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Rakers M, van Hattem N, Plag S, Chavannes N, van Os HJA, Vos RC. Population health interventions for cardiometabolic diseases in primary care: a scoping review and RE-AIM evaluation of current practices. Front Med (Lausanne) 2024; 10:1275267. [PMID: 38239619 PMCID: PMC10794664 DOI: 10.3389/fmed.2023.1275267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/13/2023] [Indexed: 01/22/2024] Open
Abstract
Introduction Cardiometabolic diseases (CMD) are the leading cause of death in high-income countries and are largely attributable to modifiable risk factors. Population health management (PHM) can effectively identify patient subgroups at high risk of CMD and address missed opportunities for preventive disease management. Guided by the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework, this scoping review of PHM interventions targeting patients in primary care at increased risk of CMD aims to describe the reported aspects for successful implementation. Methods A comprehensive search was conducted across 14 databases to identify papers published between 2000 and 2023, using Arksey and O'Malley's framework for conducting scoping reviews. The RE-AIM framework was used to assess the implementation, documentation, and the population health impact score of the PHM interventions. Results A total of 26 out of 1,100 studies were included, representing 21 unique PHM interventions. This review found insufficient reporting of most RE-AIM components. The RE-AIM evaluation showed that the included interventions could potentially reach a large audience and achieve their intended goals, but information on adoption and maintenance was often lacking. A population health impact score was calculated for six interventions ranging from 28 to 62%. Discussion This review showed the promise of PHM interventions that could reaching a substantial number of participants and reducing CMD risk factors. However, to better assess the generalizability and scalability of these interventions there is a need for an improved assessment of adoption, implementation processes, and sustainability.
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Affiliation(s)
- Margot Rakers
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, Netherlands
| | - Nicoline van Hattem
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, Netherlands
| | - Sabine Plag
- Health Campus the Hague, Leiden University Medical Center, The Hague, Netherlands
| | - Niels Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, Netherlands
| | - Hendrikus J. A. van Os
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, Netherlands
| | - Rimke C. Vos
- Health Campus the Hague, Leiden University Medical Center, The Hague, Netherlands
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Karalis DG. Strategies of improving adherence to lipid-lowering therapy in patients with atherosclerotic cardiovascular disease. Curr Opin Lipidol 2023; 34:252-258. [PMID: 37594008 DOI: 10.1097/mol.0000000000000896] [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] [Indexed: 08/19/2023]
Abstract
PURPOSE OF REVIEW Lowering LDL-C has been shown to reduce ASCVD events, yet many ASCVD patients do not achieve their guideline-directed LDL-C goals leaving patients at increased risk of another ASCVD event. This review discusses implementation strategies to improve guideline-directed lipid management in patients with ASCVD focusing on the provider, patient, and system level. RECENT FINDINGS At a provider level, under-prescribing of statin intensity due most often to statin intolerance, clinical inertia, insufficient monitoring of LDL-C levels, and the difficulty and cost of prescribing other lipid-lowering therapies such as the PCSK9 inhibitors leads to suboptimal cholesterol management in ASCVD patients. Patients concerns about medication side effects and lack of understanding of their ASCVD risk are causes of poor adherence to their lipid-lowering therapy as are barriers at a system level. SUMMARY To improve cholesterol management in ASCVD patients will require an integrated approach targeting the provider, the patient and the system. There is a need for further education of clinicians on the importance of intensive LDL-C lowering in ASCVD patients and greater use of nonstatin LDL-C-lowering therapies for those patients on a maximally tolerated statin who have not achieved their guideline-directed LDL-C goal. This will require shared decision-making with a focus on patient education and patient-clinician communication so that the clinician's goals and aims align with that of the patient.
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Affiliation(s)
- Dean G Karalis
- From the Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Berman AN, Ginder C, Wang XS, Borden L, Hidrue MK, Searl Como JM, Daly D, Sun YP, Curry WT, Del Carmen M, Morrow DA, Scirica B, Choudhry NK, Januzzi JL, Wasfy JH. A pragmatic clinical trial assessing the effect of a targeted notification and clinical support pathway on the diagnostic evaluation and treatment of individuals with left ventricular hypertrophy (NOTIFY-LVH). Am Heart J 2023; 265:40-49. [PMID: 37454754 DOI: 10.1016/j.ahj.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Electronic health records contain vast amounts of cardiovascular data, including potential clues suggesting unrecognized conditions. One important example is the identification of left ventricular hypertrophy (LVH) on echocardiography. If the underlying causes are untreated, individuals are at increased risk of developing clinically significant pathology. As the most common cause of LVH, hypertension accounts for more cardiovascular deaths than any other modifiable risk factor. Contemporary healthcare systems have suboptimal mechanisms for detecting and effectively implementing hypertension treatment before downstream consequences develop. Thus, there is an urgent need to validate alternative intervention strategies for individuals with preexisting-but potentially unrecognized-LVH. METHODS Through a randomized pragmatic trial within a large integrated healthcare system, we will study the impact of a centralized clinical support pathway on the diagnosis and treatment of hypertension and other LVH-associated diseases in individuals with echocardiographic evidence of concentric LVH. Approximately 600 individuals who are not treated for hypertension and who do not have a known cardiomyopathy will be randomized. The intervention will be directed by population health coordinators who will notify longitudinal clinicians and offer to assist with the diagnostic evaluation of LVH. Our hypothesis is that an intervention that alerts clinicians to the presence of LVH will increase the detection and treatment of hypertension and the diagnosis of alternative causes of thickened myocardium. The primary outcome is the initiation of an antihypertensive medication. Secondary outcomes include new hypertension diagnoses and new cardiomyopathy diagnoses. The trial began in March 2023 and outcomes will be assessed 12 months from the start of follow-up. CONCLUSION The NOTIFY-LVH trial will assess the efficacy of a centralized intervention to improve the detection and treatment of hypertension and LVH-associated diseases. Additionally, it will serve as a proof-of-concept for how to effectively utilize previously collected electronic health data to improve the recognition and management of a broad range of chronic cardiovascular conditions. TRIAL REGISTRATION NCT05713916.
