# Presentation: 645347

## Hypertension Self-management: The use of Telemedicine as an Intervention ToolHayden Bosworth, Ph.D. Center for Health Services Research in Primary Care, Durham VA Medical CenterDepartments of Medicine, Psychiatry and School of NursingDuke University Medical Center

**Notes:**
Thank Morris et al

## Outline

- <date/time>

**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 Hypertension

- <date/time>

**Prevalence of Hypertension**

**1 in 3 adult Americans **
**~ 65 million Americans ****(*****JAMA***** 2003)**** **
**~45 million prehypertensive**
**~ 8 million veterans (37%) ****(*****Med Care Res Rev 2003*****)**
** ****Lifetime risk for normotensive 55 year old:    90% ****	****	****	****	****(JAMA 2003)**

## Hypertension 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**

**Notes:**
Low fat, high fruits/vegetables, and fiber

## Goal of Hypertension

**Goal of Hypertension**
**Self-management  **

**Notes:**
Small changes – great impacts

## Hypertension as a Model for Self-management

**Complex, long-term, chronic disease**
**Requires initiation and maintenance of multiple behaviors**
**Requires provider/patient communication**

## Significance of Self-management Adherence

**>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 Fail

**clinical trial information alone does not result in adequate BP control**
**Specialist-based care not solution**
**Primary care clinic based management is not sufficient**
**Frequent contact with doctors in clinics does not lead to BP control**

## Disease Management Hypertension:  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 Model

- <date/time>

**Health Decision Model**

**Social  Environment**** **

_**TREATMENT  ADHERENCE **_

**Provider Characteristics**

**Communication **
**Style**

**Medical Environment**

**Bosworth HB, Olsen MK, Oddone EZ. **
**(2006). Am Heart J 149:795-803.l**
**Bosworth HB & Oddone EZ. (2002).  **
**J Nat Med Ass. 94; 236-248**

**Literacy**

**Perceived**
** ****Risks**

**Patient Characteristics**

**Coping &  Stress**

**Side Effects**

**Comorbidities**

**Depression**
**Mental Health**

**Cognition**

**Medication Regimen**

**Treatment Guidelines Adherence**

**Intensity of Therapy**

_**BLOOD  PRESSURE  CONTROL **_

**Policy**

**Notes:**

Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. 
HAS study led to development of a model to explain treatment adherence
EMPHASIZE THAT BOTH PATIENT/PROVIDER

## Patient Characteristics Relatedto Self-management

**Risk Perceptions / Knowledge**
**Cognition **
**Memory**
**Inductive Reasoning**
**Verbal Comprehension**
**Literacy / Numeracy**
**Coping / Stress **
**Avoidance**
**Daily hassle**
**Stigma**

**Notes:**
Avoidance
Discrimination
Daily hassle stress
Multiple studies have shown that patients recall and comprehend as little as 50% of what is told to them by health care providers

## Patient Characteristics Relatedto Self-management

**Comorbidities**
**Medication Side Effects**
**Depression/mental health**

**Notes:**
Avoidance
Discrimination
Daily hassle stress
Multiple studies have shown that patients recall and comprehend as little as 50% of what is told to them by health care providers

## Social Characteristics Relatedto Self-management

**Social Network**
**Social Support**
**Tangible/instrumental**
**Emotional**
**Culture**

## Medical Environment Related to Self-management

**Access and Barriers**
**Insurance (i.e., co-payments, deductibles)**
**Transportation**
**Organization and staffing**

## Provider Characteristics Related to Self-management

**Evidence-based Guideline Compliance**
**Medication Complexity**
**Medication Intensity**
**Provider Communication**

**Notes:**
40% veterans BP > 160/90 mm/hg despite M = 6 hypertension-related visits per year

## Provider Factors:  Clinical Inertia

**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 Communication

**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 information into an intervention? 

## Veterans Study to Improve TheControl of HypertensionVA Health Services ResearchInvestigator Initiated Award, 2001-06

- <date/time>

**Veterans Study to Improve The****Control of Hypertension****VA Health Services Research****Investigator Initiated Award, 2001-06**

