Recidivism to uncontrolled blood pressure in patients with previously controlled hypertension

Hypertension Control During the Coronavirus Disease 2019 Pandemic: A Cohort Study Among US Veterans

DESIGN

Retrospective cohort study.

OBJECTIVE

We sought to examine whether disruptions in follow-up intervals contributed to hypertension control.

BACKGROUND

Disruptions in health care were widespread during the coronavirus disease 2019 pandemic.

PATIENTS AND METHODS

We identified a cohort of individuals with hypertension in both prepandemic (March 2019-February 2020) and pandemic periods (March 2020-February 2022) in the Veterans Health Administration. First, we calculated follow-up intervals between the last prepandemic and first pandemic blood pressure measurement during a primary care clinic visit, and between measurements in the prepandemic period. Next, we estimated the association between the maintenance of (or achieving) hypertension control and the period using generalized estimating equations. We assessed associations between follow-up interval and control separately for periods. Finally, we evaluated the interaction between period and follow-up length.

RESULTS

A total of 1,648,424 individuals met the study inclusion criteria. Among individuals with controlled hypertension, the likelihood of maintaining control was lower during the pandemic versus the prepandemic (relative risk: 0.93; 95% CI: 0.93, 0.93). Longer follow-up intervals were associated with a decreasing likelihood of maintaining controlled hypertension in both periods. Accounting for follow-up intervals, the likelihood of maintaining control was 2% lower during the pandemic versus the prepandemic. For uncontrolled hypertension, the likelihood of gaining control was modestly higher during the pandemic versus the prepandemic (relative risk: 1.01; 95% CI: 1.01, 1.01). The likelihood of gaining control decreased with follow-up length during the prepandemic but not pandemic.

CONCLUSIONS

During the pandemic, longer follow-up between measurements contributed to the lower likelihood of maintaining control. Those with uncontrolled hypertension were modestly more likely to gain control in the pandemic.

State-Level Hypertension Prevalence and Control Among Adults in the U.S

INTRODUCTION

Improving hypertension control is a national priority. Electronic health record data have the potential to augment traditional surveillance systems. This study aimed to assess hypertension prevalence and control at the state level using a previously established electronic health record-based phenotype for hypertension.

METHODS

Adult patients (N=11,031,368) were included from the IQVIA ambulatory electronic medical record-U.S. 2019 data set. IQVIA ambulatory electronic medical record comprises electronic health records from >100,000 providers and includes patients from every U.S. state and Washington DC. Authors compared hypertension prevalence and control estimates against those from the Behavioral Risk Factor Surveillance System 2019. Results were age-standardized and stratified by state and sociodemographic characteristics. Statistical analyses were conducted in 2022-2023.

RESULTS

IQVIA ambulatory electronic medical record-U.S. patients had a median age of 55 years, and 56.7% were women. Overall age-standardized hypertension prevalence was higher in IQVIA ambulatory electronic medical record-U.S. (35.0%) than in the Behavioral Risk Factor Surveillance System (29.7%), however, state-level geographic patterns were similar, with the highest burden in the South and Appalachia. Similar patterns were also observed by sociodemographic characteristics in both data sets: hypertension prevalence was higher in older age groups (than younger), men (than women), and Black patients (than other races). Hypertension control varied widely across states: among states with >1% data coverage, control rates were lowest in Nevada (51.1%), Washington DC (52.0%), and Mississippi (55.2%); highest in Kansas (73.4%), New Jersey (72.3%), and Iowa (71.9%).

CONCLUSIONS

This study provided the first-ever estimates of hypertension control for all states and Washington DC. Electronic health record-based surveillance could support hypertension prevention and control efforts at the state level.

Identifying hypertension in pregnancy using electronic medical records: The importance of blood pressure values

OBJECTIVE

To incorporate blood pressure (BP), diagnoses codes, and medication fills from electronic medical records (EMR) to identify pregnant women with hypertension.

STUDY DESIGN

A retrospective cohort study of singleton pregnancies at three US integrated health delivery systems during 2005-2014.

MAIN OUTCOME MEASURES

Women were considered hypertensive if they had any of the following: (1) ≥2 high BPs (≥140/90 mmHg) within 30 days during pregnancy (High BP); (2) an antihypertensive medication fill in the 120 days before pregnancy and a hypertension diagnosis from 1 year prior to pregnancy through 20 weeks gestation (Treated Chronic Hypertension); or (3) a high BP, a hypertension diagnosis, and a prescription fill within 7 days during pregnancy (Rapid Treatment). We described characteristics of these pregnancies and conducted medical record review to understand hypertension presence and severity.

