nfralick
Tue, 08/29/2023 - 17:51
Edited Text
Does a hypertension
guideline assist providers
with perceived confidence
with hypertension
management in a retail
setting?
Emmanuel Ekwere, MSN
Abstract
This study is evaluates the impact of webex hypertension (HTN) guideline training on providers’ confidence in
MinuteClinic’s (MC) hypertension HTN management visits.
Confidence scores of participant in the MC training/webex education sessions provided prior to the
commencement of HTN chronic care services were obtained via survey and compared with those providers who did
not participate in the education sessions.
T-test analysis showed no statistically significant difference between the Trained group and the Non-Trained
group.
Factors enabling the lack of significant difference between the two groups and suggestions for further studies are
discussed.
Introduction – Problem Description
HTN affects 30% of US adults (approx. 75million Americans)
Most common diagnosis at outpatient office visits
Major risk factor for heart attack, heart failure, CKD, and stroke
AKA “a silent killer” since no symptoms until target organs are damaged
Defined as having blood pressure ≥ 140/90 or taking antihypertensives
Contributing or primary cause of death for over 362,000 Americans in 2010
Treatable with lifestyle modifications and pharmacology therapy
Multiple factors cause HTN not to be controlled adequately
Provider-related factors and provider’s knowledge, attitudes or behaviors have been found to be
barriers to treatment adherence
This study evaluates whether education on HTN guidelines adherence assists with provider
confidence.
Introduction – Available knowledge
Clinical practice guidelines (CPG) defined by IOM in 2011 as recommendation
statements intended to optimize patient care
Formed from the systematic review of evidence, CPGs are standard of care
For HTN, existing CPGs include JNC-8 (released in 2014), and 2017 ACC/AHA
guidelines
MC’s HTN guidelines is formed from the amalgamation of both guidelines
Lifestyle modification is the first therapy; alone or in combination with pharmacology
Lifestyle modification includes weight loss, DASH diets, smoking cessation, sodium
reduction (to ≤2400mg/day), potassium supplementation (unless contraindicated),
optimum glucose and lipids control, increased physical activity, and moderate alcohol
consumption
Introduction-Available knowledge (contd.)
For pharmacologic intervention, both guidelines differ slightly in their
recommendations
While both JNC-8 and 2017 ACC/AHA recommend initiation of therapy for all adults
at B/P ≥140/90, 2017 ACC/AHA recommends therapy for high risk individuals at B/P
≥130/80, while JNC-8 does not.
Both guidelines recommend initiation of therapy with a thiazide-type diuretic or a
calcium-channel blockers alone or in combination for black patients.
Both guidelines also included recommendations for therapy adjustment, follow up
intervals, special populations, labs, etc.
Introduction-Available knowledge (contd.)
ABPM considered the best method for diagnosing HTN
HTN classified as essential and secondary – depending on causes
Risk factors include modifiable a non-modifiable
Non-modifiable risk factors include age, race, family history, and stress
Risk factors for secondary HTN include OSA, kidney problems, adrenal gland
problems, thyroid problems, congenital defects, medications, illegal drug and alcohol
abuse
Other factors affecting HTN include white coat syndrome, B/P measuring device, cuff
size, body position, arm position, interval between measurement, difference between
both arms, skill of measurer, silence, etc.
Introduction-Available knowledge (contd.)
Aims of HTN control is to reduce complications and slow target organ damage
Target organ damage results in stroke, vision loss, heart failure, heart attack, kidney
disease/failure, and sexual dysfunction
Barriers to HTN control exist at the providers’ level, patients’ level, and health systems
level
Web-based education use for educating nurses is increasing and associated with
participants showing improved knowledge, skill, changed beliefs and confidence
This study uses MC HTN guideline, which is a proprietary information that the
company does not want to share publicly
Introduction - Rationale
Chronic Care Model (CCM) is the theoretical framework used in this study
First published in Effective Clinical Practice in 1988 and edited by Ed Wagner
Designed to improved health outcome of chronic conditions
Focuses on optimizing team members knowledge, skills, education and expertise
toward improving HTN outcome for the patients
Introduction – Specific Aims
Aim is to see whether the adoption and education of providers increased confidence in
HTN management or not
Methods - Context
Participants were
MC’s providers working in retail settings across Pennsylvania, Maryland, Ohio, New Jersey, Virginia, Michigan, New York,
Connecticut, Washington, DC, Indiana and Kentucky.
Providers
were recruited via voluntary participation using MC’s email apparatus.
Participants were gThis study is a DNP project designed using provider’s response (to survey), MC’s hypertension guideline (a proprietary
document), and evidence-based education to ascertain provider’s confidence and competence in hypertension management.
iven
A
questionnaires, and their responses were analyzed.
total of 1,290 providers, who are mostly nurse practitioners, comprising of both males and females aged 18 and above, were sent emails, 82
responded and participated in the study.
