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A Randomized Controlled Trial of an Automated Telephone Intervention to Improve Blood Pressure Control Teresa N. Harrison, SM; 1 Timothy S. Ho, MD; 2 Joel Handler, MD; 3 Michael H. Kanter, MD; 4 Ruthie A. Goldberg, MHA; 5 Kristi Reynolds, PhD, MPH 1 From the Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA; 1 Complete Care, Orange County Medical Center, Kaiser Permanente Southern California, Irvine, CA; 2 Kaiser Permanente Care Management Institute Hypertension Lead, Orange County Medical Center, Kaiser Permanente Southern California, Anaheim, CA; 3 Quality & Clinical Analysis, Kaiser Permanente Southern California, Pasadena, CA; 4 and Department of Clinical Operations, Regional Outreach & Care Support, Kaiser Permanente Southern California, Pasadena, CA 5 The objective of this study was to evaluate the effectiveness of a telephonic outreach program to improve blood pressure (BP) control among patients with hypertension. The authors identified adults 18 years and older with uncontrolled BP within the previous 12 months. Patients received either an automated telephone call advising them to have a walk-in BP check (n=31,619) or usual care (n=33,154). The primary outcome was BP control at 4 weeks. Significantly more patients who received the intervention achieved BP control compared with the usual care group (32.5% vs 23.7%; P<.0001). Patients in the intervention arm with cardiovascular disease, chronic kid- ney disease, or diabetes mellitus achieved better BP control. Older age, female sex, and having a household income above the median were associated with BP control. When designing quality-improvement interventions to increase BP control rates, health care organizations should consider utilizing an automated telephone outreach cam- paign. J Clin Hypertens (Greenwich). 2013;15:650–654. ª2013 Wiley Periodicals, Inc. Hypertension is a significant public health challenge in the United States, with a prevalence of 29% among adults 18 years and older in 20072008. 1 The extent of this problem is likely to increase as the US population ages. Hypertension is associated with coronary artery disease, renal failure, and stroke and is a significant risk factor for diabetes-related complications. Although 82% of US adults with hypertension are aware of their condition, only 53% have their hypertension under control. 2 If blood pressure (BP) control was improved, morbidity and mortality from hypertension would decrease substantially. 2,3 Uncontrolled hypertension is often asymptomatic; therefore, people often do not solicit help from their health care provider to control their hypertension. Changes in care management may be effective in improving BP control. Glynn and colleagues conducted a meta-analysis of randomized controlled trials that evaluated different models of care aimed at achieving BP goals and the effectiveness of reminders on clinic attendance among patients with hypertension. 4 The most effective approach to BP control involved multiple organizational interventions; however, the positive results were not sustained over the long-term. The majority of trials in the meta-analysis that assessed appointment reminder systems (via telephone or post- card) showed an improvement in patient follow-up visits, with two studies resulting in improved BP control. 4 Although appointment reminder systems may be effective, less time- and resource-intensive methods may improve BP control rates with greater efficiency. A practical strategy for hypertension control would facilitate patients having regular, walk-in clinic visits for BP monitoring using a simple intervention. Automated telephone outreach to individuals with hypertension may be a relatively effective approach in addressing BP control in a large population. The objective of this study was to evaluate the effectiveness of a large-scale telephonic outreach program to improve BP control among individuals with hypertension. METHODS Setting This study was conducted at Kaiser Permanente South- ern California (KPSC), an integrated health delivery system that provides comprehensive care to more than 3.5 million members at 14 medical centers and nearly 200 medical offices. Members of KPSC are socioeconomically diverse and broadly representative of the general population of Southern California. 5 KPSC’s institutional review board approved the study. Informed consent was waived. Study Population All adult members of KPSC with hypertension were potentially eligible for the study. Members with diag- nosed hypertension were identified by inpatient and outpatient International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes (Table I). The accuracy of ICD-9 coding was Address for correspondence: Kristi Reynolds, PhD, MPH, Department of Research & Evaluation, Kaiser Permanente Southern California, 100 South Los Robles, 2nd Floor, Pasadena, CA 91101 E-mail: [email protected] Manuscript received: April 1, 2013; revised: May 22, 2013; accepted: May 27, 2013 DOI: 10.1111/jch.12162 650 The Journal of Clinical Hypertension Vol 15 | No 9 | September 2013 Official Journal of the American Society of Hypertension, Inc. ORIGINAL PAPER