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Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Massachusetts General Physicians Organization, Boston, MA
| | - Curtis Ginder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Xianghong S Wang
- Division of Performance Analysis and Improvement, Massachusetts General Physicians Organization, Boston, MA
| | - Linnea Borden
- Massachusetts General Physicians Organization, Boston, MA
| | - Michael K Hidrue
- Division of Performance Analysis and Improvement, Massachusetts General Physicians Organization, Boston, MA
| | | | - Danielle Daly
- Massachusetts General Physicians Organization, Boston, MA
| | - Yee-Ping Sun
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - William T Curry
- Massachusetts General Physicians Organization, Boston, MA; Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Marcela Del Carmen
- Massachusetts General Physicians Organization, Boston, MA; Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David A Morrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin Scirica
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Niteesh K Choudhry
- Department of Medicine, Center for Healthcare Delivery Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James L Januzzi
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Heart Failure and Biomarker Trials, Baim Institute for Clinical Research, Boston, MA
| | - Jason H Wasfy
- Massachusetts General Physicians Organization, Boston, MA; Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Sithole N, Castle A, Nxumalo S, Mazibuko L, Manyaapelo T, Abrahams-Gessel S, Dlamini S, Gareta D, Orne-Gliemann J, Baisley K, Bachmann M, Magula N, Gaziano TA, Siedner MJ. Protocol: Implementation evaluation of a combination intervention for sustainable blood pressure control in rural KwaZulu-Natal, South Africa (IMPACT BP): A three-arm, unblinded, parallel group individually randomized clinical trial. Contemp Clin Trials 2023; 131:107258. [PMID: 37308076 PMCID: PMC10527603 DOI: 10.1016/j.cct.2023.107258] [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] [Received: 04/18/2023] [Revised: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Hypertension is the primary risk factor for stroke and heart disease, which are leading causes of death in South Africa. Despite the availability of treatments, there is an implementation gap in how best to deliver hypertension care in this resource-limited region. METHODS We describe a three-arm parallel group individually randomized control trial to evaluate the effectiveness and implementation of a technology-supported, community-based intervention to improve blood pressure control among people with hypertension in rural KwaZulu-Natal. The study will compare three strategies: 1) standard of care (SOC arm) clinic-based management, 2) home-based blood pressure management supported by community blood pressure monitors (CBPM arm) and a mobile health application to record blood pressure readings and enable clinic-based nurses to remotely manage care, and 3) an identical strategy to the CBPM arm, except that participants will use a cellular blood pressure cuff, which automatically transmits completed readings over cellular networks directly to clinic-based nurses (eCBPM+ arm). The primary effectiveness outcome is change in blood pressure from enrollment to 6 months. The secondary effectiveness outcome is the proportion of participants with blood pressure control at 6 months. Acceptability, fidelity, sustainability, and cost-effectiveness of the interventions will also be assessed. CONCLUSIONS In this protocol, we report the development of interventions in partnership with the South Africa Department of Health, a description of the technology-enhanced interventions, and details of the study design so that our intervention and evaluation can inform similar efforts in rural, resource-limited settings. PROTOCOL Version 3 November 9th, 2022. CLINICALTRIALS gov Trial Registration: NCT05492955 SAHPRA Trial Number: N20211201. SANCTR Number: DOH-27-112,022-4895.
