article 1

ORIGINAL ARTICLE

Quality Improvement Strategies for HypertensionManagement

A Systematic Review

Judith M. E. Walsh, MD, MPH,* Kathryn M. McDonald, MM,† Kaveh G. Shojania, MD,‡Vandana Sundaram, MPH,†§ Smita Nayak, MD,†§ Robyn Lewis, MA,†Douglas K. Owens, MD, MS,†§ and Mary Kane Goldstein, MD, MS†¶

Background: Care remains suboptimal for many patients withhypertension.Purpose: The purpose of this study was to assess the effectivenessof quality improvement (QI) strategies in lowering blood pressure.Data Sources: MEDLINE, Cochrane databases, and article bibliog-raphies were searched for this study.Study Selection: Trials, controlled before–after studies, and inter-rupted time series evaluating QI interventions targeting hypertensioncontrol and reporting blood pressure outcomes were studied.Data Extraction: Two reviewers abstracted data and classified QIstrategies into categories: provider education, provider reminders,facilitated relay of clinical information, patient education, self-management, patient reminders, audit and feedback, team change, orfinancial incentives were extracted.Data Synthesis: Forty-four articles reporting 57 comparisons un-derwent quantitative analysis. Patients in the intervention groupsexperienced median reductions in systolic blood pressure (SBP) anddiastolic blood pressure (DBP) that were 4.5 mm Hg (interquartilerange �IQR�: 1.5 to 11.0) and 2.1 mm Hg (IQR: �0.2 to 5.0) greaterthan observed for control patients. Median increases in the percent-age of individuals achieving target goals for SBP and DBP were

16.2% (IQR: 10.3 to 32.2) and 6.0% (IQR: 1.5 to 17.5). Interven-tions that included team change as a QI strategy were associatedwith the largest reductions in blood pressure outcomes. All teamchange studies included assignment of some responsibilities to ahealth professional other than the patient’s physician.Limitations: Not all QI strategies have been assessed equally,which limits the power to compare differences in effects betweenstrategies.Conclusion: QI strategies are associated with improved hyperten-sion control. A focus on hypertension by someone in addition to thepatient’s physician was associated with substantial improvement.Future research should examine the contributions of individual QIstrategies and their relative costs.

Key Words: quality improvement, blood pressure, hypertension,guideline implementation

(Med Care 2006;44: 646–657)

Hypertension care in the United States often fails tocomply with evidence-based guidelines. From 1999 to

2000, only 68.9% of individuals with hypertension wereaware of their hypertension, and only 58.4% of hypertensiveindividuals were treated.1 Even when treated, blood pressuremay not be adequately controlled. In the year 2000, only51.5% of patients in managed care health plans had con-trolled blood pressure (systolic blood pressure �SBP� �140mm Hg and diastolic blood pressure �DBP� �90 mm Hg).2

The Joint National Committee on Prevention, Detec-tion, Evaluation, and Treatment of High Blood Pressurerecommends targets for blood pressure control.3 Even smallimprovements in blood pressure control can have majorpublic health impact: lowering DBP by only 2 mm Hg couldresult in a 6% reduction in the risk of coronary heart diseaseand a 15% reduction in the risk of stroke and transientischemic attacks.4 Similarly, reducing usual SBP by 2 mm Hgis associated with 10% lower stroke mortality and approxi-mately 7% lower mortality from vascular causes in a middle-aged population.5

Many quality improvement (QI) strategies have fo-cused on improving hypertension control. QI strategies can

From the *Division of General Internal Medicine, Department of Medicine,University of California, San Francisco, California; the †Center forPrimary Care and Outcomes Research, Stanford University, Stanford,California; the ‡Department of Medicine and the Ottawa Health ResearchInstitute, University of Ottawa, Ottawa, Canada; the §VA Palo AltoHealth Care System, Palo Alto, California; and the ¶Geriatrics ResearchEducation and Clinical Center, VA Palo Alto Health Care System, PaloAlto, California.

This work was performed by the Stanford–UCSF Evidence-based PracticeCenter under contract number 290-02-0017 to the Agency for HealthcareResearch and Quality; Rockville, MD. This work was also supported inpart by the Department of Veterans Affairs.

The authors of this article are responsible for its content. Views expressed arethose of the authors and not necessarily those of the Department ofVeterans Affairs. Statements in this manuscript should not be construedas endorsements by the Agency for Healthcare Research and Quality orthe U.S. Department of Health and Human Services of a particular drug,device, test, treatment, or other clinical service.

Reprints: Mary Kane Goldstein, MD, MS, VA Palo Alto Health CareSystem, GRECC 182B, 3801 Miranda Avenue, Palo Alto, CA 94304.E-mail: [email protected].

Copyright © 2006 by Lippincott Williams & WilkinsISSN: 0025-7079/06/4407-0646

Medical Care • Volume 44, Number 7, July 2006646

include one or several components and can target the pro-vider, the patient, the healthcare system, or any combinationof these.

As part of a series of evidence reports, Closing theQuality Gap, funded by the Agency for Healthcare Researchand Quality on improving health care for selected topicsidentified by the Institute of Medicine as meriting nationalpriority,6,7 we conducted a systematic review of the evidencesupporting QI strategies for hypertension control. We ad-dressed the following questions: Are QI programs effective inproducing clinically meaningful reductions in blood pres-sure? Which QI strategies are most effective at ensuring thatblood pressures are lowered?

METHODS

Definition of Quality Improvement StrategiesWe defined a QI strategy as an intervention aimed at

reducing the quality gap (the difference between healthcareprocesses or outcomes observed in practice and those potentiallyobtainable based on current professional knowledge) for a groupof patients representative of those encountered in routine prac-tice.6 We developed our taxonomy of QI strategies by modifyingseveral well-established classification systems.8–12 A systematicreview of disease management studies that combined QI strat-egies and targets classified interventions as: provider education,provider feedback, provider reminders, patient education, patientreminders, and patient financial incentives,12 whereas an alter-native taxonomy described in a review of interventions topromote immunization and cancer screening11 specified 3 di-mensions for characterizing QI strategies: type of strategy (eg,education), mediators of intervention (eg, involvement of topmanagement), and audience targeted (eg, patients, providers,healthcare delivery systems). We modified these taxonomies toreview hypertension management evidence. We classified inter-ventions as provider education (materials/instruction given toproviders regarding appropriate care for patients), provider re-minders (prompts given to providers to perform specific caretasks), provider audit and feedback (summary clinical perfor-mance information given to healthcare providers), facilitatedrelay of clinical data to providers (clinical information collecteddirectly from patients and relayed to provider in which the dataare not routinely collected during a patient visit, eg, transmissionof a patient’s home blood pressure measurements), patient edu-cation (materials/instructions issued to patients providing hyper-tension information), patient reminders (efforts directed towardpatients encouraging them to keep appointments or adhere tocare), promotion of self-management (access to resources ordevices that enhance patients’ ability to manage their condition,eg, providing home blood pressure monitoring kit), team change(creation of multidisciplinary team, addition of new teammember�s�, change of role�s�, case or disease management), andfinancial incentives/regulation or reimbursement changes.

Included Study DesignsWe included patient- and cluster-randomized trials,

quasi-randomized trials, controlled before–after studies, andinterrupted time-series studies.13 A quasi-randomized trialwas defined as containing at least 2 cohorts of patients

assembled prospectively using an arbitrary, but nonrandomallocation procedure (eg, even/odd medical record numbers).A controlled before–after study was defined as a contempo-raneous observation for cohorts differing primarily with re-spect to exposure to the QI intervention. Interrupted timeseries required to report outcomes from at least 3 time pointsin the pre- and postintervention periods.

Included OutcomesWe restricted our analysis to studies reporting measures

of hypertension control before and after the intervention:these included SBP or DBP or change in SBP or DBP and/orthe percentage of patients achieving SBP or DBP within atarget range.

Search StrategyWe searched the MEDLINE database through July 2003

using key words and medical subject headings for hypertensionand blood pressure combined with terms related to qualityimprovement (eg, total quality management, diffusion of inno-vation, disease management). Additional search terms focusedon identifying multifactorial interventions and targeted providereducation, audit and feedback, and reminder systems (Appendix1: Search Strategy). We also reviewed citations from the Co-chrane Effective Practice and Organisation of Care (EPOC)registry of QI strategies.

