1
|
Kasanagottu K, Mukamal KJ, Landon BE. Predictors of treatment intensification in uncontrolled hypertension. J Hypertens 2024; 42:283-291. [PMID: 37889569 DOI: 10.1097/hjh.0000000000003598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
PURPOSE Prior studies have shown that treatment intensification for patients presenting with uncontrolled hypertension (HTN) rarely occurs, even during visits to the patient's own primary care physicians (PCPs). In this article, we identified predictors of treatment intensification for uncontrolled HTN. METHODS We conducted a cross-sectional study using nationally representative survey data on visits by patients aged 18 or above with uncontrolled HTN, defined as a recorded SBP at least 140 and/or a DBP at least 90 using data from the National Ambulatory Medical Care Survey (NAMCS) 2008-2018. Our outcome is treatment intensification defined as the addition of a new blood pressure medication. RESULTS We analyzed 22 559 visits to PCPs where uncontrolled HTN was noted, representing 801 023 786 visits nationally. Among these encounters, 2138 (10.3%) of the visits resulted in treatment intensification. Visits with the patient's own PCP had higher rates of treatment intensification than visits to another PCP (10.8 vs. 5.9%, P < 0.0001). Visits for patients previously on antihypertensive medications had lower rates of treatment intensification (11% for no medications, 10.4% for one medication, 6.6% for ≥2 medications, P < 0.0001), but there were no statistically significant differences in rates of intensification for those with relevant comorbidities (9.4% for no chronic conditions, 10.8% for one to two chronic conditions, 8.9% for at least three chronic conditions, P = 0.12). Multivariable adjusted results were similar to the unadjusted findings. CONCLUSION Visits for patients with uncontrolled HTN rarely result in treatment intensification. Substantial opportunity exists to improve management of HTN, particularly for patients on fewer medications or seen by a covering provider.
Collapse
Affiliation(s)
- Koushik Kasanagottu
- Division of General Medicine, Beth Israel Deaconess Medical Center, Brookline
- Department of Medicine
| | - Kenneth J Mukamal
- Division of General Medicine, Beth Israel Deaconess Medical Center, Brookline
- Department of Medicine
| | - Bruce E Landon
- Division of General Medicine, Beth Israel Deaconess Medical Center, Brookline
- Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Khoong EC, Commodore-Mensah Y, Lyles CR, Fontil V. Use of Self-Measured Blood Pressure Monitoring to Improve Hypertension Equity. Curr Hypertens Rep 2022; 24:599-613. [PMID: 36001268 PMCID: PMC9399977 DOI: 10.1007/s11906-022-01218-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To evaluate how self-measured blood pressure (SMBP) monitoring interventions impact hypertension equity. RECENT FINDINGS While a growing number of studies have recruited participants from safety-net settings, racial/ethnic minority groups, rural areas, or lower socio-economic backgrounds, few have reported on clinical outcomes with many choosing to evaluate only patient-reported outcomes (e.g., satisfaction, engagement). The studies with clinical outcomes demonstrate that SMBP monitoring (a) can be successfully adopted by historically excluded patient populations and safety-net settings and (b) improves outcomes when paired with clinical support. There are few studies that explicitly evaluate how SMBP monitoring impacts hypertension disparities and among rural, low-income, and some racial/ethnic minority populations. Researchers need to design SMBP monitoring studies that include disparity reduction outcomes and recruit from broader populations that experience worse hypertension outcomes. In addition to assessing effectiveness, studies must also evaluate how to mitigate multi-level barriers to real-world implementation of SMBP monitoring programs.
Collapse
Affiliation(s)
- Elaine C Khoong
- Division of General Internal Medicine at Zuckerberg, Department of Medicine, San Francisco General Hospital, UCSF, Building 10, Ward 13, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, USA.
