Characterizing Hypertension Specialist Care in Canada: A National Survey

Background

The hypertension specialist often receives referrals of patients with young-onset, severe, difficult-to-control hypertension, patients with hypertensive emergencies, and patients with secondary causes of hypertension. Specialist hypertension care compliments primary care for these complex patients and contributes to an overall hypertension control strategy. The objective of this study was to characterize hypertension centres and the practice patterns of Canadian hypertension specialists.

Methods

Adult hypertension specialists across Canada were surveyed to describe hypertension centres and specialist practice in Canada, including the following: the patient population managed by hypertension specialists; details on how care is provided; practice pattern variations; and differences in access to specialized hypertension resources across the country.

Results

The survey response rate was 73.5% from 25 hypertension centres. Most respondents were nephrologists and general internal medicine specialists. Hypertension centres saw between 50 and 2500 patients yearly. A mean of 17% (± 15%) of patients were referred from the emergency department and a mean of 52% (± 24%) were referred from primary care. Most centres had access to specialized testing (adrenal vein sampling, level 1 sleep studies, autonomic testing) and advanced therapies for resistant hypertension (renal denervation). Considerable heterogeneity was present in the target blood pressure in young people with low cardiovascular risk and in the diagnostic algorithms for investigating secondary causes of hypertension.

Conclusions

These results summarize the current state of hypertension specialist care and highlight opportunities for further collaboration among hypertension specialists, including standardization of the approach to specialist care for patients with hypertension.

Abstract P223: Hypertension Telemonitoring And Protocolized Case Management For Community-Dwelling Older Adults: A Randomized Controlled Trial

Background: Home blood pressure (BP) telemonitoring combined with case management leads can reduce BP in adults with hypertension. However, the benefits of telemonitoring and case management for hypertension are not well established in older (age >= 65 years) adults. Interventions that can safely improve BP control in this distinct group will be critically important, particularly given recent trials showing cardiovascular benefits of intensive BP lowering in this group, and their increased vulnerability to over-treatment-related side effects.

Methods: Twelve-month, open-label, randomized controlled trial of community-dwelling older adults comparing home BP telemonitoring (HBPM) with pharmacist-led case management versus enhanced usual care with HBPM alone. The primary outcome was the proportion achieving age-specific systolic BP targets on 24-hour ambulatory BP monitoring (ABPM). Changes in HBPM were also examined. Logistic and linear regression were used for analyses, with adjustment for baseline BP.

Results: Subjects randomized to intervention (n = 61) and control (n = 59) groups were mostly female (77%), with mean age of 79.5 years. The adjusted odds ratio (aOR) for ABPM BP target achievement was 1.48 (95% CI 0.87-2.52, p = 0.15). At 12 months, the mean difference in BP changes between intervention and control groups was -1.6/-1.1 for ABPM (p-value 0.26 for systolic and 0.10 for diastolic BP), and -4.9/-3.1 for HBPM (p-value 0.04 for systolic BP and 0.01 for diastolic BP), favoring the intervention. Intervention group subjects had a higher rate of systolic BP < 110 (21% vs 5%, p = 0.009), but no differences in orthostatic symptoms, syncope, non-mechanical falls, or ED visits. Adherence to HBPM declined by 12 months, with 65% of trial-completers providing all 4 of the study-driven 3-monthly HBPM series.

Conclusions: Home BP telemonitoring and pharmacist case management did not improve achievement of target range ambulatory BP, but did reduce home BP. It was not associated with major adverse consequences. Further trials will be necessary to refine HBPM interventions, improve adherence, and determine effectiveness in older individuals more conclusively.

Impact of Home Telemonitoring and Management Support on Blood Pressure Control in Nondialysis CKD: A Systematic Review and Meta-Analysis

Background:

Hypertension is a major cause of cardiovascular disease, chronic kidney disease (CKD), and death. Several studies have demonstrated the efficacy of home blood pressure telemonitoring (HBPT) for blood pressure (BP) control and outcomes, but the effects of this intervention remain unclear in patients with CKD.

Objective:

To determine the impact of HBPT on cardiovascular–related and kidney disease–related outcomes in patients with CKD.

Design:

Systematic review and meta-analysis.

Setting:

All studies that met our criteria regardless of country of origin.

Participants:

Patients with chronic kidney disease included in studies using HBPT for BP assessment and control.

Measurements:

Descriptive and quantitative analysis of our primary and secondary outcomes.

Methods:

We searched MEDLINE, Embase, CINAHL Plus, PsycINFO, Cochrane CENTRAL, Web of Science, and gray literature from inception for observational and randomized controlled studies in nondialysis (ND) CKD using HBPT for BP control. We selected studies that used HBPT as intervention (with or without a control arm) for BP control in ND-CKD populations. The primary outcome was change in mean systolic BP (SBP) and mean diastolic BP (DBP).

