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Patil SJ, Bhayani V, Yoshida Y, Bushweller L, Udoh EO, Todorov I, Saper R, Stange KC, Bolen S. Lay advisor interventions for hypertension outcomes: A Systematic Review, Meta-analysis and a RE-AIM evaluation. Front Med (Lausanne) 2024; 11:1305190. [PMID: 38831986 PMCID: PMC11144929 DOI: 10.3389/fmed.2024.1305190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 04/22/2024] [Indexed: 06/05/2024] Open
Abstract
Introduction Lay advisor interventions improve hypertension outcomes; however, the added benefits and relevant factors for their widespread implementation into health systems are unknown. We performed a systematic review to: (1) summarize the benefits of adding lay advisors to interventions on hypertension outcomes, and (2) summarize factors associated with successful implementation in health systems using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Methods We systematically searched several databases, including Ovid MEDLINE, CINAHL, PsycINFO from January 1981 to May 2023. All study designs of interventions delivered solely by lay advisors for adults with hypertension were eligible. If both arms received the lay advisor intervention, the study arm with lower intensity was assigned as the low-intensity intervention. Results We included 41 articles, of which 22 were RCTs, from 7,267 screened citations. Studies predominantly included socially disadvantaged populations. Meta-analysis (9 RCTs; n = 4,220) of eligible lay advisor interventions reporting outcomes showed improved systolic blood pressure (BP) [-3.72 mm Hg (CI -6.1 to -1.3; I2 88%)], and diastolic BP [-1.7 mm Hg (CI -1 to -0.9; I2 7%)] compared to control group. Pooled effect from six RCTs (n = 3,277) comparing high-intensity with low-intensity lay advisor interventions showed improved systolic BP of -3.6 mm Hg (CI -6.7 to -0.5; I2 82.7%) and improved diastolic BP of -2.1 mm Hg (CI -3.7 to -0.4; I2 70.9%) with high-intensity interventions. No significant difference in pooled odds of hypertension control was noted between lay advisor intervention and control groups, or between high-intensity and low-intensity intervention groups. Most studies used multicomponent interventions with no stepped care elements or reporting of efficacious components. Indicators of external validity (adoption, implementation, maintenance) were infrequently reported. Discussion Lay advisor interventions improve hypertension outcomes, with high intensity interventions having a greater impact. Further studies need to identify successful intervention and implementation factors of multicomponent interventions for stepped upscaling within healthcare system settings as well as factors used to help sustain interventions.
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Affiliation(s)
- Sonal J. Patil
- Center for Health Equity, Engagement, Education, and Research (CHEEER), Department of Family Medicine, The MetroHealth Campus of Case Western Reserve University, Cleveland, OH, United States
| | - Vishwa Bhayani
- Department of Public Health, University of Missouri, Columbia, MO, United States
| | - Yilin Yoshida
- Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, United States
| | - Leila Bushweller
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Eno-Obong Udoh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Irina Todorov
- Department of Wellness and Preventive Medicine, Primary Care Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Robert Saper
- Department of Wellness and Preventive Medicine, Primary Care Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Kurt C. Stange
- Center for Community Health Integration, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Shari Bolen
- Department of Medicine, Center for Health Care Research and Policy, The MetroHealth Campus of Case Western Reserve University, Cleveland, OH, United States
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Fadl Elmula FEM, Mariampillai JE, Heimark S, Kjeldsen SE, Burnier M. Medical Measures in Hypertensives Considered Resistant. Am J Hypertens 2024; 37:307-317. [PMID: 38124494 PMCID: PMC11016838 DOI: 10.1093/ajh/hpad118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Patients with resistant hypertension are the group of hypertensive patients with the highest cardiovascular risk. METHODS All rules and guidelines for treatment of hypertension should be followed strictly to obtain blood pressure (BP) control in resistant hypertension. The mainstay of treatment of hypertension, also for resistant hypertension, is pharmacological treatment, which should be tailored to each patient's specific phenotype. Therefore, it is pivotal to assess nonadherence to pharmacological treatment as this remains the most challenging problem to investigate and manage in the setting of resistant hypertension. RESULTS Once adherence has been confirmed, patients must be thoroughly worked-up for secondary causes of hypertension. Until such possible specific causes have been clarified, the diagnosis is apparent treatment-resistant hypertension (TRH). Surprisingly few patients remain with true TRH when the various secondary causes and adherence problems have been detected and resolved. Refractory hypertension is a term used to characterize the treatment resistance in hypertensive patients using ≥5 antihypertensive drugs. All pressor mechanisms may then need blockage before their BPs are reasonably controlled. CONCLUSIONS Patients with resistant hypertension need careful and sustained follow-up and review of their medications and dosages at each term since medication adherence is a very dynamic process.
