Hypertension: Improving Patient Education HIPE

1
Hypertension Improving Patient Education (HIPE)
Ryan Knopp and Keith Ratzlaff University of
Kansas School of Medicine Health of the Public,
January 2000
2
Background

• Hypertension (HTN) affects 50 million Americans
  or one out of four adults
• Most common reason in U.S. for office visits and
  for use of prescription drugs
• National programs focused on HTN
• National High Blood Pressure Education Program
  coordinated by National Heart, Lung, and Blood
  Institute

3
Trends Among Adults with HTN
4
Issues of Control

• Nearly three-fourths of adult Americans with HTN
  are not controlled
• Joint National Committee on the Prevention,
  Detection, Evaluation, and Treatment of High
  Blood Pressure (JNC-VI) issues a public health
  challenge to improve control

5
Patient Education

• Patient education is a foundation and integral
  component of any intervention
• Studies indicate patient education has wide range
  of beneficial effects
• Better patient education eventually results in
  better blood pressure control

6
Patient Education Improves . . .

• Compliance with medications
• Modification of lifestyle factors (exercise,
  weight loss, dietary changes)
• Appointment keeping
• Overall BP control

Levine DM, et al. JAMA 1979 Apr
7
Stanford Five-City Project

• Implemented community-wide health education
  program
• Tracked BP over 5 years
• Found significant decline in both systolic and
  diastolic BP in intervention group
• Important results from public health view

Fortmann SP, et al. Am J Epidemiol 1990 Oct
8
Office-Based Intervention

• Implemented health education program in general
  practice office
• Those in education group did twice as well on
  reduction of BP
• Also those in education group able to
  significantly reduce medication strength

Pierce JP, et al. Prev Med 1984 Mar
9
Whats All the HIPE About Hypertension? (Project
Goals)

• ?Develop a tool (survey) for assessing knowledge
  about HTN
• ?Assess knowledge regarding HTN among
  hypertensive patients at Silver City Health
  Center
• ?Examine the relationship between overall level
  of knowledge and BP control

10
Project Goals (cont.)

• ?Examine the relationship between subsets of
  knowledge regarding HTN and BP control
• ?Develop and implement an interactive form of
  patient education
• ?As a point of interest, look at continuity of
  care for these patients

11
Patient Population

• Previously diagnosed Hypertensive patients seen
  at the Silver City Health Center from Jan.
  1998-present
• Retrospective review of approx. 1000 charts
• 108 patients identified
• 31 surveys completed (29)
• 28 disconnected/wrong (26)
• 25 unable to contact (23)
• 15 no longer seen at Silver City (14)
• 8 refused (7)
• 1 couldnt hear (1)

12
Patient Population (n31)

• Demographics
• Age
• Range 35-93 years
• Mean age 62.9 years
• Sex
• 61 Female (19/31)
• 39 Male (12/31)
• Race
• 77 Caucasian (24/31)
• 13 Hispanic (4/31)
• 10 African American (3/31)

13
Methods

• Instrument Development
• Review of literature for prior surveys
• Compilation of 3 surveys original questions
• 19 question telephone survey to assess knowledge
  regarding hypertension and personal treatment
  issues
• 12 true, false, dont know
• 7 short answer

Williams MV, et al. Arch Intern Med, 1998 Jan
Laher M, et al. Br Med J, 1981 Apr Howard JP, et
al. J Ky Med Assn, 1988 July.
14
Survey Subsets
15
Survey, Part A

• 1) Do you have high blood pressure? If no? Have
  you ever been told you have high blood pressure
  in the past?
• 2) Do you receive your care for high blood
  pressure at the Silver City Health Center?
• 3) When was your last visit?
• 4) When is your next visit?
• 5) What was your blood pressure the last time it
  was measured?
• 6) What medicines do you take for your high blood
  pressure? Or, if question 1 was no?Have you
  ever taken medicine for high blood pressure? If
  so, do you remember these?
• 7) Can you tell me any possible side effects of
  this (or these) medicines?