We included articles if they reported QI strategies forhypertension and assessed blood pressure outcomes. We ex-cluded articles focusing only on secondary hypertension orspecialized subpopulations (eg, hypertension in patients withalcoholism). We restricted our review to interventions targetingsome component of provider behavior or organizational change(ie, articles that evaluated patient education or self-managementby themselves were excluded because these interventions withpatients as the only target constituted a separate Institute ofMedicine priority area, eg, health literacy/self-management).7

We excluded articles published before 1980, and regarded a daterestriction as appropriate given changes in hypertension care andapproaches to QI over the past 2 decades.

We screened titles and abstracts for relevance. Atfull-text review, 2 independent reviewers abstracted key in-formation (eg, study design, reported outcomes) and conflictswere resolved by consensus.

AnalysesWe conducted 2 types of quantitative analyses: calculation

of net change in blood pressure and multivariate analyses.

Calculation of Net Change in Blood PressureWe calculated the net change in the blood pressure

outcome attributable to the intervention (int) for each in-cluded study, defined as:

Net � in BP � (Postint BP � Preint BP)Study group

� (Postint BP � Preint BP)Control group

To characterize the effect of a particular type of QIstrategy, we then calculated the median change in the outcomeachieved by studies in which the intervention included this

Medical Care • Volume 44, Number 7, July 2006 Evidence Synthesis of Quality Improvement Strategies for Hypertension

© 2006 Lippincott Williams & Wilkins 647

strategy.14 For example, we computed the median of net changein SBP for the QI strategy of provider education. To do this, wefirst calculated the net change in SBP (in mm Hg), using thepreviously defined formula, for all studies that used providereducation and measured SBP. We then calculated the medianvalue of the net change for these studies. We used median ratherthan mean change to avoid having skewed summary measuresbased on outlier studies with particularly large or small changesin outcome.

Because of the possibility of overestimation of medianchange resulting from preferential reporting of positive studies,particularly with smaller studies, we analyzed studies in terms ofsample sizes comparing median change among studies withsample sizes in the lower half with those in the upper half.

We reviewed studies for 5 key methodologic features:randomized allocation of intervention, adequate concealmentof allocation, providers blinded, patients blinded, and thepossibility of unit-of-analysis errors.

To evaluate the impact of study or intervention char-acteristics, we performed a nonparametric test for differencesin median change in blood pressure, the Mann-Whitney ranksum test. These analyses were possible only for mutuallyexclusive categories, eg, all interventions with a given QIstrategy versus all interventions without this strategy. Wewere unable to compare one strategy with another because ofthe frequent occurrence of several strategies within a givenstudy. We also had insufficient information to test for differ-ences in outcomes reported as the percentage of patientsachieving SBP or DBP within a target blood pressure range.

Multivariate AnalysesWe used a mixed model incorporating fixed and ran-

dom effects to predict the postintervention difference be-tween intervention and control group values for mean SBPand DBP controlling for study size and for the difference inmean SBP and DBP values before the intervention. In uni-variate analyses, other study features (eg, trial design, studyyear) did not have significant associations with interventionoutcomes so were not included in the models. Postinterven-tion standard deviations in the control and interventiongroups were pooled with weighting by sample size in eachgroup. This measure of within-study variability provided theresidual error in a mixed model with a random study effect:

Y � X� � Z� � e; � � N�0; G� e � N�0; R�,

where � is the fixed effect, � is the random effect, and e is theerror at the study level. As described elsewhere,15 using ProcMixed (SAS software, version 8.2; SAS Institute, Cary, NC)for meta-analysis requires reversing the roles of the within-study and between-study variations and then postprocessingthe output.

Accounting for Cluster EffectsWe anticipated that a substantial number of studies

would assign study groups to providers or clinics but collectdata on individual patients (ie, the studies would exhibit“clustering”). To avoid spurious precision in our analy-

ses,16–18 we calculated an effective sample size for eachstudy, defined as:

NEffective � (k * m)/(1 (m � 1) * ICC)

Here, “k” represents the number of clusters, “m” denotes thenumber of observations per cluster, and “ICC” is the intra-cluster coefficient. For studies without clustering, ICC � 0,and NEffective � k * m (ie, the reported sample size).18,19

Descriptive Analysis of Team Change StrategiesTo provide a richer analysis of the most common

strategy evaluated, we further described the characteristicsand outcomes of the team change studies. We grouped studiesbased on common characteristics (eg, setting, involvement ofadditional caregivers, use of home monitoring). To review allof these studies together, regardless of outcomes assessed(SBP, DBP, SBP range, and DBP range), we classifiedstudies into those with improvements in blood pressure con-trol for all outcomes assessed that were consistently greaterthan the median (“consistently greater”), those with medianchanges within 10% of the median (“consistently equiva-lent”), and those with median changes less than the median(“consistently less”). Where there were conflicts betweenclassifications among multiple outcomes (eg, 2 “less” out-comes and 1 “greater” outcome), we designated the studyresults as “mixed.”

RESULTSThe search (Fig. 1) yielded 3165 citations. 359 articles

were eligible for full-text review and 110 were fully ab-stracted. Of these, 47 included patient education or self-management only, and 17 reported outcomes other than bloodpressure (eg, physician adherence to guidelines). Two studiesdid not provide information before the intervention. Theremaining 44 studies included a total of 57 comparisons of QIstrategies (because several articles had more than one inter-vention).20–63 Thirty-four studies were randomized, con-trolled trials (including 45 comparisons), 5 were quasi-ran-domized, controlled studies (including 6 comparisons), and 5were controlled before–after studies (including 6 compari-sons). (A table with comparative details about each study isavailable on request to the authors.)

Types and Numbers of Quality ImprovementStrategies

The majority of articles described interventions consist-ing of more than one strategy with the median number of QIstrategies per comparison equal to 3. Only 17.5% (10 of 57)comparisons evaluated interventions using a single strategy.Among the individual strategies, team change and patienteducation (in combination with other strategies) were mostcommonly used. Team change was used in 36 of thecomparisons and patient education was used in 28 of thecomparisons. Facilitated relay of clinical data (n � 22) andprovider education (n � 20) strategies were common aswell.

Walsh et al Medical Care • Volume 44, Number 7, July 2006

© 2006 Lippincott Williams & Wilkins648

Effect of Quality Improvement Strategies onBlood Pressure Outcomes

The majority of studies showed a modest improvementin SBP and DBP associated with QI interventions. Strategiesthat included team change, patient education, facilitated relayof clinical data, or promotion of self-management had largermedian improvements in blood pressure outcomes (Table 1,by inspection, not tested for statistical significance).

The majority of studies used a combination of QIstrategies. For both SBP and DBP reductions, there was noclear pattern of increasing or decreasing effect as the numberof QI strategies increased.

In the multivariate model adjusting for sample size andfor differences in baseline blood pressure, the mean effectsacross all interventions were reductions in SBP of 4.2 mm Hg(95% CI 1.8, 6.6) and DBP of 1.9 mm Hg (95% CI 0.7, 3.1).The differences in postintervention SBP and DBP associatedwith each of the QI strategies are shown in Figure 2. Therewere too few studies assessing financial incentives to includethis intervention in the multivariate analyses. Team change wasthe only strategy that showed significant results for both SBPand DBP. Strategies that included patient education and self-

management were associated with a significant reduction inDBP but not SBP.

For all QI strategies, the median increase in the pro-portion of patients in target SBP range and DBP range was16.2% (interquartile range �IQR�: 10.3 to 32.2) and 6.0%(IQR: 1.5 to 17.5), respectively. Again, strategies that in-cluded team change, patient education, facilitated relay ofclinical data, or promotion of self-management had the larg-est improvements (by inspection, not tested for statisticalsignificance).

