Starting the Conversation on Hypertension Self-Management in Primary Care to Improve Cardiovascular Outcomes

Saturday, 29 July 2017

Jean Ann Davison, DNP, RN, FNP-BC
School of Nursing and School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA


Cardiovascular disease (CVD) – heart disease and strokes - caused one in three deaths in the USA in 2014 and The American Heart Association (AHA) projects that by 2030, 40.5% of the U.S. population will have some form of CVD, with an estimated cost to the national health care system of $1 trillion per year (Tomaselli, Harty, Horton, & Schoeberl, 2011). In 2012 the U.S. Department of Health and Human Services (HHS) launched the Million Hearts initiative, ( to prevent 1 million heart attacks and strokes in 5 years (2012-17). Strategies were directed at the leading modifiable risks for CVD to support improved outcomes in the "ABCS" - Aspirin for those at risk, Blood pressure control, Cholesterol control, Smoking cessation and Sodium reduction in the diet. The focus of this campaign is to empower Americans to make healthy lifestyle choices to reduce CVD risks and for healthcare providers to support their patients in these healthy lifestyles.

Hypertension (HTN) is the single most independent and modifiable risk factor for cardiovascular disease (CVD), stroke, congestive heart failure, and chronic renal disease (CRD) (Chobanian et al., 2003). The Million Hearts campaign set a clinical quality measure for blood pressure control goal at 70% in the clinical population with a diagnosis of hypertension; the measurement was defined as the “percentage of patients 18 to 85 years of age with a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year”. In the Southeast Region of the United States, it is currently reported by the Department of Health and Human Services (2016) that only 53% of the of the population has achieved the clinical control blood pressure (BP < 140/90) - a large gap from the 70% goal (, 2016).

The Centers for Disease Control and Prevention (CDC, 2013) Hypertension Control: Action Steps for Clinicians recommends to:

• Provide patients who have hypertension with a written self-management plan at the end of each office visit.
• Encourage or provide patient support groups.
• Use all staff interactions with patients as opportunities to assist in self-management goal-setting and practices.
• Print visit summaries and follow-up guidance for patients.


The aim of this nurse led quality improvement (QI) project was to improve the clinical performance in the management of hypertension (HTN) with a focus on self-management support (SMS) among adult patients (18-75 years) at a rural primary care clinic with an exceptionally high rate of cardiovascular disease. The six-month QI initiative was designed with a goal to have 80% or more of the adult patients with a diagnosis of HTN actively setting goals in collaboration with their providers for CVD risk reduction.

Data Sources and Implementation:

The study design was a six month long quality improvement study. Data included a retrospective baseline of meaningful use population data (N = 1210) generated six months prior to the QI study start date and an analysis of the data during the six-month QI study (N = 1409). Interventions included provider and staff quality improvement training along with patient education and lifestyle goal setting for self-management support (SMS) of HTN. All adult patients with a diagnosis of HTN or an elevated BP reading at their office visit were offered the brochures Starting the Conversation on Blood Pressure by the NC Prevention Partners(2011) and Start with Your Heart Prescription for Better Healthfrom the NC Department of Health and Human Services(2011) in English and Spanish. Questions were answered on hypertension and risk reduction by all health care providers throughout the office visit. Specific, Measurable, Attainable, Realistic and Time specific (SMART) goal setting and action plans were encouraged and a written self-management plan was given at the end of each office visit. Electronic medical record data was used to compile population statistics for blood pressure (BP), LDL cholesterol, tobacco use, body mass index, and self-management goals monthly throughout the QI study. Pre and post results of the QI six month period were compared.

The primary objective, > 80% of adults aged 18 to 75 years would have documented self-management goals, was achieved and significantly improved from baseline. SMART goals discussed included following the recommendations for the Dietary Approaches to Stop Hypertension (DASH) diet, aerobic physical activity, weight loss for healthy body mass index, tobacco cessation, moderate alcohol consumption, stress reduction, medication adherence, home BP monitoring, and, as applicable, blood sugar control. A secondary objective was to see significant improvement in controlled HTN (BP < 140/90) for this population, but this did not occur. A limitation of this QI study was the short length (six months) of observation time.

Implications for Practice:
The goal of this QI project to help patients in self-management support for modifiable risk reduction of HTN was achieved to help reduce the burden of CVD in this population. Nurses can have a vital role in meeting the current demand for HTN management in primary care, to support patients in their self-management. Working with patients to achieve healthy lifestyle CVD risk reductions and medication management could help reduce the burden of CVD at a population level.