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Heredia NI, Garza ER, Velasco-Huerta F, Swoboda TL, Fwelo P, Mathews PD, Fernandez ME. implementation of healthy heart ambassador to improve blood pressure control at community health centers in Texas. BMC Health Serv Res 2024; 24:1105. [PMID: 39304836 PMCID: PMC11414079 DOI: 10.1186/s12913-024-11485-z] [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: 02/16/2024] [Accepted: 08/23/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Hypertension is one of the most prevalent chronic diseases in the United States and can increase a person's risk of stroke and other cardiovascular complications. Yet only 1 in 4 people with high blood pressure in the United States have their blood pressure managed. To improve hypertension control, we supported 9 health centers in Texas with the implementation of the Healthy Heart Ambassador Blood Pressure Self-Monitoring (HHA) Program. METHODS We provided health center training using the HHA Program Facilitation Training Guide, recorded barriers to implementing the HHA program, and employed strategies to overcome those barriers. RESULTS There were 68 staff members from the health centers trained to deliver the HHA program. Three health centers successfully implemented all three major components of HHA, three were able to implement two components, two adopted two components, and one withdrew due to insufficient capacity. Capability, technology infrastructure, and motivation were among the barriers most referenced. CONCLUSION Clinic non-physician team members delivering the HHA program will need training and ongoing technical assistance to overcome implementation barriers.
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Affiliation(s)
- Natalia I Heredia
- Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, 7000 Fannin, Suite 2558, Houston, TX, 77030, USA.
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Ella R Garza
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Fernanda Velasco-Huerta
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Tracy L Swoboda
- Center for Quality Health IT Improvement (CQHII), McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Pierre Fwelo
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Patenne D Mathews
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Maria E Fernandez
- Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, 7000 Fannin, Suite 2558, Houston, TX, 77030, USA
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
- Institute for Implementation Science, University of Texas Health Science Center at Houston, Houston, TX, USA
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2
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Oh DM, McManus M, Markovic D, Ovbiagele B, Sanossian N, Towfighi A. The link between insurance and blood pressure control in U.S. stroke survivors. J Neurol Sci 2024; 461:123043. [PMID: 38744215 DOI: 10.1016/j.jns.2024.123043] [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: 12/14/2023] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND After a stroke, poorly controlled blood pressure (BP) is associated with a higher risk of recurrent vascular events. Despite the importance of controlling BP to avert recurrent vascular events, fewer than half of stroke survivors in the United States achieve BP control. It is unclear to what extent insurance status affects BP levels after stroke. METHODS We assessed BP control among adults with a history of stroke who participated in the National Health and Nutrition Examination Surveys from 1999 through 2016. The relationship between insurance type and BP level (low normal: <120/80 mmHg and normal: <140/90 mmHg) were evaluated using logistic regression before and after adjusting for sociodemographic characteristics and medical comorbidities for those <65 years and ≥ 65 years. RESULTS Among 1646 adult stroke survivors (weighted n = 5,586,417), 30% had BP in the low normal range while 64% had BP in the normal range. Among 613 stroke survivors <65 years (weighted n = 2,396,980), only those with other government insurance (CHAMPVA, CHAMPUS/TRICARE) had better BP control than the uninsured (adjusted HR 2.68, 95% CI 0.99-7.25). Among 1033 participants ≥65 years (weighted n = 3,189,437), those with private insurance plus Medicare trended toward better normal BP compared to Medicare alone (adjusted HR 1.34, 95% CI 0.94-1.90). CONCLUSIONS Only stroke survivors with CHAMPVA, CHAMPUS/TRICARE government insurance in the United States have lower odds of controlled BP compared to no insurance among those <65 years. Insurance alone does not improve BP control among stroke survivors.
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Affiliation(s)
- Daniel M Oh
- Department of Neurology, Kaiser Permanente, 10800 Magnolia Ave, Riverside, CA 92505, USA.
| | - Michael McManus
- Department of Neurology, Scripps Clinic Medical Group, 9898 Genesee Ave, La Jolla, CA 92037, USA
| | - Daniela Markovic
- Department of Medicine, University of California, Los Angeles, 100 Medical Plaza Driveway, Los Angeles, CA 90095, USA.
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, 4150 Clement St, San Francisco, CA 94121, USA.
| | - Nerses Sanossian
- Department of Neurology, Los Angeles General Medical Center, 1100 N. State St, A4E, Los Angeles, CA 90033, USA; Department of Neurology, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA.
| | - Amytis Towfighi
- Department of Neurology, Los Angeles General Medical Center, 1100 N. State St, A4E, Los Angeles, CA 90033, USA; Department of Neurology, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA 90033, USA.
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Funes Hernandez M, Babakhanian M, Chen TP, Sarraju A, Seninger C, Ravi V, Azizi Z, Tooley J, Chang TI, Lu Y, Downing NL, Rodriguez F, Li RC, Sandhu AT, Turakhia M, Bhalla V, Wang PJ. Design and Implementation of an Electronic Health Record-Integrated Hypertension Management Application. J Am Heart Assoc 2024; 13:e030884. [PMID: 38226516 PMCID: PMC10926825 DOI: 10.1161/jaha.123.030884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 12/01/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND High blood pressure affects approximately 116 million adults in the United States. It is the leading risk factor for death and disability across the world. Unfortunately, over the past decade, hypertension control rates have decreased across the United States. Prediction models and clinical studies have shown that reducing clinician inertia alone is sufficient to reach the target of ≥80% blood pressure control. Digital health tools containing evidence-based algorithms that are able to reduce clinician inertia are a good fit for turning the tide in blood pressure control, but careful consideration should be taken in the design process to integrate digital health interventions into the clinical workflow. METHODS We describe the development of a provider-facing hypertension management platform. We enumerate key steps of the development process, including needs finding, clinical workflow analysis, treatment algorithm creation, platform design and electronic health record integration. We interviewed and surveyed 5 Stanford clinicians from primary care, cardiology, and their clinical care team members (including nurses, advanced practice providers, medical assistants) to identify needs and break down the steps of clinician workflow analysis. The application design and development stage were aided by a team of approximately 15 specialists in the fields of primary care, hypertension, bioinformatics, and software development. CONCLUSIONS Digital monitoring holds immense potential for revolutionizing chronic disease management. Our team developed a hypertension management platform at an academic medical center to address some of the top barriers to adoption and achieving clinical outcomes. The frameworks and processes described in this article may be used for the development of a diverse range of digital health tools in the cardiovascular space.