An
inclusion criterion is that all participants are providers (NPs mostly, PAs and MDs) working for MC.
An
exclusion criterion is non-MC providers.
Methods - Interventions
The first intervention is to determine if the provider participant did or did not complete
the hypertension services pre-roll out online education via webex by MC
The
second intervention is to determine if there is a difference in provider’s perceived
confidence after completion of the MC hypertension education program versus those who
did not complete the MC hypertension training.
Methods – Study of the interventions
Survey consists of the first polar question and 10 questions which are derived from two
scales in the Self-Determination Theory
Written permission obtained to use the Self-Determination Theory scales for academic
purpose from the Center of Self-Determination Theory via email
Perceived Competence Scales (PCS), consists of four questions
Intrinsic motivation inventory (IMI) called Post-Experimental Intrinsic Motivation
Inventory (Perceived Competence Task Evaluation Questionnaire [PCTEQ]), consists
of the remaining six questions
Methods - Measures
First question is to indicate whether provider participated in the webex session
The next 10 questions was to rate the correct response on a scale of 1-7
With “1” being not at all true and “7” being very true
Methods - Analysis
Scores are calculated by averaging the responses on the 10 items questionnaire.
The last question (#11) was a reverse score
Mean, standard deviation, skewness, kurtosis and t-test analysis were used for the
statistical analysis
Methods – Ethical considerations
Edinboro University of Pennsylvania IRB approval obtained
Participants were protected by HIPAA and its modifications of 2013
Personal identifiers of participants not included
Response to survey was synonymous with consent which was attached
Participation totally voluntary
No conflict of interest and no payments to participants
Results
The
latest version of SPSS, (Statistical Package for the Social Sciences) version 25.0, a software used for
statistical analysis was used for this statistical analysis.
The
data analysis plan was conducted in two phases.
First
of all, study variables were presented using descriptive statistics, such as, means, standard deviation,
and minimum/maximum values for continuous variables (Interval/Ratio level) and frequencies and
percentages for categorical variables (Nominal/Ratio level).
Next,
a series of bivariate tests were used to produce inferential findings.
T-test
were used to identify if dependent variable scores (i.e., Provider Confidence) differed by study group
in terms of the overall composite measure, and by individual scale items.
Results (contd.)
T-test conducted with and without outlier scores revealed no difference in statistical
significance
Reliability analysis on the Total Provider Confidence Composite Scale indicated a very
good internal consistency with a Cronbach alpha rating of 0.93
Statistical power indicted this was a medium/large size effect
Sample size of 82 in the study was sufficient statistical power
Trained group was 44 (53.7%)and Non-Trained group was 38 (46.3%)
Provider confidence measures did not have a statistical significant difference between
the Trained group and the Non-Trained group (p=0.82)
Results (contd.)
Total Provider Confidence Composite Scale Scores (10-Items)
Variable
n
M (SD)
Trained Group
44
4.98 (1.17)
0.23 (80) 0.82
Non-Trained Group 38
5.04 (1.21)
0.23 (80) 0.82
t (df)
p
Discussion - Summary
Absence of a statistically significance difference between the trained group and nontrained group is a significant finding
Relevant to the effectiveness of webex education done
Existence of reasons as to why there was no significant difference
Discussion – Interpretation
Individual provider’s experience and training before MC’s HTN services is started
Generalization of the survey questions, instead of more specific questions
Factors that can increase the quality of webex needs looked into
A case for a bigger sample size
Discussion - Limitations
This study did not measure the barriers to HTN evaluation by providers
Providers’ competence in HTN management not measured
Previous experience of providers in managing HTN before webex
Generalization of findings not advised until repeated in a different setting
Relationship between provider’s confidence and patient’s outcome, not measured
Discussion - Conclusion
Confidence scores of the two groups of providers analyzed did not yield any statistical
significant difference
Patient are more likely to equate confident provider with competent provider, which
build trust and increase adherence to recommendations; however, the relationship
between provider confidence and patient’s outcome remains to be explored
Repeat of study with a larger sample size, measuring the prior experience in HTN care,
using specific survey questions, identifying and addressing possible barriers to webex
education are needed to be addressed before generalization of findings.
References
Alsolami, F., Hou, X., & Correa-Velez, I. (2012). Factors affecting antihypertensive
adherence: A Saudi Arabian perspective. Clinical Medicine and Diagnostics, 2(4),
27-32. doi: 10.5923/j.cmd.20120204.02.
American Heart Association. (2017). Health threats from high blood pressure. Retrieved
from
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/LearnHowHB
PHarmsYourHealth/Healt-Threats-From-Blood-Pressure_UCM_002051_Article.jsp
#.WktUkzdG1PY.
American Heart Association. (2017). Understanding blood pressure readings. Retrieved
from
http://www.heart.org/HEARTORG/Cconditions/HighBloodPressure/KnowYourNum
bers/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp#.WktXpTd
G1PY.
