Check and Support -Enhancing the Treatment of Hypertension in Outpatient Care, a Multicenter Study
- Conditions
- Patient AdherenceMedication AdherenceBlood PressurePatient ComplianceHypertension
- Interventions
- Behavioral: IMB model-based initiation of antihypertensive medicationBehavioral: Usual careBehavioral: Tailored SMS-text message support
- Registration Number
- NCT02377960
- Lead Sponsor
- Kuopio University Hospital
- Brief Summary
The purpose of this pragmatic multi-centre, cluster randomized controlled trial is to test the effectiveness of tailored SMS-text message support combined with an information-motivation-behavioral skills (IMB) model-based initiation of medication in helping outpatient care patients with hypertension to achieve blood pressure target and to enhance medication adherence.
- Detailed Description
Background
Usual blood pressure is strongly related to vascular and overall mortality and high blood pressure is globally the leading risk factor for cardiovascular and related diseases. It is also well established that pharmacologic blood pressure reduction prevents cardiovascular events and deaths in persons with hypertension.
Today's physicians have plenty of knowledge and multiple effective and safety tools to treat hypertension but still majority of patients with antihypertensive medication do not achieve the blood pressure target. Poor medication adherence has been widely accepted to be the most important factor in failing to control hypertension and even 50% of hypertensive patients quit the antihypertensive medication during the first year of medication.
Numerous interventions to enhance medication adherence have been developed but even though, an intervention effective, simple and low cost enough to be carried out wide-scale in non-research settings is still to be found.
Objectives
To test whether a tailored SMS-text message support combined with an IMB model-based initiation of medication will increase the proportion of patients achieving the systolic blood pressure target at 12-month follow-up compared to usual care.
Additional objectives include investigating whether the intervention have effect on
* Medication adherence
* Systolic and diastolic blood pressure level
* Hypertension-related use of health care services
* Blood glucose, blood cholesterol, microalbuminuria, creatinine, ECG, body mass index, waist circumference exercising habits, smoking and alcohol use
* Perceived quality of life at base line and at 12-month follow-up
* Setting (physicians) and knowing (participants) an adequate BP target
And, besides
Detecting the participants who especially benefit from intervention
* Analyzing the quality and quantity of self-monitored BP and
* Assessing whether the IMB model-based structured initiation of medication can be used for screening of non-compliant patients and directing resources more accurately to them
* Collecting and analyzing participants' and physicians' feedback for future development of intervention
Study design
Pragmatic randomized controlled multicenter trial. The eight study centers are grouped to comparable pairs and randomized to function as intervention and control sites (2-cluster design).
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 119
- A clinical diagnosis of hypertension
- About to start medication for hypertension for the first time
- Aged 30-75 years
- Must own a mobile phone
- Must be able to read text messages
- Must be able to master own medication
- Must be able to perform home BP measurements
- Must agree in using electric drug prescription (standard in Finnish health care)
- Having or is suspected to have depression or psychosis
- Serious disease, which is evaluated to have an impact on life expectancy
- Atrial flutter or atrial fibrillation
- Previous history of antihypertensive medication
- Pregnancy
- Not willing to give informed consent and take part in the study
- Systolic BP more than 200 mmHg
- Diastolic BP more than 120 mmHg
- Sudden onset or worsening of hypertension
- Clinical signs of kidney disease: proteinuria (du-prot > 500 mg), glomerulus filtration rate (eGFR) less than 45 ml/min or hypokalemia
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Tailored SMS-text message support Tailored SMS-text message support Tailored SMS-text message support for the first 12 months of medication. At the beginning (2 weeks), text messages are send on daily basis and focused on medications-reminders and coping with potential side-effects of medication. After that, text messages will be sent less often and the focus will change to keeping up with medication and reminding of importance of performing adequate home BP self-monitoring, achieving the BP target and attending clinical appointments. An IMB model-based initiation of medication Tailored SMS-text message support In addition to usual care, participants allocated to intervention group will receive An IMB model-based initiation of medication i.e. a nine-point check list to be fulfilled by physician and patient together when ordering the antihypertensive medication for the first time Tailored SMS-text message support IMB model-based initiation of antihypertensive medication Tailored SMS-text message support for the first 12 months of medication. At the beginning (2 weeks), text messages are send on daily basis and focused on medications-reminders and coping with potential side-effects of medication. After that, text messages will be sent less often and the focus will change to keeping up with medication and reminding of importance of performing adequate home BP self-monitoring, achieving the BP target and attending clinical appointments. Usual care (Reference group) Usual care Treatment is leaded by treating physician according to national guide lines with no study-specific medication or clinical appointment protocol. An IMB model-based initiation of medication IMB model-based initiation of antihypertensive medication In addition to usual care, participants allocated to intervention group will receive An IMB model-based initiation of medication i.e. a nine-point check list to be fulfilled by physician and patient together when ordering the antihypertensive medication for the first time
- Primary Outcome Measures
Name Time Method The proportion of patients achieving the systolic blood pressure target at 12-month follow-up 12 months from baseline The proportion of patients (%) achieving systolic office blood pressure (BP) target (\<140 mmHg) and home BP target (\<135 mmHg) are both analyzed separately using mixed effects model.
Both office BP and home BP are measured with a validated blood pressure monitoring device (Microlife Watch BP Home A or Microlife Watch BP Home N) after appropriate rest from the left arm with an appropriately sized semi-rigid conical cuff. Office BP is the mean of three measurements separated by 15 seconds. Home BP is measured correspondingly three times in the morning and in the evening on 7 consecutive days at 12 months. Home BP is the mean of all available measurements.