| | - Yvonne Commodore-Mensah
- Johns Hopkins School of Nursing, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Courtney R Lyles
- Division of General Internal Medicine at Zuckerberg, Department of Medicine, San Francisco General Hospital, UCSF, Building 10, Ward 13, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, USA
| | - Valy Fontil
- Division of General Internal Medicine at Zuckerberg, Department of Medicine, San Francisco General Hospital, UCSF, Building 10, Ward 13, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, USA
| |
Collapse
|
3
|
Kandzari DE, Townsend RR, Bakris G, Basile J, Bloch MJ, Cohen DL, East C, Ferdinand KC, Fisher N, Kirtane A, Lee DP, Puckrein G, Rader F, Vassalotti JA, Weber MA, Willis K, Secemsky E. Renal denervation in hypertension patients: Proceedings from an expert consensus roundtable cosponsored by SCAI and NKF. Catheter Cardiovasc Interv 2021; 98:416-426. [PMID: 34343406 DOI: 10.1002/ccd.29884] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 12/19/2022]
Affiliation(s)
- David E Kandzari
- Interventional Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Raymond R Townsend
- Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Bakris
- Hypertension, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jan Basile
- Cardiology, Medical University of South Carolina and Ralph H. Johnson VA Medical Center to Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael J Bloch
- Vascular Care, Renown Institute for Heart and Vascular Health, University of Nevada, Reno School of Medicine, Reno, Nevada, USA
| | - Debbie L Cohen
- Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cara East
- Cardiology, Baylor Heart & Vascular Hospital, Dallas, Texas, USA
- Vascular Intervention, Soltero CV Research Center, Texas A&M College of Medicine
| | - Keith C Ferdinand
- Preventive Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Naomi Fisher
- Hypertension, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ajay Kirtane
- Interventional Vascular Therapy, Columbia University Irving Medical Center, New York, New York, USA
| | - David P Lee
- Interventional Cardiology, Stanford University, Stanford, California, USA
| | - Gary Puckrein
- The National Minority Quality Forum, Washington, District of Columbia, USA
| | - Florian Rader
- Hypertension Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph A Vassalotti
- Clinical Professor, Icahn School of Medicine at Mount Sinai, National Kidney Foundation, New York, New York, USA
| | - Michael A Weber
- Cardiovascular Medicine, SUNY Downstate Medical Center, New York, New York, USA
| | - Kerry Willis
- National Kidney Foundation, New York, New York, USA
| | - Eric Secemsky
- Vascular Intervention, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Kaboli PJ, Howren MB, Ishani A, Carter B, Christensen AJ, Vander Weg MW. Efficacy of Patient Activation Interventions With or Without Financial Incentives to Promote Prescribing of Thiazides and Hypertension Control: A Randomized Clinical Trial. JAMA Netw Open 2018; 1:e185017. [PMID: 30646291 PMCID: PMC6324341 DOI: 10.1001/jamanetworkopen.2018.5017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Evidence-based guidelines recommend thiazide diuretics as a first-line therapy for uncomplicated hypertension; however, thiazides are underused, and hypertension remains inadequately managed. OBJECTIVE To test the efficacy of a patient activation intervention with financial incentives to promote thiazide prescribing. DESIGN, SETTING, AND PARTICIPANTS The Veterans Affairs Project to Implement Diuretics, a randomized clinical trial, was conducted at 13 Veterans Affairs primary care clinics from August 1, 2006, to July 31, 2008, with 12 months of follow-up. A total of 61 019 patients were screened to identify 2853 eligible patients who were not taking a thiazide and not at their blood pressure (BP) goal; 598 consented to participate. Statistical analysis was conducted from December 1, 2017, to September 12, 2018. INTERVENTIONS Patients were randomized to a control group (n = 196) or 1 of 3 intervention groups designed to activate patients to talk with their primary care clinicians about thiazides and hypertension: group A (n = 143) received an activation letter, group B (n = 128) received a letter plus a financial incentive, and group C (n = 131) received a letter, financial incentive, and a telephone call encouraging patients to speak with their primary care clinicians. MAIN OUTCOMES AND MEASURES Primary outcomes were thiazide prescribing and BP control. A secondary process measure was discussion between patient and primary care clinician about thiazides. RESULTS Among 598 participants (588 men and 10 women), the mean (SD) age for the combined intervention groups (n = 402) was 62.9 (8.8) years, and the mean baseline BP was 148.1/83.8 mm Hg; the mean (SD) age for the control group (n = 196) was 64.1 (9.2) years, and the mean baseline BP was 151.0/83.4 mm Hg. At index visits, the unadjusted rate of thiazide prescribing was 9.7% for the control group (19 of 196) and 24.5% (35 of 143) for group A, 25.8% (33 of 128) for group B, and 32.8% (43 of 131) for group C (P < .001). Adjusted analyses demonstrated an intervention effect on thiazide prescribing at the index visit and 6-month visit, which diminished at the 12-month visit. For BP control, there was a significant intervention effect at the 12-month follow-up for group C (adjusted odds ratio, 1.73; 95% CI, 1.06-2.83; P = .04). Intervention groups exhibited improved thiazide discussion rates in a dose-response fashion: group A, 44.1% (63 of 143); group B, 56.3% (72 of 128); and group C, 68.7% (90 of 131) (P = .004). CONCLUSIONS AND RELEVANCE This patient activation intervention about thiazides for hypertension resulted in two-thirds of patients having discussions and nearly one-third initiating a prescription of thiazide. Adding a financial incentive and telephone call to the letter resulted in incremental improvements in both outcomes. By 12 months, improved BP control was also evident. This low-cost, low-intensity intervention resulted in high rates of discussions between patients and clinicians and subsequent thiazide treatment and may be used to promote evidence-based guidelines and overcome clinical inertia. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00265538.
