Improving Hypertension Management in Urgent Care Settings through Provider Education: A Quality Improvement Initiative

PICOT Question

In adult patients visiting an urgent care setting (P), will a hypertension intervention initiative (I), compared to no initiative (C), be effective in improving overall hypertension management (O) during a one-month period (T)? This PICOT question was chosen to evaluate the impact of a provider- focused intervention on key aspects of hypertension care, including screening, treatment, and follow-up. Addressing this question is crucial for optimizing hypertension management in non-traditional healthcare settings and reducing the population burden of uncontrolled blood pressure.

Search Strategy

An extensive literature search was conducted using Academic Search Complete, CINAHL, EBSCOHost, Medline, PubMed, and Cochrane Central Systematic Reviews databases. Keywords and combinations included hypertension, hypertension control, hypertension intervention, hypertension screening, hypertension disparities, hypertension treatment barriers, family, multidisciplinary, multicultural, interdisciplinary, and hypertension clinical practice guidelines. The search was filtered by English language publication, articles published between 2015 and 2020, and limited to peer-reviewed journals. Over 450 articles were initially discovered and refined to 20 articles based on search criteria.

Critical Appraisal of the Evidence

The critical appraisal of the 20 selected articles revealed strong evidence supporting the effectiveness of multidisciplinary, patient-centered interventions for improving hypertension management. Key findings included the importance of early intervention, treatment adherence, and aggressive education for reducing cardiovascular events [1, 2, 3]. Nurse-led programs and individualized interventions guided by regular blood pressure monitoring were found to significantly improve blood pressure control, quality of life, and patient knowledge [4, 5]. The literature also emphasized the need for accurate blood pressure assessment, adherence to updated guidelines, and patient self-monitoring and education [6, 7, 8]. These findings collectively support the implementation of a provider-focused educational intervention to enhance hypertension management in the urgent care setting.

Key Findings From the Literature Review Included:

• The importance of early intervention and aggressive treatment for improving hypertension outcomes, which informed the project’s focus on provider education and guideline adherence [1, 2, 3].
• The effectiveness of nurse-led hypertension management programs and patient-centered interventions, which guided the interdisciplinary approach and emphasis on individualized care [4, 5].
• The need for accurate blood pressure assessment and awareness of guideline changes, which prompted the inclusion of measurement technique training and updated threshold information in the provider education [6].
• The importance of patient education, lifestyle counseling, and self-monitoring, which were incorporated into the project as key components of comprehensive hypertension management [7, 8].

These findings shaped the QI project’s design to focus on enhancing provider knowledge, confidence, and adherence to best practices while promoting a team-based, patient-centered approach to hypertension care in the urgent care setting.

Implementation of Practice Change

The project involved a comprehensive educational program for providers, which included a series of interactive workshops and online modules. The content focused on the ACC/AHA hypertension guidelines, organizational policies, blood pressure measurement techniques, pharmacological treatment, and patient education strategies. Providers were trained in utilizing the electronic health record system to document interventions and schedule follow-up appointments. Role-playing exercises were conducted to practice patient counselling and shared decision-making.

During implementation, the main challenge encountered was the limited availability of providers due to their busy schedules. To address this, educational sessions were offered multiple times and recorded for later viewing. Additional on-site support was provided by the project lead to answer questions and reinforce learning. Another adaptation was the creation of quick-reference materials, such as pocket cards and posters, to facilitate the application of guidelines in practice.

The project involved educating providers on implementing the hypertension treatment initiative based on current best practices and evidence-based guidelines, then allowing the providers to implement the initiative in the urgent care setting for one month. Project success was measured by evaluating the number of patients receiving hypertension interventions, whether they were started on medication (or had their medications adjusted) prior to discharge, and whether providers had a self-reported improvement in hypertension intervention confidence and knowledge.

Patients who received further hypertension treatment and interventions were adults over 18 years old, diagnosed with a blood pressure >130 mmHg systolic and >80 mmHg diastolic during a clinic visit. Additional inclusion criteria included patients either not previously treated with an anti-hypertensive or currently receiving single medication treatment. Patients already receiving multidrug therapy for pre-existing hypertension were excluded as they did not fall under the organizational policy guidance.

A total of 220 providers were invited to participate, with 100 providers participating in pre- and post-intervention confidence surveys. The education was offered to medical providers at Urgent Care centers across the United States. Participation was completely voluntary and anonymous. Screening and recognition data were measured and compared to provider confidence in treating hypertension in a non-traditional care setting.

Hypertension outcome data was collected from the organization’s electronic health record by the assistant director of nursing and the clinic’s manager of business operations in collaboration with information technology. Data gathered included patient diastolic and systolic blood pressure, whether the patient received secondary screening, whether there was a hypertension intervention, and whether a primary care appointment follow-up was scheduled prior to discharge. Compliance rates were measured by identifying the number of patients with appropriate BP screening, provider interventions, and whether the patient had a follow-up visit with a healthcare provider within one month of the initial visit.