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Affiliation(s)
- Mario Funes Hernandez
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
- Division of Nephrology, Department of MedicineStanford University School of MedicineStanfordCAUSA
- Stanford Hypertension CenterStanford University School of MedicineStanfordCAUSA
| | - Meghedi Babakhanian
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| | - Tania P. Chen
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| | - Ashish Sarraju
- Stanford Hypertension CenterStanford University School of MedicineStanfordCAUSA
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| | - Clark Seninger
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
| | - Vishnu Ravi
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
| | - Zahra Azizi
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
| | - James Tooley
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| | - Tara I. Chang
- Division of Nephrology, Department of MedicineStanford University School of MedicineStanfordCAUSA
- Stanford Hypertension CenterStanford University School of MedicineStanfordCAUSA
| | - Ying Lu
- Department of Biomedical Data SciencesStanford University School of MedicineStanfordCAUSA
| | - N. Lance Downing
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
- Biomedical Informatics Research, Department of MedicineStanford University School of MedicineStanfordCAUSA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| | - Ron C. Li
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
- Biomedical Informatics Research, Department of MedicineStanford University School of MedicineStanfordCAUSA
| | - Alexander T. Sandhu
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
- Veterans Affairs Palo Alto Health Care SystemPalo AltoCAUSA
| | - Mintu Turakhia
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| | - Vivek Bhalla
- Division of Nephrology, Department of MedicineStanford University School of MedicineStanfordCAUSA
- Stanford Hypertension CenterStanford University School of MedicineStanfordCAUSA
| | - Paul J. Wang
- Center for Digital Health, Department of MedicineStanford UniversityStanfordCAUSA
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
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4
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Fiscella KA, Sass E, Sridhar SB, Maguire JA, Lashway K, Wong G, Thien A, Thomas M, Bisognano JD, Rosenberg T, Sanders MR, Johnson BA, Polgreen LA. Team-based home blood pressure monitoring for blood pressure equity a protocol for a stepped wedge cluster randomized trial. Contemp Clin Trials 2023; 134:107332. [PMID: 37722482 PMCID: PMC10725081 DOI: 10.1016/j.cct.2023.107332] [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: 05/31/2023] [Revised: 08/29/2023] [Accepted: 09/15/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Home Blood Pressure Monitoring (HBPM) that includes a team with a clinical pharmacist is an evidence-based intervention that improves blood pressure (BP). Yet, strategies for promoting its adoption in primary care are lacking. We developed potentially feasible and sustainable implementation strategies to improve hypertension control and BP equity. METHODS We assessed barriers and facilitators to HBPM and iteratively adapted implementation strategies through key informative interviews and guidance from a multistakeholder stakeholder team involving investigators, clinicians, and practice administration. RESULTS Strategies include: 1) pro-active outreach to patients; 2) provision of BP devices; 3) deployment of automated bidirectional texting to support patients through education messages for patients to transmit their readings to the clinical team; 3) a hypertension visit note template; 4) monthly audit and feedback reports on progress to the team; and 5) training to the patients and teams. We will use a stepped wedge randomized trial to assess RE-AIM outcomes. These are defined as follows Reach: the proportion of eligible patients who agree to participate in the BP texting; Effectiveness: the proportion of eligible patients with their last BP reading <140/90 (six months); Adoption: the proportion of patients invited to the BP texting; Implementation: patients who text their BP reading ≥10 of days per month; and Maintenance: sustained BP control post-intervention (twelve months). We will also examine RE-AIM metrics stratified by race and ethnicity. CONCLUSIONS Findings will inform the impact of strategies for the adoption of team-based HPBM and the impact of the intervention on hypertension control and equity. REGISTRATION DETAILS www. CLINICALTRIALS gov Identifier: NCT05488795.
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Affiliation(s)
- Kevin A Fiscella
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America.
| | - Emma Sass
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America
| | - Soumya B Sridhar
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Jennifer A Maguire
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Katie Lashway
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Geoff Wong
- Nuffield Department of Primary Care, Medical Sciences Division, University of Oxford, United Kingdom
| | - Amy Thien
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Marie Thomas
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America
| | - John D Bisognano
- Department of Medicine, Cardiology Division, University of Michigan, 24 Frank Lloyd Wright Dr. Ste 1300, Lobby A, Ann Arbor, MI 48106, United States of America
| | - Tziporah Rosenberg
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Mechelle R Sanders
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America
| | - Brent A Johnson
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, 265 Crittenden Blvd, Rochester, NY 14642, United States of America
| | - Linnea A Polgreen
- College of Pharmacy, Iowa University, 340 College of Pharmacy Building, 180 S Grand Ave, Iowa City, IA 5224, United States of America
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Abdalla M, Bolen SD, Brettler J, Egan BM, Ferdinand KC, Ford CD, Lackland DT, Wall HK, Shimbo D. Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association. Hypertension 2023; 80:e143-e157. [PMID: 37650292 PMCID: PMC10578150 DOI: 10.1161/hyp.0000000000000232] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Hypertension is one of the most important risk factors that contribute to incident cardiovascular events. A multitude of US and international hypertension guidelines, scientific statements, and policy statements have recommended evidence-based approaches for hypertension management and improved blood pressure (BP) control. These recommendations are based largely on high-quality observational and randomized controlled trial data. However, recent published data demonstrate troubling temporal trends with declining BP control in the United States after decades of steady improvements. Therefore, there is a widening disconnect between what hypertension experts recommend and actual BP control in practice. This scientific statement provides information on the implementation strategies to optimize hypertension management and to improve BP control among adults in the United States. Key approaches include antiracism efforts, accurate BP measurement and increased use of self-measured BP monitoring, team-based care, implementation of policies and programs to facilitate lifestyle change, standardized treatment protocols using team-based care, improvement of medication acceptance and adherence, continuous quality improvement, financial strategies, and large-scale dissemination and implementation. Closing the gap between scientific evidence, expert recommendations, and achieving BP control, particularly among disproportionately affected populations, is urgently needed to improve cardiovascular health.
