ORIGINAL ARTICLE

Quality Improvement Strategies for Hypertension

Management
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 with

hypertension.
Purpose: The purpose of this study was to assess the effectiveness
of quality improvement (QI) strategies in lowering blood pressure.
Data Sources: MEDLINE, Cochrane databases, and article bibliographies were searched for this study.
Study Selection: Trials, controlled beforeafter studies, and interrupted time series evaluating QI interventions targeting hypertension
control and reporting blood pressure outcomes were studied.
Data Extraction: Two reviewers abstracted data and classified QI
strategies into categories: provider education, provider reminders,
facilitated relay of clinical information, patient education, selfmanagement, patient reminders, audit and feedback, team change, or
financial incentives were extracted.
Data Synthesis: Forty-four articles reporting 57 comparisons underwent quantitative analysis. Patients in the intervention groups
experienced median reductions in systolic blood pressure (SBP) and
diastolic blood pressure (DBP) that were 4.5 mm Hg (interquartile
range IQR: 1.5 to 11.0) and 2.1 mm Hg (IQR: 0.2 to 5.0) greater
than observed for control patients. Median increases in the percentage of individuals achieving target goals for SBP and DBP were
From the *Division of General Internal Medicine, Department of Medicine,
University of California, San Francisco, California; the Center for
Primary Care and Outcomes Research, Stanford University, Stanford,
California; the Department of Medicine and the Ottawa Health Research
Institute, University of Ottawa, Ottawa, Canada; the VA Palo Alto
Health Care System, Palo Alto, California; and the Geriatrics Research
Education and Clinical Center, VA Palo Alto Health Care System, Palo
Alto, California.
This work was performed by the StanfordUCSF Evidence-based Practice
Center under contract number 290-02-0017 to the Agency for Healthcare
Research and Quality; Rockville, MD. This work was also supported in
part by the Department of Veterans Affairs.
The authors of this article are responsible for its content. Views expressed are
those of the authors and not necessarily those of the Department of
Veterans Affairs. Statements in this manuscript should not be construed
as endorsements by the Agency for Healthcare Research and Quality or
the 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 Care
System, GRECC 182B, 3801 Miranda Avenue, Palo Alto, CA 94304.
E-mail: [email protected].
Copyright 2006 by Lippincott Williams & Wilkins
ISSN: 0025-7079/06/4407-0646

646

16.2% (IQR: 10.3 to 32.2) and 6.0% (IQR: 1.5 to 17.5). Interventions that included team change as a QI strategy were associated
with the largest reductions in blood pressure outcomes. All team
change studies included assignment of some responsibilities to a
health professional other than the patients physician.
Limitations: Not all QI strategies have been assessed equally,
which limits the power to compare differences in effects between
strategies.
Conclusion: QI strategies are associated with improved hypertension control. A focus on hypertension by someone in addition to the
patients physician was associated with substantial improvement.
Future research should examine the contributions of individual QI
strategies and their relative costs.
Key Words: quality improvement, blood pressure, hypertension,
guideline implementation
(Med Care 2006;44: 646 657)

ypertension care in the United States often fails to

comply with evidence-based guidelines. From 1999 to
2000, only 68.9% of individuals with hypertension were
aware of their hypertension, and only 58.4% of hypertensive
individuals were treated.1 Even when treated, blood pressure
may not be adequately controlled. In the year 2000, only
51.5% of patients in managed care health plans had controlled blood pressure (systolic blood pressure SBP 140
mm Hg and diastolic blood pressure DBP 90 mm Hg).2
The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
recommends targets for blood pressure control.3 Even small
improvements in blood pressure control can have major
public health impact: lowering DBP by only 2 mm Hg could
result in a 6% reduction in the risk of coronary heart disease
and a 15% reduction in the risk of stroke and transient
ischemic attacks.4 Similarly, reducing usual SBP by 2 mm Hg
is associated with 10% lower stroke mortality and approximately 7% lower mortality from vascular causes in a middleaged population.5
Many quality improvement (QI) strategies have focused on improving hypertension control. QI strategies can
Medical Care Volume 44, Number 7, July 2006

Medical Care Volume 44, Number 7, July 2006

Evidence Synthesis of Quality Improvement Strategies for Hypertension

include one or several components and can target the provider, the patient, the healthcare system, or any combination
of these.
As part of a series of evidence reports, Closing the
Quality Gap, funded by the Agency for Healthcare Research
and Quality on improving health care for selected topics
identified by the Institute of Medicine as meriting national
priority,6,7 we conducted a systematic review of the evidence
supporting QI strategies for hypertension control. We addressed the following questions: Are QI programs effective in
producing clinically meaningful reductions in blood pressure? Which QI strategies are most effective at ensuring that
blood pressures are lowered?

METHODS
Definition of Quality Improvement Strategies
We defined a QI strategy as an intervention aimed at
reducing the quality gap (the difference between healthcare
processes or outcomes observed in practice and those potentially
obtainable based on current professional knowledge) for a group
of patients representative of those encountered in routine practice.6 We developed our taxonomy of QI strategies by modifying
several well-established classification systems.8 12 A systematic
review of disease management studies that combined QI strategies and targets classified interventions as: provider education,
provider feedback, provider reminders, patient education, patient
reminders, and patient financial incentives,12 whereas an alternative taxonomy described in a review of interventions to
promote immunization and cancer screening11 specified 3 dimensions for characterizing QI strategies: type of strategy (eg,
education), mediators of intervention (eg, involvement of top
management), and audience targeted (eg, patients, providers,
healthcare delivery systems). We modified these taxonomies to
review hypertension management evidence. We classified interventions as provider education (materials/instruction given to
providers regarding appropriate care for patients), provider reminders (prompts given to providers to perform specific care
tasks), provider audit and feedback (summary clinical performance information given to healthcare providers), facilitated
relay of clinical data to providers (clinical information collected
directly from patients and relayed to provider in which the data
are not routinely collected during a patient visit, eg, transmission
of a patients home blood pressure measurements), patient education (materials/instructions issued to patients providing hypertension information), patient reminders (efforts directed toward
patients encouraging them to keep appointments or adhere to
care), promotion of self-management (access to resources or
devices that enhance patients ability to manage their condition,
eg, providing home blood pressure monitoring kit), team change
(creation of multidisciplinary team, addition of new team
members, change of roles, case or disease management), and
financial incentives/regulation or reimbursement changes.

