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A Randomized Controlled Trial

Beverly B. Green, MD, MPH; Andrea J. Cook, PhD; James D. Ralston, MD, MPH; Paul A. Fishman, PhD; Sheryl L. Catz, PhD; James Carlson, PharmD; David Carrell, PhD; Lynda Tyll, RN, MS; Eric B. Larson, MD, MPH; Robert S. Thompson, MD

JAMA. 2008;299(24):2857-2867.

Context  Treating hypertension decreases mortality and disability from cardiovascular disease, but most hypertension remains inadequately controlled.

Objective  To determine if a new model of care that uses patient Web services, home blood pressure (BP) monitoring, and pharmacist-assisted care improves BP control.

Design, Setting, and Participants  A 3-group randomized controlled trial, the Electronic Communications and Home Blood Pressure Monitoring study was based on the Chronic Care Model. The trial was conducted at an integrated group practice in Washington state, enrolling 778 participants aged 25 to 75 years with uncontrolled essential hypertension and Internet access. Care was delivered over a secure patient Web site from June 2005 to December 2007.

Interventions  Participants were randomly assigned to usual care, home BP monitoring and secure patient Web site training only, or home BP monitoring and secure patient Web site training plus pharmacist care management delivered through Web communications.

Main Outcome Measures  Percentage of patients with controlled BP (<140/90 mm Hg) and changes in systolic and diastolic BP at 12 months.

Results  Of 778 patients, 730 (94%) completed the 1-year follow-up visit. Patients assigned to the home BP monitoring and Web training only group had a nonsignificant increase in the percentage of patients with controlled BP (<140/90 mm Hg) compared with usual care (36% [95% confidence interval {CI}, 30%-42%] vs 31% [95% CI, 25%-37%]; P = .21). Adding Web-based pharmacist care to home BP monitoring and Web training significantly increased the percentage of patients with controlled BP (56%; 95% CI, 49%-62%) compared with usual care (P < .001) and home BP monitoring and Web training only (P < .001). Systolic BP was decreased stepwise from usual care to home BP monitoring and Web training only to home BP monitoring and Web training plus pharmacist care. Diastolic BP was decreased only in the pharmacist care group compared with both the usual care and home BP monitoring and Web training only groups. Compared with usual care, the patients who had baseline systolic BP of 160 mm Hg or higher and received home BP monitoring and Web training plus pharmacist care had a greater net reduction in systolic BP (–13.2 mm Hg [95% CI, –19.2 to –7.1]; P < .001) and diastolic BP (–4.6 mm Hg [95% CI, –8.0 to –1.2]; P < .001), and improved BP control (relative risk, 3.32 [95% CI, 1.86 to 5.94]; P<.001).

Conclusion  Pharmacist care management delivered through secure patient Web communications improved BP control in patients with hypertension.

Trial Registration  clinicaltrials.gov Identifier: NCT00158639

Author Affiliations: Group Health (Drs Green, Ralston, Carlson, and Thompson) and Group Health Center for Health Studies, Seattle, Washington; School of Medicine (Drs Green, Larson, and Thompson), School of Public Health and Community Medicine (Drs Ralston, Fishman, and Larson), and Department of Biostatistics (Dr Cook), University of Washington, Seattle.

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