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Ose D, Adediran E, Owens R, Gardner E, Mervis M, Turner C, Carlson E, Forbes D, Jasumback CL, Stuligross J, Pohl S, Kiraly B. Electronic Health Record-Driven Approaches in Primary Care to Strengthen Hypertension Management Among Racial and Ethnic Minoritized Groups in the United States: Systematic Review. J Med Internet Res 2023; 25:e42409. [PMID: 37713256 PMCID: PMC10541643 DOI: 10.2196/42409] [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: 09/02/2022] [Revised: 06/01/2023] [Accepted: 07/04/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Managing hypertension in racial and ethnic minoritized groups (eg, African American/Black patients) in primary care is highly relevant. However, evidence on whether or how electronic health record (EHR)-driven approaches in primary care can help improve hypertension management for patients of racial and ethnic minoritized groups in the United States remains scarce. OBJECTIVE This review aims to examine the role of the EHR in supporting interventions in primary care to strengthen the hypertension management of racial and ethnic minoritized groups in the United States. METHODS A search strategy based on the PICO (Population, Intervention, Comparison, and Outcome) guidelines was utilized to query and identify peer-reviewed articles on the Web of Science and PubMed databases. The search strategy was based on terms related to racial and ethnic minoritized groups, hypertension, primary care, and EHR-driven interventions. Articles were excluded if the focus was not hypertension management in racial and ethnic minoritized groups or if there was no mention of health record data utilization. RESULTS A total of 29 articles were included in this review. Regarding populations, Black/African American patients represented the largest population (26/29, 90%) followed by Hispanic/Latino (18/29, 62%), Asian American (7/29, 24%), and American Indian/Alaskan Native (2/29, 7%) patients. No study included patients who identified as Native Hawaiian/Pacific Islander. The EHR was used to identify patients (25/29, 86%), drive the intervention (21/29, 72%), and monitor results and outcomes (7/29, 59%). Most often, EHR-driven approaches were used for health coaching interventions, disease management programs, clinical decision support (CDS) systems, and best practice alerts (BPAs). Regarding outcomes, out of 8 EHR-driven health coaching interventions, only 3 (38%) reported significant results. In contrast, all the included studies related to CDS and BPA applications reported some significant results with respect to improving hypertension management. CONCLUSIONS This review identified several use cases for the integration of the EHR in supporting primary care interventions to strengthen hypertension management in racial and ethnic minoritized patients in the United States. Some clinical-based interventions implementing CDS and BPA applications showed promising results. However, more research is needed on community-based interventions, particularly those focusing on patients who are Asian American, American Indian/Alaskan Native, and Native Hawaiian/Pacific Islander. The developed taxonomy comprising "identifying patients," "driving intervention," and "monitoring results" to classify EHR-driven approaches can be a helpful tool to facilitate this.
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Affiliation(s)
- Dominik Ose
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, United States
| | - Emmanuel Adediran
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, United States
| | - Robert Owens
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, United States
| | - Elena Gardner
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, United States
| | - Matthew Mervis
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, United States
| | - Cindy Turner
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, United States
| | - Emily Carlson
- Community Physicians Group, University of Utah, Salt Lake City, UT, United States
| | - Danielle Forbes
- Utah Department of Health and Human Services, Salt Lake City, UT, United States
| | | | - John Stuligross
- Utah Department of Health and Human Services, Salt Lake City, UT, United States
| | - Susan Pohl
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, United States
| | - Bernadette Kiraly
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, United States
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7
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Lowe Beasley K, Tucker-Brown A, Rein DB, Ahn R, Davis R, Spafford M, Dougherty M, Teachout E, Haynes SB. Effectiveness evaluation of a hypertension management program in a Federally Qualified Health Center (FQHC). Prev Med Rep 2023; 34:102271. [PMID: 37387725 PMCID: PMC10302854 DOI: 10.1016/j.pmedr.2023.102271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/11/2023] [Accepted: 05/30/2023] [Indexed: 07/01/2023] Open
Abstract
The objective of this study was to examine effectiveness of a Hypertension Management Program (HMP) in a Federally Qualified Health Center (FQHC). From September 2018 through December 2019, we implemented HMP in seven clinics of an FQHC in rural South Carolina. A pre/post evaluation design estimated the association of HMP with hypertension control rates and systolic blood pressure using electronic health record data among 3,941 patients. A chi-square test estimated change in mean control rates in pre- and intervention periods. A multilevel multivariable logistic regression model estimated the incremental impact of HMP on odds of hypertension control. Results showed that 53.4% of patients had controlled hypertension pre-intervention (September 2016-September 2018); 57.3% had controlled hypertension at the end of the observed implementation period (September 2018-December 2019) (p < 0.01). Statistically significant increases in hypertension control rates were observed in six of seven clinics (p < 0.05). Odds of controlled hypertension were 1.21 times higher during the intervention period compared to pre-intervention (p < 0.0001). Findings can inform the replication of HMP in FQHCs and similar health care settings, which play a pivotal role in caring for patients with health and socioeconomic disparities.
