Taking AIM at a Moving Target

Abstract

In the last half century, the challenge for clinicians in many areas of medicine has evolved from reaction, to prevention, to, most recently, population management. In hypertension, that evolution has meant a gradual broadening of responsibilities from treating the complications of hypertension to controlling blood pressure in individual patients over time, and now to controlling hypertension in an overall population, particularly in high-risk groups such as patients with diabetes mellitus. Disease management programs are now increasingly used to improve the reliability with which patients receive optimal care. These programs are often well conceived and executed. But experience is teaching us that even well-designed programs are surprisingly like medications—they may not work even when logic suggests that they should, and they may work differently, or may not work at all, in various patient populations. Article see p 2863 Thus, it is wise and appropriate that the evaluation of complex interventions in real-world settings has become a major national (and international) research priority, mandated by the Patient Protection and Affordable Care Act of 2010 and carried out by federal agencies new (Patient-Centered Outcomes Research Institute) and old (Centers for Medicare and Medicaid Innovation, Agency for Healthcare Quality and Research, and others). Conducting and analyzing these interventions, although challenging, is critical to establishing their effectiveness and prioritizing allocation of scarce resources. In this issue of Circulation , Heisler et al1 have risen to this challenge by testing an evidence-based approach to the common and important problem of uncontrolled hypertension in patients with diabetes mellitus, in the Adherence and Intensification of Medications (AIM) trial. The intervention was a primary care-team based, pharmacist-led outreach program that was designed to address known provider- and patient-level barriers contributing to poor blood pressure control: lack of medication intensification and medication nonadherence. This intervention was compared to usual …