16
Survey, Part B

• TRUE, FALSE or DONT KNOW
• 8) Losing weight may help to lower blood
  pressure. T
• 9) A blood pressure of 130/80 is normal. T
• 10) People with high blood pressure should avoid
  regular exercise. F
• 11) A person who has high blood pressure is more
  likely to have a heart attack.T
• 12) Most people with high blood pressure feel
  fine. T
• 13) A blood pressure of 160/100 is high. T
• 14) High blood pressure can cause a stroke. T
• 15) It is O.K.to go without blood pressure
  medicine for several days if you run out.F
• 16) Headaches or blurred vision may be due to
  uncontrolled high blood pressure. T
• 17) Canned vegetables are low in salt. F
• 18) You should only take your high blood pressure
  medicine when you feel bad. F
• 19) Uncontrolled high blood pressure can cause
  the kidneys to be damaged. T

17
Results, Overall Knowledge

• Mean Score 75.6 (n31)
• Most commonly missed (26 wrong answers) question
  was, Can you tell me any possible side effects
  of this high blood pressure medicine?
• Only 1 question was answered correctly by all
  subjects, Its O.K. to go without blood pressure
  medicine for several days if you run out.
• One patient claimed he did not have high blood
  pressure, which contradicted his chart.

18
Data Analysis

• Patient population divided into 2 categories
  based on last b.p. measured in the clinic
• ? Controlled b.p. ? 140/90, n13
• ? Uncontrolled b.p. gt 140/90 (either systolic or
  diastolic elevated), n18
• Does level of knowledge differ between controlled
  and uncontrolled hypertensive patients?
• Analyzed by t-test and Wilcoxon non-parametric
  test

19
Demographic Distribution

• Sex and Race are evenly distributed between
  controlled and uncontrolled groups
• Age is unbalanced
• Mean age of controlled group is approx. 10 years
  less than uncontrolled group
• When comparing age to scores, these variables do
  correlate

Analysis of Covariance (ANCOVA) must be used to
adjust for age
20
Results Overall Knowledge
Group means adjusted for age by ANCOVA model
Raw Score P0.002
Age Adjusted P0.008
21
Systolic B.P. vs Overall Score
22
Results Knowledge Subsets
Awareness/ Knowledge
23
Continuity of Care
24
Conclusions

• Overall patient knowledge regarding HTN is
  sub-optimal (avg. score 75.6)
• Patient knowledge in each of the four knowledge
  subsets is sub-optimal
• Similar results reported elsewhere
• Poorest performance on medication subset

Howard JP, et al. J Ky Med Assn 1988 Jul
25
ConclusionsThe HIPE

• Study shows definite correlation between
  knowledge and control of HTN
• Patients with controlled HTN scored higher than
  those with uncontrolled HTN on overall knowledge
  and each subset
• Patients who know more about hypertension are
  more likely to successfully control their BP

26
Conclusions

• Continuity of care appears suspect
• ?Only 81 of patients were seen in last six
  months
• ? Only 35 of patients had a known follow-up
  appointment scheduled

27
Intervention

• Keep it simple, no cost
• Consider functional health literacy
• Make it interactive
• Needs to be basic but comprehensive

Williams MV, et al. Arch Intern Med 1998 Jan
28
Intervention

• Intervention with educational brochure for
  hypertension supported
• Need interactive method - more likely to read
  brochure and retain in memory if required to
  write
• Putting two and two together our intervention

Laher M, et al. Br Med J 1981 Apr
29
Intervention

• Examined various educational materials from AHA,
  NHLBI, AAFP, JNC-VI
• Examined what was available in our own FP and IM
  clinics (pathetic!)
• Found comprehensive brochure through AAFP
• AAFP donated 300 brochures to project

30
Intervention

• Brochure offers basic overview of important
  knowledge (covers the four subsets of HTN
  knowledge)
• Interactive component consists of fill in the
  blank questions derived directly from brochure
• Also space for noting todays and next appointment

31
Criticisms

• Small sample size
• Adjusted for age, but did not assess education
  level
• Was BP measurement valid and reliable
• Method of assignment to groups
• Phone survey excluded important part of
  population (low SES, no phone, disconnected, etc.)

32
Criticisms

• Is our survey a valid assessment of knowledge
  regarding hypertension?
• May argue that knowledge does not equal behavior
• One study showed that intervening with booklet
  increased knowledge which helped establish
  desired behaviors

Zweifler AJ, et al. J Hyperten Suppl 1989 May
33
Future Directions (Studies)

• Does the intervention improve patient knowledge?
• If so, is there an improvement in BP control?
• Effect on behaviors (lifestyle factors,
  medication compliance, etc.)
• Need to address continuity of care - can we
  develop a better system for ensuring patient
  follow-up?

34
Future Directions

• Develop Spanish version of educational brochure
  to address patient needs
• Large print version for elderly
• Replenishing supply of brochures with updated
  versions in the future
• Implementing other components of overall disease
  management program for HTN

35
Knowledge and Hypertension
36

• 5 subsets
• ? General Awareness and Knowledge
• ? Symptoms/Risks
• ? Medication and Side Effects
• ? Lifestyle
• ? Continuity of Care Issues