Multifaceted strategies to improve blood pressure control in a primary care clinic: A quality improvement project

Determinants of hypertension-related knowledge, attitude, and practices (KAP) among caregivers in Neno, rural Malawi: A cross-sectional study

Background

Hypertension, a significant health concern, increases the risk of cardiovascular disease and premature mortality. Caregivers play a crucial role in ensuring optimal care for hypertensive patients and reducing associated complications. Caregivers' basic knowledge, good attitude, and relevant practices are necessary to ensure high-quality care for patients with hypertension. However, there is no research conducted in Malawi that investigated the knowledge, attitude, and practices of caregivers towards hypertension prevention and management.

Objective

The study aimed to assess knowledge, attitude, and practices towards hypertension and their determinants among caregivers of hypertensive patients in Neno, Malawi.

Methods

Our study, conducted in Neno, Malawi, involved 422 caregivers of hypertensive patients. We used a cross-sectional study design. Data was collected through a structured questionnaire and analyzed using SPSS Version 22.0.

Results

The participants had a mean age of 44.94 years (SD = 9.889), with 63.3 % being female. The mean KAP scores were 38 %, 93.3 %, and 78.7 %, respectively. Positive correlations were found between knowledge and practice (r = +0.252; p < 0.001) and knowledge and attitude (r = +0.255; p < 0.001). However, no significant relationship was observed between attitude and practice (r = +0.064; p = 0.190). Age showed a strong correlation with attitude (r = +0.233; p < 0.001) but not with knowledge or practice. On the other hand, occupation, education level, and caregiver-patient relationship significantly influenced knowledge and attitude but not practice. Gender also demonstrated a notable association with KAP regarding hypertension.

Conclusion

Caregivers demonstrated poor knowledge but engaged in good practices. Despite their limited understanding, they maintained an excellent attitude towards hypertension. This highlights the necessity for increased prevention, and control strategies within communities, emphasizing health education on lifestyle modifications and to address the gaps identified in caregivers' understanding in the prevention and management of hypertension.

An Intersectoral Approach to Hypertension Care: Solutions for Improving Blood Pressure Control in São Paulo, Brazil

BACKGROUND

Hypertension is the leading risk factor for cardiovascular diseases (CVDs) and a major public health issue worldwide. In Brazil, it affects approximately 52.5% of the adult population. We describe the solutions package and the impact of a population health initiative in São Paulo city, following the CARDIO4Cities approach for the management of cardiovascular risk.

METHODS

Using a design thinking approach, interventions were developed with a coalition of local and international stakeholders to address needs of patients, healthcare professionals, and the health system. The resulting solution package was checked to comply with guidelines for non-communicable disease and hypertension management. Clinical impact was measured by extracting the hypertension cascade of care-monitored, diagnosis, treatment, and control-from medical records.

RESULTS

Under the leadership of the municipal health authorities, nine solutions were piloted and scaled across the city. Solutions conform with local and international best-practices. Between October 2017 and December 2021, 11,406 patient records were analyzed. Results showed a 40% increase in monitored patients (patients with at least one blood pressure, BP, measurement); reduced proportions of patients diagnosed among those with available BP measurements (72%-53%) and treated among diagnosed (93%-85%); and an improvement in controlled patients among those receiving treatment (16%-27%).

CONCLUSIONS

The solution package described in this study was correlated with increased BP control. The implementation methodology and results add to the body of real-world evidence supporting population health implementation science in Brazil and beyond.

Development and Implementation of an Escalation Protocol for Internal Medicine Trainees

Background

Overnight, physicians in training receive less direct supervision. Decreased direct supervision requires trainees to appropriately assess patients at risk of clinical deterioration and escalate to supervising physicians. Failure of trainees to escalate contributes to adverse patient safety events.

Objective

To standardize the evaluation of patients at risk of deterioration overnight by internal medicine residents, increase communication between residents and supervising physicians, and improve perceptions of patient safety at a tertiary academic medical center.

