Usefulness of a Systemic In-Hospital Educational
Hypertension Program
Robert A. Gonzalez-Fernhdez, MD, Mercedes Rivera, PhD, Dominga Torres, RN, Joaquin Quiles, and Alma Jackson, RD
The effacts of an eckcational program on complianw and Mood pressure (BP) cantral were assessed in 47 hypertensive patients hospitalized for nonhypertension-related diseases. Patii wers rawbmized to receive eithsr a questknaire and an edueaioMl program (group I, 25) or qussti0nnab-e only (group II, 33). Baseline clinical characteristics, admksien diagnews and antihypertensive mediitions were similar between the groups. Antihypertenshe medicatkns used by patients before the trial were not changed. Eight weeks after the initial intewentien, patients in group I showed a significant tductim in both systok and diastolic BP (137/89 vs lS4/98 mm Hg, p = 0.005 and 0.006, respedveiy) and improved compliance (Ss vs 3696, p = 0.04), compared with patients in group II. An education program in patients with high BP is an eMactive method to improve compliince and BP wntrd in tha short-term. (AmJCardkl199o;6s:1384-1386)
A
mong the many causes for inadequate blood pressure (BP) control in hypertensive patients, poor compliance with the long-term pharmacologic treatment is the leading one.1-3 Although new techniques have been developed to improve patient adherence to the therapeutic regimens,4 it continues an important clinical problem.5 Despite awareness about the reduction in hypertension-induced complications with the use of antihypertensive drugs,6 the complexity of the therapeutic regimens, high costs, side effects and poor patient-physician relations contribute to the finding that about 60% of low-income hypertensive patients do not comply with their therapy.’ Even provision of medical care at the work site proved to be noneffective in improving complianx8 Simplification of the therapeutic regimen to a oncea-day dosing9 and educational interventions are better alternatives in improving compliance in hypertensive patients.lO Several educational programs to improve BP control through compliance in outpatient settings proved to be effective. ‘i-l6 We report a randomized clinical trial designed to evaluate the short-term efficacy of an in-hospital educational program. METHODS Patknt group: This study was performed in hospi-
From the Cardiology Section, Department of Internal Medicine, San Juan City Hospital, and the Section of Health Related Sciences, University of Puerto Rico, Rio Piedras, Puerto Rico. Manuscript received September 12,1989; revised manuscript received and accepted January 31, 1990. Address for reprints: Robert A. Gonzalez, MD, Cardiology Section, Internal Medicine Depgrtment, San Juan City Hospital, PO Box 21405, Rio Piedras, Puerto Rico 00928.
1334
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
65
talized patients with a known diagnosis of systemic hypertension. Patients were admitted to the Department of Internal Medicine at the San Juan City Hospital. Patients (26 women, 21 men) were aged 50 to 70 years (60 f 10). Each patient gave informed consent to participate in the study. Study designr During March and April 1989 there were 60 patients who met the inclusion criteria: adult, alert, literate, with known history of high BP, receiving antihypertensive therapy before and continued on admission, and with primary admission diagnoses not related to high BP. One patient refused to participate. During the first 3 days after admission, a registered nurse measured BP 3 times a day for every patient. Both arms were positioned at the heart level, and BP was measured beginning I10 minutes after a quiet rest, in the sitting position. Appropriate cuff size and mercury sphygmomanometers were used. The level of appearance of Sr was considered the systolic reading and the disappearance of the sounds (Korotkoff phase V) was considered the diastolic reading.” From these readings, mean systolic and diastolic BP were calculated as baseline in every patient. After the third day, a questionnaire was presented by the health educator to each pa-
tient to determine education and BP knowledge. After 4 days, the patients were randomized to receive the educational program (group I, 30) or not (control, group II, 29). We gave 4 educational interventions, 15 to 20 minutes each, in 2 days. The activities were: (1) “knowing high BP,” offered by a physician, (2) “diet and high BP,” offered by a registered dietitian, (3) “exercise and high BP,” offered by a health educator and (4) “medications and compliance in high BP,” offered by a physician and a pharmacy student. All activities took place in the conference room of the Department of Internal Medicine, in a classroom setting. All patients involved in the study continued receiving the antihypertensive drugs they were using before the trial, as ordered by their primary physicians, who were instructed not to alter the medications during the trial unless absolutely necessary. Eight weeks after the interventions the patients were seen for the final evaluation. Again, 3 BP measurements were taken on each arm in every patient after a resting period 110 minutes. Mean systolic and diastolic BP were calculated for every patient and compared with baseline. The patients were then asked about compliance and side effects. Pill counts were used to confirm this information. During the 8-week-period that followed the first intervention 2 patients died, 1 in each group. Ten patients were lost to follow-up, 4 in group I and 6 in group II. The results evaluated the data of the remaining 47 patients (25 in group I, 22 in group II). Statistkal analysis: The results were analyzed using the Student unpaired t test for continuous variables, and chi-square and Fisher’s exact test for differences between proportions, as appropriate. Data and results are expressed as mean f standard deviation unless otherwise stated. A p value 15% IBW) Diabetes mellitus Coronary artery disease Malignancy Compliant (%)
of Patients
Group I
Group II
P Value
25 60f 10 11/14
22 58f12 10/12
NS NS NS
7 15 12 6 4 3 20
NS NS NS NS NS NS NS
7
18 17 8 3 2 30
BP = blood pressure: IBW = ideal body weight: NS = not significant.