Collapse
Affiliation(s)
- Peter J. Kaboli
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City
| | - M. Bryant Howren
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Psychological and Brain Sciences, The University of Iowa College of Liberal Arts and Sciences, Iowa City
| | - Areef Ishani
- Center for Epidemiology and Clinical Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
- Section of Nephrology, Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis
| | - Barry Carter
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Pharmacy Practice and Science, The University of Iowa College of Pharmacy, Iowa City
- Department of Family Medicine, The University of Iowa Carver College of Medicine, Iowa City
| | - Alan J. Christensen
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City
- Department of Psychological and Brain Sciences, The University of Iowa College of Liberal Arts and Sciences, Iowa City
| | - Mark W. Vander Weg
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City
- Department of Psychological and Brain Sciences, The University of Iowa College of Liberal Arts and Sciences, Iowa City
| |
Collapse
|
5
|
Ambrose JA, Najafi A. Strategies for the Prevention of Coronary Artery Disease Complications: Can We Do Better? Am J Med 2018; 131:1003-1009. [PMID: 29729244 DOI: 10.1016/j.amjmed.2018.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/03/2018] [Accepted: 04/03/2018] [Indexed: 12/21/2022]
Abstract
Billions of dollars have been spent over the past 25 years on developing new therapies for the prevention/treatment of adverse cardiac events related to atherosclerotic cardiovascular disease. Although some therapies have been lifesaving, several mega-randomized studies have shown only a <2% absolute reduction in adverse events with a large residual event rate. Is all this money well spent? Atherosclerosis develops decades before an adverse event, and the trials previously alluded to have nearly always been applied to secondary prevention, decades after disease initiation. Will earlier intervention result in a lower incidence of events? Individuals with an absence of the usual cardiac risk factors have a lifelong low incidence of events. Early initiation of strategies against the common cardiovascular risk factors in primary or primordial prevention will lower the incidence of adverse events, although many groups have not been well studied, including individuals younger than 40 years of age. New strategies are required to realize a radical reduction in events, and this article proposes new methods of prevention/treatment for coronary artery disease complications.
