Title:

Starting the Conversation on Hypertension Self-Management in Primary Care to Improve Cardiovascular

Outcomes

Jean Ann Davison, DNP

School of Nursing and School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill,
NC, USA

Session Title:
Evidence-Based Practice Poster Session 2
Slot (superslotted):
EBP PST 2: Saturday, 29 July 2017: 12:00 PM-1:30 PM
Slot (superslotted):
EBP PST 2: Saturday, 29 July 2017: 2:45 PM-3:30 PM

Keywords:
Hypertension Self-Managment, Primary care - blood pressure and Quality Improvement for
Cardiovascular Risk Reduction

References:
Borjesson, M., Onerup, A., Lundqvist, S., & Dahlof, B. (2016). Physical activity and exercise lower blood
pressure in individuals with hypertension: Narrative review of 27 RCTs. British Journal of Sports Medicine,
50(6), 356–361. doi:10.1136/bjsports-2015-095786

Centers for Disease Control and Prevention (2013). Hypertension Control: Action Steps for Clinicians.
Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services.

Ehrlich, C., Kendall, E., Parekh, S., & Walters, C. (2015). The impact of culturally responsive self-
management interventions on health outcomes for minority population: A systematic review. Chronic
Illness, 12(1), 47–57.

Epstein, D. E., Sherwood, A., Smith, P. J., Craighead, L., Caccia, C., Lin, P. H., . . . Blumenthal, J. A.
(2012). Determinants and consequences of adherence to the dietary approaches to stop hypertension
diet in African American and white adults with high blood pressure: Results from the ENCORE trial.
Journal of the Academy of Nutrition and Dietetics, 112(11), 1763–1773. doi:10.1016/j.jand.2012.07.007

Go AS, Mozaffarian D, Roger VL, et al. (2014) Heart disease and stroke statistics—2014 update: a report
from the American Heart Association. Circulation 2014;129:e28–292.

Hinderliter, A. L., Sherwood, A., Craighead, L. W., Lin, P. H., Watkins, L., Babyak, M. A., & Blumenthal, J.
A. (2014). The long-term effects of lifestyle change on blood pressure: One-year follow-up of the
ENCORE study. American Journal of Hypertension, 27(5), 734–741. doi:10.1093/ajh/hpt183

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., . . . Ortiz,
E. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: Report
from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 311(5), 507–-
520. doi:10.1001/jama.2013.284427

Lynch, E., Liebman, R., Ventrelle, J., Avery, E., & Richardson, D. (2014). A self-management intervention
for African Americans with comorbid diabetes and hypertension: A pilot randomized controlled trial.
Preventing Chronic Disease, 11, 130349. doi:10.5888/pcd11.130349

Ndanuko, R. N., Tapsell, L. C., Charlton, K. E., Neale, E. P., & Batterham, M. J. (2016). Dietary patterns
and blood pressure in adults: A systematic review and meta-analysis of randomized controlled trials.
Advances in Nutrition, 7(1), 76–89. doi:10.3945/an.115.009753

U.S. Department of Health and Human Services. (2015). Heart disease and stroke. Retrieved from
http://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke/objectives

Abstract Summary:
A nurse-led quality improvement project was designed to improve the clinical performance of
hypertension management with a focus on self-management support for adult patients at a primary care
clinic in rural North Carolina. Greater than 80% of the patients set self-management goals for risk
reduction of cardiovascular disease.
Learning Activity:

LEARNING OBJECTIVES EXPANDED CONTENT OUTLINE

The learner will be able to - 1. describe the
present prevalence of the leading
cardiovascular disease risk factors in the USA,
the Million Hearts target goals and the clinical
quality measure used for blood pressure
control.
The learner will be able to - 2. critique
strategies use in this QI project focused on
supporting patients in self-management and
medication adherence to improve blood
pressure control and reduce the burden of
CVD.
1. Describe the prevalence of CVD in terms of
demographics and risk factors and goals of
Million Hearts in the Clinical Quality
Measures to reduce the burden of CVD.
Example: Hypertension (HTN): Controlling
High Blood Pressure – Clinical Measurement
Percentage of patients aged 18 through 85
years who had a diagnosis of HTN and whose
blood pressure was adequately controlled
(<140/90) during the measurement year
Strategies included • provider and staff quality
improvement training for the use of supporting
patients in SMS goal setting, the use of team
based care and evidence based guidelines
around HTN. • patient education and healthy
lifestyle goal setting for self-management
support (SMS) of HTN and CVD risk
reduction. • the use of electronic health
information and technology to monitor goal
setting and clinical quality measures.