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Affiliation(s)
- Fadl Elmula M Fadl Elmula
- Division of Medicine, Ullevaal University Hospital, Cardiorenal Research Centre, Oslo, Norway
- Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, KSA
| | | | - Sondre Heimark
- Division of Medicine, Ullevaal University Hospital, Cardiorenal Research Centre, Oslo, Norway
- Medical Faculty, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Nephrology, Ullevaal University Hospital, Oslo, Norway
| | - Sverre E Kjeldsen
- Division of Medicine, Ullevaal University Hospital, Cardiorenal Research Centre, Oslo, Norway
- Medical Faculty, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Ullevaal University Hospital, Oslo, Norway
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Baral N, Volgman AS, Seri A, Chelikani V, Isa S, Javvadi SLP, Paul TK, Mitchell JD. Adding Pharmacist-Led Home Blood Pressure Telemonitoring to Usual Care for Blood Pressure Control: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 203:161-168. [PMID: 37499595 DOI: 10.1016/j.amjcard.2023.06.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/23/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023]
Abstract
Health systems have been quickly adopting telemedicine throughout the United States, especially since the onset of the COVID-19 pandemic. However, there are limited data on whether adding pharmacist-led home blood pressure (BP) telemonitoring to office-based usual care improves BP. We searched PubMed/MEDLINE and Embase for randomized controlled trials from January 2000 until April 2022, comparing studies on pharmacist-led home BP telemonitoring with usual care. Six randomized controlled trials, including 1,550 participants, satisfied the inclusion criteria. There were 774 participants in the pharmacist-led telemonitoring group and 776 in the usual care group. The addition of pharmacist-led telemonitoring to usual care was associated with a significant decrease in systolic BP (mean difference -8.09, 95% confidence interval -11.15 to -5.04, p <0.001, I2 = 72%) and diastolic BP (mean difference -4.19, 95% confidence interval -5.58 to -2.81, p <0.001, I2 = 42%) compared with usual care. In conclusion, this meta-analysis showed that adding pharmacist-led home BP telemonitoring to usual care achieves better BP control than usual care alone.
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Affiliation(s)
- Nischit Baral
- Department of Internal Medicine, McLaren Flint, Michigan State University College of Human Medicine, Flint, Michigan
| | - Annabelle Santos Volgman
- Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Amith Seri
- Department of Internal Medicine, McLaren Flint, Michigan State University College of Human Medicine, Flint, Michigan
| | - Vijaya Chelikani
- Department of Internal Medicine, McLaren Flint, Michigan State University College of Human Medicine, Flint, Michigan
| | - Sakiru Isa
- Department of Internal Medicine, McLaren Flint, Michigan State University College of Human Medicine, Flint, Michigan
| | - Sri L P Javvadi
- Department of Internal Medicine, McLaren Flint, Michigan State University College of Human Medicine, Flint, Michigan
| | - Timir K Paul
- Department of Cardiovascular Sciences, University of Tennessee College of Medicine Nashville, Ascension St. Thomas Hospital, Nashville, Tennessee
| | - Joshua D Mitchell
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
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Pfoh ER, Dalton J, Jones R, Rothberg M. Long-term Outcomes of a 1-year Hypertension Quality Improvement Initiative in a Large Health System. Med Care 2023; 61:165-172. [PMID: 36728492 PMCID: PMC10011969 DOI: 10.1097/mlr.0000000000001813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Understanding whether practices retain outcomes attained during a quality improvement (QI) initiative can inform resource allocation. OBJECTIVE We report blood pressure (BP) control and medication intensification in the 3 years after a 2016 QI initiative ended. RESEARCH DESIGN Retrospective cohort. SUBJECTS Adults with a diagnosis of hypertension who had a primary care visit in a large-integrated health system between 2015 and 2019. MEASURES We report BP control (<140/90 mm Hg) at the last reading of each year. We used a multilevel regression to identify the adjusted propensity to receive medication intensification among patients with an elevated BP in the first half of the year. To examine variation, we identified the average predicted probability of control for each practice. Finally, we grouped practices by the proportion of their patients whose BP was controlled in 2016: lowest performing (<75%), middle (≥75%-<85%), and highest performing (≥85%). RESULTS The dataset contained 184,981 patients. From 2015 to 2019, the percentage of patients in control increased from 74% to 82%. In 2015, 38% of patients with elevated BP received medication intensification. This increased to 44% in 2016 and 50% in 2019. Practices varied in average BP control (from 62% to 91% in 2016 and 68% to 90% in 2019). All but one practice had a substantial increase from 2015 to 2016. Most maintained the gains through 2019. Higher-performing practices were more likely to intensify medications than lower-performing practices. CONCLUSIONS Most practices maintained gains 3 years after the QI program ended. Low-performing practices should be the focus of QI programs.
