Table 3.
Hypertension
| Reference | Design | Intervention | n, Follow-Up, Racial/Ethnic Composition | Setting | Results: Process and Patient Outcomes | Conclusion | Target | Quality Score |
|---|---|---|---|---|---|---|---|---|
| Ahluwalia 1996 | RCT | Reminder postcards sent to hypertensive patients | n = 107, 6 months, 95% AA | Urban hospital-based walk-in clinic | 45% in postcard group and 47% of controls followed up in 10 days (p = .93) | Follow-up in severe hypertensives was poor, and a mailed postcard reminder had no effect in a walk-in setting | Provider & care delivery | 16 |
| Appel 2001 | RCT | TONE: reduced Na intervention; initial individual session with dietician, 4-month intensive phase with weekly group meetings, 3-month extended phase with biweekly meetings, and a maintenance phase; periodic individual sessions | n = 681, 28 months, 23% AA in subgroup analysis | 1 of 4 TONE Clinical Centers | Primary outcome: 59% of reduced Na vs. 73% controls had BP > 150/90 (relative hazard ratio = 0.68); in AAs, the relative hazard ratio was 0.56 | A reduced Na intake is a broadly effective, nonpharmacologic therapy that can lower BP and control HTN in older individuals | Patient/family | 20 |
| Ard 2000 | Randomized modified crossover | Diet and exercise program included 1,000 kcal diet, culturally sensitive recipes, and address of exercise attitudes | n = 56, 8 weeks, 100% AA | Academic health center | Average weight loss 14.8 lb; BMI: 37.8 to 35.3 (p < .01); total cholesterol: 199 to 185 (p < .01); SBP and DBP decreased by 4.3 (p < .01), and 2.4 (p < .05); control group: no significant change | A culturally sensitive diet and exercise intervention can reduce BMI, cholesterol, and BP | Patient/family | 12 |
| Artinian 2001 | RCT | Nurse-managed HT plus usual care or nurse-managed CBM or usual care | n = 26, 3 months, 100% AA | Family community center in urban setting | HT and CBM group had significant drops (HT > CBM) in SBP and DBP at 3 months (p < .05); little change in usual-care group | Nurse case management and home/community monitoring can reduce BP | Provider & care delivery | 17 |
| Becker 2005 | RCT | Community-based multiple risk factor intervention on CV risk in black families with a history of premature coronary disease; CBC group received NP-led, community-based multicomponent education and management intervention compared to EPC | n = 364, 1 year, 100% AA | Primary care and nonclinical community sites | CBC group was two times more likely to achieve goal levels of LDL cholesterol and BP compared with the EPC group (95% CI: 1.11 to 4.20 and 1.39 to 3.88, respectively) | Multifaceted NP-directed community-based intervention can improve HTN, lipids, and tobacco cessation rates in a high-risk population | Provider & care delivery | 18 |
| Chisolm 2002 | RCT | Clinical pharmacist performing patient medication reviews, with emphasis on preventing or resolving medication-related problems and providing medication recommendations | n = 23, 1 year, 100% AA | Academic renal transplant clinic | Mean SBP significantly lower in the intervention group at second (138 vs. 169), third (136 vs. 165), and fourth (145 vs. 176) quarters of study (p < .05); mean DBP lower in intervention group at second (76 vs. 85) and fourth quarters of study (p < .05) | Pharmacist medication review and instruction improved BP control in renal transplant patients | Provider & care delivery | 21 |
| Erickson 1997 | RCT | Pharmacist preclinic counseling on HTN, drug and nondrug management, compliance, and recommendations to MD | n = 80, 5 months, 89% AA | Urban university-affiliated internal medicine clinic | Significant improvement in SBP 157 to 145 in intervention group only (p = .001); SF-36 physical functioning domain (p = .03) in intervention group without change in HTN-specific scale | Pharmacist education improved BP control in this setting | Provider & care delivery | 19 |
| Fedder 2003 | Retrospective comparison study | CHW impact on health care utilization of patients with DM with/without HTN | n = 117, 1 year, 100% AA | Urban Medicaid population | At 2 years, ER admissions decreased 53% (p = .02) | CHW-implemented HTN treatment program decreased emergency room use | Provider & care delivery | 10 |
| Haskell 2006 | RCT | Multifaceted disease management intervention using team case management | n = 148, 1 year, 89% minority (57% Hispanic, 11% Asian, 7% AA) | Urban community clinics serving low-income patients | Disease management produced clinically important decreases in selected risk factors compared with usual care, including systolic BP (p < .01) and LDL cholesterol (p < .03) | Disease management targeted at high-risk patients (24% had CAD, 64% had no health insurance) can improve HTN and lipids | Provider & care delivery | 21 |
