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.

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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)