Effect of Team Change on Blood PressureOutcomes

Team change was the most commonly used strategy andwas assessed in 28 studies (36 comparisons). Overall, studiesincluding team change demonstrated a median improvement inSBP of 9.7 mm Hg (IQR: 4.2 to 14.0) compared with a 2.0 mmHg (IQR: 1.0 to 3.9) median improvement for studies without ateam change component (Mann-Whitney U test; P � 0.005).Studies including team change also showed median improve-ment in DBP of 4.2 mm Hg (IQR: 0.2 to 6.8) compared withstudies without a team change component (median improvementin DBP of 0.6 �IQR: �0.2 to 2.1� mm Hg for studies withoutteam change component; Mann-Whitney P � 0.025 for com-parisons with versus without team change. The percentage ofpatients with SBP and DBP in the target range improved whenteam change strategies were included (Table 1).

In multivariate analyses that corrected for differences inbaseline blood pressure values, the effects of interventionswith or without team change were similar to findings with themedian net change but attenuated. Studies including teamchange showed an improvement in SBP of 5.9 mm Hg (95%CI: 2.8 to 8.9; P � 0.0004), whereas studies without teamchange showed an improvement in SBP of 1.8 mm Hg (95%CI: �1.8 to 5.4; P � 0.32). For DBP, studies including teamchange showed a lowering of 3.1 mm Hg (95% CI: 1.7 to 4.6;P � 0.0001), whereas studies without team change showed alowering of 0.2 mm Hg (95% CI: �1.4 to 1.9; P � 0.78).

Descriptive Analysis of Team Change StudiesTwenty-seven of these comparisons were conducted in the

United States20,24,25,28,30–32,34,39,42–44,47,49,52,55,56,58,60,62,63 and9 outside of the United States.23,27,29,37,38,45,46,48 Interventionswere most commonly conducted in a clinic, either a generaloutpatient clinic (n � 14)20,24,27,28,30,32,39,43,44,47,55,56 or a hy-pertension clinic (n � 7).25,29,48,58,63 Seven comparisons wereconducted in academic settings,24,32,43,44,55,58 6 at the work-site,31,34,45,46 3 at pharmacies,23,37,52 and 3 in the community.42,60,62

Six interventions included some component of the interventionoccurring at the patient’s residence.30,38,42,49,62 Of the compar-isons conducted in clinics, 14 were conducted at a singlesite,24,25,30,32,43,47,48,55,56,58,63 2 included 2 or 3 sites,28,29 and 5included 11 or more sites.20,27,39,44

Studies conducted in pharmacies reported blood pres-sure reductions consistently greater (n � 2)37,52 than orequivalent (n � 1)23 to the median reduction observed for allstudies. Studies conducted in academic settings also tended tohave bigger blood pressure reductions (4 of 7 had consistentlygreater reductions24,43,58 and only 1 study44 had outcomes

FIGURE 1. Results of the literature search. The figure showsthe flow of the article reviews starting with the number ofstudies that were identified through the search strategy.



TAB

LE1.

Effe

ctof

Qua

lity

Imp

rove

men

tSt

rate

gies

onBl

ood

Pres

sure

Out

com

es

Typ

eof

Qua

lity

Impr

ovem

ent

Med

ian

Red

ucti

onin

Syst

olic

Blo

odP

ress

ure

(mm

Hg)

�int

erqu

arti

lera

nge�

*n

�nu

mbe

rof

com

pari

sons

†

Med

ian

Red

ucti

onin

Dia

stol

icB

lood

Pre

ssur

e(m

mH

g)�i

nter

quar

tile

rang

e�*

n�

num

ber

ofco

mpa

riso

ns†

Med

ian

Abs

olut

eIn

crea

sein

Pro

port

ion

ofP

atie

nts

Ach

ievi

ngSy

stol

icB

lood

Pre

ssur

ein

aC

erta

inR

ange

�int

erqu

arti

lera

nge�

*n

�nu

mbe

rof

com

pari

sons

†

Med

ian

Abs

olut

eIn

crea

sein

Pro

port

ion

ofP

atie

nts

Ach

ievi

ngD

iast

olic

Blo

odP

ress

ure

ina

Cer

tain

Ran

ge�i

nter

quar

tile

rang

e�*

n�

num

ber

ofco

mpa

riso

ns†

Pro

vide

rre

min

ders

1.2

�1.0

–1.9

�0.

3��

0.2–

1.7�

NA

4.5

�2.0

–7.0

�

n�

633,4

1,5

1,5

3,6

1n

�63

3,4

1,5

1,5

3,6

1n

�0

n�

261

Fac

ilit

ated

rela

yof

clin

ical

data

8.0

�2.5

–12.

3�1.

8��

0.1–

4.5�

25.1

�17.

0–34

.2�

2.0

�1.6

–5.0

�

n�

1624,2

5,2

8,3

2,3

6,3

7,4

4,4

8,5

0,5

2,5

7,6

1,6

2n

�18

24,2

5,2

8,3

2,3

6,3

7,4

0,4

4,4

6,4

8,5

0,5

2,5

7,6

1,6

2n

�42

3,2

8,3

4,5

2n

�54

0,5

9,6

1

Aud

itan

dfe

edba

ck1.

5�1

.2–1

.7�

0.6

�0.4

–1.0

��

3.5

��5.

7–�

1.4�

2.0

�1.7

–4.3

�

n�

341,6

1n

�44

0,4

1,6

1n

�23

9n

�64

0,5

6,5

9,6

1

Pro

vide

red

ucat

ion

3.3

�1.2

–5.4

�0.

6��

0.7–

3.4�

10.9

�1.4

–13.

1�3.

5�1

.7–1

1.3�

n�

1121,2

8,3

3,3

5,3

8,4

1,5

1,5

3,6

1n

�16

21,2

8,3

3,3

5,3

8,4

0,4

1,5

1,5

3,5

4,6

1,6

3n

�62

1,2

7,2

8,3

5,3

9n

�62

1,3

5,4

0,6

1

Pat

ient

educ

atio

n8.

1�3

.3–1

1.8�

3.8

�0.6

–6.7

�19

.2�1

1.4–

33.2

�17

.0�1

1.4–

24.5

�

n�

1820,2

4,2

5,2

8,2

9,3

2,3

5–38,

42,4

4,4

7,4

9,5

2,5

7,6

2

n�

2120,2

4,2

5,2

8,2

9,3

2,3

5–38,4

2,4

4,

47,4

9,5

2,5

4,5

7,6

0,6

2

n�

827–29,3

1,3

4,3

5,5

2n

�72

9,3

0,3

5,4

3,4

7,6

0

Pro

mot

ion

ofse

lf–

man

agem

ent

3.3

�2.6

–10.

1�2.

8�0

.4–6

.7�

13.4

9.4

�5.3

–11.

4�

n�

935,3

6,3

8,4

7,4

9,5

0,5

7,6

2n

�13

22,3

5,3

6,3

8,4

6,4

7,4

9,5

0,5

4,5

7,6

2n

�13

5n

�32

2,3

5,4

7

Pat

ient

rem

inde

rs3.

3�2

.3–4

.5�

0.4

��2.

4–5.

0�N

A2.

0�1

.1–9

.4�

n�

537,4

7,4

8,5

7n

�92

2,3

7,4

7,4

8,5

4,5

7,6

0n

�0

n�

522,4

3,4

7,5

6,6

0

Tea

mch

ange

9.7‡

�4.2

–14.

0�4.

2‡�0

.2–6

.8�

21.8

�9.0

–33.

8�17

.0�5

.7–2

4.5�

n�

2020,2

4,2

5,2

8,2

9,3

2,3

7,3

8,4

2,4

4,

47–49,5

2,5

5,5

8,6

2

n�

2420,2

4,2

5,2

8,2

9,3

2,3

7,3

8,4

2,4

4–49,

52,5

5,5

8,6

0,6

2,6

3

n�

1223,2

7–29,3

1,3

4,3

9,5

2,5

5n

�72

9,3

0,4

3,4

7,5

6,6

0

Fin

anci

alin

cent

ives

�13

.30.

0��

2.0–

2.5�

NA

4.2

��1.

1–9.

4�

n�

147

n�

326,4

7,6

0n

�0

n�

247,6

0

All

com

pari

sons

4.5

�1.5

–11.

0�2.

1��

0.2–

5.0�

16.2

�10.

3to

32.2

�6.

