Hypertension Self-management: The use of Telemedicine as an Intervention Tool Hayden Bosworth, Ph.D. Center for Health Services Research in Primary Care,

Hypertension Hypertension Self-management: The use Self-management: The use

of Telemedicine as an of Telemedicine as an Intervention ToolIntervention ToolHayden Bosworth, Ph.D. Hayden Bosworth, Ph.D.

Center for Health Services Research in Center for Health Services Research in Primary Care, Durham VA Medical CenterPrimary Care, Durham VA Medical Center

Departments of Medicine, Psychiatry and Departments of Medicine, Psychiatry and School of NursingSchool of Nursing

Duke University Medical CenterDuke University Medical Center

Outline

Prevalence and Impact of Hypertension Chronic Disease Self-management: Barriers

and Facilitators Translation Studies

– Veterans Study to Improve The Control of Hypertension

(V-STITCH)– Hypertension Intervention Telemedicine Study (HINTS)

Take Home Messages Future Directions

Prevalence of HypertensionPrevalence of Hypertension

1 in 3 adult Americans 1 in 3 adult Americans

~ 65 million Americans ~ 65 million Americans ((JAMAJAMA 2003) 2003)

– ~45 million prehypertensive~45 million prehypertensive

~ 8 million veterans (37%) ~ 8 million veterans (37%) ((Med Care Res Rev 2003Med Care Res Rev 2003))

Lifetime risk for normotensive 55 Lifetime risk for normotensive 55 year old: 90% year old: 90% (JAMA (JAMA

2003)2003)

Hypertension Treatment FactsHypertension Treatment Facts

Life Style Matters– Weight Loss (any means)– DASH Diet– Low Na Diet– Exercise– Limited Alcohol

Medications Work– Nothing Better Than Thiazide Diuretics– Most Patients Require > 2 medications

Goal of HypertensionGoal of HypertensionSelf-management Self-management

Hypertension as a Model for Hypertension as a Model for Self-managementSelf-management

Complex, long-term, chronic diseaseComplex, long-term, chronic diseaseRequires initiation and maintenance Requires initiation and maintenance

of multiple behaviorsof multiple behaviorsRequires provider/patient Requires provider/patient

communicationcommunication

Significance of Self-management Significance of Self-management AdherenceAdherence

>80% of adults took at least 1 medication in the last week; 25% took at least five

Cost of medication non-adherence >$100 billion/year

~50% of patients non-adherent with medication

Rates of non-adherence higher in lifestyle recommendations

~50% of treatment failures are due to unrecognized patient non-adherence

Traditional Paradigms FailTraditional Paradigms Fail

clinical trial information alone does not result in adequate BP control

Specialist-based care not solutionPrimary care clinic based

management is not sufficient– Frequent contact with doctors in clinics

does not lead to BP control

Disease Management Disease Management Hypertension: EvidenceHypertension: Evidence

Cochrane review (2006)– 59 trials

• Reduces SBP (8-10 mm Hg))• Reduces DBP (4-7 mm Hg)• Improves all cause mortality

– Self-monitoring alone (17 trials)• Reduces DBP by 2 mm Hg

Health Decision Health Decision ModelModel

Social EnvironmentSocial Environment

TREATMENT ADHERENCE TREATMENT ADHERENCE

Provider CharacteristicsProvider Characteristics

Communication Communication StyleStyle

Medical EnvironmentMedical Environment

Bosworth HB, Olsen MK, Oddone EZ. Bosworth HB, Olsen MK, Oddone EZ. (2006). Am Heart J 149:795-803.l(2006). Am Heart J 149:795-803.lBosworth HB & Oddone EZ. (2002). Bosworth HB & Oddone EZ. (2002). J Nat Med Ass. 94; 236-248J Nat Med Ass. 94; 236-248

LiteracyLiteracy

PerceivedPerceived RisksRisks

Patient CharacteristicsPatient Characteristics

Coping & Coping & StressStress

Side EffectsSide EffectsComorbiditiesComorbidities

DepressionDepressionMental HealthMental Health

CognitionCognition Medication Medication RegimenRegimen

Treatment Treatment Guidelines Guidelines AdherenceAdherence

Intensity of Intensity of TherapyTherapy

BLOOD PRESSURE CONTROL BLOOD PRESSURE CONTROL

PolicyPolicy

Patient Characteristics RelatedPatient Characteristics Relatedto Self-managementto Self-management