RESULTS

Of 566,624 pregnancies, 27,049 (4.8%) met our hypertension case definition: 24,140 (89.2%) with High BP, 5,409 (20.0%) with Treated Chronic Hypertension, and 5,363 (19.8%) with Rapid Treatment (not mutually exclusive). Of hypertensive pregnancies, 19,298 (71.3%) received a diagnosis, 9,762 (36.1%) received treatment and 11,226 (41.5%) had a BP ≥ 160/110. In a random sample (n = 55) of the 7,559 pregnancies meeting the High BP criterion with no hypertension diagnosis, clinical statements about hypertension were found in medical records for 58% of them.

CONCLUSION

Incorporating EMR BP identified many pregnant women with hypertension who would have been missed by using diagnosis codes alone. Future studies should seek to incorporate BP to study treatment and outcomes of hypertension in pregnancy.

Using Values Affirmation to Reduce the Effects of Stereotype Threat on Hypertension Disparities: Protocol for the Multicenter Randomized Hypertension and Values (HYVALUE) Trial

Background

Medication nonadherence is a significant, modifiable contributor to uncontrolled hypertension. Stereotype threat may contribute to racial disparities in adherence by hindering a patient’s ability to actively engage during a clinical encounter, resulting in reduced activation to adhere to prescribed therapies.

Objective

The Hypertension and Values (HYVALUE) trial aims to examine whether a values-affirmation intervention improves medication adherence (primary outcome) by targeting racial stereotype threat.

Methods

The HYVALUE trial is a patient-level, blinded randomized controlled trial comparing a brief values-affirmation writing exercise with a control writing exercise among black and white patients with uncontrolled hypertension. We are recruiting patients from 3 large health systems in the United States. The primary outcome is patients’ adherence to antihypertensive medications, with secondary outcomes of systolic and diastolic blood pressure over time, time for which blood pressure is under control, and treatment intensification. We are comparing the effects of the intervention among blacks and whites, exploring possible moderators (ie, patients’ prior experiences of discrimination and clinician racial bias) and mediators (ie, patient activation) of intervention effects on outcomes.

Results

This study was funded by the National Heart, Lung, and Blood Institute. Enrollment and follow-up are ongoing and data analysis is expected to begin in late 2020. Planned enrollment is 1130 patients. On the basis of evidence supporting the effectiveness of values affirmation in educational settings and our pilot work demonstrating improved patient-clinician communication, we hypothesize that values affirmation disrupts the negative effects of stereotype threat on the clinical interaction and can reduce racial disparities in medication adherence and subsequent health outcomes.

Conclusions

The HYVALUE study moves beyond documentation of race-based health disparities toward testing an intervention. We focus on a medical condition—hypertension, which is arguably the greatest contributor to mortality disparities for black patients. If successful, this study will be the first to provide evidence for a low-resource intervention that has the potential to substantially reduce health care disparities across a wide range of health care conditions and populations.

Trial Registration

ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).

International Registered Report Identifier (IRRID)

DERR1-10.2196/12498

Multiple control responses and resurgence of human behavior

Behavior that was previously extinguished may reoccur, or resurge, when an alternative response contacts extinction or when reinforcement conditions worsen. Researchers have studied resurgence of human responding in laboratory settings with procedures commonly used with nonhumans. In contrast to nonhuman responding, researchers have failed to observe resurgence of the target response at rates that differ from an inactive control response with verbally competent humans. But this may have been the result of using a single control response. The current study examined this possibility by randomly allocating participants (N = 20) to a condition with either two or four control responses. When the alternative response contacted extinction, having more control responses did not reduce overall responding to control options, and aggregated responding to control options were similar to target response rates. Interestingly, most participants responded more to one control response over all other control responses when the alternative response contacted extinction. This study provides additional support for previous research that finds consistent differences between human and nonhuman responding during resurgence procedures. Two potential reasons for variability in human responding during resurgence tests include less time in experimental sessions and the influence of verbal behavior.

Modelling the impact of new patient visits on risk adjusted access at 2 clinics

OBJECTIVE

To evaluate the effect new outpatient clinic visits has on the availability of follow-up visits for established patients when patient visit frequency is risk adjusted.

DATA SOURCES

Diagnosis codes for patients from 2 Internal Medicine Clinics were extracted through billing data.

STUDY DESIGN

The HHS-HCC risk adjusted scores for each clinic were determined based upon the average of all clinic practitioners' profiles. These scores were then used to project encounter frequencies for established patients, and for new patients entering the clinic based on risk and time of entry into the clinics.

