Outcomes Research in Review

Technology-Supported Apprenticeship in the Management of Hypertension: A Randomized Controlled Trial

Journal of Clinical Outcomes Management. 2014 March;21(3)

Author(s):

John O. Moore, MD, PhD

Mary Ann Marshall, RN, INCH, BC

David C. Judge, MD

Franklin H. Moss, PhD

Scott J. Gilroy, BSc

J. Benjamin Crocker, MD

Randall M. Zusman, MD

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From the Massachusetts Institute of Technology (Dr. Moore, Dr. Moss and Mr. Gilroy) and the Massachusetts General Hospital (Ms. Marshall, Dr. Judge, Dr. Crocker, and Dr. Zusman), Boston, MA.

Abstract

Objective: To compare technology-supported appren-ticeship in hypertension management with a successful coaching model at Massachusetts General Hospital.
Methods: A randomized controlled trial was conducted. Adult patients with uncontrolled essential hypertension (average blood pressure (BP) 148/87 mm Hg) were recruited in a staggered fashion for a 12-week study period. Intervention subjects received apprenticeship support from a nurse health coach through the CollaboRhythm application on a tablet computer. Patients self-tracked medication adherence and blood pressure (via wireless device) and the coach helped them to continuously progress through lifestyle change and medication adjustment using integrated messaging. Control subjects received support from the same coach but through traditional channels of office visits, phone calls, and e-mail.
Results: 42 of 44 subjects completed the study. Intervention subjects achieved a greater decrease in systolic BP at 12 weeks than control subjects (26.3 mm Hg vs. 16.0 mm Hg, P = 0.009). A greater percentage of intervention subjects achieved goal BP ≤ 130/80 mm Hg (75.0% vs. 31.8%, P = 0.003) and 100% of them achieved goal BP ≤ 140/90 mmHg. They also rated the experience higher, although this finding was not statistically significant (8.9 vs. 7.6, P = 0.12). There was a trend toward increased cost for intervention subjects ($67.50 vs. $53.41, P = 0.15), but the projected cost is much less than standard care ($248/patient/year).
Conclusion: This study provides encouraging evidence that technology-supported apprenticeship can improve the outcomes, cost, and experience of care in managing hypertension.

Hypertension affects approximately 33% of the U.S. adult population [1]. Antihypertensive treatment has been shown to be effective at preventing complications [2,3]. Unfortunately, estimates suggest that the majority of those diagnosed with hypertension do not have their blood pressure controlled [1]. This failure is due to both clinician and patient factors. Mean adherence of clinicians to guidelines is estimated at 53.5% [4]. An electronic monitoring study showed that half of patients who are prescribed medications stop taking them within 1 year [5]. Of those who take their medications, about 10% have adherence issues on any given day and about 50% have significant adherence issues in the course of their treatment [5]. Adherence to diet and exercise self-management is even more dismal, with rates below 20% [6]. Hypertension is an expensive problem with direct medical costs (treatment and complications) greater than $100 billion a year and equally high indirect costs (lost productivity) [7–9].

In the management of chronic diseases, there is a significant trend toward empowering patients with more control and toward providing more longitudinal coaching from clinicians and from peers [10–15]. Technology-supported apprenticeship is a model of chronic disease management that builds on the success of self-management and coaching, but it is more ambitious in that its goal is for patients to lead their care with the support of health coaches and supervising clinicians. It is informed by the field of learning science, particularly in how technology can be used effectively to support learning [16–20]. Apprenticeship refers to the tutelage of a community of novices in a skill or trade by one or more masters through situated learning. Situated learning refers to the process in which novices learn through participation in legitimate tasks in the same physical and social context where they will need to perform them once independent [21,22]. It is opposed to learning through contrived exercises in an artificial environment like a classroom.