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Affiliation(s)
- Kincaid Lowe Beasley
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Aisha Tucker-Brown
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - David B. Rein
- NORC at the University of Chicago, Chicago, IL, United States
| | - Roy Ahn
- NORC at the University of Chicago, Chicago, IL, United States
| | - Rachel Davis
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | | | - Emily Teachout
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
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Abstract
We stand at a critical juncture in the delivery of health care for hypertension. Blood pressure control rates have stagnated, and traditional health care is failing. Fortunately, hypertension is exceptionally well-suited to remote management, and innovative digital solutions are proliferating. Early strategies arose with the spread of digital medicine, long before the COVID-19 pandemic forced lasting changes to the way medicine is practiced. Highlighting one contemporary example, this review explores salient features of remote management hypertensive programs, including: an automated algorithm to guide clinical decisions, home (as opposed to office) blood pressure measurements, an interdisciplinary care team, and robust information technology and analytics. Dozens of emerging hypertension management solutions are contributing to a highly fragmented and competitive landscape. Beyond viability, profit and scalability are critical. We explore the challenges impeding large-scale acceptance of these programs and conclude with a hopeful look to the future when remote hypertension care will have dramatic impact on global cardiovascular health.
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Affiliation(s)
- Simin Gharib Lee
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Naomi D.L. Fisher
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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9
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Cheung AK, Whelton PK, Muntner P, Schutte AE, Moran AE, Williams B, Sarafidis P, Chang TI, Daskalopoulou SS, Flack JM, Jennings G, Juraschek SP, Kreutz R, Mancia G, Nesbitt S, Ordunez P, Padwal R, Persu A, Rabi D, Schlaich MP, Stergiou GS, Tobe SW, Tomaszewski M, Williams KA, Mann JFE. International Consensus on Standardized Clinic Blood Pressure Measurement - A Call to Action. Am J Med 2023; 136:438-445.e1. [PMID: 36621637 PMCID: PMC10159895 DOI: 10.1016/j.amjmed.2022.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Alfred K Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah Health, Salt Lake City, Utah
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, La
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | - Aletta E Schutte
- School of Population Health, University of New South Wales, Sydney, NSW, Australia; The George Institute for Global Health, Sydney, NSW, Australia
| | - Andrew E Moran
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Bryan Williams
- Department of Medicine, University College London, London, UK
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University, Thessaloniki, Greece
| | - Tara I Chang
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stella S Daskalopoulou
- Division of Experimental Medicine, Department of Medicine, Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada; Division of Internal Medicine, Department of Medicine, McGill University Health Centre, McGill University Montreal, Canada
| | - John M Flack
- Department of Internal Medicine, Southern Illinois School of Medicine, Springfield, Ill
| | | | - Stephen P Juraschek
- Division of General Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Mass
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | | | | | - Pedro Ordunez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC
| | - Raj Padwal
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Doreen Rabi
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cardiac Sciences and Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School - Royal Perth Hospital Unit, Royal Perth Hospital Research Foundation, University of Western Australia, Perth, WA, Australia
| | - George S Stergiou
- Hypertension Centre STRIDE, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sheldon W Tobe
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kim A Williams
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, Ky
| | - Johannes F E Mann
- KfH Kidney Center, Munich, Germany; Friedrich Alexander University of Erlangen-Nürnberg, Erlangen, Germany.
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Ahmed M, Nudy M, Bussa R, Naccarelli GV, Filippone EJ, Foy AJ. A Subgroup Meta-Analysis Comparing the Renal Denervation Sham-Controlled Randomized Trials Among Those With Resistant and Nonresistant Hypertension. Am J Cardiol 2023; 191:119-124. [PMID: 36669381 DOI: 10.1016/j.amjcard.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/07/2022] [Accepted: 12/26/2022] [Indexed: 01/20/2023]
Abstract
Renal denervation (RD) has been investigated as an invasive blood pressure (BP) lowering treatment for hypertension (HTN). Resistant HTN (RHTN) has been defined as uncontrolled BP despite use of 3 antihypertensive medications of different classes, including a diuretic, at maximum tolerated doses. The impact of RD on RHTN remains under investigation. Ten sham-controlled trials testing RD were included in this trial-level analysis. A prespecified subgroup analysis was conducted to test whether efficacy of RD differed in patients with and without RHTN. The primary end points were change in 24-hour ambulatory systolic (SBP) and diastolic (DBP) using raw mean difference (RMD) between sham control and RD. Ten studies (6 RHTN and 4 nonresistant HTN) were identified that included 1,544 participants (1,001 RHTN and 543 essential HTN) with cumulative mean age (±SD) of 57 years (±3). Cochran risk of bias assessment showed 69% of the domains to be at low risk of bias. The RMD for 24-hour SBP between RD and sham control was statistically significant for nonresistant HTN trials (-4.19 mm Hg; 95% confidence interval [CI] -6.07 to -2.30) but was not statistically significant for RHTN trials (-1.86 mm Hg; 95% CI - 3.89 to 0.16). Despite the numerical difference in the subgroups, the interaction between subgroups failed to reach statistical significance (p = 0.10). The RMD for 24-hour DBP between RD and sham control was statistically significant for nonresistant HTN trials (-2.60 mm Hg; 95% CI -3.79 to -1.42) but was not statistically significant for RHTN trials (-0.67 mm Hg; 95% CI -1.84 to 0.50). The interaction between subgroups was statistically significant (p = 0.02). Our analysis indicates RD is a less effective intervention for patients with RHTN. These data may be beneficial for clinicians to consider when assessing patients with RHTN for RD.
