1. The Clinical Question
The clinical question I developed to find the article using the PICO Format is: Does care
management help to improve blood pressure control among uncontrolled hypertensive patients?
2. Search Strategy
a. Database
I found the scholarly article at MEDLINE database. MEDLINE refers to a bibliographic
database of life sciences and biomedical information and contains bibliographic information for
medicine, nursing, pharmacy, and health care articles.
b. Search Terms
I used the title of the paper to search for the article: “Hypertension Control and Management”
c. Article Chosen
My article of choice is “The role of care management as a population health intervention
to address disparities and control hypertension: A quasi-experimental observational study.” The
article was published on Ethnicity & Disease journal on July 21, 2016. Ethnicity & Disease is a
peer-reviewed medical journal that covers the connection between ethnicity and health. The
article appeared in volume 26, issue number 3.
3. A Structured Abstract
Study Design
The research employed both quasi-experimental and observational study. Quasi-
experimental research resembles experimental research. In Quasi-experimental research, there is
a manipulation of the independent variable although participants are not randomly assigned to
conditions. The study design eliminates the directionality problem but does not eliminate the
problem of confounding variables. In observational studies, researchers observe subjects and
measure variables but do not assign treatments to the subjects.
Setting
The research involved “six primary care practices in the Baltimore metropolitan region”
(Hussain et al., 2016). These clinics are part of 35 clinics in Maryland that share an electronic
medical record (EMR). Only two of all study sites are found in medically justified regions.
Participants
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The study involved 3,964 participants. The electronic medical record (EMR) helped to
find hypertensive patients and whose blood pressure was uncontrolled. Patients who had visited
PCP in the past year were also entitled for participation in the study.
Intervention
The program involved three permanent registered dietitians and part-time pharmacist who
could assist in building up hypertension care. The registered dietitians centered on “medication
and health behavior change” using the DASH diet, exercises, and “self-management behaviors”
(Hussain et al., 2016). On their part, pharmacists ensured that medication was adhered to. Care
managers assessed patients’ knowledge on reducing blood pressure and other self-management
techniques. Care managers conducted telephone outreach at no cost to patients who participated
in the study. In general, the care management program involved three sessions in a period of four
weeks apart and totaled 2 hours of face-to-face contact time.
Outcomes or diagnostic standard
The researchers used the “RE-AIM evaluation framework” to evaluate the influence of
care management on population health (Hussain et al., 2016). The researchers determined to
research on the participation rate in at least one care management session. They investigated
blood pressure between the pre-intervention period and the post-intervention period at all clinics.
They used the most current blood pressure documented in the electronic medical record at the
time of care management outreach. According to the researchers, it was critical to know how
many people completed all sessions.
Prognostic factors studied
There was no prognostic factor studied.
Follow-up period
HYPERTENSION CONTROL AND MANAGEMENT 4
There was no follow-up period in this study.
Main results or outcomes
The EMR was used to identify 3,964 uncontrolled hypertensive patients where care
managers contacted 2037 by phone. 629 patients started the program, but only 245 completed all
three sessions. According to the results, there were minor differences in pre-intervention blood
pressure between people who failed to participate, partial completers, and completers. 60 percent
of participants who registered their names at the start completed two sessions while 40 percent
managed three sessions. 95 percent of them received behavior change advice in all sessions
while more than two-thirds were counseled on at least two health topics. Almost 50 percent of
patients reported barriers to hypertension control. Pre-intervention systolic and diastolic BP
depended on race where whites had lower BPs compared with blacks. Blacks also had a higher
BMI compared to other groups.
According to the researchers, all completers reached BP control. However, Africa-
Americans completers experienced a higher drop in blood pressure compared to whites. This
implies that “disparities in pre-intervention systolic and diastolic BP” between the two races
were not “detected at post-intervention” among those who completed the care management
(Hussain et al., 2016). When using DID analysis, “BP changes seen in non-participant racial
counterparts” indicate that the “effectiveness of the intervention did not vary by race.” In this
case, did not seem to affect BP.
Conclusion
The researchers conclude that it is not difficult to achieve BP control and ensure equality
among all races. One can achieve this by employing medication titration and embracing health
behaviors. The study underscores the need to consider program reach and completion before
HYPERTENSION CONTROL AND MANAGEMENT 5
depending on CM to deal with chronic illness care. The researchers argue that future research
that can assist in improving care management comprise: sophisticated technology to track
patients, efficient care coordination services to reach many people and patient-centered methods
that ensure participants are involved until they complete the program.