TABLE
II
Primary
Admission
Diagnosis Pneumonia Diabetes mellitus Pancreatitis Chemotherapy, cancer Urinary tract infection Systemic lupus erythematosus Cellulitis
Diagnoses
of Patients
Group I
Group II
P Value
12 7
10 5
1
0
2 2 0
3 2
1
NS NS NS NS NS NS
1
1
NS
NS = not significant.
TABLE
Ill Antihypertensive
Type of Drug Diuretics Central adrenergic inhibitors a blockers 0 blockers Calcium antagonists Angiotensin-converting enzyme inhibitors Direct vasodilators Multidrug therapies Unknown by patients at baseline
Drugs
Used
Group I
Group II
P Value
10 3
12 4
NS NS
4 5 9 6
3 3 6 6
NS NS NS NS
0 15 6
0 13 4
NS NS NS
NS = not significant.
Before the interventions no significant differences were found in systolic (p = 0.30) and diastolic (p = 0.75) BP between the 2 groups. Eight weeks after the interventions, systolic and diastolic BP were significantly reduced among patients in group I (p = O.OOS),but not in group II (p = 0.63) (Table IV). When asked about their adherence to the antihypertensive therapy, 24 patients in group I (96%) and 8 patients in group II (36%) gave positive responses (p = 0.04). This information was confirmed by pill count. Compared with baseline data, significant improvement in compliance was found in group I only (from 30 to 96%, p
Hypertension Program
Robert A. Gonzalez-Fernhdez, MD, Mercedes Rivera, PhD, Dominga Torres, RN, Joaquin Quiles, and Alma Jackson, RD
The effacts of an eckcational program on complianw and Mood pressure (BP) cantral were assessed in 47 hypertensive patients hospitalized for nonhypertension-related diseases. Patii wers rawbmized to receive eithsr a questknaire and an edueaioMl program (group I, 25) or qussti0nnab-e only (group II, 33). Baseline clinical characteristics, admksien diagnews and antihypertensive mediitions were similar between the groups. Antihypertenshe medicatkns used by patients before the trial were not changed. Eight weeks after the initial intewentien, patients in group I showed a significant tductim in both systok and diastolic BP (137/89 vs lS4/98 mm Hg, p = 0.005 and 0.006, respedveiy) and improved compliance (Ss vs 3696, p = 0.04), compared with patients in group II. An education program in patients with high BP is an eMactive method to improve compliince and BP wntrd in tha short-term. (AmJCardkl199o;6s:1384-1386)
A
mong the many causes for inadequate blood pressure (BP) control in hypertensive patients, poor compliance with the long-term pharmacologic treatment is the leading one.1-3 Although new techniques have been developed to improve patient adherence to the therapeutic regimens,4 it continues an important clinical problem.5 Despite awareness about the reduction in hypertension-induced complications with the use of antihypertensive drugs,6 the complexity of the therapeutic regimens, high costs, side effects and poor patient-physician relations contribute to the finding that about 60% of low-income hypertensive patients do not comply with their therapy.’ Even provision of medical care at the work site proved to be noneffective in improving complianx8 Simplification of the therapeutic regimen to a oncea-day dosing9 and educational interventions are better alternatives in improving compliance in hypertensive patients.lO Several educational programs to improve BP control through compliance in outpatient settings proved to be effective. ‘i-l6 We report a randomized clinical trial designed to evaluate the short-term efficacy of an in-hospital educational program. METHODS Patknt group: This study was performed in hospi-
From the Cardiology Section, Department of Internal Medicine, San Juan City Hospital, and the Section of Health Related Sciences, University of Puerto Rico, Rio Piedras, Puerto Rico. Manuscript received September 12,1989; revised manuscript received and accepted January 31, 1990. Address for reprints: Robert A. Gonzalez, MD, Cardiology Section, Internal Medicine Depgrtment, San Juan City Hospital, PO Box 21405, Rio Piedras, Puerto Rico 00928.
