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Margolis KL, Bergdall AR, Crain AL, JaKa MM, Anderson JP, Solberg LI, Sperl-Hillen J, Beran MS, Green BB, Haugen P, Norton CK, Kodet AJ, Sharma R, Appana D, Trower NK, Pawloski PA, Rehrauer DJ, Simmons ML, McKinney ZJ, Kottke TE, Ziegenfuss JY, Williams RA, O’Connor PJ. Comparing Pharmacist-Led Telehealth Care and Clinic-Based Care for Uncontrolled High Blood Pressure: The Hyperlink 3 Pragmatic Cluster-Randomized Trial. Hypertension 2022; 79:2708-2720. [PMID: 36281763 PMCID: PMC9649877 DOI: 10.1161/hypertensionaha.122.19816] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND A team approach is one of the most effective ways to lower blood pressure (BP) in uncontrolled hypertension, but different models for organizing team-based care have not been compared directly. METHODS A pragmatic, cluster-randomized trial compared 2 interventions in adult patients with moderately severe hypertension (BP≥150/95 mm Hg): (1) clinic-based care using best practices and face-to-face visits with physicians and medical assistants; and (2) telehealth care using best practices and adding home BP telemonitoring with home-based care coordinated by a clinical pharmacist or nurse practitioner. The primary outcome was change in systolic BP over 12 months. Secondary outcomes were change in patient-reported outcomes over 6 months. RESULTS Participants (N=3071 in 21 primary care clinics) were on average 60 years old, 47% male, and 19% Black. Protocol-specified follow-up within 6 weeks was 32% in clinic-based care and 27% in telehealth care. BP decreased significantly during 12 months of follow-up in both groups, from 157/92 to 139/82 mm Hg in clinic-based care patients (adjusted mean difference -18/-10 mm Hg) and 157/91 to 139/81 mm Hg in telehealth care patients (adjusted mean difference -19/-10 mm Hg), with no significant difference in systolic BP change between groups (-0.8 mm Hg [95% CI, -2.84 to 1.32]). Telehealth care patients were significantly more likely than clinic-based care patients to report frequent home BP measurement, rate their BP care highly, and report that BP care visits were convenient. CONCLUSIONS Telehealth care that includes extended team care is an effective and safe alternative to clinic-based care for improving patient-centered care for hypertension. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02996565.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Beverly B. Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
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Margolis KL, Crain AL, Green BB, O'Connor PJ, Solberg LI, Beran M, Bergdall AR, Pawloski PA, Ziegenfuss JY, JaKa MM, Appana D, Sharma R, Kodet AJ, Trower NK, Rehrauer DJ, McKinney Z, Norton CK, Haugen P, Anderson JP, Crabtree BF, Norman SK, Sperl-Hillen JM. Comparison of explanatory and pragmatic design choices in a cluster-randomized hypertension trial: effects on enrollment, participant characteristics, and adherence. Trials 2022; 23:673. [PMID: 35978336 PMCID: PMC9387034 DOI: 10.1186/s13063-022-06611-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background Explanatory trials are designed to assess intervention efficacy under ideal conditions, while pragmatic trials are designed to assess whether research-proven interventions are effective in “real-world” settings without substantial research support. Methods We compared two trials (Hyperlink 1 and 3) that tested a pharmacist-led telehealth intervention in adults with uncontrolled hypertension. We applied PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) scores to describe differences in the way these studies were designed and enrolled study-eligible participants, and the effect of these differences on participant characteristics and adherence to study interventions. Results PRECIS-2 scores demonstrated that Hyperlink 1 was more explanatory and Hyperlink 3 more pragmatic. Recruitment for Hyperlink 1 was conducted by study staff, and 2.9% of potentially eligible patients enrolled. Enrollees were older, and more likely to be male and White than non-enrollees. Study staff scheduled the initial pharmacist visit and adherence to attending this visit was 98%. Conversely for Hyperlink 3, recruitment was conducted by clinic staff at routine encounters and 81% of eligible patients enrolled. Enrollees were younger, and less likely to be male and White than non-enrollees. Study staff did not assist with scheduling the initial pharmacist visit and adherence to attending this visit was only 27%. Compared to Hyperlink 1, patients in Hyperlink 3 were more likely to be female, and Asian or Black, had lower socioeconomic indicators, and were more likely to have comorbidities. Owing to a lower BP for eligibility in Hyperlink 1 (>140/90 mm Hg) than in Hyperlink 3 (>150/95 mm Hg), mean baseline BP was 148/85 mm Hg in Hyperlink 1 and 158/92 mm Hg in Hyperlink 3. Conclusion The pragmatic design features of Hyperlink 3 substantially increased enrollment of study-eligible patients and of those traditionally under-represented in clinical trials (women, minorities, and patients with less education and lower income), and demonstrated that identification and enrollment of a high proportion of study-eligible subjects could be done by usual primary care clinic staff. However, the trade-off was much lower adherence to the telehealth intervention than in Hyperlink 1, which is likely to reflect uptake under real-word conditions and substantially dilute intervention effect on BP. Trial registration The Hyperlink 1 study (NCT00781365) and the Hyperlink 3 study (NCT02996565) are registered at ClinicalTrials.gov.