**The V-STITCH Study**

## The V-STITCH Study

- <date/time>

**The V-STITCH Study**

**A randomized controlled trial testing two interventions designed to improve BP control**
**Patient Intervention:  Self-Management**
**Provider Intervention:  Decision Support **
**Durham VAMC General Medicine Clinics**
**Patients with hypertension on medications**
**24 month intervention and follow-up**

## The V-STITCH Study Design

**Notes:**
Provider clustering.

## Patient Intervention

- <date/time>

**Patient Intervention**

## Patient Intervention

- <date/time>

**Patient Intervention**

**Hypertension Knowledge**
**African American**
**Diabetes**
**Family history**
**Literacy**
**Memory**
**Patient’s Relationship with Primary Care Provider**
**Social Support**
**Side Effects**
**Lifestyle Factors (smoking, alcohol, exercise, diet, stress)**
**Missed Appointments**
**Pill Refill**

**Tailored Behavioral Delivered via Telephone**

**Notes:**
Ex. Nurse inform overweight individuals that losing even a few pounds can have an effect on reducing one’s BP. 
In addition, when risk information is conveyed, proportions (e.g., stop smoking results in a reduction of 5 out of 10 people having a stroke”) as opposed to percentages  (“if you stop smoking, you have 50% chance of reducing your risk of having a stroke”) will be used.  The former presentation method is considered more “person oriented” as opposed to the latter, which is considered more mathematical and more difficult to understand by patients 

## Patient Intervention

| 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**

**Notes:**
3 time patterns:	Set time – physician interaction, hypertension knowledge, lifestyle, social 				support;
			Baseline – memory, literacy;
			Activated when problem – side effects, missed appointment.

## Patient Intervention

**Use of Telephone**
**Telephone contact has been shown to be effective in changing patient behavior ****(*****Am J Hypertens***** 1996, *****Am J Prev Med***** 2002)**
**Allow reaching more patients**
**Tend to be more acceptable and convenient than in-person interventions.**
**Most U.S. homes have phones (>97%) – useful tool to deliver an intervention ****(U.S. Bureau of Census, 2003)**
**May enhance the interventions’ cost-effectiveness, due to reduced intervention costs and reduced visit rates.**

**Mode of Administration**

**Notes:**
Ex. Nurse inform overweight individuals that losing even a few pounds can have an effect on reducing one’s BP. 
In addition, when risk information is conveyed, proportions (e.g., stop smoking results in a reduction of 5 out of 10 people having a stroke”) as opposed to percentages  (“if you stop smoking, you have 50% chance of reducing your risk of having a stroke”) will be used.  The former presentation method is considered more “person oriented” as opposed to the latter, which is considered more mathematical and more difficult to understand by patients 

## Provider Intervention

## 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 

**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 Hypertension:****EvideNce-based Advice (ATHENA)**

## ATHENA: BP - Prescription Graphs

**Notes:**
The BP- Prescription Graphs Tab is very useful because it allows you to view the patient’s BP control over time and relate it to current prescriptions. The yellow line will always reflect the patient’s target (140/90 or 130/85). In a glance you can notice this patient’s systolic BP has been high in the last two measurements. All BP’s included in CPRS vital signs field are included. The medications will be displayed with doses and any gaps in the lines reflect actual gaps in prescription fills.
Control group patients receive minimum pop-up window – list drugs and last BP.