Abstract Text:

Background

Cardiovascular disease (CVD) – heart disease and strokes - caused one in three deaths in the USA in
2014 and The American Heart Association (AHA) projects that by 2030, 40.5% of the U.S. population will
have some form of CVD, with an estimated cost to the national health care system of $1 trillion per year
(Tomaselli, Harty, Horton, & Schoeberl, 2011). In 2012 the U.S. Department of Health and Human
Services (HHS) launched the Million Hearts initiative, (http://millionhearts.hhs.gov/) to prevent 1 million
heart attacks and strokes in 5 years (2012-17). Strategies were directed at the leading modifiable risks for
CVD to support improved outcomes in the "ABCS" - Aspirin for those at risk, Blood pressure
control, Cholesterol control, Smoking cessation and Sodium reduction in the diet. The focus of this
campaign is to empower Americans to make healthy lifestyle choices to reduce CVD risks and for
healthcare providers to support their patients in these healthy lifestyles.

Hypertension (HTN) is the single most independent and modifiable risk factor for cardiovascular disease
(CVD), stroke, congestive heart failure, and chronic renal disease (CRD) (Chobanian et al., 2003).
The Million Hearts campaign set a clinical quality measure for blood pressure control goal at 70% in the
clinical population with a diagnosis of hypertension; the measurement was defined as the “percentage of
patients 18 to 85 years of age with a diagnosis of hypertension (HTN) and whose blood pressure (BP)
was adequately controlled (<140/90) during the measurement year”. In the Southeast Region of the
United States, it is currently reported by the Department of Health and Human Services (2016) that only
53% of the of the population has achieved the clinical control blood pressure (BP < 140/90) - a large gap
from the 70% goal (http://millionhearts.hhs.gov/data-reports/cqm.html, 2016).

The Centers for Disease Control and Prevention (CDC, 2013) Hypertension Control: Action Steps for
Clinicians recommends to:

• Provide patients who have hypertension with a written self-management plan at the end of each office
visit.
• Encourage or provide patient support groups.
• Use all staff interactions with patients as opportunities to assist in self-management goal-setting and
practices.
• Print visit summaries and follow-up guidance for patients.

Purpose:

The aim of this nurse led quality improvement (QI) project was to improve the clinical performance in the
management of hypertension (HTN) with a focus on self-management support (SMS) among adult
patients (18-75 years) at a rural primary care clinic with an exceptionally high rate of cardiovascular
disease. The six-month QI initiative was designed with a goal to have 80% or more of the adult patients
with a diagnosis of HTN actively setting goals in collaboration with their providers for CVD risk reduction.

Data Sources and Implementation:

The study design was a six month long quality improvement study. Data included a retrospective baseline
of meaningful use population data (N = 1210) generated six months prior to the QI study start date and an
analysis of the data during the six-month QI study (N = 1409). Interventions included provider and staff
quality improvement training along with patient education and lifestyle goal setting for self-management
support (SMS) of HTN. All adult patients with a diagnosis of HTN or an elevated BP reading at their office
visit were offered the brochures Starting the Conversation on Blood Pressure by the NC Prevention
Partners(2011) and Start with Your Heart Prescription for Better Healthfrom the NC Department of Health
and Human Services(2011) in English and Spanish. Questions were answered on hypertension and risk
reduction by all health care providers throughout the office
visit. Specific, Measurable, Attainable, Realistic and Time specific (SMART) goal setting and action plans
were encouraged and a written self-management plan was given at the end of each office visit. Electronic
medical record data was used to compile population statistics for blood pressure (BP), LDL cholesterol,
tobacco use, body mass index, and self-management goals monthly throughout the QI study. Pre and
post results of the QI six month period were compared.
Results
The primary objective, > 80% of adults aged 18 to 75 years would have documented self-management
goals, was achieved and significantly improved from baseline. SMART goals discussed included following
the recommendations for the Dietary Approaches to Stop Hypertension (DASH) diet, aerobic physical
activity, weight loss for healthy body mass index, tobacco cessation, moderate alcohol consumption,
stress reduction, medication adherence, home BP monitoring, and, as applicable, blood sugar control.
A secondary objective was to see significant improvement in controlled HTN (BP < 140/90) for this
population, but this did not occur. A limitation of this QI study was the short length (six months) of
observation time.

Implications for Practice:

The goal of this QI project to help patients in self-management support for modifiable risk reduction of
HTN was achieved to help reduce the burden of CVD in this population. Nurses can have a vital role in
meeting the current demand for HTN management in primary care, to support patients in their self-
management. Working with patients to achieve healthy lifestyle CVD risk reductions and medication
management could help reduce the burden of CVD at a population level.