We examined the effects of two interventions—a basic information-based intervention and an augmented, nurse-led intervention—designed to improve patients’ BP outcomes through changes in the delivery of home-based post-acute care. The study demonstrated that the nurse-led intervention, providing additional medication review and patient self-management support during the 3-month post-acute care period, significantly improved BP control in a high-risk, low income black population admitted to care with JNC7 stage 2 HTN. Relative to usual care, the augmented intervention dramatically increased the probability of 3-month BP control (17.6 vs 8.9% adjusted control) among stage 2 patients. The augmented intervention also yielded an 8.3-mmHg relative reduction in SBP and a 29% relative increase in the proportion of stage 2 patients achieving at least a 20 mmHg reduction in SBP.
The findings are particularly important given the HTN-related risk profile of the study population, all uncontrolled at baseline. National data show that BP control is especially problematic for blacks, women, persons aged 70 and over, individuals with diabetes, and those who have less than a high school education1,3,16
. In this black study population, approximately a fifth were 75 or older17
, 42% had less than a high school education, 45% had an annual income of $10,000 or less, 53% were JNC7 stage 2 at baseline, and 59% had diabetes. Our study thus focused on a much higher risk population than previous HTN interventions.
The finding of significant intervention effects solely among patients with severe uncontrolled HTN, although disappointing, is not surprising. The majority of community-based HTN intervention trials enroll provider and/or patient volunteers18
, who may be more focused on or motivated to achieve BP control than participants in our study. Second, evidence suggests considerable provider inertia in adjusting BP medications among patients with lower disease severity19
. Third, patients themselves may be less adherent to medications and more reluctant to seek adjustment or adopt therapeutic lifestyle changes when BP values are perceived as within an “acceptable range”20
. Our approach of examining the interventions’ effectiveness by HTN severity, although initially unplanned, highlights the importance of targeting specific types of intervention to specific patient severity groups.
The study has several limitations. First, it is based on black patients served by a single, albeit large, home health organization providing care to an urban patient population that is poorer, less well educated, and more culturally diverse than the population typically served by post-acute home care organizations17
. Generalizability of findings to other groups is thus unclear. Second, randomization occurred at the nurse rather than the patient level. Third, the study was powered to discern significant effects for all uncontrolled patients, while significant outcomes were limited to the patient subgroup with stage 2 HTN. Although ideally subgroup effects would have been incorporated in the study’s initial design, the baseline distribution of patients by stage was unavailable a priori and therefore could provide no guidelines for power analysis. Nevertheless, the sub-group effects were sufficiently robust to achieve statistical significance despite the smaller sample size. Lastly, the BP improvements reported here were measured at 3 months, and it is possible that the intervention’s effects may have dissipated over a longer time period21
Home health patients are an especially high-risk group characterized by multiple comorbid conditions and medications22
. Keeping abreast of evidence-based practices, supporting patients’ adherence to physician-prescribed medication regimens and appropriate lifestyle changes, and linking patients to other medical and community resources are central to the nurse’s role. However, the potential for improving HTN management for this chronically ill and costly population has not been exploited. The results reported here, however, demonstrate that augmenting home health care can
significantly improve BP outcomes among black patients with severe uncontrolled HTN. The study’s cost findings suggest that in the short-term, such a home-based post-acute care intervention would be cost-neutral with respect to overall (inpatient + outpatient) costs, thus providing policy-relevant information for designing and targeting future transitional care demonstrations. These findings represent the first RCT-derived evidence estimating the effects of a transitional care intervention for post-acute home care patients otherwise at risk of “slipping through” the system with suboptimal BP management.