EHR-Based and Nurse-Led Medication Support in HTN

Study Questions:

Will an electronic health record (EHR)-based medication management tool with or without a nurse-led educational intervention improve systolic blood pressure (SBP) and medication management in hypertensive patients?

Methods:

NAMES (Northwestern University and Access Community Health Network Medication Education Study) was a cluster randomized clinical trial designed to test an EHR-based medication management tool with and without nurse-led education in hypertensive patients. Primary outcome was SBP at 12 months of follow-up. Secondary outcomes were 1) medication reconciliation, 2) patient knowledge of medication indications, 3) patient understanding of medication dosing and instructions, and 4) medication adherence by self-report.

Results:

This study was conducted at 12 community health centers in the Chicago area from 2012 to 2016. Four centers each were randomized to EHR-based intervention plus nurse-led education, EHR intervention alone, or usual care. All participants were on >3 chronic medications, spoke English, were mentally cognizant, and administered their own medications. For non-diabetics, SBP was >135; diastolic blood pressure (DBP) was >85. For diabetics, SBP was >130; DBP was >80.

  • EHR intervention involved printing a medication reconciliation sheet for each clinic visit at registration with written instructions for reconciliation. Each participant also received a medication information sheet at clinic checkout when any of 125 common medications was ordered or refilled at a clinic visit.
  • Nurse-led education intervention included initial comprehensive medication counseling, follow-up counseling, telephone contacts after initiation of new prescriptions, phone calls to patients who failed to follow up, nurse communication with treating clinicians, initiation of prescription refills, return visits and referrals, and renewal of state medical assistance.

Of 920 adult patients initially enrolled, 794 completed the study. A majority of participants were female (68.6%) and black (87.2%). Analysis was by intention-to-treat. Generalized linear mixed models were used to analyze the primary outcome.

Primary Outcome (SBP at 12 months follow-up). Baseline mean SBP was 145.2 mmHg for the entire study population.

EHR tool with nurse-led intervention

  • was superior to EHR tool only (-5.6 mmHg; p < 0.001);
  • resulted in the greatest SBP reduction in those with likely limited health literacy compared with EHR tool alone (-7.7 mmHg; p = 0.0069);
  • resulted in slightly improved SBP compared with usual care but was not statistically significant (-2.0 mmHg; p = 0.23); and
  • resulted in 61.2% achieving SBP < 140/90 versus 45.4% in the EHR tool-only group (adjusted odds ratio 2.0; p < 0.001).

EHR tool alone

  • was inferior to usual care (+3.6 mmHg; p = 0.03) and
  • resulted in 45.4% achieving SBP < 140/90 versus 60.2% in the usual care group (adjusted odds ratio 0.6; p = 0.002).

Secondary Outcomes

EHR tool with nurse-led intervention

  • resulted in better medication reconciliation at 12 months than usual care for antihypertensive medications (p = 0.01), all chronic medications (p = 0.02), and all medications (p = 0.04) and
  • resulted in better understanding of medication instructions and dosing than usual care for antihypertensive medications (p = 0.03), all chronic medications (p = 0.05), and all medications (p = 0.047).

EHR tool alone demonstrated better medication reconciliation for antihypertensive medications (p = 0.01) and for all chronic medications (p = 0.02) compared with usual care.

Other outcomes were not statistically significant.

Conclusions:

Use of the EHR tool plus nurse intervention improved SBP at 12 months follow-up compared with the EHR tool only. Compared with usual care, it resulted in improved medication reconciliation and improved understanding of medication instructions and dosing across all classes of medications. Use of the EHR tool alone resulted in worsened SBP at 12 months follow-up compared with usual care, although it improved medication reconciliation. The authors conclude that these findings demonstrate that system-level changes should be tested for effectiveness and for unintended consequences.

Perspective:

The superior overall results of the EHR tool combined with the nurse-led intervention may highlight the importance of verbal communication in addition to written communication in educating patients about medication self-management. Even with the combined intervention, the authors note that medication discrepancies, self-medication administration errors, and partial medication adherence were common and that much room for improvement remains.

Clinical Topics: Prevention, Hypertension

Keywords: Electronic Health Records, Hypertension, Health Literacy, Counseling, Medication Therapy Management, Medication Reconciliation, Medication Adherence, Community Health Centers, Blood Pressure, Self Care, Self Medication, Antihypertensive Agents, Diabetes Mellitus


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