0�1

.5–1

7.5�

n�

3320,2

1,2

4,2

5,2

8,2

9,3

2,3

3,3

5–38,

41,4

2,4

4,4

7–53,5

5,5

7,5

8,6

1,6

2

n�

4320–22,2

4–26,2

8,2

9,3

2,3

3,3

5–38,4

0–42,

44–55,5

7,5

8,6

0–63

n�

1421,2

3,2

7–29,3

1,3

4,3

5,3

9,5

2,5

5n

�16

21,2

2,2

9,3

0,3

5,4

0,4

3,4

7,5

6,5

9–61

*Whe

nn

�2,

brac

kets

show

the

actu

alre

sult

sof

each

stud

yra

ther

than

inte

rpol

ated

inte

rqua

rtil

era

nge.

†T

henu

mbe

rof

cita

tion

sli

sted

diff

ers

from

the

nin

case

sw

here

ther

ew

ere

mul

tipl

eco

mpa

riso

nsfo

ra

stud

y.‡P

�0.

05fo

rM

ann-

Whi

tney

anal

yses

ofre

duct

ions

insy

stol

icbl

ood

pres

sure

and

dias

toli

cbl

ood

pres

sure

com

pari

ngst

udie

sw

ith

the

qual

ity

impr

ovem

ent

stra

tegy

wit

hth

ose

wit

hout

it.

No

com

para

ble

stat

isti

cal

anal

yses

wer

efe

asib

lefo

rpr

opor

tion

ofpa

tien

tsac

hiev

ing

ace

rtai

nsy

stol

icbl

ood

pres

sure

ordi

asto

lic

bloo

dpr

essu

rera

nge.

NA

indi

cate

sno

tap

plic

able

.



FIGURE 2. A, Changes in systolic blood pressure associated with each quality improvement (QI) strategy adjusting for studysize and baseline differences in blood pressure. B, Changes in diastolic blood pressure associated with each QI strategy adjust-ing for study size and baseline differences in blood pressure. Forty-four studies included 57 comparisons. A total of 33 of thesecomparisons reported absolute changes in systolic blood pressure and 43 of these comparisons reported absolute changes indiastolic blood pressure. The x-axis shows each QI strategy and the y-axis shows the difference in the postintervention changein blood pressure between studies with and without a particular QI strategy (change in blood pressure in the interventiongroup minus change in blood pressure in the control group). “All comparisons” shows the estimate for all comparisons re-porting blood pressure outcomes regardless of the QI strategy included in the comparison. “Diffpre” refers to the baseline dif-ferences in blood pressure control between intervention and control groups. Each estimate represents the difference betweenthe reduction in blood pressure (systolic blood pressure for top panel and diastolic blood pressure for bottom panel) associ-ated with the presence of a particular QI strategy and the benefit observed in interventions without that strategy. The num-bers in parentheses indicate the number of studies contributing to the estimate �eg, in (A), 10 comparisons evaluated inter-ventions involving provider education). Of note, there were too few studies of financial incentives to include this strategy.Negative results reflect lower blood pressure values when a QI strategy is present compared with its absence. Positive resultsindicate that interventions with a component of the QI strategy in question produced smaller reductions in blood pressurethan did interventions without such a component. The estimates include adjustment for the effects of study size and baselinedifferences in blood pressure control between intervention and control groups.



that were consistently less than the median). Studies that wereconducted at multiple sites generally had changes that wereless than the median. There was no compelling evidence todistinguish studies performed at hypertension clinics fromstudies performed in other settings.

All of the team change interventions for hypertensioncare involved assigning some patient care responsibilities tosomeone other than the patient’s doctor. Pharmacists, nurses,physician assistants, and worksite physicians took on coordi-nation, counseling, and patient follow-up functions in manyof the studies. Sometimes, these individuals carried out allcommunication with the patient related to blood pres-sure control (“all communication transferred”; 18 compar-isons20,23,27,29,30,38,42–44,47,49,55,58,60,62); in other cases, theyworked with the doctor (“shared responsibility”; 7 compari-sons24,25,28,32,37,52,63), and in a few cases, they or othersprovided support in the form of prompts or education tophysicians who retained full responsibility for the interactionswith the patients (“doctor-focused”; 5 comparisons39,48,56).The remaining 6 comparisons31,34,45,46 involved some formof triage and monitoring at the worksite.

An example of the “all communications transferred”intervention involved a clinical pharmacist meeting with thepatient to make changes in prescribed drugs, adjust dosages,provide drug counseling, and assess adherence to treatmentregimen. Interventions designated as “shared responsibility”involved, for example, a pharmacist relaying evidence-basedtreatment recommendations to a patient’s doctors and provid-ing the patient with education on dietary and lifestyle modi-fication as well as information about drug side effects. Bloodpressure reductions for studies involving doctor-focused in-terventions such as a specialist physician reviewing patientrecords and recommending treatment changes were consis-tently less than the median improvement and in some cases (4of 6 comparisons) showed a reduction in blood pressure lessthan the control arm. Most of the worksite interventionsshowed large improvements in blood pressure outcomes, with5 of 6 comparisons greater than the median (ie, 25%, 38%,40%, and 42% improvement in net SBP range and 5.6-mm-Hg improvement in net DBP).

Other characteristics represented repeatedly in the teamchange interventions were home blood pressure monitoringor use of a standard protocol for adding drugs. Of the 5studies with stepped care protocols, 244,63 had blood pressurereductions consistently less than the median and the other320,29,60 had mixed results depending on outcome assessed. Incontrast, 4 of 5 studies with home monitoring30,46,49,62 wereconsistently greater (n � 330,49,62) than or consistently equiv-alent (n � 130) to the median.

Effect of Methodologic Features on BloodPressure Outcomes

In our assessment of methodologic features, we foundno significant differences in blood pressure outcomes acrossstudies with more rigorous versus less rigorous methodologicfeatures.

Effect of Study Size on Blood PressureOutcomes

Studies with smaller sample sizes generally reportedlarger reductions in SBP and DBP (Fig. 3). We considered thepossibility that the inclusion of clustered trials might haveconfounded the relationship between study size and magni-tude of median change. Because allocation occurs at the levelof the provider or clinic, cluster trials might be expected tohave larger numbers of patients. Among the included studies,the clustered trials included a median of 120 patients (IQR:52 to 249) and the nonclustered trials included a median of 67patients (IQR: 26 to 151). The clustered trials reported amedian reduction in SBP of 2.9 mm Hg, which was lowerthan that seen in the nonclustered trials (7.1 mm Hg; P �0.08). When we restricted our analyses to studies withoutclustering (eg, patient level randomized, controlled trials), theinverse relation between sample size and median changemagnitude remained.

DISCUSSIONQuality improvement strategies are associated with

improved control of hypertension. QI strategies generallyimproved SBP and the proportion of patients achieving targetSBP range and had a more modest effect on DBP and theproportion of patients achieving target DBP range. All of thestrategies assessed may be beneficial in terms of clinicallymeaningful reductions in blood pressure under some circum-stances and in varying combinations.

In general, team change had the largest effect on bothSBP and DBP outcomes regardless of study design or size. QIstrategies, including patient education and self-management,had a significant effect on DBP but not SBP, which may berelated to more studies assessing DBP outcomes or to the factthat until recently, the main focus of blood pressure manage-ment was on DBP.

A common feature of the team change studies wasassignment of some patient care responsibilities to someoneother than the patient’s physician.