Is the evidence likely to be biased?
Non-equivalent groups in quasi-experiments are a threat to internal validity. Internal
validity is the extent to which researchers are certain that the treatment caused the change in the
experimental group. Where researchers do not start with equivalent groups, they will not be sure
that the treatment caused the recorded change. Since researchers may lack confidence in the
cause and effect, the results are likely to be biased. It is not possible to haphazardly allocate
subjects to control groups in such studies. This means that quasi-experiments can easily lead to
selection bias where effects of treatment are confounded with prior differences in control
sequence groups.
Were there any adverse events?
There were no major adverse events when conducting this study. The study sought to find
out whether care management can help blood pressure control and disparities among various
groups in the chosen population. The main problem was that care managers could not contact 50
percent of eligible patients. Additionally, four of the six study sites recorded in this research are
found in medically underserved areas.
Identify and describe the knowledge gap your article addresses in the current
literature/protocol.
The article helps to reveal racial disparities in hypertension prevalence and how care
management can help in controlling blood pressure. From the study, it is evident that blacks are
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more likely to be affected by hypertension compared to whites and other races. However, when
care management was conducted, African-Americans completers recorded a higher drop in blood
pressure compared to white completers. The reasons for the racial disparities in hypertension
rates and related outcomes risk are not clear. It is therefore critical to find out why high blood
pressure in blacks is common and what to do to avoid developing high blood pressure. The
medical fraternity needs to study genetic and environmental factors and discover how they
influence high blood pressure. Focused research to discover the factors that lead to these
disparities is critical to address the evidence gaps.
The article emphasizes the importance of care management. Care management refers to
activities that improve patient care and minimize the need for medical services by enhancing
harmonization of care, reducing duplication, and assisting patients in managing their health
conditions. Care managers play a critical role in family education and how to deal with cases of
hypertension. Care managers can help people make informed decisions about their healthcare
and make recommendations to assist in various issues. From support groups to medical
equipment proposals, these health practitioners can connect patients to tools that make their lives
easier and more fulfilling.
Identify any real or potential ethical issues the author/s may have been faced with.
Various ethical issues can impact patients and families when researching on health care.
The first ethical issue is informed consent. Informed consent refers to a voluntary agreement to
take part in the research. It involves a process where subjects have full knowledge of the study
and the risks involved. Informed consent is vital before enrolling participants and continues once
enrolled. For this research, the researchers had to inform all participants about all the processes
and how the findings would be used.
HYPERTENSION CONTROL AND MANAGEMENT 7
Beneficence is a notion in research ethics which highlights the importance of researchers
having the welfare of the research participant at heart. Although health research aims to gather
new information that would help society, the information should not hurt others in any way. The
researchers must have ensured that confidential information was stored safely to protect patients'
privacy.
The researchers need to consider the principle of justice. When designing trials,
researchers need to consider fairness when recruiting participants and choosing the location to
conduct the research. It is vital to identify who benefits from research and those who bear the
risks of research.
Discuss how this evidence could be implemented into nursing practice, including any
barriers to implementing best practice.
Care management entails adding the role of care managers to help patients recover from
their health problems. Care managers educate patients about their chronic conditions, encourage
patients to improve their health behaviors and coordinate care across care settings. The first step
towards implementing care management is to locate eligible patients using an Electronic Health
Record. The second step is to educate and enroll patients. It is vital to encourage more patients to
be involved in the care management program. One must explain the importance of care
management and how it works. Patients should be properly educated and informed that they can
terminate the program at any time they wish. Thirdly, the program should be started once all
participants are ready. The care managers should make a detailed patient-centered plan
depending on the patient's condition and document the time spent in caring for patients. Some of
the barriers to implementing care management are when some patients fail to complete a full
program and unwillingness to follow care managers' instructions. To eradicate these barriers,
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care managers must ensure that they educate patients on the need to complete the program and
follow instructions to make improvements in their health.
References
Hussain, T., Franz, W., Brown, E., Kan, A., Okoye, M., Dietz, K., … & Anderson, C. A. (2016).
The role of care management as a population health intervention to address disparities
and control hypertension: A quasi-experimental observational study. Ethnicity & Disease,
26(3), 285–294.