e-Care for Heart Wellness

Funded by the National Heart, Lung, and Blood Institute: American Recovery and Reinvestment Act

RC1 HL100590-01

Special Thanks

Investigators

Andrea Cook, PhD

Paul Fishman, PhD

Sheryl Catz, PhD

Jennifer McClure PhD

Melissa Anderson MS

Rob Reid MD, PhD

Consultants:

Ann Vernez-Moudon

Kevin Patrick

Deborah Tate

Team

Aaron Scrol, MA

Ron Johnson

Julie Reardon

Dietitians

Terri Fox LD

Eileen Paul LD

Dawn Wilson LD

The Electronic Communications and Home Blood Pressure Trial (e-BP)

The e-BP study was a 3 arm-randomized controlled trial that randomized patients with hypertension and uncontrolled BP and Web access to receive either.

All patients were signed up to use the myGroupHealth patient Web portal

Usual Care –were told their BP was not under control and to work with their physician

Web only – were given a home BP monitor and portal training and encourage to use these tools to work with their physician to improve their BP control

Web-pharmacist care – received this plus Web-based pharmacist collaborative care Action plan – with 5 activities: BP monitoring plan, medication list, lifestyle activity to

decrease BP or CVD risk, recommendations from the pharmacist, and the follow-up plan

Pharmacist had prescriptive authority to adjust and add anti-hypertensive medications

Communications occurred every 2 weeks for the first 2 months or until BP was controlled, then less frequently for 1 year.

Web communications – Action PlanSmart Phrase: eBP1stActPlan

HI .NAME

Here is your current action plan:

1. BP monitoring: Measure your BP at least 2 times each week (with two BP measurements each time). Choose two days of the week that are easy to remember, like Saturday and

Thursday or Monday and Friday and a time that is convenient, by making a regular time it will be easier to remember. Remember to: (refer to your e-BP notebook for more detailed instructionAvoid exercise, caffeine, and tobacco for at least 30 minutes before you take your measurement. Remove tight fitting clothing from your upper arm.Sit in a comfortable position with your legs and back supported.Rest quietly for at least two minutes. Wait at least two minutes between BP measurements.Place your arm on a table or desk so that your arm is at the level of your heart.I will be sending you a secure message asking you for your BP measurements.

2. Medications:Your current medications are on ***If these are not correct please let me know.

3. Lifestyle Changes:You decided to work on *** You might want to check out some Group Health Resources such *** 4. Assessment Your average BP was 148/84. The next step would be to increase your dose of xxLet me know if you have any concern about this plan

5. Follow-up Plan:Please go to a Group Health Lab to have: ***I will send you a reminder to send me more BP readings in 2 weeks.

.Me

e-BP Blood pressure control at 12 months

Usual Care Home BP-Web Home BP-Web-Pharmacist

All 31% 36% 56%**

Systolic BP at baseline >160

20% 26% 54%**

**P < 0.001 compared to Usual Care and Home-BP WebJAMA 2008

e-BP - Questions remained:

Only 7% of e-BP participants had a normal BMI at baseline and over 2/3 had a BMI >30

The pharmacist action plan included a lifestyle behavior goal. Many patients chose weight loss.

The pharmacist intervention however, did not lead to significant weight change

However BP control was related to weight change for the entire study population.

Patients who lost >2 kg were more likely to have controlled BP (p=.008)

Could a Web-based dietitian intervention lead to improved BP control?

The e-Care for Heart Wellness Study

We proposed to conduct a pilot to test whether aWeb-based dietitian-delivered behavioral intervention could be integrated into routine health care and would result in improved control BP, weight loss, and reduction in CVD risk.

Primary Outcomes Change in mean systolic and diastolic BP, weight, and CVD risk

• Secondary Outcomes Patient satisfaction with the intervention, its effects on health related

quality of life, and the cost of delivering the intervention

e-Care Patient Eligibility

Patients age 30 – 70 were eligible if They had a Framingham 10-year risk for cardiovascular

disease of 10 -25% (moderate to high-moderate) No existing cardiovascular disease or diabetes Were secure users of MyGroupHealth Had a BMI >26 Their last BP at an outpatient visit was > 140 mm Hg systolic

or > 90 mm Hg diastolic At the research visit they also had to have a BP of > 140 mm

Hg systolic or > 90 mm Hg diastolic

e-Care Interventions

Patients randomized to Web-dietitian collaborative care received A home BP monitor, scale, and a pedometer One in-person 40 minute visit with a dietitian – they

reviewedHome Monitoring Schedule - BP, weight, fruit and vegetables 3 days a

week– pedometer reporting was optional

Heart age– their age and CVD risk (which was elevated) compared to the age this would be not elevated

Dash Diet, low salt, weight loss optional

Action Plan for decreasing BP and CVD risk

Web communications Schedule (weekly for 2 months, then every 2 weeks for 2 months, then monthly)

Monitoring Schedule

Eat more fruits & vegetables

Try to eat 8-10 servings per day.