There are many possible explanations for the success ofteam change in achieving blood pressure control. Such inter-ventions typically require administrative support, which maybe an important factor in the success of a QI strategy. Manystudies of team change include designation of specific staff toaddress hypertension, which may represent either an increasein staffing or a reallocation of staff effort to hypertension. Thefindings regarding team change are consistent with resultsfrom an observational study of the Veterans Affairs HealthCare System, which reported moderate improvements in ratesof blood pressure control after implementation of systemwidereengineering.64,65 A trial published after our search end dateconfirms the major impact that team change may exert onblood pressure outcomes. Among inner-city African Ameri-can men, interventions by a multidisciplinary team improvedblood pressure control.66

Assigning some of the responsibility for blood pressurecontrol to a healthcare professional other than the patient’sphysician was common to all of the team change studies.What makes team change work is unclear, but could include



FIGURE 3. A, Changes in systolic blood pressure based on adjusted sample sizes. B, Changes in diastolic blood pressure basedon adjusted sample sizes. Forty-four studies included 57 comparisons. A total of 33 of these comparisons reported absolutechanges in systolic blood pressure and 43 of these comparisons reported absolute changes in diastolic blood pressure. Eachbar represents the reduction in blood pressure �(A) shows reduction in systolic blood pressure and (B) shows reduction in dia-stolic blood pressure� for each quality improvement strategy. The bars with stripes show the reduction in blood pressure forthose studies that had smaller adjusted sample sizes (in the lower half) and the bars with dots show the reduction in bloodpressure for those studies that had larger adjusted sample sizes (in the upper half). The numbers in parentheses indicate thenumber of studies in each half �eg, in (A) for studies reporting systolic blood pressure outcome, there were 16 studies thathad smaller adjusted sample sizes and 17 studies with larger sample sizes). The x-axis shows each quality improvement strat-egy and the y-axis shows the reduction in blood pressure (mm Hg).



use of nonphysician providers, having a strict algorithm orguideline for hypertension control, or having clearer assign-ments of roles and responsibilities for hypertension caremanagement. Regardless of the reason for success, teamchange was an effective QI strategy in the studies included inour review. A recent Cochrane review of interventions usedto improve control of blood pressure also concluded that theuse of healthcare professionals such as nurses or pharmacistsin managing blood pressure was a successful strategy thatdeserved further evaluation.67 This review, which was limitedto randomized, controlled studies only, included 7 nurse/pharmacist-led studies and 8 other organizational interven-tions related to team change. Thus, our review almost triplesthe comparative data on team change strategies. Assigningadditional staff time for a health professional to work directlywith patients may be expensive in the short term; however, arecent report on diabetes raises the possibility that suchinterventions can be economically attractive.68

Patient education appeared to be a successful strategyfor improving blood pressure control, but we evaluated itonly when it was used in conjunction with other QI strategies.Therefore, the impact of patient education per se may beoverestimated in the studies we included, and we cannotdetermine the impact of patient education as a solo strategy.Promotion of patient self-management of blood pressure hada modest effect on blood pressure outcomes, an effect con-sistent with a recent meta-analysis that showed that promo-tion of patient self-management of hypertension and diabetescould produce clinically important benefits.69 Interventionsthat included provider education had only modest effects inaccord with the recent Cochrane review.67 Provider behaviorappears to be difficult to change9; however, relatively inex-pensive interventions directed toward providers, particularlyreminders, although yielding smaller blood pressure changeson a per-patient basis, could effect greater overall benefit asa result of the large number of patients that could be reached.In contrast, a more labor-intensive intervention might resultin a larger benefit for each patient but would reach a smallernumber of patients and at greater cost. Alternatively, chang-ing provider behavior may not be a critical factor for accom-plishing improved blood pressure control. Perhaps providerbehavior should be targeted only in conjunction with othersystem changes.70

LimitationsOnly 10 of the included studies assessed a single QI

strategy; because most studies included more than one QIstrategy, we could not discern definitively which individualQI strategies had the greatest effects, and we could notdetermine whether certain combinations of individual QIstrategies were more “potent” than others. Not all QI strate-gies have been assessed equally, which limits the power todetect statistically or clinically significant differences. Im-provements in blood pressure control were smaller in largerstudies than in smaller studies. Large studies may be morelikely to be reported than small studies if the results arenegative, raising the concern that overall measures of theeffectiveness of QI strategies may be overestimated because

of publication bias or other factors (eg, setting) potentiallyassociated with study size.

CONCLUSIONQI strategies can result in clinically important reduc-

tions in blood pressure control. Smaller studies generallyreported larger median changes, suggesting some publicationbias or an unexplained confounder. It is possible that largerstudies involved more practices and physicians who were lessenthusiastic or engaged in the project. Studies that includedteam change reported greater improvements in blood pressurecontrol than did studies without these strategies, but theevidence does not definitively establish the superiority of anyindividual QI strategy. The multidisciplinary team approachto patient care is gaining popularity and is an integral com-ponent of the management of many chronic diseases.71–73

The success of the QI strategies that involve assigning somepatient care responsibilities to someone other than the phy-sician fits well with this team approach and should be inves-tigated further. QI strategies seem to be effective in a varietyof settings, but there is inadequate evidence to suggest tai-loring of particular QI strategies to specific settings. Inaddition, the cost-effectiveness of individual QI strategies forhypertension management should be a priority for futureresearch.

ACKNOWLEDGMENTSThe authors thank Amy Markowitz, Robert Wachter,

Jeremy Grimshaw, and the Cochrane Effective Practice andOrganisation of Care for their assistance on this study. Theauthors also thank Sheryl Davies, Jody Mechanic, Christo-pher Sharp, Melinda Henne, Bimal Shah, and Jo Kay Chanfor their assistance with data abstraction and Alan Bostromfor his assistance with statistical analysis.

REFERENCES1. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and

control of hypertension in the United States, 1988–2000. JAMA. 2003;290:199–206.

2. The State of Managed Care Quality. National Committee for QualityAssurance; 2001.

3. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of theJoint National Committee on Prevention, Detection, Evaluation, andTreatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–2572.

4. Cook NR, Cohen J, Hebert PR, et al. Implications of small reductions indiastolic blood pressure for primary prevention. Arch Intern Med.1995;155:701–709.

5. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance ofusual blood pressure to vascular mortality: a meta-analysis of individualdata for one million adults in 61 prospective studies. Lancet. 2002;360:1903–1913.

6. Shojania KG, McDonald KM, Wachter RM, et al. Closing the QualityGap: A Critical Analysis of Quality Improvement Strategies, Volume1—Series Overview and Methodology. Technical Review 9 (ContractNo. 290-02-0017 to the Stanford University-UCSF Evidence-basedPractices Center). AHRQ Publication No. 04-0051-1. Rockville, MD:Agency for Health Research and Quality; August 2004.

7. Institute of Medicine. Crossing the Quality Chasm: A New HealthSystem for the 21st Century. Washington, DC: National Academy Press;2001.

8. Ellis P, Robinson P, Ciliska D, et al. Diffusion and Dissemination ofEvidence-based Cancer Control Interventions. Evidence Report/Tech-



nology Assessment No. 79 (Prepared by the McMaster UniversityEvidence-based Practice Center under contract no. 290-97-0017).AHRQ Publication No. 03-E032. Rockville, MD: Agency for HealthcareResearch and Quality; May 2003.

9. Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior:an overview of systematic reviews of interventions. Med Care. 2001;39:II-2–I-45.

10. Stafford RS. Alternative strategies for controlling rising cesarean sectionrates. JAMA. 1990;263:683–687.

11. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increaseuse of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641–651.

12. Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used indisease management programmes for patients with chronic illness—which ones work? Meta-analysis of published reports �review�. BMJ.2002;325:925.

13. Cochrane Effective Practice and Organisation of Care Group. EffectivePractice and Organisation of Care Group, vol 2004. Institute of Popu-lation Health, University of Ottawa; 2004.

14. Grimshaw J, Thomas R, MacLennan G, et al. Effectiveness and effi-ciency of guideline dissemination and implementation strategies. HealthTechnol Assess. 2004;8:1–84.

15. Normand SL. Meta-analysis: formulating, evaluating, combining, andreporting. Stat Med. 1999;18:321–359.

16. Campbell M, Grimshaw J, Steen N. Sample size calculations for clusterrandomised trials. Changing Professional Practice in Europe Group (EUBIOMED II Concerted Action). J Health Serv Res Policy. 2000;5:12–16.

17. Donner A, Klar N. Issues in the meta-analysis of cluster randomizedtrials. Stat Med. 2002;21:2971–2980.

18. Kerry SM, Bland JM. The intracluster correlation coefficient in clusterrandomisation �review�. BMJ. 1998;316:1455.

19. Campbell MK, Mollison J, Grimshaw JM. Cluster trials in implemen-tation research: estimation of intracluster correlation coefficients andsample size. Stat Med. 2001;20:391–399.

20. Mortality after 10 1/2 years for hypertensive participants in the MultipleRisk Factor Intervention Trial. Circulation. 1990;82:1616–1628.

