More rigorous protocol adherence to intensive structured management improves blood pressure control in primary care: results from the Valsartan Intensified Primary carE Reduction of Blood Pressure study.
OBJECTIVE
To examine protocol adherence to structured intensive management in the Valsartan Intensified Primary carE Reduction of Blood Pressure (VIPER-BP) study involving 119 primary care clinics and 1562 randomized participants.


METHODS
Prospective criteria for assessing adherence to treatment prescription, uptitration, and visit attendance at 6, 10, 14, and 18 weeks postrandomization were applied to 1038 intervention participants. Protocol adherence scores of 1-5 (least to most adherent) were compared to blood pressure (BP) control during 26 weeks of follow-up.


RESULTS
Mean age was 59.3 ± 12.0 years, 963 (62%) were men, and 1045 (67%) had longstanding hypertension. Clinic attendance dropped from 91 (week 6) to 83% (week 26) and pharmacological instructions were followed for 93% (baseline) to 61% at week 14 (uptitration failures commonly representing protocol deviations). Overall, 26-week BP levels and BP target attainment ranged from 132 ± 14/79 ± 9 and 51% to 141 ± 15/83 ± 11  mmHg and 19% in those participants subject to the highest (n = 270, 26%) versus least (n = 148, 14%) per protocol adherence, respectively; adjusted relative risk (RR) 1.22 per unit protocol adherence score, 95% confidence interval (CI) 1.15-1.31; for achieving BP target (P < 0.001). Participants with a per protocol score of 4 or 5 (512/1038, 49.3%) were 1.54-fold (95% CI 1.31-1.81; P < 0.001) more likely to achieve their individual BP target compared with usual care. Clinics equipped with a practice nurse significantly influenced protocol adherence (adjusted RR 1.20, 95% CI 1.06-1.37; P = 0.004) and individual BP control (RR 1.21, 95% CI 1.04-1.41; P = 0.015).


CONCLUSIONS
There is considerable potential for structured care management to improve BP control in primary care, especially when optimally applied.
aNHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease, Preventive Health, Baker IDI Heart and Diabetes Institute, Melbourne bDiscipline of General Practice, University of Adelaide, Adelaide cDepartments of Medicine and Cardiology, The University of Melbourne, Austin Health, Melbourne dSchool of Medicine, University of Queensland, Brisbane eUniversity of South Australia, Adelaide fCentre for Primary Healthcare and Equity, University of New South Wales, Sydney gSchool of Medicine & Pharmacology, Sir Charles Gairdner Hospital Unit, University of Western Australia, Perth hNovartis Pharmaceuticals Australia Ltd., Sydney, Australia.
Simon
S
Stewart
Nigel P
NP
Stocks
Louise M
LM
Burrell
Ferdinandus J
FJ
de Looze
Adrian
A
Esterman
Mark
M
Harris
Joseph
J
Hung
Carla H
CH
Swemmer
Nicol P
NP
Kurstjens
Garry L
GL
Jennings
Melinda J
MJ
Carrington
D000328:Adult; D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001794:Blood Pressure / Q000187:drug effects*; D001795:Blood Pressure Determination; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D011320:Primary Health Care / Q000458:organization & administration*; D011446:Prospective Studies; D013777:Tetrazoles / Q000627:therapeutic use*; D013997:Time Factors; D016896:Treatment Outcome; D014633:Valine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000068756:Valsartan
D000959:Antihypertensive Agents; D013777:Tetrazoles; D000068756:Valsartan; D014633:Valine