Whose Job Is it Anyway?

Feasibility and Short-Term Effects of a Multi-Component Emergency Department Blood Pressure Intervention: A Pilot Randomized Trial

Background

Emergency department (ED) visits can be opportunities to address uncontrolled hypertension. We sought to compare short‐term blood pressure measures between the Vanderbilt Emergency Room Bundle (VERB) intervention and usual care plus education.

Methods and Results

We conducted a randomized trial of 206 adult patients with hypertension and elevated systolic blood pressure (SBP) presenting to 2 urban emergency departments in Tennessee, USA. The VERB intervention included educational materials, a brief motivational interview, pillbox, primary care engagement letter, pharmacy resources, and 45 days of informational and reminder text messages. The education arm received a hypertension pamphlet. After 78 participants were enrolled, text messages requested confirmation of receipt. The primary clinical outcome was 30‐day SBP. The median 30‐day SBP was 122 and 126 mm Hg in the VERB and education arms, respectively. We estimated the mean 30‐day SBP to be 3.98 mm Hg lower in the VERB arm (95% CI, −2.44 to 10.4; P=0.22). Among participants enrolled after text messages were adapted, the respective median SBPs were 121 and 130 mm Hg, and we estimated the mean 30‐day SBP to be 8.57 mm Hg lower in the VERB arm (95% CI, 0.98‒16.2; P=0.027). In this subgroup, the median response rate to VERB text messages was 56% (interquartile range, [26%‒80%]).

Conclusions

This pilot study demonstrated feasibility and found an improvement in SBP for the subgroup for whom interactive messages were featured. Future studies should evaluate the role of interactive text messaging as part of a comprehensive emergency department intervention to improve blood pressure control.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02672787.

Hypertension Management in Emergency Departments

BACKGROUND

Elevated blood pressure (BP) is pervasive among patients that visit emergency departments (EDs) for their care.

METHODS

In this review article, we outline the current approach to the management of these individuals and highlight the crucial role emergency medicine clinicians play in reducing the morbidity associated with elevated BP.

RESULTS

We highlight the critical importance of immediate treatment when elevated BP contributes to new or worsening end-organ injury but emphasize that such hypertensive emergencies are rare. For the vast majority of patients with elevated BP in the ED who do not have new or worsening end-organ injury from elevated BP, immediate BP reduction within the ED is not recommended or safe. Nonetheless, within weeks after an ED visit, there is a pressing need to improve the care of patients with elevated or previously undiagnosed hypertension. For many, it may be their only regular point of engagement with the healthcare system. To address this, we present novel perspectives that envision a new role for emergency medicine in chronic hypertension management-one that acknowledges the significant population-level gaps in BP control that contribute to disparities in cardiovascular disease and sets the stage for future changes in systems-based practice.

CONCLUSIONS

Emergency medicine plays a key and evolving role in reducing morbidity associated with elevated BP.

Association of Elevated Blood Pressure in the Emergency Department With Chronically Elevated Blood Pressure

Background Emergency department (ED) visits for hypertension are rising, but the importance of elevated blood pressure (BP) measured during the ED visit is controversial. We evaluated the relationship between ED BP and mean BP over the subsequent year. Methods and Results We performed a retrospective cohort study from January 1, 2010 to December 31, 2013 of 8105 adult patients who made 1 visit to an academic medical center ED with ≥2 ED BPs and ≥2 BPs measured in the subsequent year. The primary exposure was lowest ED systolic BP. The primary outcome was mean systolic BP ≥140 mm Hg over the year following the index ED visit. Diastolic BP was examined as a secondary exposure and outcome. Multiple logistic regression was performed adjusting for several covariates, with interaction terms for hypertension diagnosis, ED disposition, pain-related ED chief complaint, and sex. Patients whose lowest ED systolic BP was 140 to 159 mm Hg had an adjusted odds ratio of having a mean SBP ≥140 mm Hg in the subsequent year of 10.9 (95% CI, 7.6-15.6). Patients without diagnosed hypertension and ED BP 140/90 to 159/99 mm Hg were more likely to have elevated BP in the following year. Hospitalization increased the likelihood of persistently elevated systolic BP but not diastolic BP. There was no effect modification by pain-related ED complaint. Conclusions When ED BP is consistently elevated, BP is highly likely to remain elevated in the subsequent year, regardless of pain, and particularly among patients without diagnosed hypertension. Further research is needed to determine the optimal management of elevated ED BP.

The Population Health OutcomEs aNd Information EXchange (PHOENIX) Program - A Transformative Approach to Reduce the Burden of Chronic Disease

This concept article introduces a transformative vision to reduce the population burden of chronic disease by focusing on data integration, analytics, implementation and community engagement. Known as PHOENIX (The Population Health OutcomEs aNd Information EXchange), the approach leverages a state level health information exchange and multiple other resources to facilitate the integration of clinical and social determinants of health data with a goal of achieving true population health monitoring and management. After reviewing historical context, we describe how multilevel and multimodal data can be used to facilitate core public health services, before discussing the controversies and challenges that lie ahead.

An Unmet Need Meets an Untapped Resource: Pharmacist-Led Pathways for Hypertension Management for Emergency Department Patients

PURPOSE OF REVIEW

The purpose of this review is to describe the role of the pharmacist in innovative pathways of care for hypertension (HTN) management for emergency department (ED) patients, particularly in under-resourced communities. Due to intersecting socioeconomic and personal health risk factors, these patients bear a disproportionate share of cardiovascular disease, yet often have limited access to high-quality primary care.

RECENT FINDINGS

Recent meta-analyses demonstrate a clear advantage associated with pharmacist-physician collaborative models over traditional physician-only care in achieving blood pressure control. However, no prior study has evaluated use of pharmacist-led follow-up for ED patients with uncontrolled blood pressure (BP). Thus, we developed a pharmacist-driven transitional care clinic (TCC) that utilizes a collaborative practice agreement with ED physicians to improve HTN management for ED patients. We have successfully implemented the TCC in a high-volume urban ED and in a pilot study have shown clinically relevant BP reductions with our collaborative model. The use of pharmacist-led follow-up for HTN management is highly effective. Novel programs such as our TCC, which extend the reach of such a model to ED patients, are promising, and future studies should focus on implementation through larger, multicenter, randomized trials. However, to be most effective, policy advocacy is needed to expand pharmacist prescriptive authority and develop innovative financial models to incentivize this practice.