AJH 2004; 17:921–927

Nurse Management for Hypertension

A Systems Approach
Peter Rudd, Nancy Houston Miller, Judy Kaufman, Helena C. Kraemer,
Albert Bandura, George Greenwald, and Robert F. Debusk

Background: Standard office-based approaches to UC: 14.2 ⫾ 18.1 versus 5.7 ⫾ 18.7 mm Hg systolic (P ⬍
controlling hypertension show limited success. Such sub- .01) and 6.5 ⫾ 10.0 versus 3.4 ⫾ 7.9 mm Hg diastolic,

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optimal hypertension control reflects in part the absence of respectively (P ⬍ .05). At 6 months, we observed one or
both an infrastructure for patient education and frequent, more changes in drug therapy in 97% of INT patients
regular blood pressure (BP) monitoring. We tested the versus 43% of UC patients, and 70% of INT patients
efficacy of a physician-directed, nurse-managed, home- received two or more drugs versus 46% of UC. Average
based system for hypertension management with standard- daily adherence to medication, measured by electronic
ized algorithms to modulate drug therapy, based on drug event monitors, was superior among INT subjects
patients’ reports of home BP. (mean ⫾ SD, 80.5% ⫾ 23.0%) than among UC subjects
(69.2 ⫾ 31.1%; t113 ⫽ 2.199, P ⫽ .03). There were no
Methods: We randomized outpatients requiring drug
significant adverse drug reactions in either group.
therapy for hypertension according to the Joint National
Committee on Prevention, Detection, Evaluation, and Conclusions: Telephone-mediated nurse management
Treatment of High Blood Pressure (JNC VI) criteria to can successfully address many of the systems-related and
receive usual medical care only (UC, n ⫽ 76) or usual care patient-related issues that limit pharmacotherapeutic effec-
plus nurse care management intervention (INT, n ⫽ 74) tiveness for hypertension. Am J Hypertens 2004;17:
over a 6-month period. 921–927 © 2004 American Journal of Hypertension, Ltd.
Results: Patients receiving INT achieved greater reduc- Key Words: Hypertension, nurse management, home-
tions in office BP values at 6 months than those receiving based management.

T
he control of blood pressure (BP) remains a major evaluate, and refine systems for guiding individual and
challenge in clinical practice. Only half of those groups of patients. Specialized hypertension clinics staffed
individuals with hypertension receive the diagno- by nurses have shown significant improvements in hyper-
sis, and only half of these achieve BP goals established by tension control compared with usual care.4 – 6 The present
the Joint National Committee on Prevention, Detection, study extends the model of nurse management to home-
Evaluation and Treatment of High Blood Pressure (JNC based treatment.
VI) and other scientific organizations.1,2 Contributing fac-
tors for the failure to achieve goal BP cluster as patient
related, provider related, and system related. Patient fac- Methods
tors include medication side effects, drug regimen com- Study Population
plexity, and unawareness of the need for long term We conducted a randomized controlled trial in which
therapy.3 Physician-linked issues may involve timely ac- patients received either usual care alone (UC) or usual care
cess to relevant clinical data, ignorance of evidence-based supplemented by nurse management for hypertension
management guidelines, and sense of nonaccountability (INT). For initial screening purposes we defined hyperten-
for patient outcomes. The system-related factors reflect sion as BP ⱖ140 mm Hg systolic or ⱖ90 mm Hg diastolic,
little if any attention or resources to design, implement, recorded in the medical record at least once in the previous

Received February 8, 2004. First decision June 2, 2004. Accepted June Supported by a grant to Stanford University from CorSolutions, Inc.
3, 2004. (Buffalo Grove, IL).
From Department of Medicine, Stanford University (PR, NHM, JK,
HCK, AB, RFDB), Stanford, California, and Urgent Care Department, Address correspondence and reprint requests to Dr. Robert F. De-
Kaiser Permanente Medical Care Program (GG), Mountain View, Cali- Busk, Stanford Cardiac Rehabilitation Program, 780 Welch Road, Suite
fornia. 106, Palo Alto, CA 94304-5735; e-mail: [email protected].

