A program designed to help hypertensive patients with complex medication regimens understand the drugs they are prescribed not only failed to improve adherence, but it actually raised their blood pressure.
Northwestern University researchers randomized 12 federally qualified health centers in Chicago to provide usual care, offer medication management tools through the electronic health record (EHR) or provide those EHR tools along with nurse-led education and counseling. Patients provided with just the EHR resources—medication review sheets at check-in and information sheets printed after visits—saw their average systolic blood pressures increase by 3.6 mm Hg one year later compared to the normal care group.
“The finding of higher blood pressure among the group that received EHR tools alone was unexpected,” Stephen D. Persell, MD, MPH, and colleagues wrote in JAMA Internal Medicine. “We speculate that medication information sheets (which contain some information on adverse drug effects) may have led some patients to stop or reduce antihypertensive therapy.”
All patients included in the study had hypertension, spoke English, were taking at least three medications for any purpose and were responsible for administering their own medications. A total of 794 patients completed the 12-month follow-up visit. Most participants were black (87.2 percent), used Medicaid insurance (51.1 percent) and 68.6 percent were women.
The nurse-led intervention also provided the EHR tools but added nurse educators who reviewed patients’ medication lists and physician notes to identify potential errors and then scheduled follow-up counseling sessions. This strategy was associated with a nonsignificant drop of 2 mm Hg in systolic BP when compared to normal care.
Both intervention groups showed significant improvements in medication reconciliation—the process of comparing a patient’s medication orders to what the person has actually been taking. However, only patients in the nurse-educated group had a better understanding of medication instructions and dosing than the usual care arm at their one-year visit.
Despite this knowledge boost, neither intervention cohort showed an improvement in adherence to hypertension medication.
“This study highlights the importance of testing system-level changes for unintended effects and suggests that improving some aspects of medication self-management alone is not sufficient to improve hypertension control,” Persell and colleagues wrote.
The authors speculated the approaches were ineffective because they were too low in intensity, adding that an improvement in medication reconciliation doesn’t necessarily translate to more consistent or potent treatment.
“Prior interventions using nonphysician clinicians to address hypertension have generally been most effective when these clinicians were empowered to intensify treatment if blood pressure was uncontrolled,” the researchers noted. “The nurse educators in our study focused on reducing medication errors and improving self-management and were not tasked with intensification of therapy. Empowering nurses to adjust medication based on home blood pressure measurements may yield stronger effects on blood pressure.”