Centers for Disease Control and Prevention. (2017). High blood pressure. Retrieved from
https://www.cdc.gov/bloodpressure/index.htm.
Charles, L., Triscott, J., & Dobbs, B. (2017). Secondary hypertension: Discovering the
underlying cause. American Family Physician, 96(7), 453-461.
Cifu, A., & Davis, A. (2017). Prevention, detection, evaluation and management of high
blood pressure in adults. JAMA, 318(21), 2132-2134. doi: 10.1001/jama.2017.18706.
Deci, E., Eghrari, H., Patrick, B., & Leone, D. (1994). Facilitating internalization: The
self-determination theory perspective. Journal of Personality, 62, 119-142.
Glenn, C., & Taylor, J. (n.d.). JNC 8 hypertension guideline algorithm. Retrieved from
References
http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf.
Healthy People 2020. (2014). Heart disease and stroke. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke.
Hernandez-Vila, E. (2015). A review of the JNC 8 blood pressure guideline. Texas Heart
Institute Journal, 42(3), 226-228. doi: 10.14503/THIJ-15-5067.
Institute of Medicine. (2011). Clinical practice guidelines we can trust. Retrieved from
https://www.nap.edu/read/13058/chapter/1#ii.
James, P., Oparil, S., Carter, B., Cushman, W., Dennison-Himmelfarb, C., Handler, J.,
Lackland, D.,…Ortiz, E. (2014). 2014 evidence-based guideline for the management
of high blood pressure in adults: Report from the panel members appointed to the
eighth joint national committee (JNC 8). JAMA, 311(5), 507-520. doi: 10.1001/jama.
2013.284427.
Khatony, A., Nayery, N., Ahmadi, F., Haghani, H., & Vehvilainen-Julkunen. (2009).
The effectiveness of web-based and face-to-face continuing education methods on
nurses’ knowledge about AIDS: A comparative study. BMC, 9(41), 1-7. doi: 10.1186/
1474-6920-9-41.
Khatib, R., Schwalm, J., Yusuf, S., Haynes, R., McKee, M., Khan, M., & Nieuwlaat, R.
(2014). Patient and healthcare provider barriers to hypertension awareness, treatment
and follow up: A systematic review and meta-analysis of qualitative and quantitative
studies. PLOS ONE, 9(1), 1-12. doi: 10.1371/journal.pone.0084238.
Kovell, L., Ahmed, H., Misra, S., Whelton, S., Prokopowicz, G., Blumenthal, R., &
McEvoy, J. (2015). US hypertension management guidelines: A review of the recent
past and recommendations for the future. Journal of the American Heart Association,
References
4, 1-11. doi: 10.1161/JAHA.115.002315.
Liaw, S., Wong, L., Chan, S., Ho, J., Mordiffi, S., Ang, S., Goh, P., & Ang, E. (2015).
Designing and evaluating an interactive multimedia web-based simulation for
developing nurses’ competencies in acute nursing care: randomized controlled trial.
Journal of Medical Internet Research, 17(1), 1-18. doi: http://dx.doi.org.proxyedinboro.klnpa.org/10.2196/jmir.3853.
Liaw, S., Chng, D., Wong, L., Ho, J., Mordiffi, S., Cooper, S., Chua, W., & Ang, E.
(2017). The impact of a web-based educational program on the recognition and
management of deteriorating patients. Journal of Clinical Nursing, 26, 4848-4856.
doi: 10.1111/jocn.13955.
Masuo, K. (2015). Treatments for hypertension in type 2 diabetes-non-pharmacological
and pharmacological measurements. Current Hypertension Reviews, 11(1), 61-77.
Mayoclinic. (2016). High blood pressure (hypertension). Retrieved from
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/symptomscauses/syc-20373410.
McAuley, E., Duncan, T., & Tammen, V. (1987). Psychometric properties of the Intrinsic
Motivation Inventory in a competitive sport setting: A confirmatory factor analysis.
Research Quarterly for Exercise and Sport, 60, 48-58.
Mensah, G. (2016). Hypertension and target organ damage: Don’t believe everything you
think! Ethnicity & Disease, 26(3), 275-278. doi: 10.18865/ed.26.3.275.
Mensah, G., Croft, J., & Giles, W. (2002). The heart, kidney, and brain as target organs in
hypertension. Cardiology Clinic, 20(2), 225-247.
Nader, S. (2015). Target organ damage in hypertension. In Nadar, S., & Lip, G. (Eds.),
References
Hypertension (2nd ed.). Oxford University Press.
Persu, A., O’Brien, E., & Verdecchia, P. (2014). Use of ambulatory blood pressure
measurement in the definition of resistant hypertension: A review of the evidence.
Hypertension Research, 37, 967-972. doi: 10.1038/hr.2014.83.