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Affiliation(s)
- Elizabeth R. Pfoh
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio
| | - Jarrod Dalton
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Robert Jones
- Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio
| | - Michael Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio
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Meador M, Coronado F, Roy D, Bay RC, Lewis JH, Chen J, Cheung R, Utman C, Hannan JA. Impact of COVID-19-related care disruptions on blood pressure management and control in community health centers. BMC Public Health 2022; 22:2295. [PMID: 36476418 PMCID: PMC9730629 DOI: 10.1186/s12889-022-14763-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Uncontrolled hypertension is a leading risk factor for cardiovascular disease. To ensure continuity of care, community health centers (CHCs) nationwide implemented virtual care (telehealth) during the pandemic. CHCs use the Centers for Medicare & Medicaid Services (CMS) 165v8 Controlling High Blood Pressure measure to report blood pressure (BP) control performance. CMS 165v8 specifications state that if no BP is documented during the measurement period, the patient's BP is assumed uncontrolled. METHODS To examine trends in BP documentation and control rates in CHCs as telehealth use increased during the pandemic compared with pre-pandemic period, we assessed documentation of BP measurement and BP control rates from December 2019 - October 2021 among persons ages 18-85 with a diagnosis of hypertension who had an in-person or telehealth encounter in 11 CHCs. Rates were compared between CHCs that did and did not implement self-measured BP monitoring (SMBP). RESULTS The percent of patients with hypertension with no documented BP measurement was 0.5% in December 2019 and increased to 15.2% (overall), 25.6% (non-SMBP CHCs), and 11.2% (SMBP CHCs) by October 2021. BP control using CMS 165v8 was 63.5% in December 2019 and decreased to 54.9% (overall), 49.1% (non-SMBP), and 57.2% (SMBP) by October 2021. When assessing BP control only in patients with documented BP measurements, CHCs largely maintained BP control rates (63.8% in December 2019; 64.8% (overall), 66.0% (non-SMBP), and 64.4% (SMBP) by October 2021). CONCLUSIONS The transition away from in-person to telehealth visits during the pandemic likely increased the number of patients with hypertension lacking a documented BP measurement, subsequently negatively impacting BP control using CMS 165v8. There is an urgent need to enhance the flexibility of virtual care, improve EHR data capture capabilities for patient-generated data, and implement expanded policy and systems-level changes for SMBP, an evidence-based strategy that can build patient trust, increase healthcare engagement, and improve hypertension outcomes.