1.1. Risk Perceptions / KnowledgeRisk Perceptions / Knowledge

2.2. Cognition Cognition • MemoryMemory• Inductive ReasoningInductive Reasoning• Verbal ComprehensionVerbal Comprehension

3.3. Literacy / NumeracyLiteracy / Numeracy

4.4. Coping / Stress Coping / Stress • AvoidanceAvoidance• Daily hassleDaily hassle• StigmaStigma

Patient Characteristics RelatedPatient Characteristics Relatedto Self-managementto Self-management

5.5. ComorbiditiesComorbidities

6.6. Medication Side EffectsMedication Side Effects

7.7. Depression/mental healthDepression/mental health

Social Characteristics RelatedSocial Characteristics Relatedto Self-managementto Self-management

1.1. Social NetworkSocial Network

2.2. Social SupportSocial Support• Tangible/instrumentalTangible/instrumental• EmotionalEmotional

3.3. CultureCulture

Medical Environment Related Medical Environment Related to Self-managementto Self-management

Access and BarriersAccess and Barriers

1.1. Insurance (i.e., co-payments, deductibles)Insurance (i.e., co-payments, deductibles)

2.2. TransportationTransportation

3.3. Organization and staffingOrganization and staffing

Provider Characteristics Related Provider Characteristics Related to Self-managementto Self-management

1.1. Evidence-based Guideline Evidence-based Guideline ComplianceCompliance

• Medication ComplexityMedication Complexity

• Medication IntensityMedication Intensity

2.2. Provider CommunicationProvider Communication

Provider Factors: Clinical Provider Factors: Clinical InertiaInertia

Failure of providers to initiate or intensify therapy when indicated

Reasons:– Overestimation of care provided– “Soft” reasons to avoid intensification– Lack of education, training or practice

organization – Lack of belief of efficacy

Phillips, et al. Ann Intern Med; 2001

Issues in Patient-Provider Issues in Patient-Provider CommunicationCommunication

Poor patient-physician communication is common– Physicians do >60% of talking during a visit

• Instrumental and biomedically focused• Rarely address psychosocial issues

– ~50% of the time physicians do not name the medicine or give dosing instructions

– Many patients reluctant to express• Expectations or medication preferences • Misunderstandings about the regimen

Poor patient-provider communication may contribute to health disparities in minority populations

How do you translate this How do you translate this information into an intervention? information into an intervention?

Veterans Study to Improve TheVeterans Study to Improve The

Control of HypertensionControl of Hypertension

VA Health Services ResearchVA Health Services Research

Investigator Initiated Award, 2001-06Investigator Initiated Award, 2001-06

The V-STITCH StudyThe V-STITCH Study

The V-STITCH The V-STITCH StudyStudy

A randomized controlled trial testing two A randomized controlled trial testing two interventions designed to improve BP controlinterventions designed to improve BP control

– Patient Intervention: Self-ManagementPatient Intervention: Self-Management

– Provider Intervention: Decision Support Provider Intervention: Decision Support

Durham VAMC General Medicine ClinicsDurham VAMC General Medicine Clinics

Patients with hypertension on medicationsPatients with hypertension on medications

24 month intervention and follow-up24 month intervention and follow-up

The V-STITCH Study The V-STITCH Study DesignDesign

Providers RandomlyAssigned (clusters)

R 1

ProviderIntervention

Provider Reminder

PatientIntervention

N = 150

PatientUsual Care

N = 151

PatientIntervention

N = 144

PatientUsual Care

N = 143

R 2 R 2

Patient Patient InterventionIntervention


1.1. Hypertension KnowledgeHypertension Knowledge• African AmericanAfrican American• DiabetesDiabetes• Family historyFamily history

2.2. LiteracyLiteracy

3.3. MemoryMemory

4.4. Patient’s Relationship with Primary Care ProviderPatient’s Relationship with Primary Care Provider

5.5. Social SupportSocial Support

6.6. Side EffectsSide Effects

7.7. Lifestyle Factors (smoking, alcohol, exercise, diet, Lifestyle Factors (smoking, alcohol, exercise, diet, stress)stress)

8.8. Missed AppointmentsMissed Appointments

9.9. Pill RefillPill Refill

Tailored Behavioral Delivered via TelephoneTailored Behavioral Delivered via Telephone