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Page 1: A Randomized Controlled Trial of an Automated Telephone Intervention to Improve Blood Pressure Control

A Randomized Controlled Trial of an Automated Telephone Interventionto Improve Blood Pressure Control

Teresa N. Harrison, SM;1 Timothy S. Ho, MD;2 Joel Handler, MD;3 Michael H. Kanter, MD;4 Ruthie A. Goldberg, MHA;5

Kristi Reynolds, PhD, MPH1

From the Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA;1 Complete Care, Orange County Medical

Center, Kaiser Permanente Southern California, Irvine, CA;2 Kaiser Permanente Care Management Institute Hypertension Lead, Orange County

Medical Center, Kaiser Permanente Southern California, Anaheim, CA;3 Quality & Clinical Analysis, Kaiser Permanente Southern California,

Pasadena, CA;4 and Department of Clinical Operations, Regional Outreach & Care Support, Kaiser Permanente Southern California, Pasadena, CA5

The objective of this study was to evaluate the effectivenessof a telephonic outreach program to improve bloodpressure (BP) control among patients with hypertension.The authors identified adults 18 years and older withuncontrolled BP within the previous 12 months. Patientsreceived either an automated telephone call advising themto have a walk-in BP check (n=31,619) or usual care(n=33,154). The primary outcome was BP control at4 weeks. Significantly more patients who received theintervention achieved BP control compared with the usual

care group (32.5% vs 23.7%; P<.0001). Patients in theintervention arm with cardiovascular disease, chronic kid-ney disease, or diabetes mellitus achieved better BPcontrol. Older age, female sex, and having a householdincome above the median were associated with BP control.When designing quality-improvement interventions toincrease BP control rates, health care organizations shouldconsider utilizing an automated telephone outreach cam-paign. J Clin Hypertens (Greenwich). 2013;15:650–654.ª2013 Wiley Periodicals, Inc.

Hypertension is a significant public health challenge inthe United States, with a prevalence of 29% amongadults 18 years and older in 2007–2008.1 The extent ofthis problem is likely to increase as the US populationages. Hypertension is associated with coronary arterydisease, renal failure, and stroke and is a significant riskfactor for diabetes-related complications. Although82% of US adults with hypertension are aware of theircondition, only 53% have their hypertension undercontrol.2 If blood pressure (BP) control was improved,morbidity and mortality from hypertension woulddecrease substantially.2,3

Uncontrolled hypertension is often asymptomatic;therefore, people often do not solicit help from theirhealth care provider to control their hypertension.Changes in care management may be effective inimproving BP control. Glynn and colleagues conducteda meta-analysis of randomized controlled trials thatevaluated different models of care aimed at achieving BPgoals and the effectiveness of reminders on clinicattendance among patients with hypertension.4 Themost effective approach to BP control involved multipleorganizational interventions; however, the positiveresults were not sustained over the long-term. Themajority of trials in the meta-analysis that assessedappointment reminder systems (via telephone or post-card) showed an improvement in patient follow-up

visits, with two studies resulting in improved BPcontrol.4 Although appointment reminder systems maybe effective, less time- and resource-intensive methodsmay improve BP control rates with greater efficiency.

A practical strategy for hypertension control wouldfacilitate patients having regular, walk-in clinic visits forBP monitoring using a simple intervention. Automatedtelephone outreach to individuals with hypertensionmay be a relatively effective approach in addressing BPcontrol in a large population. The objective of this studywas to evaluate the effectiveness of a large-scaletelephonic outreach program to improve BP controlamong individuals with hypertension.