© 2004 by the American Journal of Hypertension, Ltd. 0895-7061/04/$30.00

Published by Elsevier Inc. doi:10.1016/j.amjhyper.2004.06.006
922 HOME-BASED MANAGEMENT OF HYPERTENSION AJH–October 2004 –VOL. 17, NO. 10

6 months, or a history of drug treatment for hypertension. clinic BP and interviewed patients about medications
In addition, patients had to be eligible for hypertensive taken since the previous visit.
drug therapy according to JNC VI criteria.2 Clinical risk
criteria assessed the presence of coronary risk factors
(smoking, dyslipidemia, or diabetes mellitus), age ⬎60 Nurse Management Protocol
years, or a family history of premature cardiovascular The nurse care manager conducted baseline counseling on
disease or target organ damage. According to JNC VI intervention (INT) patients’ correct use of the automated
criteria,2 only patients with elevation of BP to levels BP device, regular return of the automatically printed BP
greater than 140 to 159 mm Hg systolic and/or 90 to 99 reports, tips for enhancing drug adherence, and recogni-
mm Hg diastolic are considered eligible for BP lowering tion of potential drug side effects. Printed materials ex-
drug therapy. We adopted a more stringent BP threshold
tended this instruction, and patients confirmed their ability
for hypertension: 150 mm Hg systolic, 95 mm Hg dia-
to operate the BP device. The nurse initiated follow up
stolic, or both.
phone contacts at 1 week and at 1, 2, and 4 months. The

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calls averaged 10 min in duration, or 40 min in all. During
Baseline BP Measurement phone contacts, the nurse asked INT patients about each
During the baseline clinic visit, before randomization, the medication dosage and any problems experienced since
nurse care manager measured BP with a mercury sphyg- the previous contact. The nurse also encouraged patients to
momanometer using the arm with the higher reading as the telephone anytime during regular hours with questions or
“reference” arm for all subsequent BP recordings. The concerns.
nurse used a second BP measurement, taken 5 min later, to The nurse care manager contacted physicians to obtain
establish the mean baseline BP. For study entry, subjects permission to initiate any new BP drug but did not contact
needed the mean of two BP values to be ⱖ150/95 mm Hg physicians regarding changes in medication dosage.
on two screening visits conducted on separate days at least Changes in drug therapy were categorized as either an
1 week apart. increase (a drug added or dose of drug increased) or as a
decrease (a drug withdrawn or dose of drug decreased).
Sampling The nurse care manager implemented a management al-
We screened a total of 1580 patients, finding 743 (47%) gorithm based on patients’ current medications, laboratory
who were ineligible because they lacked the risk factors values, and BP measurements.
specified by the JNC VI or had major medical comorbid- From prior studies, systolic pressures measured at
ity. An additional 603 (40%) either could not be contacted home generally run about 10 mm Hg lower than those
or refused participation after contact, and 84 (5%) had measured in the office, and diastolic pressures are approx-
mean baseline BP values below the criterion of 150 mm imately 5 mm Hg less.7 Accordingly, we chose a treatment
Hg systolic or 95 mm Hg diastolic. We ended with 150 goal of 130/85 mm Hg, as measured with the home BP
patients, representing 10% of the screened population, for device over a 2-week period.8,9 When 80% of the home
randomization. BP readings achieved this treatment goal, the nurse made
no further changes in drug therapy. When ⬍80% of mea-
Recruitment and Randomization surements met this criterion, the nurse increased drug
dosage to the maximal level recommended for each drug
The same research staff implemented the same protocol for or added one or more additional drugs in accordance with
screening and enrollment of patients at each of two par- the protocol. The project cardiologist consulted by phone
ticipating medical clinics, the Kaiser Permanente Moun-
with the nurse care manager about problematic cases as
tain View Clinic and the Primary Care Clinics of the
needed.
Stanford University Medical Center in California. We
identified patients by physician referral or review of med-
ical records. Patients received a postcard indicating their Measurements of BP
physician’s knowledge of the study and inviting study
participation. Research staff telephoned patients to estab- We used the same semiautomated portable device to mea-
lish their medical eligibility and willingness to participate sure BP at home and during each clinic visits. This device
in the study. (UA 751; A&D, Milpitas, CA), validated with a random
After establishing eligibility, patients gave written in- zero mercury sphygmomanometer,10 provided a digital
formed consent and underwent randomization using com- display of BP values. At the end of each week, the device
puter-generated assignment. All patients provided baseline generated a printed report of up to 14 measurements.
measurements of nonfasting blood urea nitrogen, creati- Patients recorded BP twice-daily at the same times each
nine, glucose, and potassium. These measurements guided day. Every 2 weeks, patients mailed the values printed by
drug therapy. At 3 and 6 months after randomization, a the BP device to the nurse care manager, who used these
research assistant blinded to group assignment measured BP data to guide drug therapy.
AJH–October 2004 –VOL. 17, NO. 10 HOME-BASED MANAGEMENT OF HYPERTENSION 923

