Journal of General Internal Medicine

, Volume 27, Issue 6, pp 630–639 | Cite as

Nurse-led Disease Management for Hypertension Control in a Diverse Urban Community: a Randomized Trial

  • Paul L. HebertEmail author
  • Jane E. Sisk
  • Leah Tuzzio
  • Jodi M. Casabianca
  • Velvie A. Pogue
  • Jason J. Wang
  • Yingchun Chen
  • Christine Cowles
  • Mary Ann McLaughlin
Original Research



Treated but uncontrolled hypertension is highly prevalent in African American and Hispanic communities.


To test the effectiveness on blood pressure of home blood pressure monitors alone or in combination with follow-up by a nurse manager.


Randomized controlled effectiveness trial.


Four hundred and sixteen African American or Hispanic patients with a history of uncontrolled hypertension. Patients with blood pressure ≥150/95, or ≥140/85 for patients with diabetes or renal disease, at enrollment were recruited from one community clinic and four hospital outpatient clinics in East and Central Harlem, New York City.


Patients were randomized to receive usual care or a home blood pressure monitor plus one in-person counseling session and 9 months of telephone follow-up with a registered nurse. During the trial, the home monitor alone arm was added.


Change in systolic and diastolic blood pressure at 9 and 18 months.


Changes from baseline to 9 months in systolic blood pressure relative to usual care was −7.0 mm Hg (Confidence Interval [CI], -13.4 to −0.6) in the nurse management plus home blood pressure monitor arm, and +1.1 mm Hg (95% CI, -5.5 to 7.8) in the home blood pressure monitor only arm. No statistically significant differences in systolic blood pressure were observed among treatment arms at 18 months. No statistically significant improvements in diastolic blood pressure were found across treatment arms at 9 or 18 months. Changes in prescribing practices did not explain the decrease in blood pressure in the nurse management arm.


A nurse management intervention combining an in-person visit, periodic phone calls, and home blood pressure monitoring over 9 months was associated with a statistically significant reduction in systolic, but not diastolic, blood pressure compared to usual care in a high risk population. Home blood pressure monitoring alone was no more effective than usual care.


hypertension randomized trial minority nurse management home blood pressure monitor 



This work was conducted while Dr. Hebert was Assistant Professor at Mount Sinai School of Medicine, Department of Health Policy. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.




Agency for Healthcare Research and Quality (5P01HS010859-050001), and National Institutes of Health National Center for Minority Health and Health Disparities (1P60MD000270-01).

Prior Presentations

Academy Health Annual Research Meeting, June 2007.