METHODS

SettingThis study was conducted at Kaiser Permanente South-ern California (KPSC), an integrated health deliverysystem that provides comprehensive care to morethan 3.5 million members at 14 medical centers andnearly 200 medical offices. Members of KPSC aresocioeconomically diverse and broadly representative ofthe general population of Southern California.5 KPSC’sinstitutional review board approved the study. Informedconsent was waived.

Study PopulationAll adult members of KPSC with hypertension werepotentially eligible for the study. Members with diag-nosed hypertension were identified by inpatient andoutpatient International Classification of Diseases,Ninth Revision, Clinical Modification (ICD-9-CM)codes (Table I). The accuracy of ICD-9 coding was

Address for correspondence: Kristi Reynolds, PhD, MPH, Department ofResearch & Evaluation, Kaiser Permanente Southern California, 100 SouthLos Robles, 2nd Floor, Pasadena, CA 91101E-mail: [email protected]

Manuscript received: April 1, 2013; revised: May 22, 2013; accepted:May 27, 2013DOI: 10.1111/jch.12162

650 The Journal of Clinical Hypertension Vol 15 | No 9 | September 2013 Official Journal of the American Society of Hypertension, Inc.

ORIGINAL PAPER

Page 2: A Randomized Controlled Trial of an Automated Telephone Intervention to Improve Blood Pressure Control

internally validated by The Permanente MedicalGroup.6 To be included in the hypertension registry,members must be 18 years or older and meet at leastone of the diagnostic criteria in Table I. The hyperten-sion registry also indicates whether a member has beendiagnosed with cardiovascular disease, chronic kidneydisease (CKD), or diabetes mellitus. We identified66,304 hypertension registry members whose mostrecent BP within 12 months prior to the date ofrandomization was ≥140/90 mm Hg, or ≥130/80 mmHg if the member had diabetes or CKD. Health planmembers were not eligible for the study if they were onhemodialysis, in hospice or a skilled nursing facility,deceased, or did not have a BP value recorded within12 months prior to the date of randomization. Werandomized the eligible members on August 2, 2010, toa usual care arm (n=33,154) and an intervention arm(n=33,150) and subsequently excluded 1531 individuals(4.8%): 1528 did not have a valid telephone numberand 3 were on a “do not call” list. The final studysample included 64,773 patients, with 31,619 membersin the intervention arm and 33,154 members in thecontrol arm.

InterventionThe goal of the intervention was to encourage BPmonitoring and to consequently improve BP control inuncontrolled hypertensive members. Outreach occurredAugust 9 to 16, 2010, using an automated telephonemessaging system. If the telephone call was answered bya live person or by a voicemail system, the automatedmessage was delivered. Failed call attempts (ie, busysignal or no answer) resulted in a maximum of 2additional call attempts on the same day. Telephonecalls were made between 10 AM and 8 PM. The contentof the automated message was developed by the KPSCoutreach team. The message included a greeting statingthe call was from Kaiser Permanente, an invitation tohave a BP measurement at a KPSC medical center, and

the hours of operation of the medical center. Theautomated message was played by default in Englishwith an option to listen to the message in Spanish. Themessage scripts may be viewed in the Appendix.

OutcomeThe primary outcome was BP control (<130/80 mm Hgfor patients with diabetes or CKD and <140/90 mm Hgfor all other patients7,8) measured at a KPSC medicalcenter during the 4-week period following randomiza-tion. BP was measured according to KPSC’s standardprotocol: a trained medical assistant measures themember’s BP using an automated sphygmomanometerand if the measurement is elevated, a second measure-ment is obtained.