Included Study Designs

We included patient- and cluster-randomized trials,
quasi-randomized trials, controlled beforeafter studies, and
interrupted time-series studies.13 A quasi-randomized trial
was defined as containing at least 2 cohorts of patients
2006 Lippincott Williams & Wilkins

assembled prospectively using an arbitrary, but nonrandom

allocation procedure (eg, even/odd medical record numbers).
A controlled beforeafter study was defined as a contemporaneous observation for cohorts differing primarily with respect to exposure to the QI intervention. Interrupted time
series required to report outcomes from at least 3 time points
in the pre- and postintervention periods.

Included Outcomes
We 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/or
the percentage of patients achieving SBP or DBP within a
target range.

Search Strategy
We searched the MEDLINE database through July 2003
using key words and medical subject headings for hypertension
and blood pressure combined with terms related to quality
improvement (eg, total quality management, diffusion of innovation, disease management). Additional search terms focused
on identifying multifactorial interventions and targeted provider
education, audit and feedback, and reminder systems (Appendix
1: Search Strategy). We also reviewed citations from the Cochrane Effective Practice and Organisation of Care (EPOC)
registry of QI strategies.
We included articles if they reported QI strategies for
hypertension and assessed blood pressure outcomes. We excluded articles focusing only on secondary hypertension or
specialized subpopulations (eg, hypertension in patients with
alcoholism). We restricted our review to interventions targeting
some component of provider behavior or organizational change
(ie, articles that evaluated patient education or self-management
by themselves were excluded because these interventions with
patients as the only target constituted a separate Institute of
Medicine priority area, eg, health literacy/self-management).7
We excluded articles published before 1980, and regarded a date
restriction as appropriate given changes in hypertension care and
approaches to QI over the past 2 decades.
We screened titles and abstracts for relevance. At
full-text review, 2 independent reviewers abstracted key information (eg, study design, reported outcomes) and conflicts
were resolved by consensus.

Analyses
We conducted 2 types of quantitative analyses: calculation
of net change in blood pressure and multivariate analyses.

Calculation of Net Change in Blood Pressure

We calculated the net change in the blood pressure
outcome attributable to the intervention (int) for each included 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 QI
strategy, we then calculated the median change in the outcome
achieved by studies in which the intervention included this

647

Walsh et al

Medical Care Volume 44, Number 7, July 2006

strategy.14 For example, we computed the median of net change

in SBP for the QI strategy of provider education. To do this, we
first calculated the net change in SBP (in mm Hg), using the
previously defined formula, for all studies that used provider
education and measured SBP. We then calculated the median
value of the net change for these studies. We used median rather
than mean change to avoid having skewed summary measures
based on outlier studies with particularly large or small changes
in outcome.
Because of the possibility of overestimation of median
change resulting from preferential reporting of positive studies,
particularly with smaller studies, we analyzed studies in terms of
sample sizes comparing median change among studies with
sample sizes in the lower half with those in the upper half.
We reviewed studies for 5 key methodologic features:
randomized allocation of intervention, adequate concealment
of allocation, providers blinded, patients blinded, and the
possibility of unit-of-analysis errors.
To evaluate the impact of study or intervention characteristics, we performed a nonparametric test for differences
in median change in blood pressure, the Mann-Whitney rank
sum test. These analyses were possible only for mutually
exclusive categories, eg, all interventions with a given QI
strategy versus all interventions without this strategy. We
were unable to compare one strategy with another because of
the frequent occurrence of several strategies within a given
study. We also had insufficient information to test for differences in outcomes reported as the percentage of patients
achieving SBP or DBP within a target blood pressure range.

ses,16 18 we calculated an effective sample size for each

study, defined as:

Multivariate Analyses

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

were eligible for full-text review and 110 were fully abstracted. Of these, 47 included patient education or selfmanagement only, and 17 reported outcomes other than blood
pressure (eg, physician adherence to guidelines). Two studies
did not provide information before the intervention. The
remaining 44 studies included a total of 57 comparisons of QI
strategies (because several articles had more than one intervention).20 63 Thirty-four studies were randomized, controlled trials (including 45 comparisons), 5 were quasi-randomized, controlled studies (including 6 comparisons), and 5
were controlled beforeafter studies (including 6 comparisons). (A table with comparative details about each study is
available on request to the authors.)

We used a mixed model incorporating fixed and random effects to predict the postintervention difference between intervention and control group values for mean SBP
and DBP controlling for study size and for the difference in
mean SBP and DBP values before the intervention. In univariate analyses, other study features (eg, trial design, study
year) did not have significant associations with intervention
outcomes so were not included in the models. Postintervention standard deviations in the control and intervention
groups were pooled with weighting by sample size in each
group. This measure of within-study variability provided the
residual error in a mixed model with a random study effect:
Y X Z e; N0; G e N0; R,
where is the fixed effect, is the random effect, and e is the
error at the study level. As described elsewhere,15 using Proc
Mixed (SAS software, version 8.2; SAS Institute, Cary, NC)
for meta-analysis requires reversing the roles of the withinstudy and between-study variations and then postprocessing
the output.

Accounting for Cluster Effects

We anticipated that a substantial number of studies
would assign study groups to providers or clinics but collect
data on individual patients (ie, the studies would exhibit
clustering). To avoid spurious precision in our analy-

648

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

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

Descriptive Analysis of Team Change Strategies

To provide a richer analysis of the most common
strategy evaluated, we further described the characteristics
and outcomes of the team change studies. We grouped studies
based on common characteristics (eg, setting, involvement of
additional caregivers, use of home monitoring). To review all
of these studies together, regardless of outcomes assessed
(SBP, DBP, SBP range, and DBP range), we classified
studies into those with improvements in blood pressure control for all outcomes assessed that were consistently greater
than the median (consistently greater), those with median
changes within 10% of the median (consistently equivalent), and those with median changes less than the median
(consistently less). Where there were conflicts between
classifications among multiple outcomes (eg, 2 less outcomes and 1 greater outcome), we designated the study
results as mixed.