Pickering, T., Hall, J., Appel, L., Falkner, B., Graves, J., Hill, M., Jones, D., Kurtz, T.,
Sheps, S., & Roccella, E. (2005). Recommendations for blood pressure measurement
in humans: A statement for professionals from the subcommittee of professional and
public education of the American heart association council on high blood pressure
research. Hypertension, 45, 142-161. doi: 10.1161/01.HYP.0000150859.47929.8e.
Potter, M., & Wilson, C., (2017). Applying bureaucratic caring theory and the chronic
care model to improve staff and patient self-efficacy. Nursing Administration
Quarterly, 41(4), 310-320. doi: 10.1097/NAQ.0000000000000256.
Ryan, R., & Deci, E. (2000). Self-determination theory and the facilitation of intrinsic
motivation, social development, and well-being. American Psychologist, 55, 68-78.
Ryan, R., Koestner, R., Deci, E. (1991). Varied forms of persistence: When free-choice
behavior is not intrinsically motivated. Motivation and Emotion, 15, 185-205.
Schwartz, C., McManus, R. (2015). What is the evidence base for diagnosing
hypertension and for subsequent blood pressure treatment targets in the prevention
of cardiovascular diseases? BMC Medicine, 13, 1-9. doi: 10.1186/s12916-015-0502-5.
U.S. Preventive Services Task Force. (2015). Final recommendation statement: High
blood pressure in adults: Screening. Retrieved from
https://www.uspreventiveservicestaskforce.org/Page/Document/Recommendation
StatementFinal/high-blood-pressure-in-adults-screening.
References
Whelton, P., Carey, R., Aronow, W., Casey, D.,…Wright, J. (2017). 2017 ACC/AHA/…/
PCNA guideline for the prevention, detection, evaluation, and management of high
blood pressure in adults. Retrieved from
http://hyper.ahajournals.org/content/early/2017/11/10/HYP.0000000000000065.
Williams, G., & Deci, E. (1996). Internalization of biopsychosocial values by medical
students: A test of self-determination theory. Journal of Personality and Social
Psychology, 70, 767-779.
Williams, G., Freedman, Z., & Deci, E. (1998). Supporting autonomy to motivate glucose
control in patients with diabetes. Diabetes Care, 21, 1644-1651.
Yank, V., Laurent, D., Plant, K., & Lorig, K. (2013). Web-based self-management
support training for health professionals: A pilot study. Patient Education and
Counseling, 90(1), 29-37. doi: http://dx.doi.org/10.1016/j.pec.2012.09.003.
Yaxley, J., & Thambar, S. (2015). Resistant hypertension: An approach to management
in primary care. Journal of Family Medicine and Primary Care, 4(2), 193-199.
doi: 10.4103/2249-4863.154630.
Does a hypertension guideline assist providers with perceived
confidence with hypertension management in a retail setting?
Emmanuel Ekwere, MSN, FNP-C
Jill Rodgers, DNP, CRNP, FNP-BC, PMHNP-BC
Clarion and Edinboro Universities of Pennsylvania
BACKGROUND
• 1 in 3 American adults has
hypertension
• Only about half (54%) of
sufferers are controlled
• Most commonly diagnosed
condition in outpatient office
• Primary cause of death for over
362,000 Americans in 2010
• Called a “silent killer” since
there are no symptoms and so
sufferers see no need to control
it
• Major risk factor for heart
attack, heart failure, stroke,
chronic kidney disease and
other conditions
• Control slows down target organ
damage
REVIEW OF LITERATURE
• The current clinical practice
guideline in use is the JNC-8
Guideline of 2014
• Another relevant guideline is
the ACC/AHA Guideline of 2017
• Both guidelines emphasis as
the initial and concurrent
therapy for hypertension
control
• There are primary and
secondary hypertension-with
the later eliminating
hypertension once corrected
• Risk factors include race, age,
hereditary, unhealthy habits
(e.g. smoking, alcohol, drugs)
METHODS
• 1,290 MinuteClinic providers
received survey by email
• 82 providers responded and
completed the survey
• Providers are mostly NPs, Pas
and MDs working in different
states surrounding Pennsylvania
• First question was whether they
attended the webex sessions
• Next 10 questions were derived
from the two scales in the SelfDetermination Theory
• The 10 questions recorded the
confidence of providers on a 1
to 7 scale with “1” being not at
all true and “7” being very true
RESULTS
CONCLUSION
• Confidence scores between the
two groups of providers did have
any statistical significant difference
• Factors contributing to the lack of
significant difference between the
two groups of providers include –
effectiveness of webex education,
the commonality of hypertension
in the community and providers’
already acquired experience in
managing hypertension visits
before survey.
• Repeat of study with larger sample
size needed before generalization
• t-test were used to identify if
dependent variable scores (i.e.,
Provider Confidence) differed in the
two study groups
• Trained group was 44 (53.7%) and
Non-Trained group was 38 (46.3%)
• Statistical power of medium/large
size effect and Cronbach alfa of 0.93
• Provider confidence measures did
not have a statistically significant
difference between the Trained
group and Non-Trained group
(p=0.82)
guideline assist providers
with perceived confidence
with hypertension
management in a retail
setting?