Statistical AnalysisSummary statistics were calculated for sociodemograph-ic characteristics (age, sex, race/ethnicity, preferredlanguage, education, and income), chronic diseasestatus, and systolic and diastolic BPs. Means andstandard deviations (SDs) were calculated for continu-ous variables and percentages were calculated forcategorical variables. Differences in characteristics wereassessed using analysis of variance for continuousvariables and chi-square tests for categorical variables.If a patient did not have a BP measurement during thestudy period, the baseline BP was carried forward andused as the outcome value. Subgroup analyses wereconducted by chronic disease status (cardiovasculardisease, diabetes, and CKD). Sensitivity analyses wereconducted to exclude patients who did not have a BPmeasurement during the study. To examine BP controlby demographic characteristics, all patients wereincluded in a multivariable logistic regression analysis.Adjustment was made for the study arm in whichpatients were enrolled. All analyses were performedusing SAS statistical software version 9.2 (SAS InstituteInc, Cary, NC).

RESULTSDemographic and clinical characteristics of the patientsare provided in Table II. The mean age among allpatients was 61 years (range, 18 to 105 years), themajority of the patients were women and had at least ahigh school diploma, and half had an annual householdincome of $66,500 or less. Administrative recordsindicated that 10% of patients preferred communicatingwith their health care provider in Spanish. The mean(SD) systolic and diastolic BPs closest to the date ofrandomization were 147.9 (11.2) and 83.5 (11.7),respectively. There were no statistically significantdifferences between patients in the intervention armcompared with those in the usual care arm.

In the intervention group, 51.2% of the outreachcalls were answered by a live person, 45.9% wererouted to a voicemail system, and 2.9% were unan-swered. BP control in both study arms was 0% at thetime of randomization. Table III shows the proportion

TABLE I. Diagnostic Criteria for Hypertension

At least one of the following:

1. Two outpatienta visits within 365 days of each other with a code for

hypertension, OR

2. One outpatient visit with a code for hypertension AND one

inpatientb discharge diagnosis code for hypertension, OR

3. At least one prescription for an antihypertensive medication

dispensed in the past 6 months AND one outpatient visit with a

code for hypertension within 365 days of the dispense date, OR

4. One outpatient visit with a code for hypertension AND a member

of one of the following populations: heart failure, coronary artery

disease, diabetes, chronic kidney disease, or cerebrovascular

accident (excluding subarachnoid, subdural, and cardioembolic)

aOutpatient International Classification of Diseases, Ninth Revision,

Clinical Modification (ICD-9-CM) diagnosis codes for hypertension:

401.xx, 402.xx, 403.xx, 405.xx, or 362.1. bInpatient ICD-9-CM diag-

nosis codes for hypertension: 401.xx, 402.xx, 403.xx, or 405.xx.

Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 15 | No 9 | September 2013 651

Telephone Intervention to Improve Blood Pressure | Harrison et al.

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of patients who achieved BP control at 4 weekspostrandomization. In the overall population, BP con-trol was significantly higher among those in theintervention arm compared with the usual care arm(32.5% vs 23.7%; P<.0001). Study patients in theintervention arm who also had cardiovascular disease,CKD, or diabetes, achieved better BP control comparedwith those who did not receive an automated telephonemessage. The absolute difference in BP control ratesranged from a low of 7.7% in participants withdiabetes to 8.8% in the general hypertensive popula-tion. Less than half of patients in each study arm(47.2% and 36.8% in the intervention and control

arms, respectively) had a BP measurement recordedduring the study follow-up period. In sensitivity anal-yses excluding patients who did not have a BPmeasurement postrandomization (52.8% and 63.2%of patients in the intervention and control arms,respectively), BP control was significantly higheramong those in the intervention arm compared withthe usual care arm (68.8% vs 64.5%; P<.0001).