1334
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
65
talized patients with a known diagnosis of systemic hypertension. Patients were admitted to the Department of Internal Medicine at the San Juan City Hospital. Patients (26 women, 21 men) were aged 50 to 70 years (60 f 10). Each patient gave informed consent to participate in the study. Study designr During March and April 1989 there were 60 patients who met the inclusion criteria: adult, alert, literate, with known history of high BP, receiving antihypertensive therapy before and continued on admission, and with primary admission diagnoses not related to high BP. One patient refused to participate. During the first 3 days after admission, a registered nurse measured BP 3 times a day for every patient. Both arms were positioned at the heart level, and BP was measured beginning I10 minutes after a quiet rest, in the sitting position. Appropriate cuff size and mercury sphygmomanometers were used. The level of appearance of Sr was considered the systolic reading and the disappearance of the sounds (Korotkoff phase V) was considered the diastolic reading.” From these readings, mean systolic and diastolic BP were calculated as baseline in every patient. After the third day, a questionnaire was presented by the health educator to each pa-
tient to determine education and BP knowledge. After 4 days, the patients were randomized to receive the educational program (group I, 30) or not (control, group II, 29). We gave 4 educational interventions, 15 to 20 minutes each, in 2 days. The activities were: (1) “knowing high BP,” offered by a physician, (2) “diet and high BP,” offered by a registered dietitian, (3) “exercise and high BP,” offered by a health educator and (4) “medications and compliance in high BP,” offered by a physician and a pharmacy student. All activities took place in the conference room of the Department of Internal Medicine, in a classroom setting. All patients involved in the study continued receiving the antihypertensive drugs they were using before the trial, as ordered by their primary physicians, who were instructed not to alter the medications during the trial unless absolutely necessary. Eight weeks after the interventions the patients were seen for the final evaluation. Again, 3 BP measurements were taken on each arm in every patient after a resting period 110 minutes. Mean systolic and diastolic BP were calculated for every patient and compared with baseline. The patients were then asked about compliance and side effects. Pill counts were used to confirm this information. During the 8-week-period that followed the first intervention 2 patients died, 1 in each group. Ten patients were lost to follow-up, 4 in group I and 6 in group II. The results evaluated the data of the remaining 47 patients (25 in group I, 22 in group II). Statistkal analysis: The results were analyzed using the Student unpaired t test for continuous variables, and chi-square and Fisher’s exact test for differences between proportions, as appropriate. Data and results are expressed as mean f standard deviation unless otherwise stated. A p value 15% IBW) Diabetes mellitus Coronary artery disease Malignancy Compliant (%)
of Patients
Group I
Group II
P Value
25 60f 10 11/14
22 58f12 10/12
NS NS NS
7 15 12 6 4 3 20
NS NS NS NS NS NS NS
7
18 17 8 3 2 30
BP = blood pressure: IBW = ideal body weight: NS = not significant.
TABLE
II
Primary
Admission
Diagnosis Pneumonia Diabetes mellitus Pancreatitis Chemotherapy, cancer Urinary tract infection Systemic lupus erythematosus Cellulitis
Diagnoses
of Patients
Group I
Group II
P Value
12 7
10 5
1
0
2 2 0
3 2
1
NS NS NS NS NS NS
1
1
NS
NS = not significant.
TABLE
Ill Antihypertensive
Type of Drug Diuretics Central adrenergic inhibitors a blockers 0 blockers Calcium antagonists Angiotensin-converting enzyme inhibitors Direct vasodilators Multidrug therapies Unknown by patients at baseline
Drugs
Used
Group I
Group II
P Value
10 3
12 4
NS NS
4 5 9 6
3 3 6 6
NS NS NS NS
0 15 6
0 13 4
NS NS NS
NS = not significant.
Before the interventions no significant differences were found in systolic (p = 0.30) and diastolic (p = 0.75) BP between the 2 groups. Eight weeks after the interventions, systolic and diastolic BP were significantly reduced among patients in group I (p = O.OOS),but not in group II (p = 0.63) (Table IV). When asked about their adherence to the antihypertensive therapy, 24 patients in group I (96%) and 8 patients in group II (36%) gave positive responses (p = 0.04). This information was confirmed by pill count. Compared with baseline data, significant improvement in compliance was found in group I only (from 30 to 96%, p
