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- Conclusions and Next Steps
J Clin Hypertens (Greenwich).
The objective of this study was to determine whether a videoconference-based telehealth network can increase hypertension management knowledge and self-assessed competency among primary care providers (PCPs) working in urban Federally Qualified Health Centers (FQHCs). We created a telehealth network among 6 urban FQHCs and our institution to support a 12-session educational program designed to teach state-of-the-art hypertension management. Each 1-hour session included a brief lecture by a university-based hypertension specialist, case presentations by PCPs, and interactive discussions among the specialist and PCPs. Twelve PCPs (9 intervention and 3 controls) were surveyed at baseline and immediately following the curriculum. The mean number of correct answers on the 26-item hypertension knowledge questionnaire increased in the intervention group (13.11 [standard deviation (SD)]=3.06) to 17.44 [SD=1.59], P<.01) but not among controls (14.33 [SD=3.21] to 13.00 [SD=3.46], P=.06). Similarly, the mean score on a 7-item hypertension management self-assessed competency scale increased in the intervention group (4.68 [SD=0.94] to 5.41 [SD=0.89], P<.01) but not among controls (5.28 [SD=0.43] to 5.62 [SD=0.67], P=.64). This model holds promise for enhancing hypertension care provided by urban FQHC providers.
Hypertension affects approximately 30% of adults in the United States1 and is the leading cause of heart disease, stroke, and kidney failure.2 Despite efforts to increase awareness and treatment of hypertension, data from the National Health and Nutrition Examination Survey (NHANES) indicate that in 2005 to 2008, more than half of adults with hypertension did not have their blood pressure (BP) under control.3 Hypertension control in adults is defined as systolic BP (SBP) <140 mm Hg and diastolic BP (DBP) <90 mm Hg among patients with high BP.4 Although patient factors such as medication noncompliance contribute to lower levels of hypertension control, studies show that many physicians do not follow published guidelines regarding hypertension management.5,6
The failure of providers to increase therapy when treatment goals are unmet is termed therapeutic inertia,7 and lack of physician awareness regarding treatment guidelines is a significant contributor to this phenomenon.8 In a national survey of primary care physicians, familiarity with Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC) guidelines for hypertension management was consistently associated with initiating treatment for SBP in older patients and intensifying treatment for mildly elevated SBP and DBP in younger patients.8 The Institute of Medicine’s (IOM’s) Committee on Public Health Priorities to Reduce and Control Hypertension recently highlighted the need to ensure that providers adhere to JNC guidelines and treat hypertension appropriately.7
Toward that end, the IOM has called for new strategies of continuing education in the health professions, including increased use of theory-based education, collaborative learning among health professionals, and increased utilization of emerging technologies.9 A professional educational system that incorporates these strategies and holds promise for improving hypertension management is the Extension for Community Healthcare Outcomes (ECHO), which was developed for use in rural populations by Arora and colleagues10 at the University of New Mexico (UNM). ECHO is based on established educational theories of learning and behavior change.11–13 In the ECHO model, university-based disease experts use telehealth technology to interact regularly with community-based primary care providers (PCPs) to provide continuing education and to co-manage patients with complex diseases. This approach permits PCPs to present challenging cases and receive advice from experts who are geographically distant. This arrangement enhances the medical knowledge of PCPs, permits patients to continue receiving care from their PCPs, and obviates the need for many referrals to specialist physicians. This is especially important for uninsured and underinsured patients, who often have reduced access to specialty care.14,15 Given the success that ECHO has achieved in other disease processes,16 we hypothesized that this model would lead to increased hypertension disease management knowledge, as well as enhanced self-assessed competency in managing hypertension among PCPs practicing in urban Federally Qualified Health Centers (FQHCs).
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- Conclusions and Next Steps
Studies show that FQHC patients, who are often uninsured or underinsured, have reduced access to specialist care. In a national survey of 439 FQHCs, medical directors indicated that they rarely had difficulty in obtaining specialty care for Medicare or privately insured patients. In contrast, the directors reported significant difficulty in obtaining specialty care for uninsured patients and those with Medicaid insurance. They also reported that approximately 25% of visits to FQHCs required medically necessary referrals.14 New strategies are therefore needed to enhance the access of uninsured and underinsured patients with complex chronic diseases to state-of-the-art care.19 At the same time, new approaches are also needed to increase PCP compliance with published hypertension management guidelines.7 Our use of the ECHO model among urban FQHCs attempted to address both of these needs.
Consistent with our hypotheses, we found that our 12-session ECHO intervention was associated with increases in hypertension management knowledge and self-assessed hypertension management competency among intervention PCPs. In contrast, no significant changes in either category were noted among control PCPs. These results cohere with studies of the UNM-based ECHO intervention. For example, Arora and colleagues10 documented increases in self-efficacy in the care of patients with hepatitis C virus (HCV) among 25 community-based PCPs who participated in HCV-oriented ECHO sessions. Arora and colleagues10 also found that more than 80% of community-based PCPs who participated in at least 6 months of HCV-oriented ECHO sessions reported a moderate to high degree of learning in several domains of HCV management.
Various strategies have been used to train PCPs on appropriate pharmacologic and nonpharmacologic methods of hypertension management. In one study, PCPs received detailed training on hypertension guidelines, as well as feedback on attainment of target BPs among their patients.20 Compared with patients cared for by providers in the control group, those cared for by the intervention group were more likely to reach their target BP (56.8% in the intervention group vs 52.5% in the control group, P=.03) at 1 year of follow-up. In addition, BP control in the intervention group was attained 2 months earlier on average and therapeutic inertia occurred significantly less often in the intervention group.