RESULTS

Types and Numbers of Quality Improvement

Strategies
The majority of articles described interventions consisting of more than one strategy with the median number of QI
strategies 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 patient
education (in combination with other strategies) were most
commonly used. Team change was used in 36 of the
comparisons and patient education was used in 28 of the
comparisons. Facilitated relay of clinical data (n 22) and
provider education (n 20) strategies were common as
well.
2006 Lippincott Williams & Wilkins

Medical Care Volume 44, Number 7, July 2006

Evidence Synthesis of Quality Improvement Strategies for Hypertension

management were associated with a significant reduction in

DBP but not SBP.
For all QI strategies, the median increase in the proportion of patients in target SBP range and DBP range was
16.2% (interquartile range IQR: 10.3 to 32.2) and 6.0%
(IQR: 1.5 to 17.5), respectively. Again, strategies that included team change, patient education, facilitated relay of
clinical data, or promotion of self-management had the largest improvements (by inspection, not tested for statistical
significance).

Effect of Team Change on Blood Pressure

Outcomes

FIGURE 1. Results of the literature search. The figure shows

the flow of the article reviews starting with the number of
studies that were identified through the search strategy.

Effect of Quality Improvement Strategies on

Blood Pressure Outcomes
The majority of studies showed a modest improvement
in SBP and DBP associated with QI interventions. Strategies
that included team change, patient education, facilitated relay
of clinical data, or promotion of self-management had larger
median improvements in blood pressure outcomes (Table 1,
by inspection, not tested for statistical significance).
The majority of studies used a combination of QI
strategies. For both SBP and DBP reductions, there was no
clear pattern of increasing or decreasing effect as the number
of QI strategies increased.
In the multivariate model adjusting for sample size and
for differences in baseline blood pressure, the mean effects
across 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 associated
with each of the QI strategies are shown in Figure 2. There
were too few studies assessing financial incentives to include
this intervention in the multivariate analyses. Team change was
the only strategy that showed significant results for both SBP
and DBP. Strategies that included patient education and self 2006 Lippincott Williams & Wilkins

Team change was the most commonly used strategy and

was assessed in 28 studies (36 comparisons). Overall, studies
including team change demonstrated a median improvement in
SBP of 9.7 mm Hg (IQR: 4.2 to 14.0) compared with a 2.0 mm
Hg (IQR: 1.0 to 3.9) median improvement for studies without a
team change component (Mann-Whitney U test; P 0.005).
Studies including team change also showed median improvement in DBP of 4.2 mm Hg (IQR: 0.2 to 6.8) compared with
studies without a team change component (median improvement
in DBP of 0.6 IQR: 0.2 to 2.1 mm Hg for studies without
team change component; Mann-Whitney P 0.025 for comparisons with versus without team change. The percentage of
patients with SBP and DBP in the target range improved when
team change strategies were included (Table 1).
In multivariate analyses that corrected for differences in
baseline blood pressure values, the effects of interventions
with or without team change were similar to findings with the
median net change but attenuated. Studies including team
change showed an improvement in SBP of 5.9 mm Hg (95%
CI: 2.8 to 8.9; P 0.0004), whereas studies without team
change showed an improvement in SBP of 1.8 mm Hg (95%
CI: 1.8 to 5.4; P 0.32). For DBP, studies including team
change showed a lowering of 3.1 mm Hg (95% CI: 1.7 to 4.6;
P 0.0001), whereas studies without team change showed a
lowering of 0.2 mm Hg (95% CI: 1.4 to 1.9; P 0.78).

Descriptive Analysis of Team Change Studies

Twenty-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 and
9 outside of the United States.23,27,29,37,38,45,46,48 Interventions
were most commonly conducted in a clinic, either a general
outpatient clinic (n 14)20,24,27,28,30,32,39,43,44,47,55,56 or a hypertension clinic (n 7).25,29,48,58,63 Seven comparisons were
conducted in academic settings,24,32,43,44,55,58 6 at the worksite,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 intervention
occurring at the patients residence.30,38,42,49,62 Of the comparisons conducted in clinics, 14 were conducted at a single
site,24,25,30,32,43,47,48,55,56,58,63 2 included 2 or 3 sites,28,29 and 5
included 11 or more sites.20,27,39,44
Studies conducted in pharmacies reported blood pressure reductions consistently greater (n 2)37,52 than or
equivalent (n 1)23 to the median reduction observed for all
studies. Studies conducted in academic settings also tended to
have bigger blood pressure reductions (4 of 7 had consistently
greater reductions24,43,58 and only 1 study44 had outcomes

649

650
4455,57,58,6063

2.1 0.25.0
n 432022,2426,28,29,32,33,3538,4042,

4.5 1.511.0
n 3320,21,24,25,28,29,32,33,3538,

41,42,44,4753,55,57,58,61,62

n 326,47,60

0.0 2.02.5

52,55,58,60,62,63

2.8 0.46.7
n 1322,35,36,38,46,47,49,50,54,57,62
0.4 2.45.0
n 922,37,47,48,54,57,60
4.2 0.26.8
20,24,25,28,29,32,37,38,42,4449,
n 24

47,49,52,54,57,60,62

n 147

13.3

4749,52,55,58,62

n 935,36,38,47,49,50,57,62
3.3 2.34.5
n 537,47,48,57
9.7 4.214.0
20,24,25,28,29,32,37,38,42,44,
n 20

3.3 2.610.1

42,44,47,49,52,57,62

0.3 0.21.7
n 633,41,51,53,61
1.8 0.14.5
n 1824,25,28,32,36,37,40,44,46,48,50,52,57,61,62
0.6 0.41.0
n 440,41,61
0.6 0.73.4
n 1621,28,33,35,38,40,41,51,53,54,61,63
3.8 0.66.7
n 2120,24,25,28,29,32,3538,42,44,

1.2 1.01.9
n 633,41,51,53,61
8.0 2.512.3
n 1624,25,28,32,36,37,44,48,50,52,57,61,62
1.5 1.21.7
n 341,61
3.3 1.25.4
n 1121,28,33,35,38,41,51,53,61
8.1 3.311.8
n 1820,24,25,28,29,32,3538,

NA

NA
16.2 10.3 to 32.2
n 1421,23,2729,31,34,35,39,52,55

n0

21.8 9.033.8
n 1223,2729,31,34,39,52,55

n0

4.2 1.19.4
n 247,60
6.0 1.517.5
n 1621,22,29,30,35,40,43,47,56,5961

9.4 5.311.4
n 322,35,47
2.0 1.19.4
n 522,43,47,56,60
17.0 5.724.5
n 729,30,43,47,56,60

2.0 1.65.0
n 540,59,61
2.0 1.74.3
n 640,56,59,61
3.5 1.711.3
n 621,35,40,61
17.0 11.424.5
n 729,30,35,43,47,60

25.1 17.034.2
n 423,28,34,52
3.5 5.71.4
n 239
10.9 1.413.1
n 621,27,28,35,39
19.2 11.433.2
n 82729,31,34,35,52
13.4
n 135

n 261

4.5 2.07.0

Median Absolute Increase in Proportion

of Patients Achieving Diastolic Blood
Pressure in a Certain Range
interquartile range*
n number of comparisons

n0

NA

Median Absolute Increase in Proportion

of Patients Achieving Systolic Blood
Pressure in a Certain Range
interquartile range*
n number of comparisons

*When n 2, brackets show the actual results of each study rather than interpolated interquartile range.