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Affiliation(s)
- Nsika Sithole
- Africa Health Research Institute, KwaZulu-Natal, South Africa.
| | - Alison Castle
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | | | | | | | | | | | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Joanna Orne-Gliemann
- University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Nombulelo Magula
- Division of Internal Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Thomas A Gaziano
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Harvard TH Chan School of Public Health, Boston, MA, United States of America
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Division of Internal Medicine, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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Blood AJ, Cannon CP, Gordon WJ, Mailly C, MacLean T, Subramaniam S, Tucci M, Crossen J, Nichols H, Wagholikar KB, Zelle D, McPartlin M, Matta LS, Oates M, Aronson S, Murphy S, Landman A, Fisher NDL, Gaziano TA, Plutzky J, Scirica BM. Results of a Remotely Delivered Hypertension and Lipid Program in More Than 10 000 Patients Across a Diverse Health Care Network. JAMA Cardiol 2023; 8:12-21. [PMID: 36350612 PMCID: PMC9647559 DOI: 10.1001/jamacardio.2022.4018] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/02/2022] [Indexed: 11/11/2022]
Abstract
Importance Blood pressure (BP) and cholesterol control remain challenging. Remote care can deliver more effective care outside of traditional clinician-patient settings but scaling and ensuring access to care among diverse populations remains elusive. Objective To implement and evaluate a remote hypertension and cholesterol management program across a diverse health care network. Design, Setting, and Participants Between January 2018 and July 2021, 20 454 patients in a large integrated health network were screened; 18 444 were approached, and 10 803 were enrolled in a comprehensive remote hypertension and cholesterol program (3658 patients with hypertension, 8103 patients with cholesterol, and 958 patients with both). A total of 1266 patients requested education only without medication titration. Enrolled patients received education, home BP device integration, and medication titration. Nonlicensed navigators and pharmacists, supported by cardiovascular clinicians, coordinated care using standardized algorithms, task management and automation software, and omnichannel communication. BP and laboratory test results were actively monitored. Main Outcomes and Measures Changes in BP and low-density lipoprotein cholesterol (LDL-C). Results The mean (SD) age among 10 803 patients was 65 (11.4) years; 6009 participants (56%) were female; 1321 (12%) identified as Black, 1190 (11%) as Hispanic, 7758 (72%) as White, and 1727 (16%) as another or multiple races (including American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, unknown, other, and declined to respond; consolidated owing to small numbers); and 142 (11%) reported a preferred language other than English. A total of 424 482 BP readings and 139 263 laboratory reports were collected. In the hypertension program, the mean (SD) office BP prior to enrollment was 150/83 (18/10) mm Hg, and the mean (SD) home BP was 145/83 (20/12) mm Hg. For those engaged in remote medication management, the mean (SD) clinic BP 6 and 12 months after enrollment decreased by 8.7/3.8 (21.4/12.4) and 9.7/5.2 (22.2/12.6) mm Hg, respectively. In the education-only cohort, BP changed by a mean (SD) -1.5/-0.7 (23.0/11.1) and by +0.2/-1.9 (30.3/11.2) mm Hg, respectively (P < .001 for between cohort difference). In the lipids program, patients in remote medication management experienced a reduction in LDL-C by a mean (SD) 35.4 (43.1) and 37.5 (43.9) mg/dL at 6 and 12 months, respectively, while the education-only cohort experienced a mean (SD) reduction in LDL-C of 9.3 (34.3) and 10.2 (35.5) mg/dL at 6 and 12 months, respectively (P < .001). Similar rates of enrollment and reductions in BP and lipids were observed across different racial, ethnic, and primary language groups. Conclusions and Relevance The results of this study indicate that a standardized remote BP and cholesterol management program may help optimize guideline-directed therapy at scale, reduce cardiovascular risk, and minimize the need for in-person visits among diverse populations.
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Affiliation(s)
- Alexander J. Blood
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Christopher P. Cannon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - William J. Gordon
- Harvard Medical School, Boston, Massachusetts
- Division of General Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Mass General Brigham Personalized Medicine, Boston, Massachusetts
| | - Charlotte Mailly
- Mass General Brigham Personalized Medicine, Boston, Massachusetts
| | - Taylor MacLean
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Samantha Subramaniam
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michela Tucci
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer Crossen
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Hunter Nichols
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - David Zelle
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Marian McPartlin
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lina S. Matta
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael Oates
- Mass General Brigham Personalized Medicine, Boston, Massachusetts
| | - Samuel Aronson
- Mass General Brigham Personalized Medicine, Boston, Massachusetts
| | - Shawn Murphy
- Harvard Medical School, Boston, Massachusetts
- Laboratory of Computer Science, Massachusetts General Hospital, Boston
- Department of Neurology, Massachusetts General Hospital, Boston
- Research Information Science and Computing, Mass General Brigham, Boston, Massachusetts
| | - Adam Landman
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Naomi D. L. Fisher
- Harvard Medical School, Boston, Massachusetts
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Thomas A. Gaziano
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jorge Plutzky
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Benjamin M. Scirica
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Berman AN, Wasfy JH. Translating Clinical Guidelines Into Care Delivery Innovation: The Importance of Rigorous Methods for Generating Evidence. J Am Heart Assoc 2022; 11:e026677. [PMID: 35766287 PMCID: PMC9333392 DOI: 10.1161/jaha.122.026677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital Harvard Medical School Boston MA
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