## Displayed patient's most recent BP
Displayed patient’s current antihypertensive drug regimen
Provided opportunity to update BP  
Offered no advisories or recommendations for medication management
Simply a reminder for hypertension

**Displayed patient’s current antihypertensive drug regimen**
**Provided opportunity to update BP  **
**Offered no advisories or recommendations for medication management**
**Simply a reminder for hypertension**

**Provider Control Group**

## Primary Care Providers 

- <date/time>

**Primary Care Providers **

**24  Attending Physicians**
**  ****6  Physician Assistants**
**  ****2  Registered Nurse Practioners**
**17 intervention providers received full decision support tailored to specific patient**
**15 control providers received display with most recent BP**

**Notes:**
CLUSTERING !

## Patient Identification 

- <date/time>

**Patient Identification **

## Patient Characteristics (N=588)

- <date/time>

**Patient Characteristics**** ****(N=588)**

**Male****	****	****	****	****98%**
**Mean age****	****	****	****63 years (21-87)**
**Married****	****	****	****68%**
**Live alone****	****	****	****22%**
**White****	****	****	****57%**
**African American****	****40%**
**High school or less****	****51%**
**Inadequate income****	****23%**

**Notes:**
Mostly men

## Patient Characteristics

- <date/time>

**Patient Characteristics**

**Taking BP meds for > 5 years****	****	****64%**
**Close relative with hypertension****	****	****65%**
**No exercise****	****	****	****	****	****44%**
**Smoke****	****	****	****	****	****	****30%**
**Diabetic****	****	****	****	****	****	****40%**
**BP in control at Baseline:****	****	****	****42%**
**	****< 130 / 85 mm/Hg diabetic**
**	****< 140 / 90 mm/Hg non-diabetic **
**	****Mean Systolic BP 138.4 (SD=18)**
**	****Mean Diastolic BP 75.5  (SD=11)**

**Notes:**
Mention BP control based upon JNC 6 because that is when the study started.

## Primary Outcome

**Blood pressure control at every primary care provider clinic visit over 24 months**

**time in weeks**

**bp control**

**0**

**10**

**20**

**30**

**40**

**50**

**60**

**no**

**yes**

**patient 1**

**time in weeks**

**bp control**

**0**

**10**

**20**

**30**

**40**

**50**

**60**

**no**

**yes**

**patient 2**

**time in weeks**

**bp control**

**0**

**10**

**20**

**30**

**40**

**50**

**60**

**no**

**yes**

**patient 3**

**time in weeks**

**bp control**

**0**

**10**

**20**

**30**

**40**

**50**

**60**

**no**

**yes**

**patient 4**

**Notes:**
Blood pressure obtained at any primary care clinic visit over the 24 months
Standard VA Clinic Protocol, RN measured with IVAC/Alaris oscillometric  devices 

## Blood Pressure Control Rates

**Time in Months**

**BP Control**

**0.2**

**0.3**

**0.4**

**0.5**

**0.6**

**0.7**

**0**

**6**

**12**

**18**

**24**

**Blood Pressure Control Rates**
**Primary Analysis**

**Reminder**
** ****N=143**

**Behavioral**
** ****N=144**

**Decision **
**Support**
** ****N=151**

**Combined**
** ****N=150**

- Time Effect: P=.01

- Group*Time Effect: P=.11

**Notes:**
Footnote: Expected baseline to 24-month improvement for the combined group was 21% (p-value = 0.005); improvement for the tailored behavior only group was 20% (p-value = 0.003); improvement for the usual care control group was 17% (p-value=0.01).  There was no change in BP control for the medication management group (p-value = 0.97). 

## Nurse Behavioral Intervention vs. None

**Nurse Behavioral Intervention vs. None**
**Secondary Analysis**

**Time in Months**

**BP Control**

**0.40**

**0.50**

**0.60**

**0.70**

**0**

**6**

**12**

**18**

**24**

**RN Behavioral**
**N=294**

**No RN**
**N=294**

**P=0.03**

## Compliance with Nurse Telephone Intervention

**Patients completing all 12 scheduled study calls:****	**** ****85%**
**Average length of call:****	**
**	****	****	****	****3 minutes  (SD 2.5 min)**

