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Understanding the Quality Chasm for Hypertension Control in Diabetes: A Structured Review of "Co-maneuvers" Used in Clinical Trials

Houston Center for Quality of Care and Utilization Studies (ADN, TTI, RLS, MEK), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
South Central Mental Illness Research, Education, and Clinical Center (MEK), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
Sections of Health Services Research (ADN, TTI, RLS, MEK), Baylor College of Medicine, Houston, TX
Geriatrics (ADN), Baylor College of Medicine, Houston, TX
Diabetes and Endocrinology (ADN), Baylor College of Medicine, Houston, TX
Menninger Department of Psychiatry, Baylor College of Medicine, Houston, TX (MEK)
Department of Communication, Texas A&M University, College Station (RLS)

Correspondence: Corresponding author: Aanand D. Naik, MD, Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey Veterans Affairs Medical Center (152), 2002 Holcombe Blvd, Houston, TX 77030 (E-mail: anaik{at}bcm.tmc.edu)

Background: Observational studies routinely describe a significant gap between rates of blood pressure control in routine diabetes care compared with those achieved in randomized controlled trials (RCTs).

Methods: We performed a systematic review of the literature to identify co-maneuvers used in RCTs, defined as ancillary activities or agents administered before, during, or immediately after the main agent under investigation (ie, principal maneuver), but not effectively translated to routine diabetes care. We searched multiple databases for RCTs evaluating the efficacy of treatments for hypertension control in adults with type 2 diabetes mellitus. We considered only phase III human studies of interventions that achieved blood pressure control and scrutinized all elements related to the implementation of the principal maneuver in each candidate study. These elements were then sorted into a taxonomy of co-maneuvers.

Results: Nearly all eligible RCTs used highly consistent groups of co-maneuvers. These typically began with (1) the use of consensual and clearly stated blood pressure goals; (2) frequent visits in which blood pressure levels were measured and compared with predefined goals; and, if the goal was not attained, (3) modifications to the treatment based on a detailed action plan that included communication of adverse events. Patient education, feedback to clinicians, and interventions for medication adherence were not commonly used among eligible trials.

Conclusions: Clinicians should translate key behavioral co-maneuvers along with clinically proven treatments for hypertension control in diabetes. These co-maneuvers are conceptually similar to collaborative goal setting and action planning interventions used in innovative chronic care programs.

This article has been cited by other articles:

				A. D. Naik, M. A. Kallen, A. Walder, and R. L. Street Jr Improving Hypertension Control in Diabetes Mellitus: The Effects of Collaborative and Proactive Health Communication Circulation, March 18, 2008; 117(11): 1361 - 1368. [Abstract] [Full Text] [PDF]