Even if you don’t meet this goal, every serving of fruit or veggies helps.

Check your blood pressure and weight

Choose three days in a row to check your blood pressure and weight.

The best time to check your blood pressure is one hour after you wake up. Please take two readings in the morning and two in the evening on each of the three days.

Note: A vegetable serving = ½ cup cooked vegetables, 1 cup leafy greens, 6oz juice A fruit serving = 1 small fruit, ¼ cup dried fruit, 1 cup diced fruit, 4oz juice

Day (circle): M T W Th F S S Weight: _____________________________lbs Blood Pressure (am): ____/_____, _____/_____ Blood Pressure (pm): ____/_____, _____/_____ Servings of Fruits and Vegetables: ___________ (List all the fruits and vegetables you ate today) Breakfast:______________________________ Lunch: _________________________________ Dinner:_________________________________ Snacks:_________________________________

Day (circle): M T W Th F S S Weight: _____________________________lbs Blood Pressure (am): ____/_____, _____/_____ Blood Pressure (pm): ____/_____, _____/_____ Servings of Fruits and Vegetables: ___________ (List all the fruits and vegetables you ate today) Breakfast:______________________________ Lunch: _________________________________ Dinner:_________________________________ Snacks:_________________________________

Day (circle): M T W Th F S S Weight: _____________________________lbs Blood Pressure (am): ____/_____, _____/_____ Blood Pressure (pm): ____/_____, _____/_____ Servings of Fruits and Vegetables: ___________ (List all the fruits and vegetables you ate today) Breakfast:______________________________ Lunch: _________________________________ Dinner:_________________________________ Snacks:_________________________________

For the week starting: Monday, _____________, 2010 Weekly Record

You are in the e-Care study because you are at moderate risk for heart disease. This means you have one or more risk factors that increase your chances of having a heart attack or stroke. Common risk factors are high blood pressure, high LDL cholesterol, and being overweight.

The e-Care study was designed to help you meet these goals.

The e-Care study is asking you to do these steps each week

Check your blood pressure and weight

Choose three days in a row to check your blood pressure and weight.

The best time to check your blood pressure is one hour after you wake up. Please take two readings in the morning and two in the evening on each of the three days.

Weigh yourself once each of the three days.

Write down your weight and blood pressure readings on your form. (You can print extra copies at www.ecarestudy.org.)

Send the results to us in a weekly email. We will email you each Monday to remind you to send us the results, so the best days to check are Friday, Saturday, and Sunday

Your age is:

62

One way to think about your risk for heart disease is to look at your heart age.* Ideally, you want your heart age to be the same or less than your real age.

What does this mean? Based on your risk factors, you have the same risk for heart attack or stroke as someone who is 73 years old.

You can lower your heart age. When you decrease your risk factors, you lower your heart age and reduce your chances of having a heart attack or stroke.

Your heart age is:

76

To lower your heart age:

??? Bring your blood pressure down to below 140 over 90 below 135 over 85 at home

??? Bring your LDL cholesterol down to below 130

??? Stay at your current weight—or try to lose 10 pounds

Eat more fruits & vegetables

Try to eat 8-10 servings per day. One serving = ½ cup.

Even if you don’t meet this goal, every serving of fruit or veggies helps.

Tips for increasing your servings: Eat at least 1 serving of fruit at every

meal—and 2 at breakfast. Eat 2 to 3 servings of veggies at lunch

and dinner.

Eat less salt

Try to stay away from salty foods—such as packaged snacks, canned foods, and frozen prepared foods.

Use salt substitutes to season your food and at the dinner table.