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Affiliation(s)
- Margaret Meador
- grid.475992.40000 0000 8526 7986Director of Clinical Integration and Education, National Association of Community Health Centers, Bethesda, MD USA
| | - Fátima Coronado
- grid.416738.f0000 0001 2163 0069Associate Director for Science, Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Debosree Roy
- grid.251612.30000 0004 0383 094XPost-doctoral Research Scholar, Department of Public Health, A.T. Still University-School of Osteopathic Medicine in Arizona, Mesa, AZ USA
| | - R. Curtis Bay
- grid.251612.30000 0004 0383 094XProfessor, Biostatistics, Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ USA
| | - Joy H. Lewis
- grid.251612.30000 0004 0383 094XProfessor of Medicine and Public Health; Chair, Department of Public Health, A.T. Still University-School of Osteopathic Medicine in Arizona, Mesa, AZ USA
| | - Jessica Chen
- Quality Improvement Program Manager, The Health Federation of Philadelphia, Philadelphia, PA USA
| | - Rachel Cheung
- Manager of Quality, Esperanza Health Centers, Chicago, IL USA
| | | | - Judith A. Hannan
- grid.416738.f0000 0001 2163 0069Million Hearts® Senior Advisor, Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA USA
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Addressing Hypertension Outcomes Using Telehealth and Population Health Managers: Adaptations and Implementation Considerations. Curr Hypertens Rep 2022; 24:267-284. [PMID: 35536464 PMCID: PMC9087161 DOI: 10.1007/s11906-022-01193-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2022] [Indexed: 01/13/2023]
Abstract
Purpose of Review There is a growing evidence base describing population health approaches to improve blood pressure control. We reviewed emerging trends in hypertension population health management and present implementation considerations from an intervention called Team-supported, Electronic health record-leveraged, Active Management (TEAM). By doing so, we highlight the role of population health managers, practitioners who use population level data and to proactively engage at-risk patients, in improving blood pressure control. Recent Findings Within a population health paradigm, we discuss telehealth-delivered approaches to equitably improve hypertension care delivery. Additionally, we explore implementation considerations and complementary features of team-based, telehealth-delivered, population health management. By leveraging the unique role and expertise of a population health manager as core member of team-based telehealth, health systems can implement a cost-effective and scalable intervention that addresses multi-level barriers to hypertension care delivery. Summary We describe the literature of telehealth-based population health management for patients with hypertension. Using the TEAM intervention as a case study, we then present implementation considerations and intervention adaptations to integrate a population health manager within the health care team and effectively manage hypertension for a defined patient population. We emphasize practical considerations to inform implementation, scaling, and sustainability. We highlight future research directions to advance the field and support translational efforts in diverse clinical and community contexts.
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Tajeu GS, Tsipas S, Rakotz M, Wozniak G. Cost-Effectiveness of Recommendations From the Surgeon General's Call-to-Action to Control Hypertension. Am J Hypertens 2022; 35:225-231. [PMID: 34661634 DOI: 10.1093/ajh/hpab162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/08/2021] [Indexed: 12/15/2022] Open
Abstract
In response to high prevalence of hypertension and suboptimal rates of blood pressure (BP) control in the United States, the Surgeon General released a Call-to-Action to Control Hypertension (Call-to-Action) in the fall of 2020 to address the negative consequences of uncontrolled BP. In addition to morbidity and mortality associated with hypertension, hypertension has an annual cost to the US healthcare system of $71 billion. The Call-to-Action makes recommendations for improving BP control, and the purpose of this review was to summarize the literature on the cost-effectiveness of these strategies. We identified a number of studies that demonstrate the cost saving or cost-effectiveness of recommendations in the Call-to-Action including strategies to promote access to and availability of physical activity opportunities and healthy food options within communities, advance the use of standardized treatment approaches and guideline-recommended care, to promote the use of healthcare teams to manage hypertension, and to empower and equip patients to use self-measured BP monitoring and medication adherence strategies. While the current review identified numerous cost-effective methods to achieve the Surgeon General's recommendations for improving BP control, future work should determine the cost-effectiveness of the 2017 American College of Cardiology and American Heart Association Hypertension guidelines, interventions to lower therapeutic inertia, and optimal team-based care strategies, among other areas of research. Economic evaluation studies should also be prioritized to generate more comprehensive data on how to provide efficient and high value care to improve BP control.