Methods

A multidisciplinary stakeholder team developed an overnight escalation-of-care protocol for residents. The protocol was implemented with badge buddies and an educational campaign targeted at residents, supervising physicians, and nursing staff. Residents and supervising physicians completed anonymous surveys to assess the use of the protocol; the frequency of overnight communication between residents and supervising physicians; and perceptions of escalation and patient safety before, immediately after ("early postintervention"), and 8 months after ("delayed postintervention") the intervention.

Results

Seventy-five (100%) residents participated in the intervention, and 57-89% of those invited to complete surveys at the various time points responded. After the intervention, 82% of residents reported using the protocol, though no change was observed in the frequency of communication between residents and supervising physicians. After the implementation, residents perceived that patient care was safer (early postintervention, 47%; delayed postintervention, 72%; P = 0.02), and interns expressed decreased fear of waking and being criticized by supervising physicians.

Conclusion

An escalation-of-care protocol was developed and successfully implemented using a multimodal approach. The implementation and dissemination of the protocol standardized resident escalation overnight and improved resident-perceived patient safety and interns' comfort with escalation.

Long-term Outcomes of a 1-year Hypertension Quality Improvement Initiative in a Large Health System

BACKGROUND

Understanding whether practices retain outcomes attained during a quality improvement (QI) initiative can inform resource allocation.

OBJECTIVE

We report blood pressure (BP) control and medication intensification in the 3 years after a 2016 QI initiative ended.

RESEARCH DESIGN

Retrospective cohort.

SUBJECTS

Adults with a diagnosis of hypertension who had a primary care visit in a large-integrated health system between 2015 and 2019.

MEASURES

We report BP control (<140/90 mm Hg) at the last reading of each year. We used a multilevel regression to identify the adjusted propensity to receive medication intensification among patients with an elevated BP in the first half of the year. To examine variation, we identified the average predicted probability of control for each practice. Finally, we grouped practices by the proportion of their patients whose BP was controlled in 2016: lowest performing (<75%), middle (≥75%-<85%), and highest performing (≥85%).

RESULTS

The dataset contained 184,981 patients. From 2015 to 2019, the percentage of patients in control increased from 74% to 82%. In 2015, 38% of patients with elevated BP received medication intensification. This increased to 44% in 2016 and 50% in 2019. Practices varied in average BP control (from 62% to 91% in 2016 and 68% to 90% in 2019). All but one practice had a substantial increase from 2015 to 2016. Most maintained the gains through 2019. Higher-performing practices were more likely to intensify medications than lower-performing practices.

CONCLUSIONS

Most practices maintained gains 3 years after the QI program ended. Low-performing practices should be the focus of QI programs.

Intensifying approaches to address clinical inertia among cardiovascular disease risk factors: A narrative review

OBJECTIVE

Clinical inertia, the absence of treatment initiation or intensification for patients not achieving evidence-based therapeutic goals, is a primary contributor to poor clinical outcomes. Effectively combating clinical inertia requires coordinated action on the part of multiple representatives including patients, clinicians, health systems, and the pharmaceutical industry. Despite intervention attempts by these representatives, barriers to overcoming clinical inertia in cardiovascular disease (CVD) risk factor control remain.

METHODS

We conducted a narrative literature review to identify individual-level and multifactorial interventions that have been successful in addressing clinical inertia.

RESULTS

Effective interventions included dynamic forms of patient and clinician education, monitoring of real-time patient data to facilitate shared decision-making, or a combination of these approaches. Based on findings, we describe three possible multi-level approaches to counter clinical inertia - a collaborative approach to clinician training, use of a population health manager, and use of electronic monitoring and reminder devices.

CONCLUSION

To reduce clinical inertia and achieve optimal CVD risk factor control, interventions should consider the role of multiple representatives, be feasible for implementation in healthcare systems, and be flexible for an individual patient's adherence needs.