Conflicts of Interest

None disclosed


  1. 1.
    Cutler JA, Sorlie PD, Wolz M, Thom T, Fields LE, Roccella EJ. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988–1994 and 1999–2004. Hypertension. 2008;52(5):818–827.PubMedCrossRefGoogle Scholar
  2. 2.
    Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347(20):1585–1592.PubMedCrossRefGoogle Scholar
  3. 3.
    Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997;336(16):1117–1124.PubMedCrossRefGoogle Scholar
  4. 4.
    Maruthur NM, Wang N-Y, Appel LJ. Lifestyle interventions reduce coronary heart disease risk: results from the PREMIER Trial. Circulation. 2009;119(15):2026–2031.PubMedCrossRefGoogle Scholar
  5. 5.
    Elmer PJ, Grimm R, Laing B, et al. Lifestyle intervention: results of the treatment of mild hypertension study (TOMHS). Prev Med. 1995;24(4):378–388.PubMedCrossRefGoogle Scholar
  6. 6.
    Chobanian AV. The hypertension paradox – more uncontrolled disease despite improved therapy. N Engl J Med. 2009;361(9):878–887.PubMedCrossRefGoogle Scholar
  7. 7.
    Ostchega Y, Yoon S, Hughes J, Louis T. Hypertension awareness, treatment, and control -- continued disparities in adults: United States, 2005–2006. NCHS data brief no Hyattsville, MD: National Center for Health Statistics. 2008. 2008.Google Scholar
  8. 8.
    Coly G, Kotchen JM, Grim CE, et al. Characteristics of inner-city African-Americans with uncontrolled hypertension. J Am Soc Hypertens. 2(5):366–371.Google Scholar
  9. 9.
    Horowitz C, Tuzzio L, Rojas M, Monteith S, Sisk J. How do urban African Americans and Latinos view the influence of diet on hypertension? J Health Care Poor Underserved. 2004;15(4):631–644.PubMedCrossRefGoogle Scholar
  10. 10.
    Bopp M, Wilcox S, Laken M, et al. Factors associated with physical activity among African-American men and women. Am J Prev Med. 2006;30(4):340–346.PubMedCrossRefGoogle Scholar
  11. 11.
    Bosworth HB, Dudley T, Olsen MK, et al. Racial differences in blood pressure control: potential explanatory factors. Am J Med. 2006;11(1):70.e79–70.e15.Google Scholar
  12. 12.
    Shea S, Misra D, Ehrlich M, Field L, Francis C. Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population. N Engl J Med. 1992;327(11):776–781.PubMedCrossRefGoogle Scholar
  13. 13.
    Hyman DJ, Pavlik VN. Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine. Arch Intern Med. 2000;160(15):2281–2286.PubMedCrossRefGoogle Scholar
  14. 14.
    Oliveria SA, Lapuerta P, McCarthy BD, L’Italien GJ, Berlowitz DR, Asch SM. Physician-related barriers to the effective management of uncontrolled hypertension. Arch Intern Med. 2002;162(4):413–420.PubMedCrossRefGoogle Scholar
  15. 15.
    Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med. 1998;339(27):1957–1963.PubMedCrossRefGoogle Scholar
  16. 16.
    Phillips LS, Twombly JG. It’s time to overcome clinical inertia. Ann Intern Med. 2008;148(10):783–785.PubMedGoogle Scholar
  17. 17.
    Goldstein C, Hebert P, Sisk J, McLaughlin M, Horowitz C, McGinn T. Hypertension management in minority communities: a clinician survey. J Gen Intern Med. 2008;23(1):81–86.PubMedCrossRefGoogle Scholar
  18. 18.
    Fahey T, Schroeder K, Ebrahim S, Glynn L. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. 2006;4.Google Scholar
  19. 19.
    Chodosh J, Morton SC, Mojica W, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med. 2005;143(6):427–438.PubMedGoogle Scholar
  20. 20.
    Walsh JME, McDonald KM, Shojania KG, et al. Quality improvement strategies for hypertension management: a systematic review. Med Care. 2006;44(7):646–657.PubMedCrossRefGoogle Scholar
  21. 21.
    Cooper LA, Hill MN, Powe NR. Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med. 2002;17:477–486.PubMedCrossRefGoogle Scholar
  22. 22.
    O’Brien E, Waeber B, Parati G, Staessen J, Myers MG. Blood pressure measuring devices: recommendations of the European Society of Hypertension. BMJ. 2001;322(7285):531–536.PubMedCrossRefGoogle Scholar
  23. 23.
    Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Correlates of nonadherence to hypertension treatment in an inner-city minority population. Am J Public Health. 1992;82(12):1607–1612.PubMedCrossRefGoogle Scholar
  24. 24.
    Kim MT, Hill MN, Bone LR, Levine DM. Development and testing of the hill-bone compliance to high blood pressure therapy scale. Prog Cardiovasc Nurs. 2000;15(3):90–96.PubMedCrossRefGoogle Scholar
  25. 25.
    Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Counsel. 1999;38(1):33–42.CrossRefGoogle Scholar
  26. 26.
    van Buuren S, Boshuizen HC, Knook DL. Multiple imputation of missing blood pressure covariates in survival analysis. Stat Med. 1999;18(6):681–694.PubMedCrossRefGoogle Scholar
  27. 27.
    StataCorp. Stata Statistical Software: Release 10.0. College Station, TX: StataCorp LP; 2005.Google Scholar
  28. 28.
    Law M, Wald N, Morris J. Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy. Health Technol Assess. 2003;7:31.Google Scholar
  29. 29.
    Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Collaboration. PS. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349):1903–1913.PubMedCrossRefGoogle Scholar
  30. 30.
    Cappuccio FP, Kerry SM, Forbes L, Donald A. Blood pressure control by home monitoring: meta-analysis of randomised trials. BMJ. 2004;329(7458):145-.PubMedCrossRefGoogle Scholar
  31. 31.
    Bosworth HB, Olsen MK, Grubber JM, et al. Two Self-management Interventions to Improve Hypertension Control. Ann Int Med. 2009.Google Scholar
  32. 32.
    Green BB, Cook AJ, Ralston JD, et al. Effectiveness of home blood pressure monitoring, web communication, and pharmacist care on hypertension control: a randomized controlled trial. JAMA. 2008;299(24):2857–2867.PubMedCrossRefGoogle Scholar
  33. 33.
    Hill MN, Han H-R, Dennison CR, et al. Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months. Am J Hypertens. 2003;16(11):906–913.PubMedCrossRefGoogle Scholar
  34. 34.
    Sisk JE, Hebert PL, Horowitz CR, McLaughlin MA, Wang JJ, Chassin MR. Effects of nurse management on the quality of heart failure care in minority communities: a randomized trial. Ann Intern Med. 2006;145(4):273–283.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Paul L. Hebert
    • 1
    • 8
    Email author
  • Jane E. Sisk
    • 2
  • Leah Tuzzio
    • 3
  • Jodi M. Casabianca
    • 4
  • Velvie A. Pogue
    • 5
  • Jason J. Wang
    • 2
  • Yingchun Chen
    • 2
  • Christine Cowles
    • 6
  • Mary Ann McLaughlin
    • 7
  1. 1.Department of Health ServicesUniversity of Washington School of Public HealthWashingtonUSA
  2. 2.Department of Health Evidence and PolicyMount Sinai School of MedicineNew YorkUSA
  3. 3.Group Health Research InstituteSeattleUSA
  4. 4.Department of PsychologyFordham UniversityNew YorkUSA
  5. 5.Department of Medicine, Division of NephrologyHarlem Hospital CenterNew YorkUSA
  6. 6.Abt SRBINew YorkUSA
  7. 7.Department of Medicine, Division of CardiologyMount Sinai School of MedicineNew YorkUSA
  8. 8.Veterans Administration Health Services Research and DevelopmentPuget Sound Medical CenterSeattleUSA

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