Emmanuel Ekwere, MSN
Abstract
This study is evaluates the impact of webex hypertension (HTN) guideline training on providers’ confidence in
MinuteClinic’s (MC) hypertension HTN management visits.
Confidence scores of participant in the MC training/webex education sessions provided prior to the
commencement of HTN chronic care services were obtained via survey and compared with those providers who did
not participate in the education sessions.
T-test analysis showed no statistically significant difference between the Trained group and the Non-Trained
group.
Factors enabling the lack of significant difference between the two groups and suggestions for further studies are
discussed.
Introduction – Problem Description
HTN affects 30% of US adults (approx. 75million Americans)
Most common diagnosis at outpatient office visits
Major risk factor for heart attack, heart failure, CKD, and stroke
AKA “a silent killer” since no symptoms until target organs are damaged
Defined as having blood pressure ≥ 140/90 or taking antihypertensives
Contributing or primary cause of death for over 362,000 Americans in 2010
Treatable with lifestyle modifications and pharmacology therapy
Multiple factors cause HTN not to be controlled adequately
Provider-related factors and provider’s knowledge, attitudes or behaviors have been found to be
barriers to treatment adherence
This study evaluates whether education on HTN guidelines adherence assists with provider
confidence.
Introduction – Available knowledge
Clinical practice guidelines (CPG) defined by IOM in 2011 as recommendation
statements intended to optimize patient care
Formed from the systematic review of evidence, CPGs are standard of care
For HTN, existing CPGs include JNC-8 (released in 2014), and 2017 ACC/AHA
guidelines
MC’s HTN guidelines is formed from the amalgamation of both guidelines
Lifestyle modification is the first therapy; alone or in combination with pharmacology
Lifestyle modification includes weight loss, DASH diets, smoking cessation, sodium
reduction (to ≤2400mg/day), potassium supplementation (unless contraindicated),
optimum glucose and lipids control, increased physical activity, and moderate alcohol
consumption
Introduction-Available knowledge (contd.)
For pharmacologic intervention, both guidelines differ slightly in their
recommendations
While both JNC-8 and 2017 ACC/AHA recommend initiation of therapy for all adults
at B/P ≥140/90, 2017 ACC/AHA recommends therapy for high risk individuals at B/P
≥130/80, while JNC-8 does not.
Both guidelines recommend initiation of therapy with a thiazide-type diuretic or a
calcium-channel blockers alone or in combination for black patients.
Both guidelines also included recommendations for therapy adjustment, follow up
intervals, special populations, labs, etc.
Introduction-Available knowledge (contd.)
ABPM considered the best method for diagnosing HTN
HTN classified as essential and secondary – depending on causes
Risk factors include modifiable a non-modifiable
Non-modifiable risk factors include age, race, family history, and stress
Risk factors for secondary HTN include OSA, kidney problems, adrenal gland
problems, thyroid problems, congenital defects, medications, illegal drug and alcohol
abuse
Other factors affecting HTN include white coat syndrome, B/P measuring device, cuff
size, body position, arm position, interval between measurement, difference between
both arms, skill of measurer, silence, etc.
Introduction-Available knowledge (contd.)
Aims of HTN control is to reduce complications and slow target organ damage
Target organ damage results in stroke, vision loss, heart failure, heart attack, kidney
disease/failure, and sexual dysfunction
Barriers to HTN control exist at the providers’ level, patients’ level, and health systems
level
Web-based education use for educating nurses is increasing and associated with
participants showing improved knowledge, skill, changed beliefs and confidence
This study uses MC HTN guideline, which is a proprietary information that the
company does not want to share publicly
Introduction - Rationale
Chronic Care Model (CCM) is the theoretical framework used in this study
First published in Effective Clinical Practice in 1988 and edited by Ed Wagner
Designed to improved health outcome of chronic conditions
Focuses on optimizing team members knowledge, skills, education and expertise
toward improving HTN outcome for the patients
Introduction – Specific Aims
Aim is to see whether the adoption and education of providers increased confidence in
HTN management or not
Methods - Context
Participants were
MC’s providers working in retail settings across Pennsylvania, Maryland, Ohio, New Jersey, Virginia, Michigan, New York,
Connecticut, Washington, DC, Indiana and Kentucky.
Providers
were recruited via voluntary participation using MC’s email apparatus.
Participants were gThis study is a DNP project designed using provider’s response (to survey), MC’s hypertension guideline (a proprietary
document), and evidence-based education to ascertain provider’s confidence and competence in hypertension management.
iven
A
questionnaires, and their responses were analyzed.
total of 1,290 providers, who are mostly nurse practitioners, comprising of both males and females aged 18 and above, were sent emails, 82
responded and participated in the study.
An
inclusion criterion is that all participants are providers (NPs mostly, PAs and MDs) working for MC.