1st & 13th months Physician Interaction, Memory, Literacy, Side effects

3rd & 15th months Hypertension knowledge, Memory, Literacy, Side effects, Missed appointments, Pill refills

5th & 17th months Lifestyle, Memory, Literacy, Side effects, Missed appointments, Pill refills

7th & 19th months Social Support, Memory, Literacy, Side effects, Missed appointments, Pill Refills

9th & 21st months Physician Interaction, Memory, Literacy, Side effects, Missed appointments, Pill Refills

11th & 23rd months Memory, Literacy, Side effects, Missed appointments, Pill Refills

Any month Patient initiated

Frequency of Nurse-base calls


Use of TelephoneUse of Telephone Telephone contact has been shown to be Telephone contact has been shown to be

effective in changing patient behavior effective in changing patient behavior ((Am J Am J HypertensHypertens 1996, 1996, Am J Prev MedAm J Prev Med 2002) 2002)

Allow reaching more patientsAllow reaching more patients Tend to be more acceptable and Tend to be more acceptable and

convenient than in-person interventions.convenient than in-person interventions. Most U.S. homes have phones (>97%) – Most U.S. homes have phones (>97%) –

useful tool to deliver an intervention useful tool to deliver an intervention (U.S. (U.S. Bureau of Census, 2003)Bureau of Census, 2003)

May enhance the interventions’ cost-May enhance the interventions’ cost-effectiveness, due to reduced intervention effectiveness, due to reduced intervention costs and reduced visit rates.costs and reduced visit rates.

Mode of AdministrationMode of Administration

Provider Provider InterventionIntervention

Displayed at point-of-care

Summarized the hypertension-relevant information from clinical record

Individualized for the patient

Educated as well as reminded Displayed reasons / explanations

Provided continuous quality improvement - quarterly

Automated Treatment for Automated Treatment for Hypertension:Hypertension:

EvideNce-based Advice (ATHENA)EvideNce-based Advice (ATHENA)

ATHENA: BP - Prescription ATHENA: BP - Prescription GraphsGraphs

Displayed patient's most recent BPDisplayed patient's most recent BP

Displayed patient’s current antihypertensive Displayed patient’s current antihypertensive drug regimendrug regimen

Provided opportunity to update BP Provided opportunity to update BP

Offered no advisories or recommendations Offered no advisories or recommendations for medication managementfor medication management

Simply a reminder for hypertensionSimply a reminder for hypertension

Provider Control GroupProvider Control Group

Primary Care Providers Primary Care Providers

24 Attending Physicians24 Attending Physicians 6 Physician Assistants6 Physician Assistants 2 Registered Nurse Practioners2 Registered Nurse Practioners

17 intervention providers received full 17 intervention providers received full decision support tailored to specific decision support tailored to specific patientpatient

15 control providers received display 15 control providers received display with most recent BPwith most recent BP

Patient Identification Patient Identification

816 816 Contacted either by Contacted either by

Telephone or In-personTelephone or In-person

588 588 EnrolledEnrolled • 76% participation 76% participation raterate

190 190 RefusedRefused

3838 Excluded Excluded

• Hospitalized last 3 months Hospitalized last 3 months • Dementia diagnosisDementia diagnosis• Resident in nursing home Resident in nursing home • Severely impaired hearing Severely impaired hearing or speech or speech

4017 4017 ICD code for Hypertension ICD code for Hypertension

Hypertensive MedicationHypertensive MedicationEnrolled Durham VAEnrolled Durham VA

• 85% 24 month 85% 24 month retention rateretention rate

Patient CharacteristicsPatient Characteristics (N=588)(N=588)

MaleMale 98%98%

Mean ageMean age 63 years 63 years (21-87)(21-87)

MarriedMarried 68%68%

Live aloneLive alone 22%22%

WhiteWhite 57%57%

African AmericanAfrican American 40%40%

High school or lessHigh school or less 51%51%

Inadequate incomeInadequate income 23%23%

Patient Patient CharacteristicsCharacteristics

Taking BP meds for > 5 yearsTaking BP meds for > 5 years 64%64%

Close relative with hypertensionClose relative with hypertension

65%65%

No exerciseNo exercise 44%44%

SmokeSmoke 30%30%

DiabeticDiabetic 40%40%

BP in control at Baseline:BP in control at Baseline:42%42%< 130 / 85 mm/Hg diabetic< 130 / 85 mm/Hg diabetic< 140 / 90 mm/Hg non-diabetic < 140 / 90 mm/Hg non-diabetic