21. Avanzini F, Corsetti A, Maglione T, et al. Simple, shared guidelinesraise the quality of antihypertensive treatment in routine care. AmHeart J. 2002;144:726–732 �online�.

22. Becker LA, Glanz K, Sobel E, et al. A randomized trial of special packagingof antihypertensive medications. J Fam Pract. 1986;22:357–361.

23. Blenkinsopp A, Phelan M, Bourne J, et al. Extended adherence supportby community pharmacists for patients with hypertension: a randomisedcontrolled trial. International Journal of Pharmacy Practice. 2000;8:165–175.

24. Bogden PE, Abbott RD, Williamson P, et al. Comparing standard carewith a physician and pharmacist team approach for uncontrolled hyper-tension. J Gen Intern Med. 1998;13:740–745.

25. Borenstein JE, Graber G, Saltiel E, et al. Physician–pharmacist coman-agement of hypertension: a randomized, comparative trial. Pharmaco-therapy. 2003;23:209–216.

26. Brook RH, Ware JE Jr, Rogers WH, et al. Does free care improve adults’health? N Engl J Med. 1983;309:1426–1434.

27. Campbell NC, Ritchie LD, Thain J, et al. Secondary prevention incoronary heart disease: a randomised trial of nurse led clinics in primarycare. Heart. 1998;80:447–452.

28. Carter BL, Barnette DJ, Chrischilles E, et al. Evaluation of hypertensivepatients after care provided by community pharmacists in a rural setting.Pharmacotherapy. 1997;17:1274–1285.

29. Curzio JL, Rubin PC, Kennedy SS, et al. A comparison of the manage-ment of hypertensive patients by nurse practitioners compared withconventional hospital care. J Hum Hypertens. 1990;4:665–670.

30. Earp JA, Ory MG, Strogatz DS. The effects of family involvement andpractitioner home visits on the control of hypertension. Am J PublicHealth. 1982;72:1146–1154.

31. Erfurt JC, Foote A, Heirich MA. Worksite wellness programs: incre-mental comparison of screening and referral alone, health education,follow-up counseling, and plant organization. Am J Health Promot.1991;5:438–448.

32. Erickson SR, Slaughter R, Halapy H. Pharmacists’ ability to influenceoutcomes of hypertension therapy. Pharmacotherapy. 1997;17:140–147.

33. Evans CE, Haynes RB, Birkett NJ, et al. Does a mailed continuingeducation program improve physician performance? Results of a ran-domized trial in antihypertensive care. JAMA. 1986;255:501–504.

34. Foote A, Erfurt JC. Hypertension control at the work site. Comparisonof screening and referral alone, referral and follow-up, and on-sitetreatment. N Engl J Med. 1983;308:809–813.

35. Fortmann SP, Winkleby MA, Flora JA, et al. Effect of long-termcommunity health education on blood pressure and hypertension control.The Stanford Five-City Project. Am J Epidemiol. 1990;132:629–646.

36. Friedman RH, Kazis LE, Jette A, et al. A telecommunications system formonitoring and counseling patients with hypertension. Impact on med-ication adherence and blood pressure control. Am J Hypertens. 1996;9:285–292.

37. Garcao JA, Cabrita J. Evaluation of a pharmaceutical care program forhypertensive patients in rural Portugal. J Am Pharm Assoc (Wash).2002;42:858–864.

38. Garcia-Pena C, Thorogood M, Armstrong B, et al. Pragmatic random-ized trial of home visits by a nurse to elderly people with hypertensionin Mexico. Int J Epidemiol. 2001;30:1485–1491.

39. Goldberg HI, Wagner EH, Fihn SD, et al. A randomized controlled trialof CQI teams and academic detailing: can they alter compliance withguidelines? Jt Comm J Qual Improv. 1998;24:130–142.

40. Gullion DS, Tschann JM, Adamson TE, et al. Management of hyper-tension in private practices: a randomized controlled trial in continuingmedical education. J Contin Educ Health Prof. 1988;8:239–255.

41. Hetlevik I, Holmen J, Kruger O. Implementing clinical guidelines in thetreatment of hypertension in general practice. Evaluation of patientoutcome related to implementation of a computer-based clinical decisionsupport system. Scand J Prim Health Care. 1999;17:35–40.

42. Hill MN, Bone LR, Hilton SC, et al. A clinical trial to improve highblood pressure care in young urban black men: recruitment, follow-up,and outcomes. Am J Hypertens. 1999;12:548–554.

43. Hla KM, Feussner JR, Blessing-Feussner CL, et al. BP control. Improve-ment in a university medical clinic by use of a physician’s associate.Arch Intern Med. 1983;143:920–923.

44. Solomon DK. Clinical and economic outcomes in the hypertension andCOPD arms of a multicenter outcomes study. J Am Pharm Assoc.1998;38:574–585. JC CP:85.

45. Logan AG, Milne BJ, Achber C, et al. Cost-effectiveness of a worksitehypertension treatment program. Hypertension. 1981;3:211–218.

46. Logan AG, Milne BJ, Flanagan PT, et al. Clinical effectiveness andcost-effectiveness of monitoring blood pressure of hypertensive employ-ees at work. Hypertension. 1983;5:828–836.

47. McClellan WM, Craxton LC. Improved follow-up care of hypertensivepatients by a nurse practitioner in a rural clinic. J Rural Health.1985;1:34–41.

48. McGhee SM, McInnes GT, Hedley AJ, et al. Coordinating and stan-dardizing long-term care: evaluation of the west of Scotland shared-carescheme for hypertension. Br J Gen Pract. 1994;44:441–445.

49. Mehos BM, Saseen JJ, MacLaughlin EJ. Effect of pharmacist interven-tion and initiation of home blood pressure monitoring in patients withuncontrolled hypertension. Pharmacotherapy. 2000;20:1384–1389.

50. Midanik LT, Resnick B, Hurley LB, et al. Home blood pressuremonitoring for mild hypertensives. Public Health Rep. 1991;106:85–89.

51. Montgomery AA, Fahey T, Peters TJ, et al. Evaluation of computerbased clinical decision support system and risk chart for management ofhypertension in primary care: randomised controlled trial. BMJ. 2000;320:686–690.

52. Park JJ, Kelly P, Carter BL, et al. Comprehensive pharmaceutical care inthe chain setting. J Am Pharm Assoc (Wash). 1996;NS36:443–451.

53. Sanders KM, Satyvavolu A. Improving blood pressure control in diabe-tes: limitations of a clinical reminder in influencing physician behavior.J Contin Educ Health Prof. 2002;22:23–32.

54. Saunders LD, Irwig LM, Gear JS, et al. A randomized controlled trial ofcompliance improving strategies in Soweto hypertensives. Med Care.1991;29:669–678.

55. Schneider PJ, Larrimer JN, Visconti JA, et al. Role effectiveness of apharmacist in the maintenance of patients with hypertension and con-gestive heart failure. Contemp Pharm Pract. 1982;5:74–79.

56. Siscovick DS, Strogatz DS, Wagner EH, et al. Provider-oriented interven-tions and management of hypertension. Med Care. 1987;25:254–258.



57. Soghikian K, Casper SM, Fireman BH, et al. Home blood pressuremonitoring. Effect on use of medical services and medical care costs.Med Care. 1992;30:855–865.

58. Vivian EM. Improving blood pressure control in a pharmacist-managedhypertension clinic. Pharmacotherapy. 2002;22:1533–1540.

59. Winickoff RN, Wilner S, Neisuler R, et al. Limitations of providerinterventions in hypertension quality assurance. Am J Public Health.1985;75:43–46.

60. Five-year findings of the hypertension detection and follow-up program.II. Mortality by race-sex and age. Hypertension Detection and Follow-upProgram Cooperative Group. JAMA. 1979;242:2572–2577.

61. Dickinson JC, Warshaw GA, Gehlbach SH, et al. Improving hyperten-sion control: impact of computer feedback and physician education. MedCare. 1981;19:843–854.

62. Artinian NT, Washington OG, Templin TN. Effects of home telem-onitoring and community-based monitoring on blood pressure controlin urban African Americans: a pilot study. Heart Lung. 2001;30:191–199.