After adjusting for study arm, certain demographicgroups had increased BP control rates following theautomated outreach campaign (Table IV). Characteris-tics associated with an increased odds of BP controlincluded older age (odds ratio [OR], 1.23; P<.0001),female sex (OR, 1.14; P<.0001), and having a

TABLE II. Characteristics of the Study Participants

VariableaAll Patients

(n=64,773)

Intervention

Group

(n=31,619)

Usual Care

Group

(n=33,154)

P

Valueb

Mean age, y 61.4 (14.4) 61.4 (14.4) 61.4 (14.4) .69

Age, y, % .67

18–49 20.7 20.7 20.7

50–59 25.1 25.1 25.1

60–69 24.6 24.4 24.8

≥70 29.7 29.8 29.5

Female, % 54.1 54.1 54.2 .67

Race/ethnicity, % .14

White 40.9 41.3 40.5

Asian 8.2 8.1 8.2

Black 17.3 17.2 17.4

Hispanic 25.2 25.1 25.2

Other/unknown 8.5 8.2 8.7

Preferred spoken language, % .29

English 88.1 88.3 87.9

Spanish 9.5 9.3 9.6

Other 2.5 2.4 2.5

Median

household

income, $c

65,857

(28,826)

65,979

(29,066)

65,741

(28,596)

.30

History of

CVD, %

38.2 38.3 38.1 .59

History of

diabetes, %

27.2 27.2 27.1 .76

History of

CKD, %

9.5 9.4 9.6 .34

Systolic BP

pre-outreach

147.9 (11.2) 147.9 (11.1) 148.0 (11.3) .20

Diastolic BP

pre-outreach

83.5 (11.7) 83.4 (11.7) 83.6 (11.8) .09

Systolic BP

post-outreach

142.2 (14.9) 141.2 (15.1) 143.1 (14.6) <.0001

Diastolic BP

post-outreach

80.8 (12.6) 80.3 (12.6) 81.3 (12.5) <.0001

Abbreviations: BP, blood pressure; CKD, chronic kidney disease;

CVD, cardiovascular disease. aValues are expressed as mean (stan-

dard deviation) or percentage. bParticipant characteristics were

compared using analysis of variance for continuous variables and

chi-square tests for categorical variables. cData are based on 2000

Census data geocoded at the block level.

TABLE III. BP Control Rates in the Overall StudyPopulation and Among Patients With a BPMeasurement at 4 Weeks, by Chronic DiseaseStatus

Overall Population

Intervention

(n=31,619)

Usual Care

(n=33,154)

Absolute

Difference P Value

General 32.5% 23.7% 8.8% <.0001

CVD (n=24,754) 36.0% 27.6% 8.4% <.0001

Diabetes

(n=17,609)

34.5% 26.8% 7.7% <.0001

CKD (n=6136) 36.3% 28.3% 8.0% <.0001

Patients with BP

measurement

(n=14,929) (n=12,186)

General 68.8% 64.5% 4.3% <.0001

CVD (n=11,919) 67.6% 63.9% 3.7% <.0001

Diabetes (n=8253) 66.8% 63.4% 3.4% .002

CKD (n=3262) 62.9% 57.9% 5.0% .004

Abbreviations: BP, blood pressure; CKD, chronic kidney disease;

CVD, cardiovascular disease.

TABLE IV. Odds Ratios of Blood Pressure ControlAmong Study Participants

Characteristic

Odds Ratio (95%

Confidence Interval) P Value

Age, per 10 y 1.23 (1.21–1.24) <.0001

Female sex 1.14 (1.10–1.18) <.0001

Race/ethnicity

White 1 (reference)

Asian 0.89 (0.83–0.95) .0008

Black 0.87 (0.83–0.92) <.0001

Hispanic 1.00 (0.95–1.05) .954

Other/unknown 0.61 (0.56–0.65) <.0001

Preferred spoken language

English 1 (reference)

Spanish 0.97 (0.90–1.04) .356

Other 0.87 (0.78–0.99) .029

Median household income

>$65,857 1.06 (1.02–1.10) .002

Intervention group 1.55 (1.50–1.60) <.0001

652 The Journal of Clinical Hypertension Vol 15 | No 9 | September 2013 Official Journal of the American Society of Hypertension, Inc.

Telephone Intervention to Improve Blood Pressure | Harrison et al.