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Affiliation(s)
- Gabriel S Tajeu
- Department of Health Services Administration and Policy, Temple University, Philadelphia, Pennsylvania, USA
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Zheutlin AR, Mondesir FL, Derington CG, King JB, Zhang C, Cohen JB, Berlowitz DR, Anstey DE, Cushman WC, Greene TH, Ogedegbe O, Bress AP. Analysis of Therapeutic Inertia and Race and Ethnicity in the Systolic Blood Pressure Intervention Trial: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2143001. [PMID: 35006243 PMCID: PMC8749480 DOI: 10.1001/jamanetworkopen.2021.43001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022] Open
Abstract
Importance Therapeutic inertia may contribute to racial and ethnic differences in blood pressure (BP) control. Objective To determine the association between race and ethnicity and therapeutic inertia in the Systolic Blood Pressure Intervention Trial (SPRINT). Design, Setting, and Participants This cross-sectional study was a secondary analysis of data from SPRINT, a randomized clinical trial comparing intensive (<120 mm Hg) vs standard (<140 mm Hg) systolic BP treatment goals. Participants were enrolled between November 8, 2010, and March 15, 2013, with a median follow-up 3.26 years. Participants included adults aged 50 years or older at high risk for cardiovascular disease but without diabetes, previous stroke, or heart failure. The present analysis was restricted to participant visits with measured BP above the target goal. Analyses for the present study were performed in from October 2020 through March 2021. Exposures Self-reported race and ethnicity, mutually exclusively categorized into groups of Hispanic, non-Hispanic Black, or non-Hispanic White participants. Main Outcomes and Measures Therapeutic inertia, defined as no antihypertensive medication intensification at each study visit where the BP was above target goal. The association between self-reported race and ethnicity and therapeutic inertia was estimated using generalized estimating equations and stratified by treatment group. Antihypertensive medication use was assessed with pill bottle inventories at each visit. Blood pressure was measured using an automated device. Results A total of 8556 participants, including 4141 in the standard group (22 844 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1467 women [35.4%]) and 4415 in the intensive group (35 453 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1584 women [35.9%]) with at least 1 eligible study visit were included in the present analysis. Among non-Hispanic White, non-Hispanic Black, and Hispanic participants, the overall prevalence of therapeutic inertia in the standard vs intensive groups was 59.8% (95% CI, 58.9%-60.7%) vs 56.0% (95% CI, 55.2%-56.7%), 56.8% (95% CI, 54.4%-59.2%) vs 54.5% (95% CI, 52.4%-56.6%), and 59.7% (95% CI, 56.5%-63.0%) vs 51.0% (95% CI, 47.4%-54.5%), respectively. The adjusted odds ratios in the standard and intensive groups for therapeutic inertia associated with non-Hispanic Black vs non-Hispanic White participants were 0.85 (95% CI, 0.79-0.92) and 0.94 (95% CI, 0.88-1.01), respectively. The adjusted odds ratios for therapeutic inertia comparing Hispanic vs non-Hispanic White participants were 1.00 (95% CI, 0.90-1.13) and 0.89 (95% CI, 0.79-1.00) in the standard and intensive groups, respectively. Conclusions and Relevance Among SPRINT participants above BP target goal, this cross-sectional study found that therapeutic inertia prevalence was similar or lower for non-Hispanic Black and Hispanic participants compared with non-Hispanic White participants. These findings suggest that a standardized approach to BP management, as used in SPRINT, may help ensure equitable care and could reduce the contribution of therapeutic inertia to disparities in hypertension. Trial Registration ClinicalTrials.gov identifier: NCT01206062.
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Affiliation(s)
- Alexander R. Zheutlin
- Department of Internal Medicine, University of Utah, School of Medicine, Salt Lake City
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City
| | - Favel L. Mondesir
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts
| | - Catherine G. Derington
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City
| | - Jordan B. King
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Chong Zhang
- Department of Internal Medicine, University of Utah, School of Medicine, Salt Lake City
| | - Jordana B. Cohen
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Dan R. Berlowitz
- Department of Public Health, University of Massachusetts-Lowell, Lowell
| | - D. Edmund Anstey
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - William C. Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
- Medical Service, Memphis VA Medical Center, Memphis, Tennessee
| | - Tom H. Greene
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City
| | - Olugbenga Ogedegbe
- Center for Healthful Behavior Change, Division of Health and Behavior, Department of Population Health, New York University School of Medicine, New York, New York