Results:

We selected 7 studies from 1669 articles that were initially identified. Overall, pooled estimates in the mean difference (MD) for SBP and DBP were −8.8 mm Hg; 95% confidence interval (CI): −16.2 to −1.4; P = .02 and −2.4 mm Hg; 95% CI: −3.8 to −1.0; P < .001, respectively. For studies comparing intervention with usual care (UC), pooled estimate in MD for SBP was −8.0 mm Hg (P = .02) with no significant reduction for DBP (−2.6 mm Hg; P = .18). In studies without a UC arm, both SBP and DBP were not significantly reduced (P > .05). The pooled estimate in MD for estimated glomerular filtration rate showed a significant improvement (5.4 mL/min/1.73 m²; P < .001).

Limitations:

Heterogeneity and few available studies for inclusion limited our ability to identify a robust link between HBPT use and BP and kidney function improvement.

Conclusion:

Home blood pressure telemonitoring is associated with mild lowering of BP and moderately improved kidney function in patients with CKD. However, larger studies with improved designs and prolonged interventions are still needed to assess the effects of HBPT on patients’ outcomes.

PROSPERO registration ID

CRD42020190705

Telemonitoring and Case Management for Hypertensive and Remote-Dwelling Patients With Chronic Kidney Disease—The Telemonitoring for Improved Kidney Outcomes Study (TIKO): A Clinical Research Protocol

Background:

Hypertension, together with poorly controlled blood pressure (BP) are known risk factors for kidney disease and progression to kidney failure as well as increased cardiovascular (CV) morbidity and mortality. Several studies in patients without kidney disease have demonstrated the efficacy of home BP telemonitoring (HBPT) for BP control.

Objective:

The primary aim of this study is to assess the mean difference in systolic BP (SBP) at 12 months, from baseline in remote dwelling patients with hypertension and chronic kidney disease (CKD) in Northern Alberta, Canada, comparing HBPT + usual care versus HBPT + a case manager. Other secondary objectives, including cost-effectiveness and acceptability of HBPT as well as occurrence of adverse events will also be assessed.

Methods

Design:

This study is designed as a pragmatic randomized controlled trial (RCT) of HBPT plus clinical case management compared to HBPT with usual care.

Setting:

Peace River region in Northern Alberta Region, Canada.

Patients:

Primary care patients with CKD and hypertension.

Measurements:

Eligible patients will be randomized 1:1 to HBPT + BP case management versus HBPT + usual care. In the intervention arm, BP will be measured 4 times daily for 1 week, with medications titrated up or down by the study case manager until guideline targets (systolic BP [SBP]: <130 mmHg) are achieved. Once BP is controlled, (ie, to guideline-concordant targets), this 1-week protocol will be repeated every 3 months for 1 year. Patients in the control arm will also follow the same BP measurement protocol; however, there will be no interactions with the case manager; they will share their BP readings with their primary care physicians or nurse practitioners at scheduled visits.

Limitations:

Potential limitations of this study include the relatively short duration of follow-up, possible technological pitfalls, and need for patients to own a smartphone and have access to the internet to participate.

Conclusions:

As this study will focus on a high-risk population that has been characterized by a large care gap, it will generate important evidence that would allow targeted and effective population-level strategies to be implemented to improve health outcomes for high-risk hypertensive CKD patients in Canada’s remote communities.

Trial Registration:

www.clinicaltrials.gov (NCT number: NCT04098354)

Optimum waveform envelopes and amplitude ratios in oscillometric blood pressure estimation

OBJECTIVE

To determine if, when using the oscillometric method, there is a specific range of amplitude ratios in the fixed-ratio algorithm that will result in blood pressure estimates that consistently fall within a mean error ≤5 mmHg and a SD of the error <8 mmHg. Additionally, to apply different representations of the oscillometric waveform envelope to verify if this will affect the accuracy of the results.

METHODS

SBP and DBP were obtained using the fixed-ratios method applied to a dataset of 219 oscillometric measurements obtained from 73 healthy volunteers and compared to their corresponding auscultation values. Ratio and envelope analysis were done on Matlab (The MathWorks, Inc., Natick, Massachusetts, USA).

RESULTS

Depending on the envelope representation, ratios between 0.44-0.74 for systolic pressure and 0.51-0.85 for diastolic pressure yield results within the limits mentioned above. When a set of optimum envelope representations and ratios are selected based on population mean, the highest percentage of subjects presenting blood pressure estimates within the limits were 72.6% for systolic and 69.9% for diastolic.

CONCLUSION

The range of ratios presenting optimum results appears to be independent of the degree of arterial stiffness given the wide range of ages of the subjects in the study. Different representations of the oscillometric waveform envelope may improve the accuracy of the method. However, there remains a considerable percentage of the population with unreliable results. It is therefore important to only use devices that have been properly validated according to standard protocol.

