Practical Lessons for Improving Care of Patients with High Blood Pressure in Urban Underserved Practices

Purpose: Assess impact of multi-component projects to improve care of racially diverse and low-income hypertension patients at three clinics in the Greater Rochester New York area. Methods: Used multi-method strategy to assess qualitative data on fouryear effort to improve care in a real world underserved setting. We reviewed direct-observation, interview, phone meeting, and patient-level blood-pressure data. To model changes, we used a logistic-regression spline model of 51,654 visits by 12,918 patients, adjusting for patient demographic characteristics and for the clustering of physician and patient. Results: Clinics that standardized blood-pressure monitoring, redesigned patient flow and scheduling, involved clinical pharmacists, embedded care management into patient flow, had frequent visits for out-of-control patients, and created a culture focusing on individual-patient needs improved control rates from 40.1% to 56.6% (P<0.001 for trend), exceeding national improvements of the time. Logistic-regression spline models confirmed these results and showed statistically significant improvements within the first 6 months and subsequent 2.5 years. Conclusions: Five themes emerged: 1) Leadership at all levels is necessary. 2) Quality- and process-improvement are integral to sustaining change. 3) Integrating care management into team-based care is critical for patients with hypertension. 4) Frequent follow-up visits are needed when hypertension is not controlled. 5) Daily review of patients on the schedule and periodic reporting of hypertension outcomes raise consciousness. Practical lessons were identified: Changing clinical processes to raise awareness and increase focus can improve control. Medication and treatment-management protocols increasing visit frequency for hypertension patients whose blood pressure is uncontrolled improve patient choices and behaviors. Assessing strategies for improving the management of hypertension, identifying daily solutions and tracking outcomes by patient and doctor help improve control rates in clinics serving low-income populations.