A ED-based Intervention to Improve Antihypertensive Adherence
Condition: Hypertensive Emergency; Hypertension; Blood Pressure
MeSH terms: Emergencies
Study type: Interventional

Summary: 
      Despite great strides, hypertension remains an incredibly important disease and public health
      problem. This study addresses this critical need among ED patients, a unique population of
      patients who are (a) likely to benefit from an antihypertensive adherence intervention due to
      their high prevalence of uncontrolled blood pressure and poor adherence, and (b) at high risk
      for poor cardiovascular outcomes. The protocol provides for a multicomponent intervention
      bundle to be tested among ED patients. Successful clinic-based behavioral interventions
      generally target a combination of barriers to adherence; bundled interventions have shown
      success in a wide range of settings and diseases. In some cases, bundled components were
      necessary to achieve blood pressure benefit in a primary care setting; isolated educational
      efforts have had mixed success in the ED.
    

Detailed description: 
      More than 37 million Americans have uncontrolled hypertension, with associated costs of $93.5
      billion in 2010. Emergency department visits for hypertension rose 25% from 2006 to 2011.
      According to the Centers for Disease Control and Prevention, "improved hypertension
      control…require[s] an expanded effort and an increased focus on blood pressure from
      health-care systems, clinicians, and individuals."

      ED visits among patients with uncontrolled blood pressure are often missed opportunities for
      the ED to serve as an additional healthcare touchpoint and opportunity to impact chronic
      disease control by complementing chronic care. The ED is a common access point into the
      healthcare system, with more than 120 million visits annually among 20% of Americans. ED
      visits specifically for hypertension are also common, with more than 5 million visits per
      year and rising rapidly as more newly insured and chronically ill patients seek ED care.
      Elevated blood pressure (BP) is noted in 15-25% of all ED visits and cannot be attributed
      solely to pain. An ED-based intervention places focus on patients who are at increased risk
      for poor clinical outcomes and who are likely to gain benefit from interventions.

      Medication adherence, or taking medications as prescribed, is crucial for BP control. Until
      now, measuring antihypertensive adherence in the ED has been limited to self-report, which is
      influenced by recall and social desirability biases and lack of an established
      patient-provider relationship. As a result, little is known regarding factors related to
      antihypertensive adherence or optimal interventions to improve adherence among ED patients.
      This project utilizes a validated mass spectrometry plasma assay as a measure of
      antihypertensive adherence to overcome these limitations. This tool will be combined with a
      conceptual framework in order to test our understanding of how adherence relates to blood
      pressure control among ED patients. The conceptual framework is based on work by
      Krousel-Wood, Bosworth, Murray, and Gellad and is grounded in the
      Information-Motivation-Behavioral Skills model of health behavior change, Social Cognitive
      Theory, and successful clinic-based adherence interventions.
    

Intervention name(s): ED-based behavioral intervention; ED usual care plus education
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Data collection, antihypertensive adherence assay, antihypertensive interview and EHR review, barrier identification, personalized goal setting, communication with PCP, and reminder messages/engagement messages.; Data collection, antihypertensive adherence assay, antihypertensive interview, EHR review, and usual care education.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Antihypertensive adherence; Emergency medicine; Antihypertensives