## Primary Care VisitsDuring Study (24 Months)

- <date/time>

**Primary Care Visits****During Study (24 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 |

**Notes:**
7.7 (SD=4.7; median=7.0); was 7.4 (SD=3.6; median=7.0); and combined was 7.1 (SD=3.5; median=7.0) 

## Two-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 |

**Notes:**
< 130 / 85 mm/Hg diabetic;  < 140 / 90 mm/Hg non-diabetic.

## Average Behavioral Intervention Costs 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 |

**Notes:**
< 130 / 85 mm/Hg diabetic;  < 140 / 90 mm/Hg non-diabetic.

## Provider Intervention Results

**ATHENA displayed at 68% of visits (929/1370)**
** ****Among displayed, providers interacted with  intervention 57% of time (38.5% overall)**
** ****54% BP control when provider interacted  versus 45% when provider did not interact**

**Notes:**
For the 929 visits in which the provider intervention was displayed, providers interacted with the intervention 56.8% of the time (n=528) (across all patient visits, providers interacted with the provider intervention for 528 of the 1370 visits 38.5%).  The most common form of interaction with the intervention was updating patients’ BP and subsequently considering a medication recommendation.  Across all visits where the provider intervention was displayed and the provider interacted with the intervention, the BP control rates were 54.2% and 45.1% when the provider intervention was displayed, but the provider did not interact with the intervention. 

## Provider Intervention Results

**Most common reasons for disregarding recommendations**
** ****68% inadequate BP control due to med non-adherence**
** ****68% concern that an inaccurate BP reading was used to generate recommendations**
** ****46% insufficient time**

**Notes:**
For the 929 visits in which the provider intervention was displayed, providers interacted with the intervention 56.8% of the time (n=528) (across all patient visits, providers interacted with the provider intervention for 528 of the 1370 visits 38.5%).  The most common form of interaction with the intervention was updating patients’ BP and subsequently considering a medication recommendation.  Across all visits where the provider intervention was displayed and the provider interacted with the intervention, the BP control rates were 54.2% and 45.1% when the provider intervention was displayed, but the provider did not interact with the intervention. 

## Summary

**Brief telephone intervention improved BP control by 21% at 24 months**
**12.6% improvement compared to the non-behavioral group**
**No increase in clinic utilization**
**Cost effective**
**Computer Decision Support did not significantly improve BP control rates at 24 months**

**Notes:**
At 12 months 8% - overall, nurse intervention 
Demographic Factors
Education
Income
Psychosocial Factors
Social support				Risk Perception
Participatory Decision making		Literacy
Memory					Knowledge
Clinical Factors
Diabetes					 Parental history
Use of home BP monitor		 Exercise
Length of being hypertensive		 Smoking
Number of hypertensive meds
Number of side effects and specific side effects

## Next Study

**How can we overcome provider inertia with a stronger medication management intervention?**
**Focus intensive interventions on those at greater risk (i.e., out of control)**
**Can we monitor and treat blood pressure outside of clinic? **

**Notes:**
Among displayed, providers interacted with intervention 57% of time (38.5% overall)
(54% control when provider interacted versus 45% when provider did not interact)

## Hypertension Intervention Telemedicine Study(HINTS)

**Department of Veterans Affairs, **
**Grant IIR 04-426 (2005-2008)**
**Established Investigator Award, **
**American Heart Association (2006-2011)**

## Hypertension Intervention Nurse Telemedicine Study (HINTS)

**600 primary care veterans with poor BP control **
**Home BP tele-monitoring used to activate interventions**
**Nurse-administered via telephone for 18 months**

**Notes:**
Enrolled 230 thus far

## HINTS Study:  Design

**Four Group Design**
**Usual Care**
** ****PCP drive management, no special program**
**Tailored Behavioral Phone Intervention**
** ****Home BP monitoring evaluated by nurse**
** ****Tailored behavioral modules**
**Medication Management (ATHENA) Phone Intervention**
** ****Home BP monitoring evaluated by nurse**
** ****Medication management implemented by study MD/RN**
**Combined Intervention**
** ****Home BP monitoring evaluated by nurse**
** ****Medication management/tailored behavioral modules**

**Notes:**
Interventions activated when home BP poorly controlled

Bp values 5 points lower
Non-diabetic 135/85
Diabetic 130/85

## Why BP Monitors as Interventions?

**Improve BP control**
**Self-monitoring programs are used in clinical practice to assist PCP in treating their patients**
**Encourage patients to monitor their disease**
**Provide objective information to motivate patients to control their health condition**

