Original Article

Improving Hypertension and Diabetes Mellitus Control with a Dedicated Patient Navigator

Authors: Justin Marsden, MBA, Jingwen Zhang, MS, Chloe Bays, MPH, Samuel O. Schumann, MD, MSCR, Andrew D. Schreiner, MD, MSCR, Afifah Khan, MD, Patrick D. Mauldin, PhD, Kimberly S. Davis, MD, William P. Moran, MD, MS

Abstract

Objectives: Hypertension and diabetes mellitus (DM) are the leading causes of cardiovascular, cerebrovascular, and chronic kidney diseases. They affect an estimated 47% and 11% of Americans, respectively. In this study, we assessed whether a dedicated patient navigator embedded within a patient-centered medical home (PCMH) using a structured panel management and patient outreach strategy could improve blood pressure and glycemic control in primary care patients with uncontrolled hypertension and DM.

Methods: We performed a prospective study comparing blood pressure and glycemic control in primary care patients before and after implementation of a patient navigator executing a hypertension and DM-focused panel management plan.

Results: From January 2014 to October 2019, inclusion criteria were met 5164 times, which comprised 1958 unique patients within a PCMH. Multivariate regression analysis reveals a significant decrease in uncontrolled systolic blood pressure (SBP) over time, with an actual decrease of roughly 40% of uncontrolled episodes of SBP becoming controlled by 12 months. Multivariate regression analysis reveals a significant decrease in uncontrolled hemoglobin A1c (HbA1c) over time for each plot (P < 0.0001), with an actual decrease of roughly 30% of uncontrolled episodes of HbA1c becoming controlled by 12 months.

Conclusions: This study demonstrated the benefit of a dedicated patient navigator embedded within a PCMH on improving BP and glycemic control in primary care patients with uncontrolled hypertension and DM. Glycemic control was achieved, with 30% of episodes reaching an HbA1c of <8% and BP control achieved for 40% of episodes with SBP <140 mm Hg at 12 months. There were no differences by the social determinants of race and poverty.
Posted in: Endocrinology, Diabetes, and Metabolism40 Hypertension17

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