The number of citations listed differs from the n in cases where there were multiple comparisons for a study.

P 0.05 for Mann-Whitney analyses of reductions in systolic blood pressure and diastolic blood pressure comparing studies with the quality improvement strategy with those without it. No comparable statistical analyses
were feasible for proportion of patients achieving a certain systolic blood pressure or diastolic blood pressure range.
NA indicates not applicable.

All comparisons

Financial incentives

Team change

Patient reminders

Promotion of self
management

Patient education

Provider education

Audit and feedback

Facilitated relay of
clinical data

Provider reminders

Type of Quality
Improvement

Median Reduction in Diastolic

Blood Pressure (mm Hg)
interquartile range*
n number of comparisons

Median Reduction in Systolic

Blood Pressure (mm Hg)
interquartile range*
n number of comparisons

TABLE 1. Effect of Quality Improvement Strategies on Blood Pressure Outcomes

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

2006 Lippincott Williams & Wilkins

Medical Care Volume 44, Number 7, July 2006

Evidence Synthesis of Quality Improvement Strategies for Hypertension

FIGURE 2. A, Changes in systolic blood pressure associated with each quality improvement (QI) strategy adjusting for study
size and baseline differences in blood pressure. B, Changes in diastolic blood pressure associated with each QI strategy adjusting for study size and baseline differences in blood pressure. Forty-four studies included 57 comparisons. A total of 33 of these
comparisons reported absolute changes in systolic blood pressure and 43 of these comparisons reported absolute changes in
diastolic blood pressure. The x-axis shows each QI strategy and the y-axis shows the difference in the postintervention change
in blood pressure between studies with and without a particular QI strategy (change in blood pressure in the intervention
group minus change in blood pressure in the control group). All comparisons shows the estimate for all comparisons reporting blood pressure outcomes regardless of the QI strategy included in the comparison. Diffpre refers to the baseline differences in blood pressure control between intervention and control groups. Each estimate represents the difference between
the reduction in blood pressure (systolic blood pressure for top panel and diastolic blood pressure for bottom panel) associated with the presence of a particular QI strategy and the benefit observed in interventions without that strategy. The numbers in parentheses indicate the number of studies contributing to the estimate eg, in (A), 10 comparisons evaluated interventions 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 results
indicate that interventions with a component of the QI strategy in question produced smaller reductions in blood pressure
than did interventions without such a component. The estimates include adjustment for the effects of study size and baseline
differences in blood pressure control between intervention and control groups.

2006 Lippincott Williams & Wilkins

651

Walsh et al

that were consistently less than the median). Studies that were
conducted at multiple sites generally had changes that were
less than the median. There was no compelling evidence to
distinguish studies performed at hypertension clinics from
studies performed in other settings.
All of the team change interventions for hypertension
care involved assigning some patient care responsibilities to
someone other than the patients doctor. Pharmacists, nurses,
physician assistants, and worksite physicians took on coordination, counseling, and patient follow-up functions in many
of the studies. Sometimes, these individuals carried out all
communication with the patient related to blood pressure control (all communication transferred; 18 comparisons20,23,27,29,30,38,42 44,47,49,55,58,60,62); in other cases, they
worked with the doctor (shared responsibility; 7 comparisons24,25,28,32,37,52,63), and in a few cases, they or others
provided support in the form of prompts or education to
physicians who retained full responsibility for the interactions
with the patients (doctor-focused; 5 comparisons39,48,56).
The remaining 6 comparisons31,34,45,46 involved some form
of triage and monitoring at the worksite.
An example of the all communications transferred
intervention involved a clinical pharmacist meeting with the
patient to make changes in prescribed drugs, adjust dosages,
provide drug counseling, and assess adherence to treatment
regimen. Interventions designated as shared responsibility
involved, for example, a pharmacist relaying evidence-based
treatment recommendations to a patients doctors and providing the patient with education on dietary and lifestyle modification as well as information about drug side effects. Blood
pressure reductions for studies involving doctor-focused interventions such as a specialist physician reviewing patient
records and recommending treatment changes were consistently less than the median improvement and in some cases (4
of 6 comparisons) showed a reduction in blood pressure less
than the control arm. Most of the worksite interventions
showed large improvements in blood pressure outcomes, with
5 of 6 comparisons greater than the median (ie, 25%, 38%,
40%, and 42% improvement in net SBP range and 5.6mm-Hg improvement in net DBP).
Other characteristics represented repeatedly in the team
change interventions were home blood pressure monitoring
or use of a standard protocol for adding drugs. Of the 5
studies with stepped care protocols, 244,63 had blood pressure
reductions consistently less than the median and the other
320,29,60 had mixed results depending on outcome assessed. In
contrast, 4 of 5 studies with home monitoring30,46,49,62 were
consistently greater (n 330,49,62) than or consistently equivalent (n 130) to the median.

Effect of Methodologic Features on Blood

Pressure Outcomes
In our assessment of methodologic features, we found
no significant differences in blood pressure outcomes across
studies with more rigorous versus less rigorous methodologic
features.

652

Medical Care Volume 44, Number 7, July 2006

Effect of Study Size on Blood Pressure

Outcomes
Studies with smaller sample sizes generally reported
larger reductions in SBP and DBP (Fig. 3). We considered the
possibility that the inclusion of clustered trials might have
confounded the relationship between study size and magnitude of median change. Because allocation occurs at the level
of the provider or clinic, cluster trials might be expected to
have 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 67
patients (IQR: 26 to 151). The clustered trials reported a
median reduction in SBP of 2.9 mm Hg, which was lower
than that seen in the nonclustered trials (7.1 mm Hg; P
0.08). When we restricted our analyses to studies without
clustering (eg, patient level randomized, controlled trials), the
inverse relation between sample size and median change
magnitude remained.