| | - Adam P. Bress
- Department of Population Health Sciences, University of Utah, School of Medicine, Salt Lake City
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Lee YS, Lee HY, Kim TH. Cost-effectiveness analysis of intensive blood pressure control in Korea. Hypertens Res 2021; 45:507-515. [PMID: 34934160 DOI: 10.1038/s41440-021-00774-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/10/2021] [Accepted: 09/04/2021] [Indexed: 01/09/2023]
Abstract
This study was a cost-effectiveness analysis of intensive blood pressure (BP) control among hypertensive patients in Korea. We constructed a Markov model comparing intensive versus standard BP control treatment and calculated the incremental cost-effectiveness ratio. The study population consisted of hypertensive patients over 50 years old with systolic blood pressures (SBPs) exceeding 140 mmHg and at high risk of cardiovascular disease. Treatment alternatives included lowering the SBP below 120 mmHg (intensive) and 140 mmHg (standard) for target BP. We assumed five scenarios with different medication adherence. The effectiveness variable was quality-adjusted life years (QALYs), and costs included medical costs related to hypertension (HT), complications, and nonmedical costs. In addition, we performed a sensitivity analysis to confirm the robustness of the results of this study. Scenario 5, with 100% medication adherence, showed the lowest incremental cost-effectiveness ratio (ICER) of $1,373 USD, followed by scenario 1 (first 15 years: 62.5%, 16-30 years: 65.2%, after 30 years: 59.5%), scenario 2 (first five years: 62.5% decrease by 5% every five years), and scenario 3 (first 10 years: 62.5% decrease by 10% every 10 years). The ICERs in all scenarios were lower than the willingness to pay (WTP) threshold of $9,492-$32,907 USD in Korea. Tornado analysis showed that the ICERs were changed greatly according to stroke incidence. Intensive treatment of HT prevents cardiovascular disease (CVD); therefore, intensive treatment is more cost-effective than standard treatment despite the consumption of more health resources. ICERs are considerably changed according to medication adherence, confirming the importance of patient adherence to treatment.
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Affiliation(s)
- Ye Seol Lee
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.,National Traffic Injury Rehabilitation Research Institute, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Division of Cardiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae Hyun Kim
- Department of Healthcare Management, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea.
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Santschi V, Wuerzner G, Pais B, Chiolero A, Schaller P, Cloutier L, Paradis G, Burnier M. Team-Based Care for Improving Hypertension Management: A Pragmatic Randomized Controlled Trial. Front Cardiovasc Med 2021; 8:760662. [PMID: 34760950 PMCID: PMC8572997 DOI: 10.3389/fcvm.2021.760662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/30/2021] [Indexed: 12/20/2022] Open
Abstract
Objective: We evaluated the effect on long term blood pressure (BP) of an interprofessional team-based care (TBC) intervention, involving nurses, pharmacists, and physicians, compared to usual care. Methods: We conducted a pragmatic randomized controlled study in ambulatory clinics and community pharmacies in Switzerland (ClinicalTrials.gov: NCT02511093). Uncontrolled treated hypertensive patients were randomized to TBC or usual care (UC). In the TBC group, nurses and pharmacists met patients every 6 weeks to measure BP, assess lifestyle, support medication adherence, and provide health education for 6 months. After each visit, they wrote a report to the physician who could adjust antihypertensive therapy. The outcome was the intention-to-treat difference in mean daytime ambulatory blood pressure measurement (ABPM) and control (<135/85 mmHg) at 6 and 12 months. Results: Eighty-nine patients (60 men/29 women; mean (SD) age: 61(12) year) were randomized to TBC (n = 43) or UC (n = 46). At baseline, mean (SD) BP was 144(10)/90(8) mmHg and 147(12)/87(11) mmHg in the TBC and UC groups. At 6 months, the between-groups difference in daytime systolic ABPM was−3 mmHg [95% confidence interval (CI):−10 to +4; p = 0.45]; at 12 months, this difference was−7 mmHg [95% CI:−13 to−2; p = 0.01]. At 6 months, the between-groups difference in daytime diastolic ABPM was +2 mmHg [95% CI:−1 to +6; p = 0.20]; at 12 months, this difference was−2 mmHg [95% CI:−5 to +2; 0.42]. Upon adjustment for baseline covariates including baseline BP, the between-groups differences at 6 and 12 months were maintained. At 6 months, there was no difference in BP control. At 12 months, the TBC group tended to have a better control in systolic BP (p = 0.07) but not in diastolic BP (p = 0.33). Conclusion: While there was not significant effect on BP at 6 months of follow-up, the TBC intervention can help decrease long-term systolic BP among uncontrolled hypertensive patients.