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household income above the median (OR, 1.06;P=.002). Those with Asian, black and other/unknownrace/ethnicity were less likely to have their BP controlledcompared with whites.

DISCUSSIONAutomated telephone messaging was effective inincreasing BP control rates in a large, integrated healthcare system. Overall BP control rates at 4 weeks were32.5% in the intervention arm and 23.7% in the usualcare arm with slightly lower rates among participantswith cardiovascular disease, diabetes, or CKD. Thesefindings highlight the impact that an automated tele-phone intervention encouraging patients to have aclinic-based BP measurement could have on hyperten-sion control rates.

The modest increase in overall BP control rates inour study was not surprising given that none of thetarget population had controlled hypertension at thebeginning of the study. Derose and colleagues con-ducted a randomized controlled trial to evaluate theeffectiveness of an automated messaging campaign toimprove diabetes laboratory monitoring among resis-tant patients.9 Compliance with laboratory testingincreased as much as 20% among patients whoreceived an automated telephone message and rose to26% with the addition of automated letters. In asimilar study, the paired call-letter intervention wasmore effective than the automated phone messagealone in improving immunization coverage rates ofchildren.10 An automated telephone outreach campaignconducted among health plan members due for fecaloccult blood testing increased colorectal screening ratesby 23% compared with the intervention group.11

Although the target population in these studies differedfrom the population in our study, they were conductedin health care delivery settings with similar electronichealth record systems used to monitor utilization andoutcomes.

Our results suggest that walk-in, clinic-based BPmeasurements may have a positive effect on hyperten-sion control, particularly among individuals who lackregular monitoring. For example, clinic-based staff hasthe opportunity to educate and refer patients for follow-up care or counseling.8 The statistically significant butsmall absolute difference between the two study groupsmay be due to medication treatment intensification orimproved medication and lifestyle adherence as a resultof the medical encounter. Furthermore, individuals whoare motivated to have their BP measured in the clinicmay also be more motivated to achieve BP control.Interestingly, older, higher-income women in our studywere more likely to have controlled hypertension at theend of the follow-up period, which may be a result ofthese individuals having more time and resources tomanage their BP. National-level data also show higherhypertension control rates among women, older-agepersons (40 years and older), and those with higherincome.12

STUDY LIMITATIONS AND STRENGTHSThere are several limitations to the current study. Theresults of this study may not be generalizable to healthcare settings without integrated electronic systems,which link the pieces of health information necessaryfor an automated outreach campaign. Additionally, thefindings may not apply to populations with otherconditions that may require invasive tests, more fre-quent monitoring, and/or a scheduled appointment. Alonger follow-up period would be necessary to assesswhether the intervention group maintained improvedBP control and whether the comparison group mighthave received treatment intensification to close thehypertension control gap. Lastly, health plan memberscould have had a BP measurement between studyselection and recruitment, which may have resulted inover-reporting BP control rates in one or both studygroups.

Despite these limitations, our study has severalstrengths. First, our study sample was large and diverse.Second, we used a disease registry to identify patientsdiagnosed with hypertension, which would limit mis-classification of a hypertension diagnosis. Third, weused clinic-based BP measurements, which wouldreduce the potential of recall bias that results fromusing self-reported BP measurement levels.

CONCLUSIONSAn automated telephone outreach program was effec-tive in increasing BP control rates in patients withhypertension and uncontrolled BP. Additionally, theintervention has the potential to reach a large popula-tion at low marginal costs. Future studies assessing theeffectiveness of an automated telephone interventionshould assess the impact of antihypertensive medicationintensification on BP control rates and should measuresuch changes over an extended period. When designingquality-improvement interventions to increase BP con-trol rates, health care organizations should considerutilizing an automated telephone outreach campaign aspart of a comprehensive chronic care managementprogram.