DISCUSSION
Quality improvement strategies are associated with
improved control of hypertension. QI strategies generally
improved SBP and the proportion of patients achieving target
SBP range and had a more modest effect on DBP and the
proportion of patients achieving target DBP range. All of the
strategies assessed may be beneficial in terms of clinically
meaningful reductions in blood pressure under some circumstances and in varying combinations.
In general, team change had the largest effect on both
SBP and DBP outcomes regardless of study design or size. QI
strategies, including patient education and self-management,
had a significant effect on DBP but not SBP, which may be
related to more studies assessing DBP outcomes or to the fact
that until recently, the main focus of blood pressure management was on DBP.
A common feature of the team change studies was
assignment of some patient care responsibilities to someone
other than the patients physician.
There are many possible explanations for the success of
team change in achieving blood pressure control. Such interventions typically require administrative support, which may
be an important factor in the success of a QI strategy. Many
studies of team change include designation of specific staff to
address hypertension, which may represent either an increase
in staffing or a reallocation of staff effort to hypertension. The
findings regarding team change are consistent with results
from an observational study of the Veterans Affairs Health
Care System, which reported moderate improvements in rates
of blood pressure control after implementation of systemwide
reengineering.64,65 A trial published after our search end date
confirms the major impact that team change may exert on
blood pressure outcomes. Among inner-city African American men, interventions by a multidisciplinary team improved
blood pressure control.66
Assigning some of the responsibility for blood pressure
control to a healthcare professional other than the patients
physician was common to all of the team change studies.
What makes team change work is unclear, but could include
2006 Lippincott Williams & Wilkins

Medical Care Volume 44, Number 7, July 2006

Evidence Synthesis of Quality Improvement Strategies for Hypertension

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

2006 Lippincott Williams & Wilkins

653

Walsh et al

use of nonphysician providers, having a strict algorithm or

guideline for hypertension control, or having clearer assignments of roles and responsibilities for hypertension care
management. Regardless of the reason for success, team
change was an effective QI strategy in the studies included in
our review. A recent Cochrane review of interventions used
to improve control of blood pressure also concluded that the
use of healthcare professionals such as nurses or pharmacists
in managing blood pressure was a successful strategy that
deserved further evaluation.67 This review, which was limited
to randomized, controlled studies only, included 7 nurse/
pharmacist-led studies and 8 other organizational interventions related to team change. Thus, our review almost triples
the comparative data on team change strategies. Assigning
additional staff time for a health professional to work directly
with patients may be expensive in the short term; however, a
recent report on diabetes raises the possibility that such
interventions can be economically attractive.68
Patient education appeared to be a successful strategy
for improving blood pressure control, but we evaluated it
only when it was used in conjunction with other QI strategies.
Therefore, the impact of patient education per se may be
overestimated in the studies we included, and we cannot
determine the impact of patient education as a solo strategy.
Promotion of patient self-management of blood pressure had
a modest effect on blood pressure outcomes, an effect consistent with a recent meta-analysis that showed that promotion of patient self-management of hypertension and diabetes
could produce clinically important benefits.69 Interventions
that included provider education had only modest effects in
accord with the recent Cochrane review.67 Provider behavior
appears to be difficult to change9; however, relatively inexpensive interventions directed toward providers, particularly
reminders, although yielding smaller blood pressure changes
on a per-patient basis, could effect greater overall benefit as
a result of the large number of patients that could be reached.
In contrast, a more labor-intensive intervention might result
in a larger benefit for each patient but would reach a smaller
number of patients and at greater cost. Alternatively, changing provider behavior may not be a critical factor for accomplishing improved blood pressure control. Perhaps provider
behavior should be targeted only in conjunction with other
system changes.70

Limitations
Only 10 of the included studies assessed a single QI
strategy; because most studies included more than one QI
strategy, we could not discern definitively which individual
QI strategies had the greatest effects, and we could not
determine whether certain combinations of individual QI
strategies were more potent than others. Not all QI strategies have been assessed equally, which limits the power to
detect statistically or clinically significant differences. Improvements in blood pressure control were smaller in larger
studies than in smaller studies. Large studies may be more
likely to be reported than small studies if the results are
negative, raising the concern that overall measures of the
effectiveness of QI strategies may be overestimated because

654

Medical Care Volume 44, Number 7, July 2006

of publication bias or other factors (eg, setting) potentially

associated with study size.

CONCLUSION
QI strategies can result in clinically important reductions in blood pressure control. Smaller studies generally
reported larger median changes, suggesting some publication
bias or an unexplained confounder. It is possible that larger
studies involved more practices and physicians who were less
enthusiastic or engaged in the project. Studies that included
team change reported greater improvements in blood pressure
control than did studies without these strategies, but the
evidence does not definitively establish the superiority of any
individual QI strategy. The multidisciplinary team approach
to patient care is gaining popularity and is an integral component of the management of many chronic diseases.7173
The success of the QI strategies that involve assigning some
patient care responsibilities to someone other than the physician fits well with this team approach and should be investigated further. QI strategies seem to be effective in a variety
of settings, but there is inadequate evidence to suggest tailoring of particular QI strategies to specific settings. In
addition, the cost-effectiveness of individual QI strategies for
hypertension management should be a priority for future
research.

ACKNOWLEDGMENTS
The authors thank Amy Markowitz, Robert Wachter,
Jeremy Grimshaw, and the Cochrane Effective Practice and
Organisation of Care for their assistance on this study. The
authors also thank Sheryl Davies, Jody Mechanic, Christopher Sharp, Melinda Henne, Bimal Shah, and Jo Kay Chan
for their assistance with data abstraction and Alan Bostrom
for his assistance with statistical analysis.
REFERENCES
1. 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 Quality
Assurance; 2001.
3. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the
Joint National Committee on Prevention, Detection, Evaluation, and
Treatment 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 in
diastolic blood pressure for primary prevention. Arch Intern Med.
1995;155:701709.
5. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of
usual blood pressure to vascular mortality: a meta-analysis of individual
data for one million adults in 61 prospective studies. Lancet. 2002;360:
19031913.
6. Shojania KG, McDonald KM, Wachter RM, et al. Closing the Quality
Gap: A Critical Analysis of Quality Improvement Strategies, Volume
1Series Overview and Methodology. Technical Review 9 (Contract
No. 290-02-0017 to the Stanford University-UCSF Evidence-based
Practices 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 Health
System for the 21st Century. Washington, DC: National Academy Press;
2001.
8. Ellis P, Robinson P, Ciliska D, et al. Diffusion and Dissemination of
Evidence-based Cancer Control Interventions. Evidence Report/Tech-

2006 Lippincott Williams & Wilkins

Medical Care Volume 44, Number 7, July 2006

9.