Physician Review of Protocol Table 1. Study Population

Before the study, the investigators met with the medical Usual Inter-
staffs at the two sites to discuss the study protocol and Care vention
management algorithm, based on the JNC VI report,2 that (n ⴝ 76) (n ⴝ 74)
were used by the nurse care manager for INT patients. Sex
After the 6-month clinic visit, all physicians received a Female (% of total) 56 50
final report of their patients’ medications and BP values. Age (y; mean ⫾ SD) 60 ⫾ 9 59 ⫾ 10
The Stanford University institutional review board re- Marital status* (%)
Married 80 60
viewed and approved the project protocol. Divorced 8 15
Usual care patients in both groups continued to receive Separated 2 5
the routine care that they had received before the study. No Widowed 4 3
attempt was made to alter the frequency of office visits or Single 6 17
Ethnicity (%)
any other aspect of doctor-patient interactions. Only pa- White 72 76

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tients randomized to nurse management received portable African American 8 11
BP monitors. Asian American 4 4
Hispanic 8 1
Other 8 8
Patient Monitoring
Educational status (%)
Patients in both groups returned to the clinic at 3 and 6 Some high school 5 5
High school graduate 19 17
months for BP measurements, which were performed by Some college 23 24
study staff blinded to group assignment. Patients in both College degree 31 27
groups received instruction in the use of the electronic Postdoctoral degree 22 27
drug event monitor (eDEM; AARDEX-USA, Union City, Occupational status (%)
Full time 51 49
CA). Each monitor contained a microchip in the pill bottle Part time 7 7
lid11,12 to dispense the BP medication used most fre- Disabled or unemployed 4 4
quently. At 3- and 6-month clinic visits, project staff Retired 32 32
Other 6 8
downloaded the data from the electronic drug event mon-
Coronary risk factors (%)
itor but provided no feedback on drug adherence to pa- Dyslipidemia* 30 16
tients, physicians, or nurse care managers. Current smoker 2 4
Diabetes 14 14
Statistical Analysis Family history of CAD 18 22
CAD 4 8
The primary outcome measure was change in BP from Cerebrovascular Disease 5 10
baseline to 6-month visit, considering both systolic and CAD ⫽ coronary artery disease.
diastolic BP and using a wall-mounted clinic sphygmoma- * P ⬍ .05 by ␹2 analysis.
nometer. The primary statistical analysis was a two-sam-
ple t test comparing the change in BP measured between
baseline and 6 months. We performed secondary analyses moved out of the area; the remainder declined to return for
of BP medication, frequency of drug changes, and adher- the 6-month follow-up visit. Two of the INT patients
ence to medication with the Student t test. The level of experienced difficulty in using the BP device and declined
significance was a two-sided probability value of P ⬍ .05. continued participation; three moved out of the area.

Results Patterns of BP
Population Characteristics
The UC and INT groups displayed similar patterns of
The two patient samples, representative of hypertensive baseline BP: 36% had elevation of both systolic and dia-
patients in the two participating clinics, exhibited similar stolic pressure, 55% had elevation of systolic pressure
sociodemographic and clinical characteristics, so data only, and 9% had elevation of diastolic pressure only.
were pooled (Table 1). Patients were typically of middle Between baseline and 6 months, systolic BP fell by 14.2
age, high educational status, and modest rates of cardio- mm Hg in the INT group (95% CI ⫺18.1 to ⫺10.0) and by
vascular comorbidities. The usual care only (UC) and 5.7 mm Hg in the UC group (95% CI ⫺10.2 to ⫺1.3; P ⬍
usual care plus nurse care management intervention (INT) .01). One-way ANOVA confirmed significant decreases in
randomization successfully produced similar groups ex- both systolic (F212 ⫽ 17.30; P ⬍ .01) and diastolic BP
cept for higher rates of married status and dyslipidemia (F212 ⫽ 6.22; P ⬍ .01) among INT patients but nonsig-
among usual care patients. A total of 13 patients (9%), nificant changes among UC patients. Figure 1 depicts
eight in the UC group and five in the intervention group, changes in office-based systolic BP.
did not return for the 6-month visit and were classified as Between baseline and 6 months, diastolic BP fell by 6.5
dropouts. Five of the eight dropouts in the UC group mm Hg in the intervention group (95% CI ⫺8.8 to ⫺4.1)
924 HOME-BASED MANAGEMENT OF HYPERTENSION AJH–October 2004 –VOL. 17, NO. 10

