and 22%. physician-directed. Pattern of medication use. Among UC patients.199. mostly initiated during office visits. Systolic and diastolic BP measured at home fell monitor. the average rapidly during the first 3 months of the study and remained number of days on which patients took the correct number relatively constant through month 6. assessed daily adherence (that is.2% numbers of BP medications at baseline. we found that home- Figure 4 summarizes the pattern of medication use in based.03). The size of achieved reductions in systolic and diastolic BP approximate those reported for intensive in- terventions in other trials. ing patients rarely telephoned the nurse care manager. nurse-guided drug therapy the study subjects. respectively. By 6 months. diuretics. 10 HOME-BASED MANAGEMENT OF HYPERTENSION 925 mained similar in both groups at baseline and at 3 and 6 months. 25%. Participat- the 6 months of the study. once-daily regimens yielded higher patients had significantly increased the number and daily adherence rates than for more frequent dosing. providers’ nonaccountability for clinical outcomes.69 changes/ Blood pressure measured at home over a 2-week period patient). 41% for twice-daily or more than twice-daily dosing in the tients. and FIG. of doses as prescribed). diverse comorbidities. NO. among those receiving nurse management. and calcium blockers approximated respectively 40%.5% ⫾ Antihypertensive Medications 23. whereas the rate of UC patients was 69. 22% of intervention patients and 30% of UC patients t113 ⫽ 2. Office versus home-based systolic blood pressure: inter. ⫾ 31. 3.97 changes/patient. This pattern was consistent throughout required telephone discussion with a physician. 4. tracked by the electronic drug event 94%). 43% reported one or more changes in drug ther- apy during the 6-month study period. among INT and UC pa. the greater proportion of patients on antihypertensive therapy. The proportion of patients taking angiotensin- converting enzyme inhibitors.

when the number of home determinations is factory control. Detection. Blumenthal participating patients. the par. Results from the Third National Health and Nutrition self-regulation when most needed rather than at fixed Examination Survey. cation no. The core fea- 1. and management of fail to implement consistent and optimally effective guide- side effects.16:906 –913. offered more confi. priate antihypertensive therapies.23 The behavioral model reflects self-regulation. Second. Dennison CR. tion. patients’ measurement and reporting of home BP. The present study provides a successful example of mov- odic phone contacts. com. Labarthe D: Prevalence of hypertension in the US adult knowledge. given the larger recruitment pool.21 The accuracy of clinic measurements may suffer the value of collaboration among teams of health profes- from nonstandardized measurement and brief sampling. it reduces the need for sphygmomanometer. more than four times the number of drug changes than UC Medical measurement devices for home use will soon patients and usually achieved control in less than 3 months. and corrective population.7 In the present management protocols. cepted by physicians in both managed care settings (Kai. and terventions contingent on the progress being made. Evaluation. RS. These technological innovations do not home-based intervention.20. the management system reliable alternative to office BP measurement19 and sug. INT patients underwent cardiologist. Third. clinical guidelines. Levine DM. Over the 6-month trial. tension at the work site. therapy. . Campbell WP. Individual clinicians— clinical guidelines (JNC VI2) to define entry criteria. Han HR. Miller NH: Compliance with treatment regimens in chronic asymp- modulation of drug therapy by standardized protocol. Kim MT. and tomatic diseases.293:65– 68. By sociodemographic characteristics. and distraction by unrelated medical Several implications emerge for optimizing future an- priorities. Bone LR. 17. values and responsive changes in drug therapy. Achber C. 10 lowitz et al14 reported that physicians defer changing drug ticipants represent an affluent and well educated cohort. Higgins M. 98-4080). The study inescapably includes some limitations. intervals. dence about central tendency with day-to-day BP The present care management system facilitates and fluctuations. evaluating comorbid risk factors and to prescribing appro- monly ⬎300 measurements in all. Joint National Committee on Prevention. NO. Haynes RB: Work- site treatment of hypertension by specially trained nurses—a con- ser) and fee-for-service academic settings (Stanford). Burt VL. Clinical inertia will likely The nurse management system in this study addressed continue in the absence of efforts toward standardization some of the relevant obstacles. Roccella EJ. as in JNC VI. 2. the management system reinforces large. monitoring. Evaluation. and skilled—may still ment goals. Post WS: Hypertension care and control may be atypical in their willingness or ability to monitor in underserved urban African American men: behavioral and phys- home BP. critical appraisal. encourages physicians to focus their energies on problem gests that it provides a more representative indicator of BP cases.22 The theoretical underpinning for the current study comes from social cognitive theory. Lancet 1979. and Treatment of High Blood Pressure (JNC VI). even when BP remain elevated: “clinical inertia” The two clinical facilities are typical of similar settings. Alderman MH. systematic phone contacts. goal setting. 5. These results approximate those of Mehos et al permit guidance via the Internet similar to nurse-mediated applying pharmacists’ regulation of BP medications in a case management. Schoenbaum EF: Detection and treatment of hyper- the management system was readily understood and ac. By peri. Roary MC. Whelton P. sionals. Hypertension 1995. physicians to mediate the routine tasks of managing anti- This study supports using home BP measurement as a hypertensive therapy. treat. the nurse managers made timely ing from general guidelines. self-monitoring. knowledgeable. It closely linked ongoing surveillance of BP lines of diagnosis. Cutler JA. trolled trial. enabling patients to differ. The system used external and accountability for outcomes.102:43– 49. and treatment adjustment. however devoted. to an opera- medication changes. tures of effective self-regulation of health habits include Horan MJ. iologic outcomes at 36 months. Brown C. Despite its relative complexity. Hill MN. expands the reach and scope of traditional health care by mated clinic BP with both portable device and mercury three interdependent means.18 diminish the need for physicians’ active involvement in Most prior studies of home BP measurement reported the creation. US Dept of Health and Human management system as a whole rather than the relative Services. Am J Med 1997.17 tihypertensive management. Logan AG. 4. ignorance of established even if not representative of all primary care practices.926 HOME-BASED MANAGEMENT OF HYPERTENSION AJH–October 2004 –VOL. The 6. Formal study of such hypertension case manage- Training patients can standardize BP measurement19 and ment will likely confirm its cost-effectiveness. N Engl J Med 1973. from infrequent assessments.25:305–313.153:1175–1178. adjusting treatment intensity as tional protocol for nurses working with a consultant needed. Home BP determinations closely approxi. First.24 minimize so-called white coat effects. Treatment of High Blood Pressure: The Sixth Report of the Joint This study assessed the efficacy of the home-based National Committee on Detection. Milne BJ. preferred medications. 1988 –1991. References entially select health promoting behaviors. Physicians will remain vital to study. Ongoing interactivity permits adjustment of in. 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