An
exclusion criterion is non-MC providers.
Methods - Interventions
The first intervention is to determine if the provider participant did or did not complete
the hypertension services pre-roll out online education via webex by MC
The
second intervention is to determine if there is a difference in provider’s perceived
confidence after completion of the MC hypertension education program versus those who
did not complete the MC hypertension training.
Methods – Study of the interventions
Survey consists of the first polar question and 10 questions which are derived from two
scales in the Self-Determination Theory
Written permission obtained to use the Self-Determination Theory scales for academic
purpose from the Center of Self-Determination Theory via email
Perceived Competence Scales (PCS), consists of four questions
Intrinsic motivation inventory (IMI) called Post-Experimental Intrinsic Motivation
Inventory (Perceived Competence Task Evaluation Questionnaire [PCTEQ]), consists
of the remaining six questions
Methods - Measures
First question is to indicate whether provider participated in the webex session
The next 10 questions was to rate the correct response on a scale of 1-7
With “1” being not at all true and “7” being very true
Methods - Analysis
Scores are calculated by averaging the responses on the 10 items questionnaire.
The last question (#11) was a reverse score
Mean, standard deviation, skewness, kurtosis and t-test analysis were used for the
statistical analysis
Methods – Ethical considerations
Edinboro University of Pennsylvania IRB approval obtained
Participants were protected by HIPAA and its modifications of 2013
Personal identifiers of participants not included
Response to survey was synonymous with consent which was attached
Participation totally voluntary
No conflict of interest and no payments to participants
Results
The
latest version of SPSS, (Statistical Package for the Social Sciences) version 25.0, a software used for
statistical analysis was used for this statistical analysis.
The
data analysis plan was conducted in two phases.
First
of all, study variables were presented using descriptive statistics, such as, means, standard deviation,
and minimum/maximum values for continuous variables (Interval/Ratio level) and frequencies and
percentages for categorical variables (Nominal/Ratio level).
Next,
a series of bivariate tests were used to produce inferential findings.
T-test
were used to identify if dependent variable scores (i.e., Provider Confidence) differed by study group
in terms of the overall composite measure, and by individual scale items.
Results (contd.)
T-test conducted with and without outlier scores revealed no difference in statistical
significance
Reliability analysis on the Total Provider Confidence Composite Scale indicated a very
good internal consistency with a Cronbach alpha rating of 0.93
Statistical power indicted this was a medium/large size effect
Sample size of 82 in the study was sufficient statistical power
Trained group was 44 (53.7%)and Non-Trained group was 38 (46.3%)
Provider confidence measures did not have a statistical significant difference between
the Trained group and the Non-Trained group (p=0.82)
Results (contd.)
Total Provider Confidence Composite Scale Scores (10-Items)
Variable
n
M (SD)
Trained Group
44
4.98 (1.17)
0.23 (80) 0.82
Non-Trained Group 38
5.04 (1.21)
0.23 (80) 0.82
t (df)
p
Discussion - Summary
Absence of a statistically significance difference between the trained group and nontrained group is a significant finding
Relevant to the effectiveness of webex education done
Existence of reasons as to why there was no significant difference
Discussion – Interpretation
Individual provider’s experience and training before MC’s HTN services is started
Generalization of the survey questions, instead of more specific questions
Factors that can increase the quality of webex needs looked into
A case for a bigger sample size
Discussion - Limitations
This study did not measure the barriers to HTN evaluation by providers
Providers’ competence in HTN management not measured
Previous experience of providers in managing HTN before webex
Generalization of findings not advised until repeated in a different setting
Relationship between provider’s confidence and patient’s outcome, not measured
Discussion - Conclusion
Confidence scores of the two groups of providers analyzed did not yield any statistical
significant difference
Patient are more likely to equate confident provider with competent provider, which
build trust and increase adherence to recommendations; however, the relationship
between provider confidence and patient’s outcome remains to be explored
Repeat of study with a larger sample size, measuring the prior experience in HTN care,
using specific survey questions, identifying and addressing possible barriers to webex
education are needed to be addressed before generalization of findings.
References
Alsolami, F., Hou, X., & Correa-Velez, I. (2012). Factors affecting antihypertensive
adherence: A Saudi Arabian perspective. Clinical Medicine and Diagnostics, 2(4),
27-32. doi: 10.5923/j.cmd.20120204.02.
American Heart Association. (2017). Health threats from high blood pressure. Retrieved
from
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/LearnHowHB
PHarmsYourHealth/Healt-Threats-From-Blood-Pressure_UCM_002051_Article.jsp
#.WktUkzdG1PY.
American Heart Association. (2017). Understanding blood pressure readings. Retrieved
from
http://www.heart.org/HEARTORG/Cconditions/HighBloodPressure/KnowYourNum
bers/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp#.WktXpTd
G1PY.
Centers for Disease Control and Prevention. (2017). High blood pressure. Retrieved from
https://www.cdc.gov/bloodpressure/index.htm.