10.
11.

12.

13.

14.

15.
16.

17.
18.
19.

20.
21.

22.
23.

24.

25.

26.
27.

28.

29.

30.

31.

32.

Evidence Synthesis of Quality Improvement Strategies for Hypertension

nology Assessment No. 79 (Prepared by the McMaster University

Evidence-based Practice Center under contract no. 290-97-0017).
AHRQ Publication No. 03-E032. Rockville, MD: Agency for Healthcare
Research and Quality; May 2003.
Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior:
an overview of systematic reviews of interventions. Med Care. 2001;
39:II-2I-45.
Stafford RS. Alternative strategies for controlling rising cesarean section
rates. JAMA. 1990;263:683 687.
Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase
use of adult immunization and cancer screening services: a metaanalysis. Ann Intern Med. 2002;136:641 651.
Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in
disease management programmes for patients with chronic illness
which ones work? Meta-analysis of published reports review. BMJ.
2002;325:925.
Cochrane Effective Practice and Organisation of Care Group. Effective
Practice and Organisation of Care Group, vol 2004. Institute of Population Health, University of Ottawa; 2004.
Grimshaw J, Thomas R, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health
Technol Assess. 2004;8:1 84.
Normand SL. Meta-analysis: formulating, evaluating, combining, and
reporting. Stat Med. 1999;18:321359.
Campbell M, Grimshaw J, Steen N. Sample size calculations for cluster
randomised trials. Changing Professional Practice in Europe Group (EU
BIOMED II Concerted Action). J Health Serv Res Policy. 2000;5:1216.
Donner A, Klar N. Issues in the meta-analysis of cluster randomized
trials. Stat Med. 2002;21:29712980.
Kerry SM, Bland JM. The intracluster correlation coefficient in cluster
randomisation review. BMJ. 1998;316:1455.
Campbell MK, Mollison J, Grimshaw JM. Cluster trials in implementation research: estimation of intracluster correlation coefficients and
sample size. Stat Med. 2001;20:391399.
Mortality after 10 1/2 years for hypertensive participants in the Multiple
Risk Factor Intervention Trial. Circulation. 1990;82:1616 1628.
Avanzini F, Corsetti A, Maglione T, et al. Simple, shared guidelines
raise the quality of antihypertensive treatment in routine care. Am
Heart J. 2002;144:726 732 online.
Becker LA, Glanz K, Sobel E, et al. A randomized trial of special packaging
of antihypertensive medications. J Fam Pract. 1986;22:357361.
Blenkinsopp A, Phelan M, Bourne J, et al. Extended adherence support
by community pharmacists for patients with hypertension: a randomised
controlled trial. International Journal of Pharmacy Practice. 2000;8:
165175.
Bogden PE, Abbott RD, Williamson P, et al. Comparing standard care
with a physician and pharmacist team approach for uncontrolled hypertension. J Gen Intern Med. 1998;13:740 745.
Borenstein JE, Graber G, Saltiel E, et al. Physicianpharmacist comanagement of hypertension: a randomized, comparative trial. Pharmacotherapy. 2003;23:209 216.
Brook RH, Ware JE Jr, Rogers WH, et al. Does free care improve adults
health? N Engl J Med. 1983;309:1426 1434.
Campbell NC, Ritchie LD, Thain J, et al. Secondary prevention in
coronary heart disease: a randomised trial of nurse led clinics in primary
care. Heart. 1998;80:447 452.
Carter BL, Barnette DJ, Chrischilles E, et al. Evaluation of hypertensive
patients after care provided by community pharmacists in a rural setting.
Pharmacotherapy. 1997;17:1274 1285.
Curzio JL, Rubin PC, Kennedy SS, et al. A comparison of the management of hypertensive patients by nurse practitioners compared with
conventional hospital care. J Hum Hypertens. 1990;4:665 670.
Earp JA, Ory MG, Strogatz DS. The effects of family involvement and
practitioner home visits on the control of hypertension. Am J Public
Health. 1982;72:1146 1154.
Erfurt JC, Foote A, Heirich MA. Worksite wellness programs: incremental comparison of screening and referral alone, health education,
follow-up counseling, and plant organization. Am J Health Promot.
1991;5:438 448.
Erickson SR, Slaughter R, Halapy H. Pharmacists ability to influence
outcomes of hypertension therapy. Pharmacotherapy. 1997;17:140 147.