160

155
Systolic Blood Pressure (mm Hg)

150

SBP INT
145
SBP UC

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*
140

135

130
Baseline 3 month 6 month

FIG. 1. Change in office-based systolic blood pressure (SBP). INT ⫽ usual care plus nurse care management intervention; UC ⫽ usual care only.

and 3.4 mm Hg in the UC group (95% CI of ⫺5.3 to ⫺1.5, Blood pressure measured with the mercury sphygmo-
P ⬍ .05). Figure 2 depicts changes in office-based diastolic manometer during clinic visits averaged 1 to 2 mm Hg
BP. higher than that measured with the semiautomated device.

90

88

86
Diastolic Blood Pressure (mm Hg)

84

DBP INT
82
DBP UC

80
*

78

76

74
Baseline 3 month 6 month

FIG. 2. Change in office-based diastolic blood pressure (DBP). INT ⫽ usual care plus nurse care management intervention; UC ⫽ usual care only.
AJH–October 2004 –VOL. 17, NO. 10 HOME-BASED MANAGEMENT OF HYPERTENSION 925

mained similar in both groups at baseline and at 3 and 6

months. The proportion of patients taking angiotensin-
converting enzyme inhibitors, diuretics, ␤ -blockers, and
calcium blockers approximated respectively 40%, 25%,
20%, and 15% at the three assessment points. Among UC
patients, 43% reported one or more changes in drug ther-
apy during the 6-month study period, mostly initiated
during office visits. In contrast, the rate of patients report-
ing changes in drug therapy was more than doubled (97%)
FIG. 3. Office versus home-based systolic blood pressure: inter- among those receiving nurse management. Most therapy
vention patients only. changes among INT patients arose from scheduled phone
contacts. The number of medication changes (mean ⫾ SD)
reported by UC patients was 52 ⫾ 1 (mean 0.69 changes/

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Blood pressure measured at home over a 2-week period patient). The INT patients noted 223 ⫾ 6 medication
using the semiautomated device was approximately 10 changes (mean 2.97 changes/patient; P ⬍ .01). Less than
mm Hg lower than that measured with the same device 5% of treatment decisions made by the nurse care manager
during clinic visits. This pattern was consistent throughout required telephone discussion with a physician. Participat-
the 6 months of the study. ing patients rarely telephoned the nurse care manager.
Figure 3 summarizes differences between office versus
home-based systolic BP. The INT subjects performed Medication Adherence
most scheduled home BP measurements (range 89% to Drug adherence, tracked by the electronic drug event
94%). Systolic and diastolic BP measured at home fell monitor, assessed daily adherence (that is, the average
rapidly during the first 3 months of the study and remained number of days on which patients took the correct number
relatively constant through month 6. of doses as prescribed). The INT patients’ rate of daily
adherence during the 6-month study period was 80.5% ⫾
Antihypertensive Medications 23.0% (mean ⫾ SD, with 25th and 75th percentile values
Patients in both INT and UC groups reported similar 77% to 95%), whereas the rate of UC patients was 69.2%
numbers of BP medications at baseline. At baseline, ⫾ 31.1% (25th and 75th percentile values 50% to 93%;
22% of intervention patients and 30% of UC patients t113 ⫽ 2.199, P ⫽ .03).
were taking no BP medications (NS). By 6 months, INT In both groups, once-daily regimens yielded higher
patients had significantly increased the number and daily adherence rates than for more frequent dosing. The
variety of antihypertensive medications. The proportion respective adherence rates were 82% ⫾ 28% and 75% ⫾
of patients reporting two or more drugs at 6 months was 27% for once-daily dosing and 69% ⫾ 34% and 49% ⫾
70% and 46%, respectively, among INT and UC pa- 41% for twice-daily or more than twice-daily dosing in the
tients. Similarly, the proportion of patients reporting no INT and UC groups. None of these differences reached
drug therapy at 6 months was 4% and 22%, respec- statistical significance.
tively, among INT and UC subjects (P ⬍ .01). The
maximal dose of each individual medication was similar Discussion
in the two groups.
In this randomized controlled trial, we found that home-
Figure 4 summarizes the pattern of medication use in
based, physician-directed, nurse-guided drug therapy
the study subjects. The distribution of medications re-
proved superior in BP control to standard office-based
management among eligible hypertensive patients by JNC
VI criteria. The size of achieved reductions in systolic and
diastolic BP approximate those reported for intensive in-
terventions in other trials.13 Pill-taking adherence by the
electronic drug event monitor remained high in both
groups but reached statistically higher levels among INT
subjects. The greater variety of BP drugs, the greater
proportion of patients on antihypertensive therapy, and the
progressive medication adjustment contributed to the su-
perior INT outcomes.
Most hypertension management studies reflect ambula-
tory settings.14 –16 Inauspicious characteristics include
large numbers of patients, diverse comorbidities, no con-
sistent standards for antihypertensive management, and
FIG. 4. Pattern of medication use. providers’ nonaccountability for clinical outcomes. Ber-
926 HOME-BASED MANAGEMENT OF HYPERTENSION AJH–October 2004 –VOL. 17, NO. 10