PRINCIPAL FINDINGS

A distinct mean risk frequency distribution for physicians in each clinic could be defined providing model parameters. Within the model, follow-up visit utilization at the highest risk adjusted visit frequencies would require more follow-up slots than currently available when new patient no-show rates and annual patient loss are included. Patients seen at an intermediate or lower visit risk adjusted frequency could be accommodated when new patient no-show rates and annual patient clinic loss are considered.

CONCLUSIONS

Value-based care is driven by control of cost while maintaining quality of care. In order to control cost, there has been a drive to increase visit frequency in primary care for those patients at increased risk. Adding new patients to primary care clinics limits the availability of follow-up slots that accrue over time for those at highest risk, thereby limiting disease and, potentially, cost control. If frequency of established care visits can be reduced by improved disease control, closing the practice to new patients, hiring health care extenders, or providing non-face to face care models then quality and cost of care may be improved.

An integrated program with home blood-pressure monitoring and village health volunteers for treating poorly controlled hypertension at the primary care level in an urban community of Thailand

Purpose

Hypertension (HT) is accountable for death in half of the patients suffering from heart disease and stroke. Many treatment strategies have been used, but little research exists on an integrated program with home blood pressure monitoring (HBPM) and village health volunteers (VHVs) in an urban area of Thailand. The present study aims to determine the effectiveness of the integrated program, HBPM, and VHVs in supporting the target population.

Patients and methods

This quasi-experiment was conducted from July to November 2017. Patients with poorly controlled HT were randomly selected from each of the two primary care units in Nakhon Ratchasima, Thailand. The participants were separated into an experiment (n=63) and control group (n=65). The experiment group participated in the integrated program, which was based on the 20-item Health Literate Care Model. A valid and reliable questionnaire was used to collect data from participant interviews. Blood-pressure monitoring was used to measure systolic home blood pressure and diastolic home blood pressure. Descriptive statistics, chi-squared tests, Fisher’s exact test, the independent t-test, and the Wilcoxon–Mann–Whitney test were used to compare the baseline data. Multiple logistic regression was used to compare the differences between the mean changes in the outcomes.

Results

At the end of the 3-month follow-up appointment, significant statistical changes were found. Systolic home blood pressure, diastolic home blood pressure, and body mass index changed −4.61 (95% CI −8.32, −0.90) mmHg (P-value=0.015), −3.5 (95% CI −5.31, −1.72) mmHg (P-value <0.001), and −0.86 (95% CI −1.29, −042) (P-value <0.001) respectively. Participant scores in lifestyle and management knowledge, and self-management behaviors significantly increased by 0.76 (95% CI 0.15–1.38) point (P-value=0.016) and 0.15 (95% CI 0.06, 0.24) point (P-value=0.001), respectively.

Conclusion

The integrated program, HBPM, and VHVs were effective in decreasing blood pressure and body mass index, and increasing knowledge and self-management behaviors among urban patients with poorly controlled HT.

Endocrinology Telehealth Consultation Improved Glycemic Control Similar to Face-to-Face Visits in Veterans

BACKGROUND

Rates of diabetes for veterans who receive health care through the Veterans Health Administration are higher than rates in the general population. Furthermore, many veterans live in rural locations, far from Veterans Affairs (VA) hospitals, thus limiting their ability to readily seek face-to-face endocrinology care for diabetes. Telehealth (TH) technologies present an opportunity to improve access to specialty diabetes care for such patients; however, there is a lack of evidence regarding the ability of TH to improve glycemic control in comparison to traditional face-to-face consultations.

METHODS

This was a retrospective cohort study of all new endocrinology diabetes consultations at the Denver VA Medical Center over a 1-year period.

RESULTS

A total of 189 patients were included in the analysis. In all, 85 patients had received face-to-face (FTF) endocrinology consultation for diabetes and 104 patients had received TH consultation. Subjects were mostly males (94.7%) and the mean age was 62.8 ± 10.1 years old. HbA1c improved from 9.76% (9.40% to 10.11%) to 8.55% (8.20% to 8.91%) (P < .0001) for the TH group and from 9.56% (9.16% to 9.95%) to 8.62% (8.22% to 9.01%) (P < .0001) for the FTF group after 1 visit. This change in HbA1c was not significantly different in the TH and FTF groups (P = .24). TH visits were associated with a hypothetical savings in median distance traveled of 231.2 miles per trip (which equates to $94.79 saved per trip).

CONCLUSIONS

Endocrinology TH consultations improved short-term glycemic control as effectively as traditional FTF visits in a veteran population with diabetes.