| Hill 1999 | RCT | Nurse-CHW special (SI) educational-behavioral intervention, individualized counseling, monthly phone calls, home visit | n = 204, 12 months, 100% AA | Home and outpatient clinic at academic medical center | No significant differences in BP control | Nurse and CHW care consisting of multifaceted intervention did not improve BP control | Provider & care delivery | 18 |
| Hill 2003; Dennison 2007 | RCT | NP/CHW/MD educational-behavioral-pharmacologic vs. less intensive education referral | n = 309, 36 months, 100% AA | Home and outpatient clinic at academic medical center | At 36 months, SBP/DBP: -7.5/-10.1 (more intensive) vs. +3.4/-3.7 (less intensive), p = .001 and p = .005, respectively; LVM lower 274 g (more intensive) vs. 311 g (less intensive) (p = .004) | Combined nurse, CHW, MD behavioral pharmacological intervention improved BP control | Provider & care delivery | 21 |
| Jenkins 2006 | Pre/post study | General CV disease quality improvement | n = 2,860, 1 year 48% AA with subgroup analysis | Academic family practice clinic | Significant improvements occurred in BP control for all adults (OR = 1.44) and those with HTN (OR = 1.82); measures of total cholesterol (OR = 1.10) and HDL cholesterol (OR = 1.27) for all patients | Multifaceted intervention can improve process measures and CV outcomes | Provider & care delivery | 17 |
| Kokkinos 1995 | RCT | Moderate-intensity exercise plus BP medication or BP medication alone | n = 46, 32 weeks, 100% AA | Not mentioned | At 16 weeks, mean DBP decreased in exercise group (88 to 83 mm Hg) and increased in nonexercise group (88 to 90 mm Hg) (p = .002) | Effectiveness of moderately intense exercise extends to patients with severe HTN | Patient/family | 18 |
| Krieger 1999 | RCT | Enhanced tracking and follow-up services provided by CHWs to promote medical follow-up of persons with elevate BP | n = 421, 3 months, 79% AA | Urban community-based clinics | Follow-up visits were completed by 65.1% of intervention group vs. 46.7% of those in the usual-care group (p = .001) | Enhanced tracking and follow-up services by CHW improved compliance with follow-up visits | Provider & care delivery | 17 |
| Kumanyika 1999 | RCT | Nutrition program using food cards, audiotapes, and four classes vs. cards and nutrition guide | n = 255, 1 year, 100% AA | Community-based clinic affiliated with an academic medical center | Trend toward improvement but no significant difference in lipids and BP | Intensive nutrition intervention may improve lipid and BP control | Patient/family | 18 |
| Lenz 2004 | Comparative study, 2-year follow-up of RCT | NP-run or physician-run primary care practice | n = 406, 2 years, 93% Hispanic | Urban ambulatory primary care clinic | No statistically significant difference in SBP or DBP for NP vs. MD patients at 2-year follow-up | No difference between care provided by NPs and MDs | Provider & care delivery | 17 |
| Levine 2003 | RCT | Nurse-supervised indigenous CHWs deliver intervention with two different intensity levels to reduce BP | n = 817, 40 months, 100% AA | Urban community clinics | Singinficant decrease in SBP/DBP in both levels of intervention (p < 0.05); significant increase in the percentage with controlled high BP | Nurse-supervised CHW intervention in urban setting improved BP control | Provider & care delivery | 17 |
| Rogers 2001 | RCT | Home BP monitoring service and electronic reports provided weekly to the PCP and patient | n = 121, 11 weeks, 12.3% AA with subgroup analysis | University-affiliated primary care clinics | Among AA patients, MAP decreased by 9.6 mm Hg with home service and increased by 5.25 mm Hg in usual care (p = .047) | Telecommunication service was efficacious in reducing the mean arterial pressure of patients with established HTN | Provider & care delivery | 19 |
| Sanders 2002 | RCT | Chart-based reminder system for patients with HTN and DM | n = 320, 55% AA | Primary care practice of a Veterans Affairs Medical Center | Only 33% of visits resulted in medication change, although BP greater than guideline in 93% of patients | Chart reminder failed to improve MD compliance with the clinical guideline for HTN management in diabetics | Provider & care delivery | 17 |
| Schneider 2005 | RCT | TM vs. PMR vs. HE | n = 150, 1 year 100% AA | Urban community health center | TM group showed decreased BP 3-5 mm Hg and reduced BP medication relative to PMR (p = .001) and HE (p = .09) groups | A stress reduction approach, the Transcendental Mediation Program, may be useful as an adjunct in the treatment of HTN | Patient/family | 18 |