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Affiliation(s)
| | - Matthew Nudy
- Division of Cardiology, Heart and Vascular Institute, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | - Gerald V Naccarelli
- Division of Cardiology, Heart and Vascular Institute, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Edward J Filippone
- Division of Nephrology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Andrew J Foy
- Division of Cardiology, Heart and Vascular Institute, Penn State Hershey Medical Center, Hershey, Pennsylvania
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11
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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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12
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Fontil V, Modrow MF, Cooper‐DeHoff RM, Wozniak G, Rakotz M, Todd J, Azar K, Murakami L, Sanders M, Chamberlain AM, O'Brien E, Lee A, Carton T, Pletcher MJ. Improvement in Blood Pressure Control in Safety Net Clinics Receiving 2 Versions of a Scalable Quality Improvement Intervention: BP MAP A Pragmatic Cluster Randomized Trial. J Am Heart Assoc 2023; 12:e024975. [PMID: 36695297 PMCID: PMC9973613 DOI: 10.1161/jaha.121.024975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 12/06/2022] [Indexed: 01/26/2023]
Abstract
Background Uncontrolled blood pressure (BP) remains a leading cause of death in the United States. The American Medical Association developed a quality improvement program to improve BP control, but it is unclear how to efficiently implement this program at scale across multiple health systems. Methods and Results We conducted BP MAP (Blood Pressure Measure Accurately, Act Rapidly, and Partner With Patients), a comparative effectiveness trial with clinic-level randomization to compare 2 scalable versions of the quality improvement program: Full Support (with support from quality improvement expert) and Self-Guided (using only online materials). Outcomes were clinic-level BP control (<140/90 mm Hg) and other BP-related process metrics calculated using electronic health record data. Difference-in-differences were used to compare changes in outcomes from baseline to 6 months, between intervention arms, and to a nonrandomized Usual Care arm composed of 18 health systems. A total of 24 safety-net clinics in 9 different health systems underwent randomization and then simultaneous implementation. BP control increased from 56.7% to 59.1% in the Full Support arm, and 62.0% to 63.1% in the Self-Guided arm, whereas BP control dropped slightly from 61.3% to 60.9% in the Usual Care arm. The between-group differences-in-differences were not statistically significant (Full Support versus Self-Guided=+1.2% [95% CI, -3.2% to 5.6%], P=0.59; Full Support versus Usual Care=+3.2% [-0.5% to 6.9%], P=0.09; Self-Guided versus Usual Care=+2.0% [-0.4% to 4.5%], P=0.10). Conclusions In this randomized trial, 2 methods of implementing a quality improvement intervention in 24 safety net clinics led to modest improvements in BP control that were not statistically significant. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03818659.
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Affiliation(s)
- Valy Fontil
- University of California San FranciscoSan FranciscoCA
| | | | | | | | | | | | - Kristen Azar
- University of California San FranciscoSan FranciscoCA
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13
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Lewinski AA, Jazowski SA, Goldstein KM, Whitney C, Bosworth HB, Zullig LL. Intensifying approaches to address clinical inertia among cardiovascular disease risk factors: A narrative review. PATIENT EDUCATION AND COUNSELING 2022; 105:3381-3388. [PMID: 36002348 PMCID: PMC9675717 DOI: 10.1016/j.pec.2022.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Clinical inertia, the absence of treatment initiation or intensification for patients not achieving evidence-based therapeutic goals, is a primary contributor to poor clinical outcomes. Effectively combating clinical inertia requires coordinated action on the part of multiple representatives including patients, clinicians, health systems, and the pharmaceutical industry. Despite intervention attempts by these representatives, barriers to overcoming clinical inertia in cardiovascular disease (CVD) risk factor control remain. METHODS We conducted a narrative literature review to identify individual-level and multifactorial interventions that have been successful in addressing clinical inertia. RESULTS Effective interventions included dynamic forms of patient and clinician education, monitoring of real-time patient data to facilitate shared decision-making, or a combination of these approaches. Based on findings, we describe three possible multi-level approaches to counter clinical inertia - a collaborative approach to clinician training, use of a population health manager, and use of electronic monitoring and reminder devices. CONCLUSION To reduce clinical inertia and achieve optimal CVD risk factor control, interventions should consider the role of multiple representatives, be feasible for implementation in healthcare systems, and be flexible for an individual patient's adherence needs. PRACTICE IMPLICATIONS Representatives (e.g., patients, clinicians, health systems, and the pharmaceutical industry) could consider approaches to identify and monitor non-adherence to address clinical inertia.
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Affiliation(s)
- Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Duke University School of Nursing, Box 3322 DUMC, Durham, NC 27710, USA.
| | - Shelley A Jazowski
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC 27599‑7400, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701, USA; Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave, Suite 1200, Nashville, TN 37203, USA.
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC 27701, USA.
| | - Colette Whitney
- Cascades East Family Medicine Residency, Oregon Health & Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098, USA.
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Duke University School of Nursing, Box 3322 DUMC, Durham, NC 27710, USA; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, 170 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC 27599‑7400, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, P.O. Box 102508, Durham, NC 27710, USA.
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Attn: HSR&D COIN (558/152), 508 Fulton Street, Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701, USA.
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14
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Khoong EC, Commodore-Mensah Y, Lyles CR, Fontil V. Use of Self-Measured Blood Pressure Monitoring to Improve Hypertension Equity. Curr Hypertens Rep 2022; 24:599-613. [PMID: 36001268 PMCID: PMC9399977 DOI: 10.1007/s11906-022-01218-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To evaluate how self-measured blood pressure (SMBP) monitoring interventions impact hypertension equity. RECENT FINDINGS While a growing number of studies have recruited participants from safety-net settings, racial/ethnic minority groups, rural areas, or lower socio-economic backgrounds, few have reported on clinical outcomes with many choosing to evaluate only patient-reported outcomes (e.g., satisfaction, engagement). The studies with clinical outcomes demonstrate that SMBP monitoring (a) can be successfully adopted by historically excluded patient populations and safety-net settings and (b) improves outcomes when paired with clinical support. There are few studies that explicitly evaluate how SMBP monitoring impacts hypertension disparities and among rural, low-income, and some racial/ethnic minority populations. Researchers need to design SMBP monitoring studies that include disparity reduction outcomes and recruit from broader populations that experience worse hypertension outcomes. In addition to assessing effectiveness, studies must also evaluate how to mitigate multi-level barriers to real-world implementation of SMBP monitoring programs.