Collapse
Affiliation(s)
| | - Amir Najafi
- University of California San Francisco, Fresno
| |
Collapse
|
6
|
Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, Brettler J, Rashid M, Hsu B, Foxx-Drew D, Moy N, Reid AE, Elashoff RM. A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops. N Engl J Med 2018; 378. [PMID: 29527973 PMCID: PMC6018053 DOI: 10.1056/nejmoa1717250] [Citation(s) in RCA: 355] [Impact Index Per Article: 59.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Uncontrolled hypertension is a major problem among non-Hispanic black men, who are underrepresented in pharmacist intervention trials in traditional health care settings. METHODS We enrolled a cohort of 319 black male patrons with systolic blood pressure of 140 mm Hg or more from 52 black-owned barbershops (nontraditional health care setting) in a cluster-randomized trial in which barbershops were assigned to a pharmacist-led intervention (in which barbers encouraged meetings in barbershops with specialty-trained pharmacists who prescribed drug therapy under a collaborative practice agreement with the participants’ doctors) or to an active control approach (in which barbers encouraged lifestyle modification and doctor appointments). The primary outcome was reduction in systolic blood pressure at 6 months. RESULTS At baseline, the mean systolic blood pressure was 152.8 mm Hg in the intervention group and 154.6 mm Hg in the control group. At 6 months, the mean systolic blood pressure fell by 27.0 mm Hg (to 125.8 mm Hg) in the intervention group and by 9.3 mm Hg (to 145.4 mm Hg) in the control group; the mean reduction was 21.6 mm Hg greater with the intervention (95% confidence interval, 14.7 to 28.4; P<0.001). A blood-pressure level of less than 130/80 mm Hg was achieved among 63.6% of the participants in the intervention group versus 11.7% of the participants in the control group (P<0.001). In the intervention group, the rate of cohort retention was 95%, and there were few adverse events (three cases of acute kidney injury). CONCLUSIONS Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in larger blood-pressure reduction when coupled with medication management in barbershops by specialty-trained pharmacists. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT02321618 .).
Collapse
Affiliation(s)
- Ronald G Victor
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Kathleen Lynch
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Ning Li
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Ciantel Blyler
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Eric Muhammad
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Joel Handler
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Jeffrey Brettler
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Mohamad Rashid
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Brent Hsu
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Davontae Foxx-Drew
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Norma Moy
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Anthony E Reid
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| | - Robert M Elashoff
- From the Smidt Heart Institute at Cedars-Sinai Medical Center (R.G.V., K.L., C.B., E.M., M.R., B.H., D.F.-D., N.M., A.E.R.), the Department of Biomathematics, David Geffen School of Medicine, University of California, Los Angeles (N.L., R.M.E.), and Kaiser Permanente (J.H., J.B.) - all in Los Angeles
| |
Collapse
|
7
|
Fontil V, Bibbins‐Domingo K, Nguyen OK, Guzman D, Goldman LE. Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians' Offices. Health Serv Res 2017; 52:807-825. [PMID: 27283354 PMCID: PMC5346492 DOI: 10.1111/1475-6773.12516] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To examine adherence to guideline-concordant hypertension treatment practices at community health centers (CHCs) compared with private physicians' offices. DATA SOURCES/STUDY SETTING National Ambulatory Medical Care Survey from 2006 to 2010. STUDY DESIGN We examined four guideline-concordant treatment practices: initiation of a new medication for uncontrolled hypertension, use of fixed-dose combination drugs for patients on multiple antihypertensive medications, use of thiazide diuretics among patients with uncontrolled hypertension on ≥3 antihypertensive medications, and use of aldosterone antagonist for resistant hypertension, comparing use at CHC with private physicians' offices overall and by payer group. DATA COLLECTION/EXTRACTION METHODS We identified visits of nonpregnant adults with hypertension at CHCs and private physicians' offices. PRINCIPAL FINDINGS Medicaid patients at CHCs were as likely as privately insured individuals to receive a new medication for uncontrolled hypertension (AOR 1.0, 95 percent CI: 0.6-1.9), whereas Medicaid patients at private physicians' offices were less likely to receive a new medication (AOR 0.3, 95 percent CI: 0.1-0.6). Use of fixed-dose combination drugs was lower at CHCs (AOR 0.6, 95 percent CI: 0.4-0.9). Thiazide use for patients was similar in both settings (AOR 0.8, 95 percent CI: 0.4-1.7). Use of aldosterone antagonists was too rare (2.1 percent at CHCs and 1.5 percent at private clinics) to allow for statistically reliable comparisons. CONCLUSIONS Increasing physician use of fixed-dose combination drugs may be particularly helpful in improving hypertension control at CHCs where there are higher rates of uncontrolled hypertension.