| Svetkey 1999; Bray 2004 | RCT | DASH: randomized controlled feeding study of (1) a diet rich in fruits and vegetables or (2) combination diet rich in fruits, vegetables, and low-fat dairy foods and reduced in saturated fat, total fat, and cholesterol (the DASH combination diet); weight and salt intake were held constant | n = 459, 8 weeks, 60% AA, 6% other minorities | Four academic medical centers | Combination diet: lowered SBP in all subgroups (p < .008), lowered DBP (p < .01) in all but two subgroups; combination diet lowered SBP significantly more in AA (6.8 mm Hg) than whites (3.0 mm Hg) | DASH combination diet may be an effective strategy for preventing and treating HTN in a broad cross-section of the population | Patient/family | 21 |
| Svetkey 2005; Appel 2003; Elmer 2006 | RCT | PREMIER, comprehensive lifestyle on diet, weight, lipids, BP; advice only vs. weight, exercise, EtOH, Na+ (established), vs. est + DASH | n = 810, 18 months, 34% AA with subgroup analysis | Four clinical centers | 18-month follow-up: diet and weight changed, BP marginally so; optimal BP 19% advice only, 30% in est, 35% in est + DASH | DASH modest supplemental help to established interventions; less of an effect with home meal preparation; BP effects greater in patients > 50; AA males and white males most responsive, AA females least | Patient/family | 22 |
| Tao 2003 | Pre/post study | Multidisciplinary HTN clinic: MDs, nurses, pharmacists, and nutritionists assessed and reinforced objectives tailored to individual needs | n = 50, 6 months, 94% AA | Public hospital-based clinic | 58% of patients achieved target BP at 6 months but 22% were lost to follow-up | Multidisciplinary clinic can improve BP control in patients with resistant HTN, at least for the short term | Provider & care delivery | 11 |
| Tobe 2006 | RCT | Home care nurse treatment using predefined HTN algorithm compared to RN home care visits (monitoring only) with MD treatment decisions | n = 95, 12 months, 100% Native American with DM and HTN | Home | SBP down 24 vs. 13.5 in control; albumin excretion no change | Home care nurse monitoring significantly improves SBP; algorithm-driven treatment by RNs provides additional DBP improvement | Provider & care delivery | 21 |
| TOHP Phase I and Phase II 1992, 1997; Kumanyika 2005 | RCT | Telephone-delivered dietary and behavioral change program led by dietitians, psychologists, and health conselors focused reducing Na intake | n = 2,382, 36 months, 18% AA with subgroup analysis | Nine academic medical centers | At 36 months I > C (weight loss, 1.3/0.9 mm Hg; Na reduction, 1.2/0.7 mm Hg; combined, 1.1/0.6 mm Hg) (p < .001), 21% Na reduction participants achieved the targeted level of Na excretion below 80 mmol/24 hr; no variation by race | Through 48 months, the incidence of HTN (140/90) was significantly less in each active intervention group than the usual-care group (average relative risks, 0.78-0.82); modest results with highly motivated and extensively counseled individuals; Na reduction sufficient to help population will be difficult to achieve without food supply changes | Patient/family | 18 |
| Vivian 2002 | RCT | Monthly meetings with a clinical pharmacist who changed drugs, adjusted doses, provided drug counseling, compared to usual MD care | n = 56, 6 months, 77% AA | Veterans Affairs Medical Center | BP < 140/90 attained in 81% of intervention group and 30% in usual care; patient satisfaction and adherence similar | Monthly pharmacist meeting with medication changes and dose adjustment improve BP control | Provider & care delivery | 20 |
| Walker 2000 | RCT | Programmed telephone calls with HTN messages | n = 83, 3 months, 100% AA | Home and outpatient clinic at an academic medical center | No significant improvements in HTN knowledge; SBP and DBP declined for both HTN and control (spiritual messages) | Programmed telephone calls do not improve HTN knowledge or medication adherence | Patient/family | 13 |
Note: AA = African American; BMI = body mass index; BP = blood pressure; C = control; CAD = coronary artery disease; CBC = community-based care; CBM = community-based monitoring; CHW = community health worker; CV = cardiovascular; DASH = Dietary Approaches to Stop Hypertension; DBP = diastolic blood pressure; DM = diabetes mellitus; EPC = enhanced primary care; ER = emergency room; HE = health education; HT = home telemonitoring; HTN = hypertension; I = intervention; LVM = left ventricular mass; MAP = mean arterial pressure; MD = medical doctor; Na = sodium; NP = nurse practitioner; PCP = primary care provider; PMR = progressive muscle relaxation; RCT = randomized controlled trial; RN = registered nurse; SBP = systolic blood pressure; SF = short form; TM = transcendental meditation; TOHP = Trials of Hypertension Prevention; TONE = Trial of Non-Pharmacologic Intervention in the Elderly.