63. Krishan I, Davis CS, Nobrega FT, et al. The Mayo three-communityhypertension control program. IV. Five-year outcomes of intervention inentire communities. Mayo Clin Proc. 1981;56:3–10.

64. Kizer KW, Demakis JG, Feussner JR. Reinventing VA health care:systematizing quality improvement and quality innovation. Med Care.2000;38:I7–16.

65. Jha AK, Perlin JB, Kizer KW, et al. Effect of the transformation of the

Veterans Affairs health care system on the quality of care. N Engl J Med.2003;348:2218–2227.

66. Hill MN, Han HR, Dennison CR, et al. Hypertension care and control inunderserved urban African American men: behavioral and physiologicoutcomes at 36 months. Am J Hypertens. 2003;16:906–913.

67. Fahey T, Schroeder K, Ebrahim S. Interventions used to improve controlof blood pressure in patients with hypertension. Cochrane Database SystRev. 2005:CD005182.

68. Villagra VG, Ahmed T. Effectiveness of a disease management programfor patients with diabetes. Health Aff (Millwood). 2004;23:255–266.

69. Chodosh J, Morton SC, Mojica W, et al. Meta-analysis: chronic diseaseself-management programs for older adults. Ann Intern Med. 2005;143:427–438.

70. Goldstein MK, Lavori P, Coleman R, et al. Improving adherence toguidelines for hypertension drug prescribing: cluster-randomized con-trolled trial of general versus patient-specific recommendations. Am JManag Care. 2005;11:677–685.

71. Wagner EH, Glasgow RE, Davis C, et al. Quality improvement in chronicillness care: a collaborative approach. Jt Comm J Qual Improv. 2001;27:63–80.

72. Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care:translating evidence into action. Health Aff (Millwood). 2001;20:64–78.

73. Casalino L, Gillies RR, Shortell SM, et al. External incentives, infor-mation technology, and organized processes to improve health carequality for patients with chronic diseases. JAMA. 2003;289:434–441.



APP

END

IX1

Sear

chSt

rate

gySe

arch

Sear

chSt

ring

Cit

atio

ns†

1T

arge

tsQ

Ist

rate

gies

that

tend

tobe

mul

ti-f

acto

rial

usin

gre

leva

ntM

eSH

term

san

dti

tle

wor

d

Dis

ease

Man

agem

ent

�mh�

OR

Pat

ient

Car

eP

lann

ing

�mh�

OR

Pat

ient

-Cen

tere

dC

are

�mh�

OR

Pri

mar

yH

ealt

hC

are

�mh�

OR

Pro

gres

sive

Pat

ient

Car

e�m

h�O

RC

riti

cal

Pat

hway

s�m

h�O

RD

eliv

ery

ofH

ealt

hC

are,

Inte

grat

ed�m

h�O

RH

ealt

hS

ervi

ces

Acc

essi

bili

ty�m

h�O

RM

anag

edC

are

Pro

gram

s�m

h�O

RP

rodu

ctL

ine

Man

agem

ent

�mh�

OR

Pat

ient

Car

eT

eam

�mh�

OR

Pat

ient

-Cen

tere

dC

are

�mh�

OR

Beh

avio

rC

ontr

ol�m

h�O

RC

ouns

elin

g�m

h�O

RH

ealt

hP

rom

otio

n�m

h�O

RP

atie

ntC

ompl

ianc

e�m

h�O

RA

fter

-Hou

rsC

are

�mh�

OR

((co

ordi

nati

on�t

i�O

Rco

ordi

nate

d�t

i�O

RM

ulti

fact

oria

l�t

i�O

RM

ulti

fact

oria

l�t

i�O

RM

ulti

com

pone

nt�t

i�O

RM

ulti

com

pone

nt�t

i�O

Rm

ulti

disc

ipli

nary

�ti�

OR

mul

tidi

scip

lina

ry�t

i�O

Rin

terd

isci

plin

ary

�ti�

OR

inte

rdis

cipl

inar

y�t

i�O

Rin

tegr

ated

�ti�

OR

com

mun

ity-

base

d�t

i�O

Ror

gani

zed

�ti�

)A

ND

(car

e�t

i�O

Rap

proa

ch�t

i�O

Rin

terv

enti

on�t

i�O

Rst

rate

gy�t

i�O

Rst

rate

gies

�ti�

OR

man

agem

ent

�ti�

OR

man

agin

g�t

i�O

Rce

nter

*�t

i�O

Rcl

inic

*�ti�)

)O

RO

rgan

izat

ion

and

Adm

inis

trat

ion

�mh�

683,

000

2T

arge

tsT

QM

and

CQ

IT

otal

Qua

lity

Man

agem

ent

�mh�

OR

Qua

lity

cont

rol

�mh�

OR

TQ

M�t

i�O

RC

QI

�ti�

OR

(qua

lity

�ti�

AN

D(c

onti

nuou

s�t

i�O

Rto

tal

�ti�

)A

ND

(man

agem

ent

�ti�

OR

impr

ovem

ent

�ti�

))28

,087

3T

arge

tspr

ovid

ered

ucat

ion

Edu

cati

on,

Con

tinu

ing

�mh�

OR

(Edu

cati

on�t

i�A

ND

Con

tinu

ing

�ti�

AN

D(m

edic

al�t

i�O

Rpr

ofes

sion

al*

�ti�

OR

nurs

ing

�ti�

OR

phys

icia

n*�t

i�O

Rnu

rse*

�ti�

))O

R(o

utre

ach

�ti�

AN

D(v

isit

*�ti�

OR

educ

atio

nal

�ti�

)O

R(a

cade

mic

�ti�

AN

Dde

tail

ing

�ti�

))35

,276

4T

arge

tsdi

ffus

ion

ofin

nova

tion

Dif

fusi

onof

Inno

vati

on�m

h�O

R(D

iffu

sion

�ti�

AN

D(I

nnov

atio

n�t

i�O

Rte

chno

logy

�ti�

))48

895

Tar

gets

audi

tan

dfe

edba

ck,

rem

inde

rsy

stem

s,an

dfi

nanc

ial

ince

ntiv

es

Med

ical

audi

t�m

h�O

R((

Aud

it�t

i�O

Rfe

edba

ck�t

i�O

Rco

mpl

ianc

e�t

i�O

Rad

here

nce

�ti�

OR

trai

ning

�ti�

)A

ND

(im

prov

emen

t*�t

i�O

Rim

prov

ing

�ti�

OR

impr

oves

�ti�

OR

impr

ove

�ti�

OR

guid

elin

e*�t

i�O

Rpr

acti

ce*

�ti�

OR

med

ical

�ti�

OR

prov

ider

*�t

i�O

Rph

ysic

ian*

�ti�

OR

nurs

e*�t

i�O

Rcl

inic

ian*

�ti�

OR

prac

tice

guid

elin

es�m

h�O

Rac

adem

ic�t

i�O

Rvi

sit*

�ti�

))O

RR

emin

der

Sys

tem

s�m

h�O

RR

emin

der*

�ti�

OR

((fi

nanc

ial

�ti�

OR

econ

omic

�ti�

OR

phys

icia

n*�t

i�O

Rpa

tien

t*)

AN

Din

cent

ive*

�ti�

)O

RR

eim

burs

emen

tM

echa

nism

s�m

h�

36,8

52

6T

arge

tsin

form

atic

san

dte

lem

edic

ine

Med

ical

Info

rmat

ics

�mh�

OR

com

pute

r�t

i�O

R(d

ecis

ion

�ti�

AN

Dsu

ppor

t�t

i�)

OR

Tel

emed

icin

e�m

h�O

RT

elem

edic

ine

�ti�

OR

tele

com

mun

icat

ion*

�ti�

OR

Inte

rnet

�mh�

OR

web

�ti�

OR

mod

em�t

i�O

Rte

leph

one*

�ti�

OR

tele

phon

e�m

h�30

6,70

3

7C

ombi

nes

1–6

for

over

all

set

ofar

ticl

esre

lati

ngto

QI

1O

R2

OR

3O

R4

OR

5O

R6

988,

356

8C

ombi

nes

over

all

QI

sear

chke

yte

rms

for

arti

cles

invo

lvin

ghy

pert

ensi

on

7A

ND

(Hyp

erte

nsio

n�m

h�O

RH

yper

tens

ion

�ti�

OR

(blo

od�t

i�A

ND

pres

sure

�ti�

))75

74

9Id

enti

fies

subs

etof

8li

kely

toin

volv

eor

igin

alre

sear

chor

syst

emat

icre

view

s

8A

ND

(sys

tem

atic

revi

ewse

arch

stri

ng‡

OR

orig

inal

rese

arch

stri

ng§)