## Case for Telemedicine

**Effective use of home BP monitoring improve hypertension outcomes **
**Treating at home may avert visits and result in better BP control**
**Alternative way to integrate home BP monitoring into primary care**

**Notes:**
Define telemedicine – home BP values transmitted to central location

## HINTS Study:  Telemedicine

**Notes:**
Interventions activated when home BP poorly controlled

## Baseline Patient Characteristics

**546 subjects enrolled**
**Minority****	****	****	****	****51%**
**Low Literate****	****	****	****38%**
**Diabetic****	****	****	****	****44%**
**Males****	****	****	****	****98%**

**Notes:**
**Make sure you have explained the safety alerts.
result without adverse events.98  Treatment goals for diabetics are 5 mm Hg lower than for non-diabetics.  As a result, we have chosen to activate intensification of therapy based on a 2-week average home BP of >135/85 for non-diabetics and >130/80 for diabetics. 

## Summary of Intervention

**Safety alert activated**** **
**	****(2 values within 12 hours ****>175 systolic, >105 diastolic, pulse **_**<**_**40 or **_**>**_**110) **
**	****144 times, 51 unique pts**
**Intervention activated**** ****	**
**	****687 times, 241 unique pts**
**Praise alert activated****	****	**
**	****74 times, 68 unique pts**

**Notes:**
**Make sure you have explained the safety alerts.
result without adverse events.98  Treatment goals for diabetics are 5 mm Hg lower than for non-diabetics.  As a result, we have chosen to activate intensification of therapy based on a 2-week average home BP of >135/85 for non-diabetics and >130/80 for diabetics. 

## Summary of Intervention

**Technicals activated**
**	****634 times, 220 unique pts**
**	****7% Did not understand how to set up or use equipment**
**	****66% nonadherence**
**	****27% technical problems with equipment**
**	**

**Notes:**
**Make sure you have explained the safety alerts.
result without adverse events.98  Treatment goals for diabetics are 5 mm Hg lower than for non-diabetics.  As a result, we have chosen to activate intensification of therapy based on a 2-week average home BP of >135/85 for non-diabetics and >130/80 for diabetics. 

## Home Readings: Console View

## RN:MD Dialogue for Medication Change

## Outcomes

**BP control **
**0, 6, 12, 18 months**
**Health-related quality of life (SF-12)**
**Hypertension knowledge**
**Adherence to hypertension regimen **
**Cost-effectiveness of both interventions**

**Notes:**
Self-efficacy found to significantly increase intervention group whereas decrease in usual care.

## Summary 

**Need to consider**
**Alternative methods of implementing interventions**
**Telemedicine not panacea for all**
**Cost of implementing interventions**
**Methods of reimbursement**
**Not just initiating, but maintaining multiple health behaviors**
**Both patient/provider and possibly system**

## Recommendations 

**	**
** ****Self-management adherence-enhancing strategies need to occur:**
**	****Introduction of treatment**
**	****Later in the course (remediation)**
**	****Maintenance (less attention) **
** **
** ****Strategies include:**
**	**_**Social Support**_
**	**_**Educational Interventions**_** (written and/or verbal**
**	****instructions delivered individually, group,**
**	****telephone, or audiovisually) **
**	**_**Behavioral Strategies**_** (self-monitoring, positive ****	****	****	****	****reinforcement, goal setting, cueing, chaining)**

## Recommendations 

**Educational Interventions**** **
** ****Knowledge alone will not change behavior **
** ****Establish what is known before offering new knowledge  **
** ****Use concrete examples**

## Recommendations 

**Ways of Presenting Written Information**
** ****Instructions should be clear and structured**
** ****Picture charts, color-coded medication schedules and large print **

## Recommendations 

**Behavioral Interventions**
**Strategies include:**
** ****Developing prompts and reminder systems**
** ****Identifying a potential relapse into old behavior**
** ****Setting appropriate and realistic goals**
** ****Simplifying regimens to once or twice daily**
**Use opportunities to model behavior**
**Reinforce positive behaviors**

