Interactive Spaced Education to Optimize Hypertension Management

Anticipated Impacts on Veterans' Healthcare: This study aims to demonstrate that online
interactive spaced education (ISE) can improve providers' care of patients with hypertension.
ISE is the type of intervention that can be deployed across the VHA with content tailored to
meet specific needs and can be implemented as a tool to improve performance measures and
clinical outcomes.

Project Background/Rationale: ISE is a novel educational methodology based on the "spacing
effect", the psychological finding that repeated presentations of educational material over
spaced intervals increase learning efficiency and improve knowledge retention. ISE is
delivered using periodic emails that contain clinical case scenarios and multiple-choice
questions. We recently completed a randomized trial involving 95 VISN 1 primary care
providers (PCPs) which demonstrated that an ISE intervention can significantly improve
clinician's practice patterns. Those clinicians randomized to the ISE intervention on
prostate cancer screening demonstrated a 26% relative reduction in inappropriate screening.

Project Objectives: Lowering blood pressure in hypertensive patients unequivocally decreases
the incidence of stroke and cardiovascular events and is highly cost-effective. The majority
of patients with blood pressure above the treatment target do not have their
anti-hypertensive medications appropriately intensified at clinician visits. A reduced
frequency of treatment intensification is alternatively termed 'clinical inertia'. Our
preliminary results show that clinicians' knowledge of hypertension management guidelines is
limited, and few clinicians report following the guidelines consistently. We propose to
conduct a randomized controlled trial involving PCPs in VISN 1 to determine whether ISE can
(1) increase knowledge of the appropriate treatment of hypertensive patients, (2) reduce
clinical inertia in hypertension management, and (3) improve the blood pressure control in
hypertensive patients.

Project Methods: One hundred six VISN 1 primary care practitioners (physicians, nurse
practitioners, and physician assistants) will be recruited via email to participate in the
study. Participants will be randomized to one of two cohorts: (1) the intervention cohort
will receive ISE over year 1, and (2) the control cohort will receive no intervention and
will represent the "standard of education" on hypertension management. The ISE intervention
will consist of an email every 4 days containing 1 multiple-choice questions based on a
curriculum derived from clinical practice guidelines on appropriate hypertension management.
Providers will submit answers to the questions online and immediately receive the correct
answer and an explanation of the pertinent clinical issues. Using a new adaptive methodology,
the spacing and content of the educational intervention will be individualized for each
clinician based on their performance. The ISE intervention will be completed in 9-11 months.
Hypertension knowledge will be assessed by a post-test at the end of year 1. Providers'
clinical inertia and the blood pressures of their patients will be assessed over 2 years:
initial changes attributable to ISE will be identified in year 1, while the retention of
these changes will be monitored in year 2. Drawing on the interdisciplinary expertise of our
investigator team, the study is positioned to enrich national debates about how best to
improve the ways in which clinicians can meet their lifelong learning needs.

Inclusion Criteria:

- VA VISN 1 primary care clinicians (MD, NP, PA) who have at least a 50% (4/8 time)
clinical appointment.

Exclusion Criteria:

- VA VISN 1 primary care clinicians (MD, NP, PA) who do not have at least a 50% (4/8
time) clinical appointment.