- Secondary Outcome Measures
Name Time Method Hypertension-related use of health care services 0-12 months from baseline Hypertension-related use of health care services (outpatient care and hospital admissions) is assessed by examining participants' electronic health records and with a questionnaire regarding the use of health services other than study centers. Proportion of scheduled clinic appointments attended is also analyzed.
The proportion of participants knowing the adequate home BP target baseline and 12 months from baseline Knowing the target is assessed by questionnaire at baseline and at 12 months. The results are divided into three groups: (i) knows the adequate target (ii) knows the target but it is not adequate (iii) do not know the target.
The target is considered adequate if it differs less than 5/3 mmHg from the Finnish national guide lines for treating hypertension (Office BP target \<140/90 mmHg except diabetics \<140/80 mmHg. Home BP target \<135/85 mmHg except diabetics \<135/75 mmHg)Blood glucose level baseline and 12 months from baseline Blood glucose level is tested at baseline (timeframe 6 months before - 1 month after initiation of medication) and at 12 months.
Measured medication adherence 12 months from baseline Medication adherence is assessed by pharmacy refill data and by self-report strategy (Morisky Medication Adherence Scale, MMAS-8). Tresholds for good adherence are correspondingly (i) Medication possession ratio (MPR) 80 % or more and (ii) MMAS-8 with a score of 6 or more. Both are analyzed separately using generalized mixed effects model.
Besides, medication adherence is analyzed as follows:
* Persistence: time (days) from the newly initiated medication order to (i) last dispensation before failing to refill within 180 days or (ii) end of follow-up period
* Early non-persistence: newly initiated medication order dispensed within 30 days of the initial order with no refills within 180 days
* Primary non-adherence: newly initiated medication order not dispensed within 30 days of the initial orderChange in systolic and diastolic blood pressure 12 months from baseline Both office BP and home BP are measured with a validated blood pressure monitoring device (Microlife Watch BP Home A or Microlife Watch BP Home N) after appropriate rest from the left arm with an appropriately sized semi-rigid conical cuff. Office BP is the mean of three measurements separated by 15 seconds. Home BP is measured correspondingly three times in the morning and evening on 7 consecutive days at 12 months. Home BP is the mean of all available measurements.
Change in office BP and home BP are both analyzed separately using generalized mixed effects model. Change in systolic and diastolic blood pressure are as well both analyzed separately using generalized mixed effects model.Blood cholesterol level baseline and 12 months from baseline Blood cholesterol level is tested at baseline (timeframe 6 months before - 1 month after initiation of medication) and at 12 months.
Microalbuminuria baseline and 12 months from baseline The presence of microalbuminuria is tested at baseline (timeframe 6 months before - 1 month after initiation of medication) and at 12 months.
Creatinine level baseline and 12 months from baseline Creatinine level is tested at baseline (timeframe 6 months before - 1 month after initiation of medication) and at 12 months.
Alcohol use baseline and 12 months from baseline Every participant meets a query measuring participants' alcohol use (Audit-c) at baseline and at 12 months.
Perceived quality of life baseline and 12 months from baseline Perceived quality of life is assessed by EQ-5D-5L questionnaire
The proportion of patients whose BP target is adequately set 12 months from baseline Setting the target is assessed by examining the electric health record at 12 months The results are divided into three groups: (i) written target is set and adequate (ii) written target is set but not adequate and (iii) written target is not set.
The target is considered adequate if it differs less than 5/3 mmHg from the national guide lines for treating hypertension (Office BP target \<140/90 mmHg except diabetics \<140/80 mmHg. Home BP target \<135/85 mmHg except diabetics \<135/75 mmHg)The quality and quantity of self-monitored blood pressure baseline and 12 months from baseline The quality and quantity of self-monitored blood pressure measurements made prior to follow-up period is assessed first at base line. All participants are then equipped with a validated blood pressure monitoring device (Microlife Watch BP Home A or Microlife Watch BP Home N) with a memory space up to 250 measurements. The quality and quantity of self-monitored blood pressure measurements during the follow-up is assessed by examining the memory of every single device at and,the written follow-up form filled up by each participant at 12 months.
The target is considered adequate if it differs less than 5/3 mmHg from the national guide lines for treating hypertension (Office BP target \<140/90 mmHg except diabetics \<140/80 mmHg. Home BP target \<135/85 mmHg except diabetics \<135/75 mmHg)ECG baseline and 12 months from baseline ECG is taken at baseline (timeframe 6 months before - 1 month after initiation of medication) and at 12 months.
Body mass index baseline and 12 months from baseline Participant's height and weight are measured by nurse/treating physician and BMI calculated at baseline and at 12 month.
Waist circumference baseline and 12 months from baseline Participant's waist circumference is measured by nurse/treating physician at baseline and at 12 month.
Exercising habits baseline and 12 months from baseline Every participant meets a query measuring participants' exercising habits (Kasari -index) at baseline and at 12 months.
Smoking baseline and 12 months from baseline Every participant meets a query measuring participants' smoking (Heaviness of smoking -index) at baseline and at 12 months.
Trial Locations
- Locations (6)
Mehiläinen Jyväskylä Occupational Health Services
🇫🇮Jyväskylä, Finland
Oma Lääkärisi Korpilahti
🇫🇮Jyväskylä, Finland
Sote kuntayhtymä/Perusturvaliikelaitos Saarikka
🇫🇮Saarijärvi, Finland
Oma Lääkärisi Tikkakoski
🇫🇮Jyväskylä, Finland
Health Centre of Jyväskylä Cooperation Area
🇫🇮Jyväskylä, Finland
Central Finland Hospital District (Perusterveydenhuollon liikelaitos Seututerveyskeskus)
🇫🇮Jyväskylä, Finland