## Recommendations 

**Clinical Issues**
** ****Key validated question “Have you missed any pills in the past week?” **
** ****Sensitivity > 50% of those with low adherence**
** ****Specificity of 87%**
**	****Common misperceptions should be anticipated and avoided **
** ****i.e.,  medication can be stopped when the prescription runs out or symptoms are guides to when to take the medication****  **

## Recommendations 

**Clinical Issues (continued)**
**	**
** ****Missing appointments is correlated with lower adherence rates - first sign of dropping out of care entirely, the most severe form of nonadherence.  **
** ****Telephone or appointment reminders provide relatively easy method to overcome nonadherence.**

## Recommendations

**Effective, *****collaborative***** provider-patient communication should be the foundation of all clinical interventions designed to improve patient self-management.**

## Future Directions & Conclusions

**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 Olsen
- Mike Harrelson		Felicia McCant		Kelly Deal
- Pam Gentry	 	Laura Svetkey		Mary Goldstein
- Rowena Dolor		Tara Dudley 		Laurie Marbrey
- Martha Adams 		Shelby Reed		Santanu Datta
- Laurie Leeson		Anthony Goodin		Gwen McKoy
- Courtney Van Houtven	Ben Powers		Cindy Rose
- Sharon Hooker		Tina Hong		David Simel
- Janet Grubber

## Relevant Publications

**Bosworth HB, Olsen MK, McCant F, et al. Hypertension Intervention Nurse Telemedicine **
**Study (HINTS). *****Am Heart J***** 2007;153(6):918-24.**
**2. Bosworth HB, Olsen MK, Goldstein MK, et al. The veterans' study to improve the control **
**of hypertension (V-STITCH): design and methodology. *****Contemp Clin Trials***** 2005;26:155-68.**
**3. Chan AS, Coleman RW, Martins SB, et al. Evaluating provider adherence in a trial of a **
**guideline-based decision support system for hypertension. *****Medinfo***** 2004;11(Pt 1):125-9.**
**4. Goldstein MK, Coleman RW, Tu SW, et al. Translating research into practice: **
**organizational issues in implementing automated decision support for hypertension in **
**three medical centers. *****J Am Med Inform Assoc***** 2004;11(5):368-76.**
**5. Goldstein MK, Hoffman BB, Coleman RW, et al. Implementing clinical practice guidelines **
**while taking account of changing evidence. *****Proc AMIA Symp***** 2000:300-4.**
**6. Goldstein MK, Hoffman BB, Coleman RW, et al. Patient safety in guideline-based decision **
**support for hypertension management: ATHENA DSS. *****Proc AMIA Symp***** 2001:214-8.**

## Relevant Publications

**7. Lin ND, Martins SB, Chan AS, et al. Identifying barriers to hypertension guideline **
**adherence using clinician feedback at the point of care. *****AMIA Annu Symp Proc***** 2006:494-8.**
**8. Bosworth HB, Oddone EZ. Telemedicine and Hypertension. *****J Clin Outcomes Management***** 2004;11(8):517-522.**
**9. Bosworth HB, Oddone EZ, Weinberger M. Patient treatment adherence: Concepts**
**interventions, and measurement. Mahwah, NJ: Lawrence Erlbaum Associates, 2006.**
**10. Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood pressure control: **
**potential explanatory factors. *****Am J Med***** 2006;119(1):70.**
**11. Bosworth HB, Oddone EZ. A model of psychosocial and cultural antecedents of **
**blood pressure control. *****Journal of the National Medical Association***** 2002;94:236-248.**
**12. Bosworth HB, Olsen MK, Gentry P, et al. Nurse administered telephone intervention for **
**blood pressure control. *****Patient Educ Couns *****2005;57(1):5-14.**
**13. Bosworth HB, Olsen MK, Oddone EZ. Improving blood pressure control by tailored **
**feedback to patients and clinicians. *****Am Heart J***** 2005;149(5):795-803.****	****	**