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Tuesday, 19 October 2004

This presentation is part of: Poster Session - Clinical Strategies; Judgment and Decison Making

QUALITY IMPROVEMENT STRATEGIES FOR HYPERTENSION: A SYSTEMATIC REVIEW

Judith Walsh, MD, MPH1, Kathryn M. McDonald, MM2, Kaveh G. Shojania, MD1, Vandana Sundaram, MPH3, Robyn Lewis, MA3, Smita Nayak, MD3, Jody Mechanic, RN3, Douglas K. Owens, MD, MS4, and Mary K. Goldstein, MD3. (1) University of California, San Francisco, Department of Medicine, San Francisco, CA, (2) Stanford University, Center for Primary Care and Outcomes Reasearch, Stanford, CA, (3) Stanford University, Center for Primary Care and Outcomes Research, Stanford, CA, (4) VA Palo Alto Health Care System, Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA

Purpose: We systematically assessed the effect of quality improvement (QI) strategies on hypertension management.

Methods: We searched MEDLINE, Cochrane databases, and bibliographies for experimental evaluations of QI interventions targeting hypertension management. Two reviewers abstracted data and classified each intervention into one or more of the following: provider education, provider reminders, facilitated relay of clinical information, patient education, self-management, patient reminders, audit and feedback, organizational change, or financial incentives. We compared strategies in terms of the median effects on changes in blood pressure or changes in the percentage of individuals achieving a blood pressure goal (%GOAL).

Results: 64 articles reporting 83 comparisons met inclusion criteria. Overall the median reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 4.5 mmHg (interquartile range (IQR): 1.5, 11.0) and 2.1 mmHg (IQR: -0.2, 5.0), respectively. Median increases in %GOAL for SBP and DBP were 16.2% (IQR: 10.3, 32.2), and 6.0% (IQR: 1.5, 17.5). Organizational change was associated with median reductions in SBP and DBP of 9.7 mmHg (IQR 4.2, 14.0) and 4.2 mm Hg (IQR 0.2, 6.8), and median increases in %GOAL for SBP and DBP of 21.8% (IQR: 9.0, 33.8) and 17.0% (IQR: 5.7, 24.5). Patient education was associated with median reductions in SBP and DBP of 8.1 mm Hg (IQR: 3.3, 11.8) and 3.8 mm Hg (IQR: 0.6, 6.7) and median increases in %GOAL for SBP and DBP of 19.2% (IQR: 11.4, 33.2) and 17.0% (IQR: 11.4, 24.5). Facilitated relay was associated with median reductions in SBP and DBP of 8.0 mm Hg (IQR: 2.5, 12.3) and 1.8 mm Hg (IQR –0.1, 4.5), and median increases in %GOAL for SBP and DBP of 25.1% (IQR: 17.0, 34.2) and 2.0% (IQR: 1.6, 5.0). Self-management was associated with median reductions in SBP and DBP of 3.3 mm Hg (IQR: 2.6, 10.1) and 2.8 mm Hg (IQR: 0.4, 6.7), and a median increase in %GOAL for DBP of 9.4% (IQR: 5.3, 11.4). Other strategies were associated with modest improvements in blood pressure outcomes.

Conclusion: Multiple QI strategies are associated with improved hypertension control. Since most studies included more than one QI strategy it is not possible to discern which strategies have the greatest effects. Future research should define the relative contributions of individual strategies within QI initiatives.


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