Mean Systolic BP 138.4 (SD=18)Mean Systolic BP 138.4 (SD=18)Mean Diastolic BP 75.5 (SD=11)Mean Diastolic BP 75.5 (SD=11)

Primary OutcomePrimary OutcomeBlood pressure control at every primary Blood pressure control at every primary care provider clinic visit over 24 monthscare provider clinic visit over 24 months

time in weekstime in weeks

bp

co

ntr

ol

bp

co

ntr

ol

00 1010 2020 3030 4040 5050 6060

nono

yesyes

patient 1patient 1


bp

co

ntr

ol

bp

co

ntr

ol

00 1010 2020 3030 4040 5050 6060

nono

yesyes

patient 2patient 2


bp

co

ntr

ol

bp

co

ntr

ol

00 1010 2020 3030 4040 5050 6060

nono

yesyes

patient 3patient 3


bp

co

ntr

ol

bp

co

ntr

ol

00 1010 2020 3030 4040 5050 6060

nono

yesyes

patient 4patient 4

Time in Months

BP

Co

ntr

ol

0.2

0.3

0.4

0.5

0.6

0.7

0 6 12 18 24

Blood Pressure Control RatesPrimary Analysis

ReminderReminder N=143N=143

BehavioralBehavioral N=144N=144

Decision Decision SupportSupport N=151N=151

CombinedCombined N=150N=150

Time Effect: P=.01 Group*Time Effect: P=.11

Nurse Behavioral Intervention vs. NoneNurse Behavioral Intervention vs. NoneSecondary AnalysisSecondary Analysis

Time in MonthsTime in Months

BP

Co

ntr

ol

BP

Co

ntr

ol

0.40

0.40

0.50

0.50

0.60

0.60

0.70

0.70

00 66 1212 1818 2424

RN BehavioralRN BehavioralN=294N=294

No RNNo RNN=294N=294

P=0.03P=0.03

Compliance with Nurse Compliance with Nurse Telephone InterventionTelephone Intervention

Patients completing all 12 scheduled study calls: 85%

Average length of call:

3 minutes (SD 2.5 min)

Primary Care VisitsPrimary Care VisitsDuring Study (24 During Study (24

Months)Months)

Mean SD

Usual Care 7.7 4.7

Behavior only 7.3 3.6

Decision Support

7.4 3.6

Combined 7.1 3.5

Two-Year Outpatient CostsTwo-Year Outpatient Costs

Cost Category Total cost Average cost per Subject

Behavioral intervention (n=294)

$2,863,775 $9,741

Non-Behavioral

(N=294)

$2,822,215 $9,599

Average Behavioral Intervention Average Behavioral Intervention Costs Per Patient over 24 monthsCosts Per Patient over 24 months

Cost Category

Patients Overseen by Nurse

Number of Patients

1120 840 560

Direct Costs/per patient

$70

($61-81)

$94

($82-$109)

$141

($123-$163)

Average min/per patient

15 20 30

Provider Intervention Provider Intervention ResultsResults

ATHENA displayed at 68% of visits ATHENA displayed at 68% of visits (929/1370)(929/1370)

• Among displayed, providers Among displayed, providers interacted with intervention 57% of interacted with intervention 57% of time (38.5% overall)time (38.5% overall)

• 54% BP control when provider 54% BP control when provider interacted versus 45% when provider interacted versus 45% when provider did not interactdid not interact

Provider Intervention Provider Intervention ResultsResults

Most common reasons for Most common reasons for disregarding recommendationsdisregarding recommendations

• 68% inadequate BP control 68% inadequate BP control due to med non-adherencedue to med non-adherence

• 68% concern that an 68% concern that an inaccurate BP reading was used inaccurate BP reading was used to generate recommendationsto generate recommendations

• 46% insufficient time46% insufficient time

SummarSummaryy

Brief telephone intervention improved Brief telephone intervention improved BP control by 21% at 24 monthsBP control by 21% at 24 months

• 12.6% improvement compared to the 12.6% improvement compared to the non-behavioral groupnon-behavioral group

No increase in clinic utilizationNo increase in clinic utilization

Cost effectiveCost effective

Computer Decision Support did not Computer Decision Support did not significantly improve BP control rates at significantly improve BP control rates at 24 months24 months

Next Next StudyStudy

How can we overcome provider How can we overcome provider inertia with a stronger medication inertia with a stronger medication management intervention?management intervention?