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Affiliation(s)
- Elaine C Khoong
- Division of General Internal Medicine at Zuckerberg, Department of Medicine, San Francisco General Hospital, UCSF, Building 10, Ward 13, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, USA.
| | - Yvonne Commodore-Mensah
- Johns Hopkins School of Nursing, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Courtney R Lyles
- Division of General Internal Medicine at Zuckerberg, Department of Medicine, San Francisco General Hospital, UCSF, Building 10, Ward 13, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, USA
| | - Valy Fontil
- Division of General Internal Medicine at Zuckerberg, Department of Medicine, San Francisco General Hospital, UCSF, Building 10, Ward 13, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, USA
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15
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Affiliation(s)
- Daniel W Jones
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Donald Clark
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Michael E Hall
- Department of Medicine, University of Mississippi Medical Center, Jackson
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16
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Champagne BM, Antonio Ochoa E, Khanchandani HS, Schoj V. Civil society’s role in improving hypertension control in Latin America. Rev Panam Salud Publica 2022; 46:e165. [PMID: 36128471 PMCID: PMC9482131 DOI: 10.26633/rpsp.2022.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022] Open
Abstract
Despite effort in Latin America to implement the HEARTS initiative, hypertension control is still inadequate. There are many advances in the medical and technical arena, but little to promote political and systemic change. The vibrant civil society that has advanced policy change in tobacco control, food policy, and other public health initiatives can make a crucial contribution to prioritize hypertension control in the political agenda, ensure sustainable funding, promote the procurement of affordable and effective medications, and expand community demand for action. The recommended first step for civil society’s involvement is to analyze the political landscape to design an advocacy plan. The political landscape includes a legal analysis, policy mapping, stakeholders mapping, identifying obstacles, mapping community strategies, and risk assessment. The second step is to define policy goals and an advocacy strategy. Based on experience, there would be two main policy goals: to increase political will to make hypertension a top priority, securing necessary resources; and strengthen community awareness and social demand for action. The third step is to develop and implement the advocacy plan with the tools familiar to civil society, including building a case for support, advocacy towards decision makers, media advocacy, coalition building, countering the opposition, and civil society monitoring and accountability. To jumpstart this approach, there should be incentives for civil society and a transition for transferring competencies to a new arena. The results would be more sustainable and scalable hypertension control, better health outcomes, and advances toward the 2030 Sustainable Development Goals and universal health coverage.
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Affiliation(s)
| | | | | | - Verónica Schoj
- Global Health Advocacy Incubator, Washington DC, United States of America
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17
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Tajeu GS, Colvin CL, Hardy ST, Bress AP, Gaye B, Jaeger BC, Ogedegbe G, Sakhuja S, Sims M, Shimbo D, O’Brien EC, Spruill TM, Muntner P. Prevalence, risk factors, and cardiovascular disease outcomes associated with persistent blood pressure control: The Jackson Heart Study. PLoS One 2022; 17:e0270675. [PMID: 35930588 PMCID: PMC9355196 DOI: 10.1371/journal.pone.0270675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/14/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Maintaining blood pressure (BP) control over time may contribute to lower risk for cardiovascular disease (CVD) among individuals who are taking antihypertensive medication. METHODS The Jackson Heart Study (JHS) enrolled 5,306 African-American adults ≥21 years of age and was used to determine the proportion of African Americans that maintain persistent BP control, identify factors associated with persistent BP control, and determine the association of persistent BP control with CVD events. This analysis included 1,604 participants who were taking antihypertensive medication at Visit 1 and had BP data at Visits 1 (2000-2004), 2 (2005-2008), and 3 (2009-2013). Persistent BP control was defined as systolic BP <140 mm Hg and diastolic BP <90 mm Hg at all three visits. CVD events were assessed from Visit 3 through December 31, 2016. Hazard ratios (HR) for the association of persistent BP control with CVD outcomes were adjusted for age, sex, systolic BP, smoking, diabetes, and total and high-density lipoprotein cholesterol at Visit 3. RESULTS At Visit 1, 1,226 of 1,604 participants (76.4%) with hypertension had controlled BP. Overall, 48.9% of participants taking antihypertensive medication at Visit 1 had persistent BP control. After multivariable adjustment for demographic, socioeconomic, clinical, behavioral, and psychosocial factors, and access-to-care, participants were more likely to have persistent BP control if they were <65 years of age, women, had family income ≥$25,000 at each visit, and visited a health professional in the year prior to each visit. The multivariable adjusted HR (95% confidence interval) comparing participants with versus without persistent BP control was 0.71 (0.46-1.10) for CVD, 0.68 (0.34-1.34) for coronary heart disease, 0.65 (0.27-1.52) for stroke, and 0.55 (0.33-0.90) for heart failure. CONCLUSION Less than half of JHS participants taking antihypertensive medication had persistent BP control, putting them at increased risk for heart failure.