Web- based Dietitian Care

e-CareAction Plan Used for Web Communications

Smart Phrase: eCareAVS1stactionplan

Below is the Action Plan we worked on together to decrease your heart disease and stroke risk. PLEASE LET ME KNOW – if anything is incorrect

There are 4 parts – 1. Your monitoring plan (things you check at home) 2. Your medications for blood pressure (BP) and cholesterol 3. Your LONG-term targets and SHORT-term plans to achieve these. 4. Follow-up plans

e-CareAction Plan Used for Web Communications

1. MONITORING – (1) Blood Pressure - Measure your blood pressure 3 days a week (with 2 blood pressure measurements each day). Measuring your blood pressure more often is fine. Experts say to check your blood pressure within 1 hour of waking up, but it is OK if you check at other times of the day. (2) Weight – you agreed to measure your weight *** (3) Fruits and Vegetables**** (4) Other***

2. MEDICATIONS – this is your list of blood pressure and cholesterol medications. {CHRONIC DISEASE BP MEDS: 20657}. ..actmed or .actmedn if in clinic

3. (1) LONG-TERM TARGETS Blood pressure <135/85 home (<140/90 office) LDL <130 Increasing fruit and veggies 8-10 servings a day ***Losing 10 pounds

(2) SHORT-TERM PLANS: 4. FOLLOW-UP PLAN- I will send you an e-mail reminder in 1 week. Please go to your MyGroupHealth Inbox when you get this

e-Care Recruitment Flow

Eligible based on automated records, sent invitation letters, and called

(age 30-70, CVD risk 10 – 25%, BMI > 26, no

diabetes, no cardiovascular disease)

N = 965

Remained eligible and invited to attend a screening visit

N = 386 (40%)

Unable to contact = 108 (11%)

Refused = 345 (36%)

Ineligible = 126 (13%)

Enrolled

N = 101 (26%)

No show = 39 (10%)

Refused = 39 (10%)

BP controlled = 206 (54%)

Ineligible = 1(BP monitor errors)

Baseline Characteristics

Characteristics Controlsn = 50

Web-dietitiann = 51

Age (mean) 57 58

Female (%) 30% 53%

Race, nonwhite (%) 16% 14%

Education, > college degree 66% 58%

Systolic BP mm Hg (SD) 151 (11.9) 150 (11.6)

Diastolic BP mm Hg (SD) 91 (9.5) 93 (8.8)

BMI (SD) 33.3 (5.6) 34.5 (5.8)

CVD risk, Framingham CVD 10 yr 17 (6.6) 15.6 (6.7)

Primary Outcomes

Controln = 46

Web-dietitiann=51

P-value

Change from baseline:

Systolic BP (mm Hg) - 11.4 (-7.2, -15.5) - 13.9 (-9.7, -18.1) 0.40

Weight loss ( kg) -0.4 (-0.7, -1.2) -3.7 (-2.5, -4.9) <0.001

CVD Risk Score -2.5 (-1.4,-3.5) -3.0 (-2.0,-4.0) 0.5

Binary outcomes at follow-up

BP control 39% (25% ,54%) 55% (39% ,70%) 0.32

Wt Loss > 4 11% (2%, 20%) 32% (18%, 46%) 0.02

Secondary Outcomes

Change from baseline Control Web-Dietitian P-value

HbA1c 0.07 (-.01,.14) -0.02 (-0.11,0.06) 0.11

Fasting BS -1.0 (-3.9,1.8) -0.7 (-3.3,1.9) 0.86

Fruits and vegetables(number of servings)

0.1 (-0.5,0.6) 2.3 (1.4,3.2) 0.003

Regular physical activity at follow up

71% (57%,84%) 95% (89%, 100%) 0.002

Satisfaction with BP/cholesterol care

-0.5(-1.1,0.2) 1.3 (0.4,2.1) 0.01

Patient Perceptions Heart age

“shocking” - “I wanted to take the corrective stuff” “shocking” - “Your heart is already aged to 80 years, how are you going

to correct that?”

Collaborative dietitian care

“If I had some input to her, she could help me with a suggestion, she was right on target (snaps finger), getting it back ASAP – “a little dietitian in your pocket”

“I receive an e-mail from the doctor’s office who said we saw these BP’s, we would like you to come in – saying I was in the e-Care study and he said okay, never mind”

Dietitian Exit Comments

Patients want to work on lifestyle not medications Patients wanted to try diet and lifestyle changes for 3 months or more

before considering medication. One patient wanted to wait until study completion even when warned of risks of high blood pressure.

Some patients stopped responding to my emails when medication was encouraged.

Many patients were opposed to cholesterol lowering medication because of strong negative perceptions (media related).

There were challenges in providing collaborative care with the physician Doctors were not well integrated into the study care team. One doctor said

“if the patient is not interested in taking meds, then I am not interested in meds for this patient.”

Conclusions

E-care Dietitian led to weight loss but did not significantly decrease systolic BP

Patients found e-Care convenient and self-monitoring was not burdensome

We need to understand more about how patients make decisions about lifestyle versus medication changes

Next stepsTraining physicians to pay attention to dietitian based

team care?Linking care to pharmacist who could adjust meds?