title: Improving adherence to guidelines for hypertension drug prescribing: cluster-randomized controlled trial of general versus patient-specific recommendations.
abstract: OBJECTIVE
  To determine whether an intervention focusing clinician attention on drug choice for hypertension treatment improves concordance between drug regimens and guidelines.
  
  
  METHODS
  Cluster-randomized controlled trial comparing an individualized intervention with a general guideline implementation in geographically diverse primary care clinics of a university-affiliated Department of Veterans Affairs healthcare system.
  
  
  METHODS
  Participants were 36 attending physicians and nurse practitioners (16 in the general group and 20 in the individualized group), with findings based on 4500 hypertensive patients. A general guideline implementation for all clinicians, including education about guideline-based drug recommendations and goals for adequacy of blood pressure control, was compared with addition of a printed individualized advisory sent to clinicians at each patient visit, indicating whether or not the patient's antihypertensive drug regimen was guideline concordant. We measured change from baseline to end point in the proportion of clinicians' patients whose drug therapy was guideline concordant.
  
  
  RESULTS
  The individualized intervention resulted in an improvement in guideline concordance more than twice that observed for the general intervention (10.9% vs 3.8%, t = 2.796, P = .008). Bootstrap analysis showed that being in the individualized group increased the odds of concordance 1.5-fold (P = .025). The proportion of patients with adequate blood pressure control increased within each study group; however, the difference between groups was not significant.
  
  
  CONCLUSIONS
  An individualized advisory regarding drug therapy for hypertension given to the clinician at each patient visit was more effective in changing clinician prescribing behavior than implementation of a general guideline.
authors.affiliation: VA Palo Alto Health Care System GRECC 182B, 3801 Miranda Avenue, Palo Alto, CA 94304, USA. goldstein@stanford.edu
authors.forename: Mary K
authors.initials: MK
authors.lastname: Goldstein
authors.forename: Philip
authors.initials: P
authors.lastname: Lavori
authors.forename: Robert
authors.initials: R
authors.lastname: Coleman
authors.forename: Aneel
authors.initials: A
authors.lastname: Advani
authors.forename: Brian B
authors.initials: BB
authors.lastname: Hoffman
mesh_terms: D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D016000:Cluster Analysis; D011307:Drug Prescriptions; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D012495:San Francisco
chemical_list: D000959:Antihypertensive Agents