In another study, six 4-hour interactive conferences were held at various locations on the East Coast of the United States.21 These conferences combined didactic training, case-based discussions, question and answer sessions, and the use of an emerging technology (an audience response system). Topics reviewed at the conference included: (1) effectiveness of various drug classes as they relate to different patient populations; (2) Seventh Report of the JNC (JNC 7) hypertension guideline recommendations for patients with compelling indications; (3) benefits and limitations of the Framingham and Reynolds risk scores as they relate to cardiovascular risk assessment in women; (4) rationale for hypertension disparities in African Americans and management considerations in this population; (5) managing elderly patients with isolated systolic hypertension; and (6) strategies to improve adherence to antihypertensive regimens. Conference participants (n=588) and nonparticipants (n=50) were surveyed regarding each of the topics covered and analysis revealed that participants were more likely than nonparticipants to choose evidence-based answers in response to questions related to: (1) JNC 7 guideline recommendations; (2) appropriate pharmacologic therapy in patients with compelling indications, including the elderly and those at risk for stroke; and (3) strategies to improve adherence to medication regimens.
A third intervention utilized internet-based training, self-monitoring, and quarterly feedback reports to physicians, as well as weekly group meetings and monthly telephone counseling of patients regarding weight loss, diet, exercise, and reduced sodium intake.22 For the 2 internet-based training modules, the first focused on JNC 7 guidelines and the second emphasized strategies to encourage lifestyle modifications among hypertensive patients. Eight primary care practices (32 physicians) were randomized to the intervention or control groups. In addition, 574 patients within these practices were randomized to the intervention or control groups. A nested 2×2 randomized controlled study design was used. At 6 months, the mean SBP of patients in the physician intervention group did not differ from the mean SBP of patients in the physician control group. However, a significant reduction in SBP was noted in the patient intervention compared with the patient control group. When the physician and patient interventions were combined, the result was an even larger reduction in mean SBP, suggesting synergy between the physician and patient interventions. However, these SBP differences did not persist at 18 months.
As with our intervention, each of these interventions emphasized physician training. Two of the interventions also provided clinical feedback to physicians,20,22 while one emphasized case-based learning.21 Two also used technology-based learning tools, including an audience response system21 and internet-based training modules.22 All of the interventions attained success, although one measured provider outcomes21 while the other 2 measured BP among patients.20,22 Our results add to the options of strategies that can be used to improve physician knowledge regarding hypertension management and/or enhance BP control among hypertensive patients.
Although our study has not yet documented improved hypertension control, our intervention may have advantages over others, at least in terms of enhancing physician knowledge regarding hypertension management. First, the ECHO approach is theory-based, utilizing Bandura’s social cognitive theory,23 Vygotsky’s12 situated learning theory, and the communities of practice theory.12,13 Social cognitive theory argues that in order for individuals to change their behavior, they must have confidence in their ability to perform specific behaviors in a variety of circumstances.23 In the ECHO model, community providers develop this confidence or self-efficacy when they assume increasing responsibility in delivering best practice care. Our finding of increased self-assessed competency in the intervention group supports this notion.
Situated learning theory posits that optimal learning requires social interaction and collaboration.12 ECHO achieves this through telehealth technology, which provides learners the opportunity to interact with disease specialists and peers at health centers that serve similar patient populations. Participants therefore learn from discussions regarding their own patients as well as from discussions related to other patients. In addition, hearing and seeing other providers describe similarly challenging cases fosters both interaction and collaboration.
Lave and Wenger’s community of practice theory13 extends Vygotsky’s situated learning theory by emphasizing the benefits of creating communities of learners. In the ECHO model, communities of learners are created when PCPs from different settings engage in videoconference discussions. This community, when combined with the disease specialist, becomes a “knowledge network,” which fosters learning through iterative collegial interactions. PCPs are mentored by disease experts but they also learn from the feedback and actions of their peers. Participants in our study indicated that they enjoyed the videoconferences, not just because they learned new skills but also because they no longer felt isolated in managing complex patients. In effect, they became members of a community of practice. Perceiving oneself as part of a community may provide a learning benefit above and beyond that afforded by the training described in the other interventions.
Arora and colleagues17 have shown that the ECHO model permits PCPs to manage complex chronic diseases among rural patients with limited access to specialty care. As a result, continuity of care can be maintained between patients and PCPs, thereby reducing the need for patients to travel to specialty clinics or experience delays in obtaining specialty appointments. We expanded the use of this model by applying it to urban FQHCs, which also care for individuals with barriers to specialty care. Our intervention increased access among FQHC patients to state-of-the-art care via ECHO-trained PCPs without requiring patients to leave their community or medical home.
A limitation of this study is the possibility of a type II error in the control group, which was smaller than the intervention group. While there was a trend toward an increased mean score in self-assessed competency in the control group, this change was not statistically significant. A larger number in the control group may have revealed a significant increase. For hypertension management knowledge, there was a trend toward a decrease in mean score in the control group. With a larger number, it is possible this decrease would have been significant. A second limitation of this study was the lack of randomization. Participants and controls self-selected to their respective groups and it is possible that the changes we found can be attributed to selection bias. In addition, regression toward the mean can occur with pre-post study designs, and this phenomenon may have contributed to the lack of changes in knowledge and self-assessed competency in the control group. Finally, we used t tests to compare preintervention knowledge and self-assessed competency with postintervention knowledge and self-assessed competency. Such tests assume that the data sampled are from populations that follow a normal distribution. Because our intervention and control group sample sizes are small, this assumption is tenuous and our results should be viewed with some caution.