Collapse
Affiliation(s)
- Valy Fontil
- Division of General Internal MedicineSan Francisco General HospitalUniversity of California San FranciscoSan FranciscoCA
- UCSF Center for Vulnerable Populations at San Francisco General HospitalSan FranciscoCA
| | - Kirsten Bibbins‐Domingo
- Division of General Internal MedicineSan Francisco General HospitalUniversity of California San FranciscoSan FranciscoCA
- UCSF Center for Vulnerable Populations at San Francisco General HospitalSan FranciscoCA
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCA
| | - Oanh Kieu Nguyen
- Divisions of General Internal Medicine and Outcomes and Health Services ResearchUT SouthwesternDallasTX
| | - David Guzman
- Division of General Internal MedicineSan Francisco General HospitalUniversity of California San FranciscoSan FranciscoCA
| | - Lauren Elizabeth Goldman
- Division of General Internal MedicineSan Francisco General HospitalUniversity of California San FranciscoSan FranciscoCA
| |
Collapse
|
8
|
Wozniak G, Khan T, Gillespie C, Sifuentes L, Hasan O, Ritchey M, Kmetik K, Wynia M. Hypertension Control Cascade: A Framework to Improve Hypertension Awareness, Treatment, and Control. J Clin Hypertens (Greenwich) 2016; 18:232-9. [PMID: 26337797 PMCID: PMC5049660 DOI: 10.1111/jch.12654] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/07/2015] [Accepted: 07/12/2015] [Indexed: 01/11/2023]
Abstract
Evidence-based interventions differ for increasing hypertension awareness, treatment, and control and should be targeted for specific patient panels. This study developed a hypertension control cascade to identify patients with a usual source of care represented at each level of the cascade using the 2007-2012 National Health and Nutrition Examination Survey. Overall, 10.7 million adults in the United States were unaware of their condition, 3.8 million were aware but untreated, and 15.8 million were treated but uncontrolled. The results also suggest that failure to attain hypertension control because of lack of awareness or lack of treatment despite awareness occurs mainly among younger individuals and those with no annual healthcare visits, while the elderly and minorities are more likely to remain uncontrolled when aware and treated. Opportunities to leverage population health management functions in electronic health information systems to align the specific patient subgroups facing barriers to hypertension control at each level of the cascade with targeted hypertension management interventions are discussed.
Collapse
|
9
|
Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model. J Gen Intern Med 2015; 30:1147-55. [PMID: 25749880 PMCID: PMC4510247 DOI: 10.1007/s11606-015-3231-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 01/13/2015] [Accepted: 02/03/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Only half of hypertensive adults achieve blood pressure (BP) control in the United States, and it is unclear how BP control rates may be improved most effectively and efficiently at the population level. OBJECTIVE We sought to compare the potential effects of system-wide isolated improvements in medication adherence, visit frequency, and higher physician prescription rate on achieving BP control at 52 weeks. DESIGN We developed a Markov microsimulation model of patient-level, physician-level, and system-level processes involved in controlling hypertension with medications. The model is informed by data from national surveys, cohort studies and trials, and was validated against two multicenter clinical trials (ALLHAT and VALUE). SUBJECTS We studied a simulated, nationally representative cohort of patients with diagnosed but uncontrolled hypertension with a usual source of care. INTERVENTIONS We simulated a base case and improvements of 10 and 50%, and an ideal scenario for three modifiable parameters: visit frequency, treatment intensification, and medication adherence. Ideal scenarios were defined as 100% for treatment intensification and adherence, and return visits occurring within 4 weeks of an elevated office systolic BP. MAIN OUTCOME BP control at 52 weeks of follow-up was examined. RESULTS Among 25,000 hypothetical adult patients with uncontrolled hypertension (systolic BP ≥ 140 mmHg), only 18% achieved BP control after 52 weeks using base-case assumptions. With 10/50%/idealized enhancements in each isolated parameter, enhanced treatment intensification achieved the greatest BP control (19/23/71%), compared with enhanced visit frequency (19/21/35%) and medication adherence (19/23/26%). When all three processes were idealized, the model predicted a BP control rate of 95% at 52 weeks. CONCLUSION Substantial improvements in BP control can only be achieved through major improvements in processes of care. Healthcare systems may achieve greater success by increasing the frequency of clinical encounters and improving physicians' prescribing behavior than by attempting to improve patient adherence to medications.