Charles, L., Triscott, J., & Dobbs, B. (2017). Secondary hypertension: Discovering the
underlying cause. American Family Physician, 96(7), 453-461.
Cifu, A., & Davis, A. (2017). Prevention, detection, evaluation and management of high
blood pressure in adults. JAMA, 318(21), 2132-2134. doi: 10.1001/jama.2017.18706.
Deci, E., Eghrari, H., Patrick, B., & Leone, D. (1994). Facilitating internalization: The
self-determination theory perspective. Journal of Personality, 62, 119-142.
Glenn, C., & Taylor, J. (n.d.). JNC 8 hypertension guideline algorithm. Retrieved from
References
http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf.
Healthy People 2020. (2014). Heart disease and stroke. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke.
Hernandez-Vila, E. (2015). A review of the JNC 8 blood pressure guideline. Texas Heart
Institute Journal, 42(3), 226-228. doi: 10.14503/THIJ-15-5067.
Institute of Medicine. (2011). Clinical practice guidelines we can trust. Retrieved from
https://www.nap.edu/read/13058/chapter/1#ii.
James, P., Oparil, S., Carter, B., Cushman, W., Dennison-Himmelfarb, C., Handler, J.,
Lackland, D.,…Ortiz, E. (2014). 2014 evidence-based guideline for the management
of high blood pressure in adults: Report from the panel members appointed to the
eighth joint national committee (JNC 8). JAMA, 311(5), 507-520. doi: 10.1001/jama.
2013.284427.
Khatony, A., Nayery, N., Ahmadi, F., Haghani, H., & Vehvilainen-Julkunen. (2009).
The effectiveness of web-based and face-to-face continuing education methods on
nurses’ knowledge about AIDS: A comparative study. BMC, 9(41), 1-7. doi: 10.1186/
1474-6920-9-41.
Khatib, R., Schwalm, J., Yusuf, S., Haynes, R., McKee, M., Khan, M., & Nieuwlaat, R.
(2014). Patient and healthcare provider barriers to hypertension awareness, treatment
and follow up: A systematic review and meta-analysis of qualitative and quantitative
studies. PLOS ONE, 9(1), 1-12. doi: 10.1371/journal.pone.0084238.
Kovell, L., Ahmed, H., Misra, S., Whelton, S., Prokopowicz, G., Blumenthal, R., &
McEvoy, J. (2015). US hypertension management guidelines: A review of the recent
past and recommendations for the future. Journal of the American Heart Association,
References
4, 1-11. doi: 10.1161/JAHA.115.002315.
Liaw, S., Wong, L., Chan, S., Ho, J., Mordiffi, S., Ang, S., Goh, P., & Ang, E. (2015).
Designing and evaluating an interactive multimedia web-based simulation for
developing nurses’ competencies in acute nursing care: randomized controlled trial.
Journal of Medical Internet Research, 17(1), 1-18. doi: http://dx.doi.org.proxyedinboro.klnpa.org/10.2196/jmir.3853.
Liaw, S., Chng, D., Wong, L., Ho, J., Mordiffi, S., Cooper, S., Chua, W., & Ang, E.
(2017). The impact of a web-based educational program on the recognition and
management of deteriorating patients. Journal of Clinical Nursing, 26, 4848-4856.
doi: 10.1111/jocn.13955.
Masuo, K. (2015). Treatments for hypertension in type 2 diabetes-non-pharmacological
and pharmacological measurements. Current Hypertension Reviews, 11(1), 61-77.
Mayoclinic. (2016). High blood pressure (hypertension). Retrieved from
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/symptomscauses/syc-20373410.
McAuley, E., Duncan, T., & Tammen, V. (1987). Psychometric properties of the Intrinsic
Motivation Inventory in a competitive sport setting: A confirmatory factor analysis.
Research Quarterly for Exercise and Sport, 60, 48-58.
Mensah, G. (2016). Hypertension and target organ damage: Don’t believe everything you
think! Ethnicity & Disease, 26(3), 275-278. doi: 10.18865/ed.26.3.275.
Mensah, G., Croft, J., & Giles, W. (2002). The heart, kidney, and brain as target organs in
hypertension. Cardiology Clinic, 20(2), 225-247.
Nader, S. (2015). Target organ damage in hypertension. In Nadar, S., & Lip, G. (Eds.),
References
Hypertension (2nd ed.). Oxford University Press.
Persu, A., O’Brien, E., & Verdecchia, P. (2014). Use of ambulatory blood pressure
measurement in the definition of resistant hypertension: A review of the evidence.
Hypertension Research, 37, 967-972. doi: 10.1038/hr.2014.83.