3698

109

Lim

itto

Eng

lish

3144

1110

Lim

itto

Pub

sinc

e19

8029

4212

11B

UT

NO

T(e

dito

rial

�pt�

OR

com

men

t�p

t�O

Rle

tter

�pt�

)28

4213

Add

itio

nal

yiel

dof

jour

nal

sear

ch(8

AN

DJo

urna

lS

earc

hS

trin

g¶)

BU

TN

OT

(9O

Red

itor

ial

�pt�

OR

com

men

t�p

t�O

Rle

tter

�pt�

)�L

imit

edto

Eng

lish

,19

80�

220

14A

ddit

iona

lyi

eld

ofau

thor

sear

ch(8

AN

Dau

thor

sear

ch� )

BU

TN

OT

(13

OR

edit

oria

l�p

t�O

Rco

mm

ent

�pt�

OR

lett

er�p

t�)

�Lim

ited

toE

ngli

sh,

1980

�29

TO

TA

L12

OR

13O

R14

3070

refe

renc

esto

tal

†N

umbe

rsof

cita

tion

sre

flec

tse

arch

resu

lts

from

July

8,20

03.

‡((

met

a-an

alys

is�p

t�O

Rm

eta-

anal

ysis

�tw

�O

Rm

eta-

anal

ysis

�tw

�)O

R((

revi

ew�p

t�O

Rgu

idel

ine

�pt�

OR

cons

ensu

s�t

i�O

Rgu

idel

ine*

�ti�

OR

lite

ratu

re�t

i�O

Rov

ervi

ew�t

i�O

Rre

view

�ti�

OR

Dec

isio

nS

uppo

rtT

echn

ique

s�m

h�)

AN

D((

Coc

hran

e�t

w�

OR

Med

line

�tw

�O

RC

INA

HL

�tw

�O

R(N

atio

nal

�tw

�A

ND

Lib

rary

�tw

�))

OR

(han

dsea

rch*

�tw

�O

Rse

arch

*�t

w�

OR

sear

chin

g�t

w�)

AN

D(h

and

�tw

�O

Rm

anua

l�t

w�

OR

elec

tron

ic�t

w�

OR

bibl

iogr

aphi

*�t

w�

OR

data

base

*O

R(C

ochr

ane

�tw

�O

RM

edli

ne�t

w�

OR

CIN

AH

L�t

w�

OR

(Nat

iona

l�t

w�

AN

DL

ibra

ry�t

w�)

))))

OR

((sy

nthe

sis

�ti�

OR

over

view

�ti�

OR

revi

ew�t

i�O

Rsu

rvey

�ti�

)A

ND

(sys

tem

atic

�ti�

OR

crit

ical

�ti�

OR

met

hodo

logi

c�t

i�O

Rqu

anti

tati

ve�t

i�O

Rqu

alit

ativ

e�t

i�O

Rli

tera

ture

�ti�

OR

evid

ence

�ti�

OR

evid

ence

-bas

ed�t

i�))

)B

UT

NO

T(c

ase

repo

rt�m

h�O

Rca

se*

�ti�

OR

repo

rt�t

i�O

Red

itor

ial

�pt�

OR

com

men

t�p

t�O

Rle

tter

�pt�

)�

38,8

65M

ED

LIN

Ere

cord

s.§R

ando

mis

ed�t

i�O

RR

ando

miz

ed�t

i�O

RC

ontr

olle

d�t

i�O

Rin

terv

enti

on�t

i�O

Rev

alua

tion

�ti�

OR

impa

ct�t

i�O

Ref

fect

iven

ess

�ti�

OR

Eva

luat

ion

�ti�

OR

Stu

dies

�ti�

OR

stud

y�t

i�C

ompa

rati

ve�t

i�O

RF

easi

bili

ty�t

i�O

RP

rogr

am�t

i�O

RD

esig

n�t

i�O

RC

lini

cal

Tri

al�p

t�O

RR

ando

miz

edC

ontr

olle

dT

rial

�pt�

OR

Epi

dem

iolo

gic

Stu

dies

�mh�

OR

Eva

luat

ion

Stu

dies

�mh�

OR

Com

para

tive

Stu

dy�m

h�O

RF

easi

bili

tyS

tudi

es�m

h�O

RIn

terv

enti

onS

tudi

es�m

h�O

RP

rogr

amE

valu

atio

n�m

h�O

RE

pide

mio

logi

cR

esea

rch

Des

ign

�mh�

—

2,55

1,48

6M

ED

LIN

Ere

cord

s.¶N

Eng

lJ

Med

�ta�

OR

JAM

A�t

a�O

RA

nnIn

tern

Med

�ta�

OR

Am

JM

ed�t

a�O

RA

rch

Inte

rnM

ed�t

a�O

RJ

Gen

Inte

rnM

ed�t

a�O

RB

MJ

�ta�

OR

Lan

cet

�ta�

OR

CM

AJ

�ta�

OR

Cli

nIn

vest

Med

�ta�

OR

Arc

hF

amM

ed�t

a�O

RJ

Fam

Pra

ct�t

a�O

RF

amP

ract

�ta�

OR

Ann

Med

�ta�

OR

Br

JG

enP

ract

�ta�

OR

JIn

tern

Med

�ta�

OR

Med

JA

ust

�ta�

OR

Sou

thM

edJ

�ta�

OR

Wes

tJ

Med

�ta�

OR

Aus

tN

ZJ

Med

�ta�

OR

Med

Car

e�t

a�O

RH

ealt

hS

erv

Res

�ta�

OR

Inqu

iry

�ta�

OR

Mil

bank

Q�t

a�O

RH

ealt

hA

ff(M

illw

ood)

�ta�

OR

Hea

lth

Car

eF

inan

cR

ev�t

a�O

RM

edC

are

Res

Rev

�ta�

OR

eff

clin

prac

t�t

a�O

Rev

alhe

alth

prof

�ta�

OR

JtC

omm

JQ

ual

Impr

ov�t

a�O

RQ

ual

Saf

Hea

lth

Car

e�t

a�O

RIn

tJ

Qua

lH

ealt

hC

are

�mh�

OR

Qua

lH

ealt

hC

are

�ta�

OR

Qua

lH

ealt

hR

es�t

a�O

RR

epM

edG

uide

lO

utco

mes

Res

�ta�

OR

Am

JM

anag

Car

e�t

a�O

RA

mJ

Med

Qua

l�t

a�O

RJ

Con

tin

Edu

cH

ealt

hP

rof

�ta�

OR

Pre

vM

ed�t

a�O

RA

mJ

Pre

vM

ed�t

a�O

RP

atie

ntE

duc

Cou

ns�t

a�O

RA

nnB

ehav

Med

�ta�

OR

JH

umH

yper

tens

�ta�

OR

Hyp

erte

nsio

n�t

a�O

RA

mJ.

� (Ber

wic

kD

�au�

OR

berl

owit

zd

�au�

OR

davi

sd

�au�

OR

kief

ec

�au�

OR

wag

ner

e�a

u�O

Rgl

asgo

wr

�au�

OR

bodd

enhe

imer

t�a

u�O

RH

ulsc

her

M�a

u�O

Rgr

olr

�au�

OR

grim

shaw

j�a

u�O

Rha

ynes

b�a

u�O

Rha

ynes

rb�a

u�O

Rsa

cket

td

�au�

OR

gold

berg

h�a

u�O

RH

irsc

hI

�au�

OR

nash

d�a

u�O

Rro

per

w�a

u�O

Rw

eing

arte

ns

�au�

)—

6401

ME

DL

INE

reco

rds.



article 1

Documents

blood pressure control

lowering blood pressure

blood pressuremay

hypertension care

control patients

hg iqr

hg interquartilerange

qi interventions