2006 Lippincott Williams & Wilkins

33. Evans CE, Haynes RB, Birkett NJ, et al. Does a mailed continuing
education program improve physician performance? Results of a randomized trial in antihypertensive care. JAMA. 1986;255:501504.
34. Foote A, Erfurt JC. Hypertension control at the work site. Comparison
of screening and referral alone, referral and follow-up, and on-site
treatment. N Engl J Med. 1983;308:809 813.
35. Fortmann SP, Winkleby MA, Flora JA, et al. Effect of long-term
community 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 for
monitoring and counseling patients with hypertension. Impact on medication adherence and blood pressure control. Am J Hypertens. 1996;9:
285292.
37. Garcao JA, Cabrita J. Evaluation of a pharmaceutical care program for
hypertensive patients in rural Portugal. J Am Pharm Assoc (Wash).
2002;42:858 864.
38. Garcia-Pena C, Thorogood M, Armstrong B, et al. Pragmatic randomized trial of home visits by a nurse to elderly people with hypertension
in Mexico. Int J Epidemiol. 2001;30:14851491.
39. Goldberg HI, Wagner EH, Fihn SD, et al. A randomized controlled trial
of CQI teams and academic detailing: can they alter compliance with
guidelines? Jt Comm J Qual Improv. 1998;24:130 142.
40. Gullion DS, Tschann JM, Adamson TE, et al. Management of hypertension in private practices: a randomized controlled trial in continuing
medical education. J Contin Educ Health Prof. 1988;8:239 255.
41. Hetlevik I, Holmen J, Kruger O. Implementing clinical guidelines in the
treatment of hypertension in general practice. Evaluation of patient
outcome related to implementation of a computer-based clinical decision
support system. Scand J Prim Health Care. 1999;17:35 40.
42. Hill MN, Bone LR, Hilton SC, et al. A clinical trial to improve high
blood 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. Improvement in a university medical clinic by use of a physicians associate.
Arch Intern Med. 1983;143:920 923.
44. Solomon DK. Clinical and economic outcomes in the hypertension and
COPD 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 worksite
hypertension treatment program. Hypertension. 1981;3:211218.
46. Logan AG, Milne BJ, Flanagan PT, et al. Clinical effectiveness and
cost-effectiveness of monitoring blood pressure of hypertensive employees at work. Hypertension. 1983;5:828 836.
47. McClellan WM, Craxton LC. Improved follow-up care of hypertensive
patients 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 standardizing long-term care: evaluation of the west of Scotland shared-care
scheme for hypertension. Br J Gen Pract. 1994;44:441 445.
49. Mehos BM, Saseen JJ, MacLaughlin EJ. Effect of pharmacist intervention and initiation of home blood pressure monitoring in patients with
uncontrolled hypertension. Pharmacotherapy. 2000;20:1384 1389.
50. Midanik LT, Resnick B, Hurley LB, et al. Home blood pressure
monitoring for mild hypertensives. Public Health Rep. 1991;106:85 89.
51. Montgomery AA, Fahey T, Peters TJ, et al. Evaluation of computer
based clinical decision support system and risk chart for management of
hypertension in primary care: randomised controlled trial. BMJ. 2000;
320:686 690.
52. Park JJ, Kelly P, Carter BL, et al. Comprehensive pharmaceutical care in
the chain setting. J Am Pharm Assoc (Wash). 1996;NS36:443 451.
53. Sanders KM, Satyvavolu A. Improving blood pressure control in diabetes: limitations of a clinical reminder in influencing physician behavior.
J Contin Educ Health Prof. 2002;22:2332.
54. Saunders LD, Irwig LM, Gear JS, et al. A randomized controlled trial of
compliance improving strategies in Soweto hypertensives. Med Care.
1991;29:669 678.
55. Schneider PJ, Larrimer JN, Visconti JA, et al. Role effectiveness of a
pharmacist in the maintenance of patients with hypertension and congestive heart failure. Contemp Pharm Pract. 1982;5:74 79.
56. Siscovick DS, Strogatz DS, Wagner EH, et al. Provider-oriented interventions and management of hypertension. Med Care. 1987;25:254 258.

655

Medical Care Volume 44, Number 7, July 2006

Walsh et al

57. Soghikian K, Casper SM, Fireman BH, et al. Home blood pressure
monitoring. 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-managed
hypertension clinic. Pharmacotherapy. 2002;22:15331540.
59. Winickoff RN, Wilner S, Neisuler R, et al. Limitations of provider
interventions 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-up
Program Cooperative Group. JAMA. 1979;242:25722577.
61. Dickinson JC, Warshaw GA, Gehlbach SH, et al. Improving hypertension control: impact of computer feedback and physician education. Med
Care. 1981;19:843 854.
62. Artinian NT, Washington OG, Templin TN. Effects of home telemonitoring and community-based monitoring on blood pressure control
in urban African Americans: a pilot study. Heart Lung. 2001;30:191
199.
63. Krishan I, Davis CS, Nobrega FT, et al. The Mayo three-community
hypertension control program. IV. Five-year outcomes of intervention in
entire communities. Mayo Clin Proc. 1981;56:310.
64. Kizer KW, Demakis JG, Feussner JR. Reinventing VA health care:
systematizing quality improvement and quality innovation. Med Care.
2000;38:I716.
65. Jha AK, Perlin JB, Kizer KW, et al. Effect of the transformation of the

656

66.
67.
68.
69.
70.

71.
72.
73.

Veterans Affairs health care system on the quality of care. N Engl J Med.
2003;348:2218 2227.
Hill MN, Han HR, Dennison CR, et al. Hypertension care and control in
underserved urban African American men: behavioral and physiologic
outcomes at 36 months. Am J Hypertens. 2003;16:906 913.
Fahey T, Schroeder K, Ebrahim S. Interventions used to improve control
of blood pressure in patients with hypertension. Cochrane Database Syst
Rev. 2005:CD005182.
Villagra VG, Ahmed T. Effectiveness of a disease management program
for patients with diabetes. Health Aff (Millwood). 2004;23:255266.
Chodosh J, Morton SC, Mojica W, et al. Meta-analysis: chronic disease
self-management programs for older adults. Ann Intern Med. 2005;143:
427 438.
Goldstein MK, Lavori P, Coleman R, et al. Improving adherence to
guidelines for hypertension drug prescribing: cluster-randomized controlled trial of general versus patient-specific recommendations. Am J
Manag Care. 2005;11:677 685.
Wagner EH, Glasgow RE, Davis C, et al. Quality improvement in chronic
illness care: a collaborative approach. Jt Comm J Qual Improv. 2001;27:
63 80.
Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care:
translating evidence into action. Health Aff (Millwood). 2001;20:64 78.
Casalino L, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to improve health care
quality for patients with chronic diseases. JAMA. 2003;289:434 441.