Focus intensive interventions on Focus intensive interventions on those at greater risk (i.e., out of those at greater risk (i.e., out of control)control)

Can we monitor and treat blood Can we monitor and treat blood pressure outside of clinic? pressure outside of clinic?

Hypertension Intervention Hypertension Intervention

Telemedicine StudyTelemedicine Study((HINTS)HINTS)

Department of Veterans Affairs, Grant IIR 04-426 (2005-2008)

Established Investigator Award, American Heart Association (2006-2011)

Hypertension Intervention Nurse Hypertension Intervention Nurse

Telemedicine Study (HINTS)Telemedicine Study (HINTS)600 primary care veterans with poor BP 600 primary care veterans with poor BP

control control

Home BP tele-monitoring used to Home BP tele-monitoring used to activate interventionsactivate interventions

Nurse-administered via telephone for Nurse-administered via telephone for 18 months18 months

HINTS Study: DesignFour Group DesignFour Group Design

Usual CareUsual Care PCP drive management, no special programPCP drive management, no special program

Tailored Behavioral Phone InterventionTailored Behavioral Phone Intervention Home BP monitoring evaluated by nurseHome BP monitoring evaluated by nurse Tailored behavioral modulesTailored behavioral modules

Medication Management (ATHENA) Phone InterventionMedication Management (ATHENA) Phone Intervention Home BP monitoring evaluated by nurseHome BP monitoring evaluated by nurse Medication management implemented by study MD/RNMedication management implemented by study MD/RN

Combined InterventionCombined Intervention Home BP monitoring evaluated by nurseHome BP monitoring evaluated by nurse Medication management/tailored behavioral modulesMedication management/tailored behavioral modules

Why BP Monitors as Interventions?Why BP Monitors as Interventions?

• Improve BP controlImprove BP control

• Self-monitoring programs are used in Self-monitoring programs are used in clinical practice to assist PCP in treating clinical practice to assist PCP in treating their patientstheir patients

• Encourage patients to monitor their Encourage patients to monitor their diseasedisease

• Provide objective information to Provide objective information to motivate patients to control their health motivate patients to control their health conditioncondition

Case for TelemedicineCase for Telemedicine

Effective use of home BP monitoring Effective use of home BP monitoring improve hypertension outcomes improve hypertension outcomes

Treating at home may avert visits and Treating at home may avert visits and result in better BP controlresult in better BP control

Alternative way to integrate home BP Alternative way to integrate home BP monitoring into primary caremonitoring into primary care

HINTS Study: Telemedicine

Baseline Patient CharacteristicsBaseline Patient Characteristics

546 subjects enrolled546 subjects enrolled

MinorityMinority 51%51%

Low LiterateLow Literate 38%38%

DiabeticDiabetic 44%44%

MalesMales 98%98%

Summary of Summary of InterventionIntervention

• Safety alert activatedSafety alert activated

(2 values within 12 hours (2 values within 12 hours >175 systolic, >105 diastolic,

pulse <40 or >110)

144 times, 51 unique pts144 times, 51 unique pts• Intervention activatedIntervention activated

687 times, 241 unique pts687 times, 241 unique pts• Praise alert activatedPraise alert activated

74 times, 68 unique pts74 times, 68 unique pts

Summary of Summary of InterventionIntervention

• Technicals activatedTechnicals activated

634 times, 220 unique pts634 times, 220 unique pts

7% Did not understand how to set up or 7% Did not understand how to set up or

use equipmentuse equipment

66% nonadherence66% nonadherence

27% technical problems with equipment27% technical problems with equipment

Home Readings: Console ViewHome Readings: Console View

RN:MD Dialogue for Medication RN:MD Dialogue for Medication ChangeChange

OutcomeOutcomess

BP control BP control – 0, 6, 12, 18 months0, 6, 12, 18 months

Health-related quality of life (SF-12)Health-related quality of life (SF-12) Hypertension knowledgeHypertension knowledge Adherence to hypertension regimen Adherence to hypertension regimen Cost-effectiveness of both interventionsCost-effectiveness of both interventions