Barriers to learning and using point-of-care ultrasound: a survey of practicing internists in six North American institutions

Background

Point-of-care ultrasound (POCUS) is increasingly used in internal medicine, but a lack of trained faculty continues to limit the spread of POCUS education. Using a framework based on organizational change theories, this study sought to identify barriers and enablers for hospital-based practicing internists to learn and use POCUS in clinical practice.

Methods

We invited practicing internists at six North American institutions to participate in an electronic survey on their opinions regarding 39 barriers and enablers.

Results

Of the 342 participants invited, 170 participated (response rate 49.3%). The top barriers were lack of training (79%), lack of handheld ultrasound devices (78%), lack of direct supervision (65%), lack of time to perform POCUS during rounds (65%), and lack of quality assurance processes (53%). The majority of participants (55%) disagreed or strongly disagreed with the statement “My institution provides funding for POCUS training.” In general, participants’ attitudes towards POCUS were favourable, and future career opportunities and the potential for billing were not considered significant factors by our participants in the decision to learn or use POCUS.

Conclusions

This survey confirms the perceived importance of POCUS to practicing internists. To assist in closing faculty development gap, interventions should address training, supervision, quality assurance processes, availability of handheld devices, as well as dedicated time to perform POCUS during clinical care.

Correction to: Internal Medicine Point of Care Ultrasound: Indicators It's Here to Stay

This editorial, "Internal Medicine Point of Care Ultrasound: Indicators It's Here to Stay" (DOI: 10.1007/s11606-019-05268-0), was intended to accompany "Education Indicators for Internal Medicine Point-of-Care Ultrasound: a Consensus Report from the Canadian Internal Medicine Ultrasound (CIMUS) Group".

Non-pharmacologic interventions to improve sleep of medicine inpatients: a controlled study

Background: Sleep quality in hospitalized medicine patients is poor, with environmental factors among the most frequently cited reasons.

Objective: We tested the efficacy of a non-pharmacologic intervention on the sleep quality of medicine inpatients.

Design/Methods: A controlled study to evaluate our non-pharmacologic multidisciplinary ‘TUCK-in’ protocol (which includes timed lights-off periods, minimizing night-time noise, distribution of earplugs at bedtime, cued toileting before bedtime, and identification and reduction of modifiable interruptions) was deployed on two of five identical medicine wards. Randomization was at the level of the ward.

The main outcome measure was self-reported duration of night-time sleep within 48 hours prior to discharge. Additional outcome measures included the Verran–Snyder-Halpern (VSH) Sleep Score and inpatient sleep pharmaceutical use.

Results: Self-reported duration of night-time sleep (median 5.0 vs. 5.0 hours, p = 0.29) and daytime sleep (1.0 versus 0.5 hours, p = 0.43) did not differ between the 40 intervention patients and the 41 control patients (p = 0.13 on multivariate analysis). Cumulative VSH sleep disturbance (median 420 versus 359, p = 0.19), efficacy (median 169 versus 192, p = 0.29), or supplementation (median 97 versus 100, p = 0.51) scales were also not different between study arms.

Conclusions: Although staff reported the protocol to be achievable and worthwhile, there were no significant differences in any of the outcomes between intervention and control patients.​

Sleep Quality and Factors Influencing Self-Reported Sleep Duration and Quality in the General Internal Medicine Inpatient Population

BACKGROUND

Sleep quality in hospitalized Canadian General Internal Medicine patients is not well characterized. Our goals were to characterize hospital sleep quality in this population and identify potentially modifiable barriers to good sleep.

METHODS

GIM inpatients at a quaternary centre in Edmonton, Canada completed a survey, including the Verran-Snyder Halpern (VSH) questionnaire, to characterize the previous night's sleep within 48 hours prior to discharge. A chart review was also completed to assess comorbidities, discharge diagnoses, and pharmaceutical sleep aid use.

RESULTS

Patients reported significantly worse nighttime sleep duration in hospital compared with home (mean 5.5 versus 7.0 hours per night, p < 0.0001). Sleep quality was poor, as measured by the VSH disturbance (mean 371), effectiveness (190), and supplementation (115) subscales. Variables independently associated with poorer sleep duration in multivariable regression include prior diagnosis of sleep disorder and multi-patient occupancy rooms. Age, sex, admitting diagnosis, length of stay, frequency of vital checks, and use of sleep pharmaceuticals during the index hospitalization were not associated with sleep duration. The most frequently reported reasons for poor sleep included noise (59%), nursing interruptions (30%), uncomfortable beds (18%), bright lights (16%), unfamiliar surroundings (14%), and pain (9%).

CONCLUSIONS

Sleep quality for GIM inpatients is significantly worse in hospital than at home. There is a need to test non-pharmacologic interventions to address the most frequently identified factors causing poor sleep hygiene for GIM inpatients.

Medi-Cal managed care

Managed care programs may give California communities a cost effective way to provide health care to a growing Medi-Cal population. In this issue California Hospitals explores the benefits and risks of these programs.