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Affiliation(s)
- Gabriel S. Tajeu
- Department of Health Services Administration and Policy, Temple University, Philadelphia, PA, United States of America
| | - Calvin L. Colvin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Shakia T. Hardy
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Adam P. Bress
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Bamba Gaye
- INSERM, U970, Paris Cardiovascular Research Center, Department of Epidemiology, Paris, France
- Sorbonne Paris Cité, Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Byron C. Jaeger
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Wake Forest, NC, United States of America
| | - Gbenga Ogedegbe
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States of America
| | - Swati Sakhuja
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Mario Sims
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, United States of America
| | - Daichi Shimbo
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, United States of America
| | - Emily C. O’Brien
- Departments of Population Health Sciences and Neurology, Duke University School of Medicine, Durham, NC, United States of America
| | - Tanya M. Spruill
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States of America
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States of America
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18
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Baldridge AS, Aluka-Omitiran K, Orji IA, Shedul GL, Ojo TM, Eze H, Shedul G, Ugwuneji EN, Egenti NB, Okoli RCB, Ale BM, Nwankwo A, Osagie S, Ye J, Chopra A, Sanuade OA, Tripathi P, Kandula NR, Hirschhorn LR, Huffman MD, Ojji DB. Hypertension Treatment in Nigeria (HTN) Program: rationale and design for a type 2 hybrid, effectiveness, and implementation interrupted time series trial. Implement Sci Commun 2022; 3:84. [PMID: 35918703 PMCID: PMC9344662 DOI: 10.1186/s43058-022-00328-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/10/2022] [Indexed: 11/23/2022] Open
Abstract
Background Hypertension is the most common cardiovascular disease in Nigeria and contributes to a large non-communicable disease burden. Our aim was to implement and evaluate a large-scale hypertension treatment and control program, adapted from the Kaiser Permanent Northern California and World Health Organization HEARTS models, within public primary healthcare centers in the Federal Capital Territory, Nigeria. Methods A type 2 hybrid, interrupted time series design was used to generate novel information on large-scale implementation and effectiveness of a multi-level hypertension control program within 60 primary healthcare centers in the Federal Capital Territory, Nigeria. During the formative phase, baseline qualitative assessments were held with patients, health workers, and administrators to inform implementation package adaptation. The package includes a hypertension patient registry with empanelment, performance and quality reporting, simplified treatment guideline emphasizing fixed-dose combination therapy, reliable access to quality essential medicines and technology, team-based care, and health coaching and home blood pressure monitoring. Strategies to implement and adapt the package were identified based on barriers and facilitators mapped in the formative phase, previous implementation experience, mid-term qualitative evaluation, and ongoing stakeholder and site feedback. The control phase included 11 months of sequential registration of hypertensive patients at participating primary healthcare centers, followed by implementation of the remainder of the package components and evaluation over 37 subsequent, consecutive months of the intervention phase. The formative phase was completed between April 2019 and August 2019, followed by initiation of the control phase in January 2020. The control phase included 11 months (January 2020 to November 2020) of sequential registration and empanelment of hypertensive patients at participating primary healthcare centers. After completion of the control phase in November 2020, the intervention phase commenced in December 2020 and will be completed in December 2023. Discussion This trial will provide robust evidence for implementation and effectiveness of a multi-level implementation package more broadly throughout the Federal Capital Territory, which may inform hypertension systems of care throughout Nigeria and in other low- and middle-income countries. Implementation outcome results will be important to understand what system-, site-, personnel-, and patient-level factors are necessary for successful implementation of this intervention. Trial registration ClinicalTrials.gov NCT04158154. The trial was prospectively registered on November 8, 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00328-9.
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Affiliation(s)
| | | | - Ikechukwu A Orji
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Gabriel L Shedul
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Tunde M Ojo
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Abuja, Nigeria.,Federal Ministry of Health, Abuja, Nigeria.,University of Abuja, Abuja, Nigeria
| | - Helen Eze
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Grace Shedul
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Eugenia N Ugwuneji
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Nonye B Egenti
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Abuja, Nigeria.,University of Abuja, Abuja, Nigeria
| | | | - Boni M Ale
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Abuja, Nigeria.,Holo Healthcare, Nairobi, Kenya
| | - Ada Nwankwo
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Abuja, Nigeria
| | | | - Jiancheng Ye
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Aashima Chopra
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Olutobi A Sanuade
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Spencer Fox Eccles School of Medicine, University of Utah, UT, Salt Lake City, USA
| | - Priya Tripathi
- Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Lisa R Hirschhorn
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark D Huffman
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Cardiovascular Division and Global Health Center, Washington University in St. Louis, St. Louis, MO, USA.,The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Dike B Ojji
- Cardiovascular Research Unit, University of Abuja Teaching Hospital, Abuja, Nigeria.,University of Abuja, Abuja, Nigeria
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19
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Ford ND, Robbins CL, Hayes DK, Ko JY, Loustalot F. Prevalence, Treatment, and Control of Hypertension Among US Women of Reproductive Age by Race/Hispanic Origin. Am J Hypertens 2022; 35:723-730. [PMID: 35511899 PMCID: PMC10123529 DOI: 10.1093/ajh/hpac053] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/07/2022] [Accepted: 04/26/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To explore the prevalence, pharmacologic treatment, and control of hypertension among US nonpregnant women of reproductive age by race/Hispanic origin to identify potential gaps in care. METHODS We pooled data from the 2011 to March 2020 (prepandemic) National Health and Nutrition Examination Survey cycles. Our analytic sample included 4,590 nonpregnant women aged 20-44 years who had at least 1 examiner-measured blood pressure (BP) value. We estimated prevalences and 95% confidence intervals (CIs) of hypertension, pharmacologic treatment, and control based on the 2003 Joint Committee on High Blood Pressure (JNC 7) and the 2017 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines. We evaluated differences by race/Hispanic origin using Rao-Scott chi-square tests. RESULTS Applying ACC/AHA guidelines, hypertension prevalence ranged from 14.0% (95% CI: 12.0, 15.9) among Hispanic women to 30.9% (95% CI: 27.8, 34.0) among non-Hispanic Black women. Among women with hypertension, non-Hispanic Black women had the highest eligibility for pharmacological treatment (65.5%, 95% CI: 60.4, 70.5); current use was highest among White women (61.8%, 95% CI: 53.8, 69.9). BP control ranged from 5.2% (95% CI: 1.1, 9.3) among women of another or multiple non-Hispanic races to 18.6% (95% CI: 12.1, 25.0) among Hispanic women. CONCLUSIONS These findings highlight the importance of monitoring hypertension, pharmacologic treatment, and control by race/Hispanic origin and addressing barriers to equitable hypertension care among women of reproductive age.