Pickering, T., Hall, J., Appel, L., Falkner, B., Graves, J., Hill, M., Jones, D., Kurtz, T.,
Sheps, S., & Roccella, E. (2005). Recommendations for blood pressure measurement
in humans: A statement for professionals from the subcommittee of professional and
public education of the American heart association council on high blood pressure
research. Hypertension, 45, 142-161. doi: 10.1161/01.HYP.0000150859.47929.8e.
Potter, M., & Wilson, C., (2017). Applying bureaucratic caring theory and the chronic
care model to improve staff and patient self-efficacy. Nursing Administration
Quarterly, 41(4), 310-320. doi: 10.1097/NAQ.0000000000000256.
Ryan, R., & Deci, E. (2000). Self-determination theory and the facilitation of intrinsic
motivation, social development, and well-being. American Psychologist, 55, 68-78.
Ryan, R., Koestner, R., Deci, E. (1991). Varied forms of persistence: When free-choice
behavior is not intrinsically motivated. Motivation and Emotion, 15, 185-205.
Schwartz, C., McManus, R. (2015). What is the evidence base for diagnosing
hypertension and for subsequent blood pressure treatment targets in the prevention
of cardiovascular diseases? BMC Medicine, 13, 1-9. doi: 10.1186/s12916-015-0502-5.
U.S. Preventive Services Task Force. (2015). Final recommendation statement: High
blood pressure in adults: Screening. Retrieved from
https://www.uspreventiveservicestaskforce.org/Page/Document/Recommendation
StatementFinal/high-blood-pressure-in-adults-screening.
References
Whelton, P., Carey, R., Aronow, W., Casey, D.,…Wright, J. (2017). 2017 ACC/AHA/…/
PCNA guideline for the prevention, detection, evaluation, and management of high
blood pressure in adults. Retrieved from
http://hyper.ahajournals.org/content/early/2017/11/10/HYP.0000000000000065.
Williams, G., & Deci, E. (1996). Internalization of biopsychosocial values by medical
students: A test of self-determination theory. Journal of Personality and Social
Psychology, 70, 767-779.
Williams, G., Freedman, Z., & Deci, E. (1998). Supporting autonomy to motivate glucose
control in patients with diabetes. Diabetes Care, 21, 1644-1651.
Yank, V., Laurent, D., Plant, K., & Lorig, K. (2013). Web-based self-management
support training for health professionals: A pilot study. Patient Education and
Counseling, 90(1), 29-37. doi: http://dx.doi.org/10.1016/j.pec.2012.09.003.
Yaxley, J., & Thambar, S. (2015). Resistant hypertension: An approach to management
in primary care. Journal of Family Medicine and Primary Care, 4(2), 193-199.
doi: 10.4103/2249-4863.154630.
Does a hypertension guideline assist providers with perceived
confidence with hypertension management in a retail setting?
Emmanuel Ekwere, MSN, FNP-C
Jill Rodgers, DNP, CRNP, FNP-BC, PMHNP-BC
Clarion and Edinboro Universities of Pennsylvania
BACKGROUND
• 1 in 3 American adults has
hypertension
• Only about half (54%) of
sufferers are controlled
• Most commonly diagnosed
condition in outpatient office
• Primary cause of death for over
362,000 Americans in 2010
• Called a “silent killer” since
there are no symptoms and so
sufferers see no need to control
it
• Major risk factor for heart
attack, heart failure, stroke,
chronic kidney disease and
other conditions
• Control slows down target organ
damage
REVIEW OF LITERATURE
• The current clinical practice
guideline in use is the JNC-8
Guideline of 2014
• Another relevant guideline is
the ACC/AHA Guideline of 2017
• Both guidelines emphasis as
the initial and concurrent
therapy for hypertension
control
• There are primary and
secondary hypertension-with
the later eliminating
hypertension once corrected
• Risk factors include race, age,
hereditary, unhealthy habits
(e.g. smoking, alcohol, drugs)
METHODS
• 1,290 MinuteClinic providers
received survey by email
• 82 providers responded and
completed the survey
• Providers are mostly NPs, Pas
and MDs working in different
states surrounding Pennsylvania
• First question was whether they
attended the webex sessions
• Next 10 questions were derived
from the two scales in the SelfDetermination Theory
• The 10 questions recorded the
confidence of providers on a 1
to 7 scale with “1” being not at
all true and “7” being very true
RESULTS
CONCLUSION
• Confidence scores between the
two groups of providers did have
any statistical significant difference
• Factors contributing to the lack of
significant difference between the
two groups of providers include –
effectiveness of webex education,
the commonality of hypertension
in the community and providers’
already acquired experience in
managing hypertension visits
before survey.
• Repeat of study with larger sample
size needed before generalization
• t-test were used to identify if
dependent variable scores (i.e.,
Provider Confidence) differed in the
two study groups
• Trained group was 44 (53.7%) and
Non-Trained group was 38 (46.3%)
• Statistical power of medium/large
size effect and Cronbach alfa of 0.93
• Provider confidence measures did
not have a statistically significant
difference between the Trained
group and Non-Trained group
(p=0.82)