Summary Summary

Need to considerNeed to consider• Alternative methods of implementing Alternative methods of implementing

interventionsinterventions

• Telemedicine not panacea for allTelemedicine not panacea for all

• Cost of implementing interventionsCost of implementing interventions

• Methods of reimbursementMethods of reimbursement

• Not just initiating, but maintaining Not just initiating, but maintaining multiple health behaviorsmultiple health behaviors

• Both patient/provider and possibly Both patient/provider and possibly systemsystem

RecommendationsRecommendations

• Self-management adherence-enhancing strategies Self-management adherence-enhancing strategies need to occur:need to occur:

Introduction of treatmentIntroduction of treatmentLater in the course (remediation)Later in the course (remediation)Maintenance (less attention) Maintenance (less attention)

• Strategies include:Strategies include:

•Social SupportSocial Support•Educational InterventionsEducational Interventions (written and/or verbal (written and/or verbal

instructions delivered individually, group,instructions delivered individually, group,telephone, or audiovisually) telephone, or audiovisually)

•Behavioral StrategiesBehavioral Strategies (self-monitoring, positive (self-monitoring, positive reinforcement, goal setting, cueing, reinforcement, goal setting, cueing,

chaining)chaining)


Educational InterventionsEducational Interventions

• Knowledge alone will not change behavior Knowledge alone will not change behavior

• Establish what is known before offering new Establish what is known before offering new knowledge knowledge

• Use concrete examplesUse concrete examples


Ways of Presenting Written InformationWays of Presenting Written Information

• Instructions should be clear and structuredInstructions should be clear and structured

• Picture charts, color-coded medication Picture charts, color-coded medication schedules and large print schedules and large print


Behavioral InterventionsBehavioral Interventions

Strategies include:Strategies include:

• Developing prompts and reminder systemsDeveloping prompts and reminder systems

• Identifying a potential relapse into old behaviorIdentifying a potential relapse into old behavior

• Setting appropriate and realistic goalsSetting appropriate and realistic goals

• Simplifying regimens to once or twice dailySimplifying regimens to once or twice daily

•Use opportunities to model behaviorUse opportunities to model behavior

•Reinforce positive behaviorsReinforce positive behaviors


Clinical IssuesClinical Issues

• Key validated question “Have you missed any Key validated question “Have you missed any pills in the past week?” pills in the past week?”

Sensitivity > 50% of those with low adherenceSensitivity > 50% of those with low adherence Specificity of 87%Specificity of 87%

• Common misperceptions should be anticipated Common misperceptions should be anticipated and avoided and avoided

i.e., medication can be stopped when the i.e., medication can be stopped when the prescription runs out or symptoms are guides to prescription runs out or symptoms are guides to

when to take the medicationwhen to take the medication


Clinical Issues (continued)Clinical Issues (continued)

• Missing appointments is correlated with Missing appointments is correlated with lower adherence rates - first sign of dropping lower adherence rates - first sign of dropping out of care entirely, the most severe form of out of care entirely, the most severe form of nonadherence. nonadherence.

• Telephone or appointment reminders provide Telephone or appointment reminders provide relatively easy method to overcome relatively easy method to overcome nonadherence.nonadherence.


Effective, Effective, collaborativecollaborative provider- provider-patient communication should be the patient communication should be the foundation of all clinical interventions foundation of all clinical interventions designed to improve patient self-designed to improve patient self-management.management.

Future Directions & Future Directions & ConclusionsConclusions

Examining tailoring of intervention mode to needs and intensity of intervention (Stepped level care)

Disseminating and sustaining interventions in the community

Expanding behavioral interventions to multiple chronic diseases

Translating evidence into practice

Acknowledgements

Research Team

Alice Neary Melinda Orr Maren OlsenMike Harrelson Felicia McCant Kelly DealPam Gentry Laura Svetkey Mary GoldsteinRowena Dolor Tara Dudley Laurie MarbreyMartha Adams Shelby Reed Santanu DattaLaurie Leeson Anthony Goodin Gwen McKoyCourtney Van Houtven Ben Powers Cindy RoseSharon Hooker Tina Hong David SimelJanet Grubber

Relevant Publications1.1. Bosworth HB, Olsen MK, McCant F, et al. Hypertension Intervention Bosworth HB, Olsen MK, McCant F, et al. Hypertension Intervention