Collapse
|
10
|
|
11
|
Johnson HM, Thorpe CT, Bartels CM, Schumacher JR, Palta M, Pandhi N, Sheehy AM, Smith MA. Antihypertensive medication initiation among young adults with regular primary care use. J Gen Intern Med 2014; 29:723-31. [PMID: 24493322 PMCID: PMC4000352 DOI: 10.1007/s11606-014-2790-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Revised: 12/03/2013] [Accepted: 01/10/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Young adults with hypertension have the lowest prevalence of controlled blood pressure compared to middle-aged and older adults. Uncontrolled hypertension, even among young adults, increases future cardiovascular event risk. However, antihypertensive medication initiation is poorly understood among young adults and may be an important intervention point for this group. OBJECTIVE The purpose of this study was to compare rates and predictors of antihypertensive medication initiation between young adults and middle-aged and older adults with incident hypertension and regular primary care contact. DESIGN A retrospective analysis PARTICIPANTS Adults ≥ 18 years old (n = 10,022) with incident hypertension and no prior antihypertensive prescription, who received primary care at a large, Midwestern, academic practice from 2008-2011. MAIN MEASURES The primary outcome was time from date of meeting hypertension criteria to antihypertensive medication initiation, or blood pressure normalization without medication. Kaplan-Meier analysis was used to estimate the probability of antihypertensive medication initiation over time. Cox proportional-hazard models (HR; 95% CI) were fit to identify predictors of delays in medication initiation, with a subsequent subpopulation analysis for young adults (18-39 years old). KEY RESULTS After a mean follow-up of 20 (±13) months, 34% of 18-39 year-olds with hypertension met the endpoint, compared to 44% of 40-59 year-olds and 56% of ≥ 60 year-olds. Adjusting for patient and provider factors, 18-39 year-olds had a 44% slower rate of medication initiation (HR 0.56; 0.47-0.67) than ≥ 60 year-olds. Among young adults, males, patients with mild hypertension, and White patients had a slower rate of medication initiation. Young adults with Medicaid and more clinic visits had faster rates. CONCLUSIONS Even with regular primary care contact and continued elevated blood pressure, young adults had slower rates of antihypertensive medication initiation than middle-aged and older adults. Interventions are needed to address multifactorial barriers contributing to poor hypertension control among young adults.
Collapse
Affiliation(s)
- Heather M Johnson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, USA,
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Differential treatment of hypertension by primary care providers and hypertension specialists in a barber-based intervention trial to control hypertension in Black men. Am J Cardiol 2013; 112:1421-6. [PMID: 23978276 DOI: 10.1016/j.amjcard.2013.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 07/12/2013] [Accepted: 07/12/2013] [Indexed: 01/13/2023]
Abstract
Black men have less physician contact than other groups and thus lower rates of hypertension treatment and control. In the Barber-Assisted Reduction in Blood Pressure among Ethnic Residents trial, hypertension control in 8 active-intervention barbershops where barbers offered blood pressure (BP) checks with haircuts and motivated black male patrons with high BP to seek provider follow-up showed a small improvement over that in 7 comparison shops where patrons received hypertension pamphlets but not barber-BP checks. Undertreatment of hypertension, which is common in primary care, may have impacted the outcomes. Thus, in patrons with a baseline systolic BP of ≥140 mm Hg and 10-month follow-up including BP and medication data, we performed post hoc comparison of systolic BP reduction between comparison-arm patrons (n = 68) treated by primary care providers (PCPs) with (1) intervention-arm patrons (n = 37) treated by PCPs or (2) intervention-arm patrons (n = 33) who lacked access to PCPs and were treated by hypertension specialist physicians serving as safety net providers. The latter group had higher baseline systolic BP than the others (162 ± 3 vs 155 ± 2 and 154 ± 2 mm Hg, respectively, p <0.01). After adjustment for baseline systolic BP and other covariates, systolic BP reduction was 21 ± 4 mm Hg greater than in the comparison group (p <0.0001), when barbers referred patrons to hypertension specialists but was no different when they referred to PCPs (4 ± 4 mm Hg, p = 0.31). Specialist-treated patrons received more BP medication and different classes of medication than PCP-treated patrons. In conclusion, the barber-based intervention-if connected directly to specialty-level medical care-could have a large public health impact on hypertensive disease in black men.