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Affiliation(s)
- Karen L Margolis
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA.
| | - A Lauren Crain
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Av, Seattle, WA, 98101, USA
| | - Patrick J O'Connor
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Leif I Solberg
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - MarySue Beran
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Anna R Bergdall
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Pamala A Pawloski
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Jeanette Y Ziegenfuss
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Meghan M JaKa
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Deepika Appana
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Rashmi Sharma
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Amy J Kodet
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Nicole K Trower
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Daniel J Rehrauer
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Zeke McKinney
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Christine K Norton
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Patricia Haugen
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Jeffrey P Anderson
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, New Brunswick, NJ, 08901, USA
| | - Sarah K Norman
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
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Richesson RL, Marsolo KS, Douthit BJ, Staman K, Ho PM, Dailey D, Boyd AD, McTigue KM, Ezenwa MO, Schlaeger JM, Patil CL, Faurot KR, Tuzzio L, Larson EB, O'Brien EC, Zigler CK, Lakin JR, Pressman AR, Braciszewski JM, Grudzen C, Fiol GD. Enhancing the use of EHR systems for pragmatic embedded research: lessons from the NIH Health Care Systems Research Collaboratory. J Am Med Inform Assoc 2021; 28:2626-2640. [PMID: 34597383 PMCID: PMC8633608 DOI: 10.1093/jamia/ocab202] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/05/2021] [Accepted: 09/02/2021] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE We identified challenges and solutions to using electronic health record (EHR) systems for the design and conduct of pragmatic research. MATERIALS AND METHODS Since 2012, the Health Care Systems Research Collaboratory has served as the resource coordinating center for 21 pragmatic clinical trial demonstration projects. The EHR Core working group invited these demonstration projects to complete a written semistructured survey and used an inductive approach to review responses and identify EHR-related challenges and suggested EHR enhancements. RESULTS We received survey responses from 20 projects and identified 21 challenges that fell into 6 broad themes: (1) inadequate collection of patient-reported outcome data, (2) lack of structured data collection, (3) data standardization, (4) resources to support customization of EHRs, (5) difficulties aggregating data across sites, and (6) accessing EHR data. DISCUSSION Based on these findings, we formulated 6 prerequisites for PCTs that would enable the conduct of pragmatic research: (1) integrate the collection of patient-centered data into EHR systems, (2) facilitate structured research data collection by leveraging standard EHR functions, usable interfaces, and standard workflows, (3) support the creation of high-quality research data by using standards, (4) ensure adequate IT staff to support embedded research, (5) create aggregate, multidata type resources for multisite trials, and (6) create re-usable and automated queries. CONCLUSION We are hopeful our collection of specific EHR challenges and research needs will drive health system leaders, policymakers, and EHR designers to support these suggestions to improve our national capacity for generating real-world evidence.
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Affiliation(s)
- Rachel L Richesson
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Keith S Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian J Douthit
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,US Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Karen Staman
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - P Michael Ho
- Department of Medicine, University of Colorado Medicine, Denver, Colorado, USA
| | - Dana Dailey
- Center for Health Sciences, St. Ambrose University, Davenport, Iowa and Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA
| | - Andrew D Boyd
- Department of Biomedical and Health Information Sciences University of Illinois Chicago, Chicago, Illinois, USA
| | - Kathleen M McTigue
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Miriam O Ezenwa
- Department of Biobehavioral Nursing Science, University of Florida, College of Nursing, Gainesville, Florida, USA
| | - Judith M Schlaeger
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois, USA
| | - Crystal L Patil
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois, USA
| | - Keturah R Faurot
- Department of Physical Medicine and Rehabilitation, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christina K Zigler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joshua R Lakin
- Palliative Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alice R Pressman
- Center for Health Systems Research, Sutter Health Center for Health Systems Research, Walnut Creek, California, USA
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
| | - Corita Grudzen
- Department of Emergency Medicine, New York University School of Medicine, New York, New York, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
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