lowitz et al14 reported that physicians defer changing drug ticipants represent an affluent and well educated cohort.
therapy, even when BP remain elevated: “clinical inertia” The two clinical facilities are typical of similar settings,
from infrequent assessments, ignorance of established even if not representative of all primary care practices.
clinical guidelines, and distraction by unrelated medical Several implications emerge for optimizing future an-
priorities.17 tihypertensive management. Clinical inertia will likely
The nurse management system in this study addressed continue in the absence of efforts toward standardization
some of the relevant obstacles. The system used external and accountability for outcomes. Individual clinicians—
clinical guidelines (JNC VI2) to define entry criteria, treat- however devoted, knowledgeable, and skilled—may still
ment goals, preferred medications, and management of fail to implement consistent and optimally effective guide-
side effects. It closely linked ongoing surveillance of BP lines of diagnosis, monitoring, and treatment adjustment.
values and responsive changes in drug therapy. By peri- The present study provides a successful example of mov-
odic phone contacts, the nurse managers made timely
ing from general guidelines, as in JNC VI, to an opera-
medication changes, adjusting treatment intensity as
tional protocol for nurses working with a consultant

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needed. Over the 6-month trial, INT patients underwent
cardiologist.
more than four times the number of drug changes than UC
Medical measurement devices for home use will soon
patients and usually achieved control in less than 3
months. These results approximate those of Mehos et al permit guidance via the Internet similar to nurse-mediated
applying pharmacists’ regulation of BP medications in a case management. These technological innovations do not
home-based intervention.18 diminish the need for physicians’ active involvement in
Most prior studies of home BP measurement reported the creation, critical appraisal, and periodic refinement of
BP sampling over only a few days.7 In the present management protocols. Physicians will remain vital to
study, sampling twice daily over several months, com- evaluating comorbid risk factors and to prescribing appro-
monly ⬎300 measurements in all, offered more confi- priate antihypertensive therapies.
dence about central tendency with day-to-day BP The present care management system facilitates and
fluctuations. Home BP determinations closely approxi- expands the reach and scope of traditional health care by
mated clinic BP with both portable device and mercury three interdependent means. First, it reduces the need for
sphygmomanometer. physicians to mediate the routine tasks of managing anti-
This study supports using home BP measurement as a hypertensive therapy. Second, the management system
reliable alternative to office BP measurement19 and sug- encourages physicians to focus their energies on problem
gests that it provides a more representative indicator of BP cases, such as those individuals who fail to achieve satis-
status, when the number of home determinations is factory control. Third, the management system reinforces
large.20,21 The accuracy of clinic measurements may suffer the value of collaboration among teams of health profes-
from nonstandardized measurement and brief sampling. sionals. Formal study of such hypertension case manage-
Training patients can standardize BP measurement19 and ment will likely confirm its cost-effectiveness.24
minimize so-called white coat effects.22
The theoretical underpinning for the current study
comes from social cognitive theory.23 The behavioral
model reflects self-regulation, enabling patients to differ- References
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