Collapse
|
13
|
Tinsel I, Buchholz A, Vach W, Siegel A, Dürk T, Buchholz A, Niebling W, Fischer KG. Shared decision-making in antihypertensive therapy: a cluster randomised controlled trial. BMC FAMILY PRACTICE 2013; 14:135. [PMID: 24024587 PMCID: PMC3847233 DOI: 10.1186/1471-2296-14-135] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 08/20/2013] [Indexed: 11/10/2022]
Abstract
Background Hypertension is one of the key factors causing cardiovascular diseases. A substantial proportion of treated hypertensive patients do not reach recommended target blood pressure values. Shared decision making (SDM) is to enhance the active role of patients. As until now there exists little information on the effects of SDM training in antihypertensive therapy, we tested the effect of an SDM training programme for general practitioners (GPs). Our hypotheses are that this SDM training (1) enhances the participation of patients and (2) leads to an enhanced decrease in blood pressure (BP) values, compared to patients receiving usual care without prior SDM training for GPs. Methods The study was conducted as a cluster randomised controlled trial (cRCT) with GP practices in Southwest Germany. Each GP practice included patients with treated but uncontrolled hypertension and/or with relevant comorbidity. After baseline assessment (T0) GP practices were randomly allocated into an intervention and a control arm. GPs of the intervention group took part in the SDM training. GPs of the control group treated their patients as usual. The intervention was blinded to the patients. Primary endpoints on patient level were (1) change of patients’ perceived participation (SDM-Q-9) and (2) change of systolic BP (24h-mean). Secondary endpoints were changes of (1) diastolic BP (24h-mean), (2) patients’ knowledge about hypertension, (3) adherence (MARS-D), and (4) cardiovascular risk score (CVR). Results In total 1357 patients from 36 general practices were screened for blood pressure control by ambulatory blood pressure monitoring (ABPM). Thereof 1120 patients remained in the study because of uncontrolled (but treated) hypertension and/or a relevant comorbidity. At T0 the intervention group involved 17 GP practices with 552 patients and the control group 19 GP practices with 568 patients. The effectiveness analysis could not demonstrate a significant or relevant effect of the SDM training on any of the endpoints. Conclusion The study hypothesis that the SDM training enhanced patients’ perceived participation and lowered their BP could not be confirmed. Further research is needed to examine the impact of patient participation on the treatment of hypertension in primary care. Trial registration German Clinical Trials Register (DRKS): DRKS00000125
Collapse
Affiliation(s)
- Iris Tinsel
- Department of Medicine, Division of General Practice, University Medical Centre Freiburg, Elsässerstr 2m, Freiburg 79110, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Untreated hypertension: prevalence and patient factors and beliefs associated with under-treatment in a population sample. J Hum Hypertens 2012; 27:453-62. [PMID: 23235365 DOI: 10.1038/jhh.2012.62] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Identifying barriers to hypertension management may facilitate cardiovascular risk reduction. Therefore, our objective, was to determine the prevalence of hypertension not managed with medication ('untreated') in a representative adult sample and identify patient factors/beliefs, and aspects of the patient-general practitioner (GP) relationship associated with untreated hypertension. The North West Adelaide Health Study, a biomedical cohort study over three stages from 2000-2009, assesses hypertension (systolic > or =140 mm Hg and/or > or =90 mm Hg or current treatment with anti-hypertensive medication), chronic disease and associated risk factors and health-care experiences, including risk perception, decision-making preferences, GP/primary care provider affiliation and satisfaction with care (n=2425). The prevalence of hypertension was 32.1% (n=781) comprised of treated (19.0%, n=462) and untreated (13.1%, n=319) hypertension. Thus, 40.8% of hypertension was untreated. Among hypertensive subjects, non-treatment was significantly associated with male sex, age <45 years, workforce participation, infrequent GP visits, dissatisfaction with recent medical care, high total cholesterol, moderate-level physical activity and lower body weights. Compared with participants without hypertension (and no treatment), untreated subjects demonstrated significant (15%) 10-year Framingham general cardiovascular risk (odds ratio=6.44, 95% confidence interval=4.52-9.17). Novel screening strategies and public health messages to address beliefs and perceptions of both patients and the health system are required to identify untreated, at-risk hypertensive individuals.
Collapse
|