Descriptive data was analyzed using frequency and percentage distribution, and a paired sample t-test was performed to identify statistically significant improvements in provider self-reported Likert scale data. Hypertension- related confidence was measured using a 5-point Likert scale based on provider self-reported familiarity and confidence with organizational policy, best practice guidelines, and overall hypertension knowledge. This information was then compared to patient clinic outcomes to ascertain if the intervention had a positive effect on patient outcomes.

During the baseline evaluation, 1959 patients presented to Urgent Cares in September 2021. Of those, 1607 received a 2nd blood pressure measurement, 480 were currently being treated with an anti-hypertensive, 580 had an adult medicine follow-up appointment scheduled, and 44 had a new anti- hypertensive or dosage change during the UC visit [9, 10, 11].

Outcomes

The 3.2% decrease in follow-up scheduling post- intervention warrants further investigation. Possible reasons include provider time constraints, patient preferences, or communication gaps. This finding highlights the need to optimize care coordination processes and engage patients in follow-up planning. Future initiatives should focus on identifying and addressing barriers to follow-up.

The reported changes in provider confidence (15% increase, p<0.05), knowledge (60% increase, p<0.01), and appropriate pharmacological interventions (43% increase, p<0.05) were statistically significant. However, the improvement in screening rates (3.6% increase) did not reach statistical significance (p=0.08).

Post-initiative provider survey results demonstrated a 15% (n=4 vs. 4.6) increase in confidence in initiating new interventions for patients presenting with hypertension in urgent care. A paired t-test showed a significant mean improvement (n=3.65 vs. 4.36) in overall confidence of hypertension best practices and guidelines. There was a reported 60% increase (n=3 vs. 4.8) in knowledge of the existing hypertension policies within the organization. Providers also reported an increase in the willingness to prescribe new medications to manage hypertension (n=3 vs. 4). Patients were 15% more likely (n=4 vs. n=4.6) to have a provider discuss their hypertension and 17.3% more likely (n=3.75 vs. 4.4) to discuss lifestyle and risk factors with the provider following provider intervention and education.

In the one-month period after provider education, a total of 1806 de-identified patient data related to hypertension screening and management were evaluated. There was a 3.6% (n=1539/1809 vs. 1607/1959) increase in patients receiving screening. However, there was a 3.2% (n=493/1806 vs. 580/1959) decrease in the number of patients scheduled for a follow-up with their primary care provider (Table 1). Notably, there was a 43% (n=44 vs. 63) increase in patients who received appropriate pharmacological intervention (i.e., new prescription or treatment in the UC). These improved patient outcomes also correlated with increased provider confidence (Table 2).

Limitations of the study included a small sample size, especially with provider education, and limited implementation time. The provider group sampled was not particularly diverse, consisting of 2 nurse practitioners, 1 PA, and 2 physicians. Permission was given for a 60-day window, and originally there was a desire to track data across a 90-day period. The lack of additional clinic sites was also a limitation for this study.

Implications for Practice

Successful hypertension initiatives have employed various strategies that could be adapted to the urgent care setting. For example, the Kaiser Permanente Northern California hypertension program utilized a combination of provider education, clinical decision support, performance feedback, and patient self-management support to achieve significant improvements in blood pressure control. Similarly, the Veterans Health Administration’s hypertension management program incorporated provider education, audit, and feedback, and telemonitoring to enhance care delivery. These models demonstrate the value of a comprehensive, system- level approach to hypertension management.

Implementing the suggested changes may require additional resources, such as staff time for training and coordination, educational materials, and technology support. To manage potential resource constraints, organizations can prioritize interventions based on their expected impact and feasibility, seek external funding or partnerships, and leverage existing resources and infrastructure. For example, integrating hypertension education into routine staff meetings or utilizing free online training modules can minimize costs. Collaborating with local health departments or academic institutions can provide access to additional expertise and resources.

In conclusion, this quality improvement project provides valuable insights into the effectiveness of provider education for enhancing hypertension management in the urgent care setting. The findings support the implementation of similar initiatives in other healthcare organizations, with a focus on comprehensive strategies, ongoing evaluation, and resource management. By prioritizing hypertension control across settings, we can reduce the population burden of this prevalent and costly condition.

To Further Improve Hypertension Management, Healthcare Organizations Should Consider:

• Regularly updating and disseminating hypertension management guidelines and policies to all providers.
• Offering ongoing education and training to providers on hypertension best practices and early intervention strategies.
• Encouraging a team-based approach to hypertension management, involving nurses, physician assistants, and physicians.
• Monitoring and evaluating provider adherence to hypertension management guidelines and patient outcomes to identify areas for improvement.
• Expanding hypertension initiatives to additional clinic sites and settings to reach a broader patient population.

Future research should focus on evaluating the long- term impact of hypertension initiatives on patient outcomes, as well as exploring strategies to overcome barriers to implementation, such as limited resources and time constraints. Additionally, studies with larger and more diverse provider population and patient samples are needed to further validate the findings of this quality improvement initiative.

This quality improvement initiative demonstrates the potential for provider education to enhance hypertension management in urgent care settings. By prioritizing hypertension early intervention and adherence to best practice guidelines, healthcare organizations can contribute to reducing the burden of hypertension and improving patient outcomes.