PRACTICE IMPLICATIONS

Representatives (e.g., patients, clinicians, health systems, and the pharmaceutical industry) could consider approaches to identify and monitor non-adherence to address clinical inertia.

Identifying Root Causes of Important Service Failures across Medical Examination Processes with Integration of 4M1E, ITLV, GRA, DEMATEL and FMEA

Medical examination plays an essential role in most medical treatment processes, and thus, the quality of service relevant to medical examination has great impact on patient satisfaction. The targeted hospital has long been faced with the problem that patient satisfaction of its medical examination department is below average. An assessment model, integrating 4M1E, ITLV, GRA, DEMATEL and FMEA, was developed in this study to identify the root causes of important service failures across medical examination processes, where (1) a cause-and-effect diagram was enhanced with 4M1E, identifying the list of failure modes relevant to service quality over the medical examination process with the 4M1E analysis framework, (2) FMEA experts were enabled to report their assessment results in their preferred ways by using the ITLV scheme, (3) causes of failure to failure modes with was figured out with DEMATEL, and (4) the evaluation results were improved by integrating GRA. Experimental results obtained by the proposed approach are compared with several benchmarks, and it was observed that (1) the results obtained by the proposed model are more suitable when FMEA experts prefer using different assessment languages versus other approaches; (2) the proposed model can figure out the key root causes according to their impact on overall failure modes.

Disparities in Prevalence and Barriers to Hypertension Control: A Systematic Review

Controlling hypertension (HTN) remains a challenge, as it is affected by various factors in different settings. This study aimed to describe the disparities in the prevalence and barriers to hypertension control across countries of various income categories. Three scholarly databases-ScienceDirect, PubMed, and Google Scholar-were systematically examined using predefined search terms to identify potentially relevant studies. Original research articles published in English between 2011 and 2022 that reported the prevalence and barriers to HTN control were included. A total of 33 studies were included in this systematic review. Twenty-three studies were conducted in low and middle-income countries (LMIC), and ten studies were from high-income countries (HIC). The prevalence of hypertension control in the LMIC and HIC studies ranged from (3.8% to 50.4%) to (36.3% to 69.6%), respectively. Concerning barriers to hypertension control, patient-related barriers were the most frequently reported (n = 20), followed by medication adherence barriers (n = 10), lifestyle-related barriers (n = 8), barriers related to the affordability and accessibility of care (n = 8), awareness-related barriers (n = 7), and, finally, barriers related to prescribed pharmacotherapy (n = 6). A combination of more than one category of barriers was frequently encountered, with 59 barriers reported overall across the 33 studies. This work reported disparities in hypertension control and barriers across studies conducted in LMIC and HIC. Recognizing the multifactorial nature of the barriers to hypertension control, particularly in LMIC, is crucial in designing and implementing customized interventions.

Strategies to improve blood pressure control: A step forward to winning the battle

OBJECTIVE

Hypertension represents a common risk factor for all major cardiovascular diseases. The issue of inappropriate blood pressure control in the hypertensive population is a worldwide still unsolved problem, with heavy consequences on the health care systems. A call to action is required to optimize blood pressure control and to reduce the cardiovascular risk.

METHODS AND RESULTS

In this issue of the journal a new study presents the results of a multifaceted complex approach, in the context of a quality improvement program, through the involvement of a high functioning multidisciplinary team. A patient population largely underprivileged, urban and 75% African American, referring to an Internal Medicine Clinic, included a large majority of hypertensive patients with inappropriate blood pressure control. By addressing identified barriers to achieve optimal blood pressure control, the current improvement program pursued the education of physicians, nurses and patients as a key driver to optimize patients-provider communication and to achieve a satisfactory final result.

CONCLUSIONS

The strategy described in the study by Sadeghi et al. allowed to maintain positive results for one year and thereafter. Despite some weaknesses, this multifaceted complex approach deserves particular attention since it describes relevant findings that represent a significant step forward to improving blood pressure control in the hypertensive population.