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Affiliation(s)
- Valérie Santschi
- La Source, School of Nursing Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Bruno Pais
- La Source, School of Nursing Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Arnaud Chiolero
- Population Health Laboratory, #PopHealthLab, University of Fribourg, Fribourg, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,School of Population and Global Health, McGill University, Montreal, QC, Canada
| | | | - Lyne Cloutier
- Département des sciences infirmières, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Gilles Paradis
- School of Population and Global Health, McGill University, Montreal, QC, Canada
| | - Michel Burnier
- Service of Nephrology and Hypertension, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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11
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Bress AP, Cohen JB, Anstey DE, Conroy MB, Ferdinand KC, Fontil V, Margolis KL, Muntner P, Millar MM, Okuyemi KS, Rakotz MK, Reynolds K, Safford MM, Shimbo D, Stuligross J, Green BB, Mohanty AF. Inequities in Hypertension Control in the United States Exposed and Exacerbated by COVID-19 and the Role of Home Blood Pressure and Virtual Health Care During and After the COVID-19 Pandemic. J Am Heart Assoc 2021; 10:e020997. [PMID: 34006116 PMCID: PMC8483507 DOI: 10.1161/jaha.121.020997] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The COVID‐19 pandemic is a public health crisis, having killed more than 514 000 US adults as of March 2, 2021. COVID‐19 mitigation strategies have unintended consequences on managing chronic conditions such as hypertension, a leading cause of cardiovascular disease and health disparities in the United States. During the first wave of the pandemic in the United States, the combination of observed racial/ethnic inequities in COVID‐19 deaths and social unrest reinvigorated a national conversation about systemic racism in health care and society. The 4th Annual University of Utah Translational Hypertension Symposium gathered frontline clinicians, researchers, and leaders from diverse backgrounds to discuss the intersection of these 2 critical social and public health phenomena and to highlight preexisting disparities in hypertension treatment and control exacerbated by COVID‐19. The discussion underscored environmental and socioeconomic factors that are deeply embedded in US health care and research that impact inequities in hypertension. Structural racism plays a central role at both the health system and individual levels. At the same time, virtual healthcare platforms are being accelerated into widespread use by COVID‐19, which may widen the divide in healthcare access across levels of wealth, geography, and education. Blood pressure control rates are declining, especially among communities of color and those without health insurance or access to health care. Hypertension awareness, therapeutic lifestyle changes, and evidence‐based pharmacotherapy are essential. There is a need to improve the implementation of community‐based interventions and blood pressure self‐monitoring, which can help build patient trust and increase healthcare engagement.
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Affiliation(s)
- Adam P Bress
- Department of Population Health Sciences Division of Health System Innovation and Research University of Utah School of Medicine Salt Lake City UT
| | - Jordana B Cohen
- Department of Medicine Renal-Electrolyte and Hypertension Division Perelman School of Medicine at the University of Pennsylvania Philadelphia PA.,Department of Biostatistics, Epidemiology, and Informatics Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - David Edmund Anstey
- Division of Cardiology Department of Medicine Columbia University Medical Center New York NY
| | - Molly B Conroy
- Division of General Internal Medicine, Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | | | - Valy Fontil
- Division of General Internal Medicine Department of Medicine Zuckerberg San Francisco General HospitalUniversity of California San Francisco CA.,Center for Vulnerable Populations Zuckerberg San Francisco General HospitalUniversity of California San Francisco CA
| | | | - Paul Muntner
- Department of Epidemiology School of Public Health University of Alabama at Birmingham Birmingham AL
| | - Morgan M Millar
- Division of General Internal Medicine, Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT
| | - Kolawole S Okuyemi
- Department of Family & Preventive Medicine University of Utah School of Medicine Salt Lake City UT
| | | | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA Pasadena CA.,Kaiser Permanente Bernard J. Tyson School of Medicine Pasadena CA
| | - Monika M Safford
- Department of Medicine Joan and Sanford I Weill Medical College of Cornell University New York NY
| | - Daichi Shimbo
- Division of Cardiology Department of Medicine Columbia University Medical Center New York NY
| | | | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute Seattle WA
| | - April F Mohanty
- Division of General Internal Medicine, Department of Internal Medicine University of Utah School of Medicine Salt Lake City UT.,Informatics Decision-Enhancement, and Analytic Sciences Center (IDEAS) VA Salt Lake City Health Care System Salt Lake City UT
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