Acknowledgements: We thank the entire Southern California Kaiser Perma-nente Regional Outreach and Care Support team; Rita Gevorkyan of ClinicalOperations; Diana Moulder and Jocelyn Tran-Nguyen of Pharmacy AnalyticalServices; Carla Riggs of the Kaiser Permanente Notification System; andJacqueline Porcel for programming support. This study was funded bySouthern California Permanente Medical Group. Preliminary results of thisstudy were presented at the 26th Annual Scientific Meeting and Exhibition ofthe American Society of Hypertension, May 2011, in New York, NY.

Disclosure: The authors report no specific funding in relation to this researchand no conflicts of interest to disclose.

References1. Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness,

treatment, and control of hypertension, 1988-2008. JAMA. 2010;20:2043–2050.

2. Go AS, Mozaffarian D, Roger VL, et al; On behalf of the AmericanHeart Association Statistics C, Stroke Statistics S. Heart disease andstroke statistics–2013 update: a report from the American HeartAssociation. Circulation. 2013;1:e6–e245.

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3. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of thejoint national committee on prevention, detection, evaluation, andtreatment of high blood pressure: the JNC 7 Report. JAMA.2003;19:2560–2572.

4. Glynn LG, Murphy AW, Smith SM, et al. Interventions used toimprove control of blood pressure in patients with hypertension.Cochrane Database Syst Rev. 2010;3:CD005182.

5. Koebnick C, Langer-Gould AM, Gould MK, et al. Sociodemo-graphic characteristics of members of a large, integrated healthcare system: comparison with US Census Bureau data. Perm J.2012;3:37–41.

6. Bhandari SK, Pashayan S, Liu IL, et al. 25-hydroxyvitamin D levelsand hypertension rates. J Clin Hypertens (Greenwich). 2011;3:170–177.

7. Arauz-Pacheco C, Parrott MA, Raskin P. The treatment of hyper-tension in adult patients with diabetes. Diabetes Care. 2002;1:134–147.

8. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of thejoint national committee on prevention, detection, evaluation, andtreatment of high blood pressure. Hypertension. 2003;6:1206–1252.

9. Derose SF, Nakahiro RK, Ziel FH. Automated messaging to improvecompliance with diabetes test monitoring. Am J Manag Care.2009;7:425–431.

10. Lieu TA, Capra AM, Makol J, et al. Effectiveness and cost-effective-ness of letters, automated telephone messages, or both for underim-munized children in a health maintenance organization. Pediatrics.1998;4:E3.

11. Mosen DM, Feldstein AC, Perrin N, et al. Automated telephone callsimproved completion of fecal occult blood testing. Med Care.2010;7:604–610.

12. Yoon PW, Gillespie CD, George MG, et al. Centers for DiseaseControl and Prevention. Control of hypertension among adults –national health and nutrition examination survey, United States,2005-2008. MMWR 2012; 61 suppl: 19–25.

APPENDIX OUTREACH CALL SCRIPTEnglish version with Spanish prompt: “Hello. This is a Complete Care message from Kaiser Permanente for [name].Para espa~nol, oprima el numero 2. We know how busy you are but it’s important to remember to take care of yourhealth. We would like to invite you to stop by your doctor’s office for a blood pressure check. Staff will be availableMonday through Friday 9 AM to 12 noon and 1:30 PM to 4 PM. You don’t need an appointment; you can juststop by.”Spanish version: “Hola. Este es un mensaje de Cuidado Integral de Kaiser Permanente para [nombre]. Sabemos loocupado que est�a, pero es importante que recuerde cuidar su salud. Quisi�eramos invitarle a usted que visite la oficinade su doctor para chequear su presi�on arterial. Puede acercarse a la oficina de su doctor de lunes a viernes de 9:00 de lama~nana a 12:00 del medio d�ıa y de 1:30 PM a 4:00 PM. Usted no necesita cita previa; simplemente ac�erquese a laoficina.”

654 The Journal of Clinical Hypertension Vol 15 | No 9 | September 2013 Official Journal of the American Society of Hypertension, Inc.

Telephone Intervention to Improve Blood Pressure | Harrison et al.