Presenting Author:
Lauren Gard, M.P.H.
Principal Investigator:
Stephen Persell, M.D.
Department:
Medicine
Keywords:
Hypertension, Randomized Controlled Trial (RCT), Electronic Health Record (EHR), Medication, Health Literacy, Nurse, Blo... [Read full text]
Location:
Third Floor, Feinberg Pavilion, Northwestern Memorial Hospital
PH27 - Public Health & Social Sciences
The Northwestern and Access Community Health Network Medication Education Study
Background: Hypertension is a chronic medical condition that can require treatment with complex medication regimes. It is often difficult for patients with limited health literacy to perform the medical self-management behaviors needed to effectively control this condition. We sought to determine if electronic health record (EHR) tools would offer low-cost approaches to support medical management among adults with uncontrolled hypertension. Methods: We performed a three-arm 12-clinic-level cluster-randomized trial in a Chicago area network of federally qualified community health centers that compared: usual care, EHR-based medication management tools alone (printed medication), and EHR tools plus nurse-led medication management support (one-on-one counseling about medication regimens). We recruited patients from randomized clinics who were ≥18 years of age with ≥3 prescribed medications and suboptimal blood pressure (≥130/80 mm Hg if diabetes or ≥135/85 mm Hg diastolic if not). Outcomes at 1 year included systolic blood pressure (primary outcome, using a standard protocol), blood pressure control (<140/90 mm Hg), basic understanding of medication indications, reconciliation between patient-report and the medical record, and self-reported 4-day adherence. Analyses of study arm effects used generalized linear models accounting for subjects’ baseline outcome values and clinic-level random effects. Results: 920 participants enrolled; 796 completed 1-year follow up. Of subjects completing follow up, mean age was 53 years, 69% were women, 87% were African American, 67% had high school education or less and 47% had limited health literacy. Subjects used a mean of 5.4 medications and 25% used 7 or more. At 1 year, systolic blood pressure was higher with EHR-tools only (+3.3 mm Hg [95% CI 0.2 to 6.5]) vs usual care and lowest in the EHR + nurse arm (-5.5 mm Hg [-3.1 to -7.8]) vs EHR-only, (-2.1 mm Hg [-5.4 to +1.1]) vs usual care. Compared to usual care, blood pressure control at 1 year was better in the EHR + nurse arm (odds ratio [OR] 1.21 [1.01-1.45]) but worse in the EHR-only arm (0.68 [0.58-0.78]). Understanding of indications was not changed with either intervention compared to usual care. Medication reconciliation substantially improved with both interventions, OR (95% CI) compared to usual care for antihypertensives, chronic disease medications, and all medications with EHR-tools only: 1.7 (1.2-2.4), 2.3 (1.3-4.2), and 4.6 (1.7-13), respectively and for EHR tools + nurse: 1.9 (1.4-2.7), 2.1 (1.2-3.5), 4.9 (1.6-15), but did not significantly differ between active intervention groups. Medication adherence was worse than usual care in the EHR-tools only arm for all chronic disease medications, OR 0.83 (0.71-0.98). Conclusions: Both interventions improved medication reconciliation. Only nurse-led medication management plus EHR tools improved hypertension control. EHR tools only may have had unintended effects on blood pressure control.