2006 Lippincott Williams & Wilkins

Search Strategy

2006 Lippincott Williams & Wilkins

683,000

Disease Management mh OR Patient Care Planning mh OR Patient-Centered Care mh OR Primary Health Care mh OR Progressive Patient
Care mh OR Critical Pathways mh OR Delivery of Health Care, Integrated mh OR Health Services Accessibility mh OR Managed Care
Programs mh OR Product Line Management mh OR Patient Care Team mh OR Patient-Centered Care mh OR Behavior Control mh OR
Counseling mh OR Health Promotion mh OR Patient Compliance mh OR After-Hours Care mh OR ((coordination ti OR coordinated ti
OR Multifactorial ti OR Multifactorial ti OR Multicomponent ti OR Multicomponent ti OR multidisciplinary ti OR multidisciplinary ti
OR interdisciplinary ti OR interdisciplinary ti OR integrated ti OR community-based ti OR organized ti) AND (care ti OR approach ti
OR intervention ti OR strategy ti OR strategies ti OR management ti OR managing ti OR center* ti OR clinic*ti)) OR Organization
and Administration mh
Total Quality Management mh OR Quality control mh OR TQM ti OR CQI ti OR (quality ti AND (continuous ti OR total ti) AND
(management ti OR improvement ti))
Education, Continuing mh OR (Education ti AND Continuing ti AND (medical ti OR professional* ti OR nursing ti OR physician* ti
OR nurse* ti)) OR (outreach ti AND (visit*ti OR educational ti) OR (academic ti AND detailing ti))
Diffusion of Innovation mh OR (Diffusion ti AND (Innovation ti OR technology ti))
Medical audit mh OR ((Audit ti OR feedback ti OR compliance ti OR adherence ti OR training ti) AND (improvement* ti OR
improving ti OR improves ti OR improve ti OR guideline* ti OR practice* ti OR medical ti OR provider* ti OR physician* ti OR
nurse* ti OR clinician* ti OR practice guidelines mh OR academic ti OR visit* ti)) OR Reminder Systems mh OR Reminder* ti OR
((financial ti OR economic ti OR physician* ti OR patient*) AND incentive* ti) OR Reimbursement Mechanisms mh
Medical Informatics mh OR computer ti OR (decision ti AND support ti) OR Telemedicinemh OR Telemedicine ti OR
telecommunication* ti OR Internet mh OR web ti OR modem ti OR telephone* ti OR telephone mh
1 OR 2 OR 3 OR 4 OR 5 OR 6

3144
2942
2842
220

9 Limit to English
10 Limit to Pub since 1980
11 BUTNOT (editorial pt OR comment pt OR letter pt)
(8 AND Journal Search String) BUTNOT (9 OR editorial pt OR comment pt OR letter pt) Limited to English, 1980

12 OR 13 OR 14

3070 references total

29

3698

8 AND (systematic review search string OR original research string)

(8 AND author search) BUTNOT (13 OR editorial pt OR comment pt OR letter pt) Limited to English, 1980

7574

7 AND (Hypertension mh OR Hypertension ti OR (blood ti AND pressure ti))

988,356

306,703

4889
36,852

35,276

28,087

Citations

Search String

Numbers of citations reflect search results from July 8, 2003.

((meta-analysis pt OR meta-analysis tw OR meta-analysis tw) OR ((review pt OR guideline pt OR consensus ti OR guideline* ti OR literature ti OR overview ti OR review ti OR Decision Support Techniques
mh) AND ((Cochrane tw OR Medline tw OR CINAHL tw OR (National tw AND Library tw)) OR (handsearch* tw OR search* tw OR searching tw) AND (hand tw OR manual tw OR electronic tw OR
bibliographi* tw OR database* OR (Cochrane tw OR Medline tw OR CINAHL tw OR (National tw AND Library tw))))) OR ((synthesis ti OR overview ti OR review ti OR survey ti) AND (systematic ti OR
critical ti OR methodologic ti OR quantitative ti OR qualitative ti OR literature ti OR evidence ti OR evidence-based ti))) BUTNOT (case report mh OR case* ti OR report ti OR editorial pt OR comment pt
OR letter pt) 38,865 MEDLINE records.

Randomised ti OR Randomized ti OR Controlled ti OR intervention ti OR evaluation ti OR impact ti OR effectiveness ti OR Evaluation ti OR Studies ti OR study ti Comparative ti OR Feasibility ti OR
Program ti OR Design ti OR Clinical Trial pt OR Randomized Controlled Trial pt OR Epidemiologic Studies mh OR Evaluation Studies mh OR Comparative Study mh OR Feasibility Studies mh OR Intervention
Studies mh OR Program Evaluation mh OR Epidemiologic Research Design mh2,551,486 MEDLINE records.

N Engl J Med ta OR JAMA ta OR Ann Intern Med ta OR Am J Med ta OR Arch Intern Med ta OR J Gen Intern Med ta OR BMJ ta OR Lancet ta OR CMAJ ta OR Clin Invest Med ta OR Arch Fam Med
ta OR J Fam Pract ta OR Fam Pract ta OR Ann Med ta OR Br J Gen Pract ta OR J Intern Med ta OR Med J Aust ta OR South Med J ta OR West J Med ta OR Aust N Z J Med ta OR Med Care ta OR Health
Serv Res ta OR Inquiry ta OR Milbank Q ta OR Health Aff (Millwood) ta OR Health Care Financ Rev ta OR Med Care Res Rev ta OR eff clin pract ta OR eval health prof ta OR Jt Comm J Qual Improv ta OR
Qual Saf Health Care ta OR Int J Qual Health Care mh OR Qual Health Care ta OR Qual Health Res ta OR Rep Med Guidel Outcomes Res ta OR Am J Manag Care ta OR Am J Med Qual ta OR J Contin Educ
Health Prof ta OR Prev Med ta OR Am J Prev Med ta OR Patient Educ Couns ta OR Ann Behav Med ta OR J Hum Hypertens ta OR Hypertension ta OR Am J.

(Berwick D au OR berlowitz d au OR davis d au OR kiefe c au OR wagner e au OR glasgow r au OR boddenheimer t au OR Hulscher M au OR grol r au OR grimshaw j au OR haynes b au OR haynes
rb au OR sackett d au OR goldberg h au OR Hirsch I au OR nash d au OR roper w au OR weingarten s au)6401 MEDLINE records.

6 Targets informatics and

telemedicine
7 Combines 16 for overall set
of articles relating to QI
8 Combines overall QI search
key terms for articles involving
hypertension
9 Identifies subset of 8 likely to
involve original research or
systematic reviews
10
11
12
13 Additional yield of journal
search
14 Additional yield of author
search
TOTAL

4 Targets diffusion of innovation

5 Targets audit and feedback,
reminder systems, and financial
incentives

3 Targets provider education

2 Targets TQM and CQI

1 Targets QI strategies that tend

to be multi-factorial using
relevant MeSH terms and title
word

Search

APPENDIX 1

Medical Care Volume 44, Number 7, July 2006

Evidence Synthesis of Quality Improvement Strategies for Hypertension

657