Nurse Telemedicine Nurse Telemedicine Study (HINTS). Study (HINTS). Am Heart JAm Heart J 2007;153(6):918-24. 2007;153(6):918-24.2. Bosworth HB, Olsen MK, Goldstein MK, et al. The veterans' study to 2. Bosworth HB, Olsen MK, Goldstein MK, et al. The veterans' study to

improve the control improve the control of hypertension (V-STITCH): design and methodology. of hypertension (V-STITCH): design and methodology. Contemp Clin TrialsContemp Clin Trials

2005;26:155-68.2005;26:155-68.3. Chan AS, Coleman RW, Martins SB, et al. Evaluating provider adherence 3. Chan AS, Coleman RW, Martins SB, et al. Evaluating provider adherence

in a trial of a in a trial of a guideline-based decision support system for hypertension. guideline-based decision support system for hypertension. MedinfoMedinfo

2004;11(Pt 1):125-9.2004;11(Pt 1):125-9.4. Goldstein MK, Coleman RW, Tu SW, et al. Translating research into 4. Goldstein MK, Coleman RW, Tu SW, et al. Translating research into

practice: practice: organizational issues in implementing automated decision support for organizational issues in implementing automated decision support for

hypertension in hypertension in three medical centers. three medical centers. J Am Med Inform AssocJ Am Med Inform Assoc 2004;11(5):368-76. 2004;11(5):368-76.5. Goldstein MK, Hoffman BB, Coleman RW, et al. Implementing clinical 5. Goldstein MK, Hoffman BB, Coleman RW, et al. Implementing clinical

practice guidelines practice guidelines while taking account of changing evidence. while taking account of changing evidence. Proc AMIA SympProc AMIA Symp 2000:300-4. 2000:300-4.6. Goldstein MK, Hoffman BB, Coleman RW, et al. Patient safety in 6. Goldstein MK, Hoffman BB, Coleman RW, et al. Patient safety in

guideline-based decision guideline-based decision support for hypertension management: ATHENA DSS. support for hypertension management: ATHENA DSS. Proc AMIA SympProc AMIA Symp

2001:214-8.2001:214-8.

Relevant Publications7. Lin ND, Martins SB, Chan AS, et al. Identifying barriers to hypertension 7. Lin ND, Martins SB, Chan AS, et al. Identifying barriers to hypertension

guideline guideline adherence using clinician feedback at the point of care. adherence using clinician feedback at the point of care. AMIA Annu Symp AMIA Annu Symp

ProcProc 2006:494-8. 2006:494-8.8. Bosworth HB, Oddone EZ. Telemedicine and Hypertension. 8. Bosworth HB, Oddone EZ. Telemedicine and Hypertension. J Clin J Clin

Outcomes ManagementOutcomes Management 2004;11(8):517-522. 2004;11(8):517-522.9. Bosworth HB, Oddone EZ, Weinberger M. Patient treatment adherence: 9. Bosworth HB, Oddone EZ, Weinberger M. Patient treatment adherence:

ConceptsConceptsinterventions, and measurement. Mahwah, NJ: Lawrence Erlbaum interventions, and measurement. Mahwah, NJ: Lawrence Erlbaum

Associates, 2006.Associates, 2006.10. Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood 10. Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood

pressure control: pressure control: potential explanatory factors. potential explanatory factors. Am J MedAm J Med 2006;119(1):70. 2006;119(1):70.11. Bosworth HB, Oddone EZ. A model of psychosocial and cultural 11. Bosworth HB, Oddone EZ. A model of psychosocial and cultural

antecedents of antecedents of blood pressure control. blood pressure control. Journal of the National Medical AssociationJournal of the National Medical Association

2002;94:236-248.2002;94:236-248.12. Bosworth HB, Olsen MK, Gentry P, et al. Nurse administered telephone 12. Bosworth HB, Olsen MK, Gentry P, et al. Nurse administered telephone

intervention for intervention for blood pressure control. blood pressure control. Patient Educ Couns Patient Educ Couns 2005;57(1):5-14.2005;57(1):5-14.13. Bosworth HB, Olsen MK, Oddone EZ. Improving blood pressure control 13. Bosworth HB, Olsen MK, Oddone EZ. Improving blood pressure control

by tailored by tailored feedback to patients and clinicians. feedback to patients and clinicians. Am Heart JAm Heart J 2005;149(5):795-803. 2005;149(5):795-803.

Documents

Hypertension Self-management: The use of Telemedicine as an Intervention Tool Hayden Bosworth, Ph.D. Center for Health Services Research in Primary Care,