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Affiliation(s)
- Nicole D Ford
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cheryl L Robbins
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Donald K Hayes
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jean Y Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,U.S. Public Health Service Commissioned Corps, Atlanta, Georgia, USA
| | - Fleetwood Loustalot
- Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,U.S. Public Health Service Commissioned Corps, Atlanta, Georgia, USA
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20
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Kottke TE, Gupta AK, Thomas RJ. Failing Cardiovascular Health. J Am Coll Cardiol 2022; 80:152-154. [DOI: 10.1016/j.jacc.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 10/17/2022]
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Vaughan AS, Coronado F, Casper M, Loustalot F, Wright JS. County-Level Trends in Hypertension-Related Cardiovascular Disease Mortality-United States, 2000 to 2019. J Am Heart Assoc 2022; 11:e024785. [PMID: 35301870 PMCID: PMC9075476 DOI: 10.1161/jaha.121.024785] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Amid stagnating declines in national cardiovascular disease (CVD) mortality, documenting trends in county‐level hypertension‐related CVD death rates can help activate local efforts prioritizing hypertension prevention, detection, and control. Methods and Results Using death certificate data from the National Vital Statistics System, Bayesian spatiotemporal models were used to estimate county‐level hypertension‐related CVD death rates and corresponding trends during 2000 to 2010 and 2010 to 2019 for adults aged ≥35 years overall and by age group, race or ethnicity, and sex. Among adults aged 35 to 64 years, county‐level hypertension‐related CVD death rates increased from a median of 23.2 per 100 000 in 2000 to 43.4 per 100 000 in 2019. Among adults aged ≥65 years, county‐level hypertension‐related CVD death rates increased from a median of 362.1 per 100 000 in 2000 to 430.1 per 100 000 in 2019. Increases were larger and more prevalent among adults aged 35 to 64 years than those aged ≥65 years. More than 75% of counties experienced increasing hypertension‐related CVD death rates among patients aged 35 to 64 years during 2000 to 2010 and 2010 to 2019 (76.2% [95% credible interval, 74.7–78.4] and 86.2% [95% credible interval, 84.6–87.6], respectively), compared with 48.2% (95% credible interval, 47.0–49.7) during 2000 to 2010 and 66.1% (95% credible interval, 64.9–67.1) for patients aged ≥65 years. The highest rates for both age groups were among men and Black populations. All racial and ethnic categories in both age groups experienced widespread county‐level increases. Conclusions Large, widespread county‐level increases in hypertension‐related CVD mortality sound an alarm for intensified clinical and public health actions to improve hypertension prevention, detection, and control and prevent subsequent CVD deaths in counties across the nation.
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Affiliation(s)
- Adam S. Vaughan
- Division for Heart Disease and Stroke PreventionCenters for Disease Control and PreventionAtlantaGA
| | - Fátima Coronado
- Division for Heart Disease and Stroke PreventionCenters for Disease Control and PreventionAtlantaGA
| | - Michele Casper
- Division for Heart Disease and Stroke PreventionCenters for Disease Control and PreventionAtlantaGA
| | - Fleetwood Loustalot
- Division for Heart Disease and Stroke PreventionCenters for Disease Control and PreventionAtlantaGA
| | - Janet S. Wright
- Division for Heart Disease and Stroke PreventionCenters for Disease Control and PreventionAtlantaGA
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22
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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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Ma A, Sanchez A, Ma M. Racial disparities in health care utilization, the affordable care act and racial concordance preference. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2022; 22:91-110. [PMID: 34427837 DOI: 10.1007/s10754-021-09311-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/17/2021] [Indexed: 06/13/2023]
Abstract
The Affordable Care Act was implemented with the aim of increasing coverage and affordable access with hopes of improving health outcomes and reducing costs. Yet, disparities persist. Coverage and affordable access alone cannot explain the health care gap between racial/ethnic minorities and white patients. Instead, the focus has turned to other factors affecting utilization rates such as the patient-provider relationship. Data from nationally represented U.S. households in 2009-2017 were used to study the association between patient-provider social distance as measured by "racial/ethnic concordance" and health care utilization rates for periods covering pre- and post-ACA. Despite the reduction in financial barriers to health access with the implementation of the ACA, the correlation between racial/ethnic concordance and utilization remains positive and significant. The results suggest that while the ACA may have improved coverage and affordability, other dimensions of access, particularly acceptability, as measured by patient-provider clinical interaction experience, remains a factor in the decision to utilize care.
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Affiliation(s)
- Alyson Ma
- Department of Economics, University of San Diego School of Business, 5998 Alcala Park, San Diego, CA, 92110, USA
| | - Alison Sanchez
- Department of Economics, University of San Diego School of Business, 5998 Alcala Park, San Diego, CA, 92110, USA.
| | - Mindy Ma
- Department of Psychology and Neuroscience, Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, FL, 33314, USA
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Levitz C, Jones M, Nudelman J, Cox M, Camacho D, Wielunski A, Rothman M, Tomlin J, Jaffe M. Reducing Cardiovascular Risk for Patients With Diabetes: An Evidence-Based, Population Health Management Program. J Healthc Qual 2022; 44:103-112. [PMID: 34700325 PMCID: PMC8887839 DOI: 10.1097/jhq.0000000000000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Those with diabetes are at an increased risk of cardiovascular disease (CVD). Safety net clinics serve populations that bear a significant burden of disease and disparities and are a key setting in which to focus on reducing CVD. An integrated health system provided funding and technical assistance (TA) to safety net organizations (community health centers and public hospitals) in Northern California to decrease the risk of cardiovascular events for patients with diabetes. This was a program called Preventing Heart Attacks and Strokes Everyday (PHASE), which combined an evidence-based medication protocol with population health management and team-based care strategies. The TA supported organizations by sharing best practices, providing quality improvement coaching, and facilitating peer learning. A mixed-methods evaluation found that organizations involved in PHASE improved rates of blood pressure control and cardioprotective medication prescriptions for patients with diabetes. They made progress on these measures through strategies such as leveraging team-based care, providing education on evidence-based protocols, and using data to drive improvements. The evaluation concluded that financially supporting and providing focused TA to safety net organizations can help them build capacity and leverage their strengths to improve outcomes and potentially decrease the risk of heart attacks and strokes in communities.
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25
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Leung AA, Williams JVA, Tran KC, Padwal RS. Epidemiology of Resistant Hypertension in Canada. Can J Cardiol 2022; 38:681-687. [PMID: 35122938 DOI: 10.1016/j.cjca.2022.01.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/21/2022] [Accepted: 01/27/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Resistant hypertension is associated with cardiovascular morbidity and mortality. The objective of this study was to estimate the prevalence of apparent treatment-resistant hypertension in Canadian adults and examine the characteristics of those affected. METHODS A nationally-representative, cross-sectional study was conducted using Canadian Health Measures Survey (2007-2017) data. The frequency of respondents with uncontrolled blood pressure despite 3 or more antihypertensive medications of different drug classes (and at least one agent being a diuretic), or treatment with 4 or more agents, irrespective of blood pressure, was determined. RESULTS A total of 245,700 people were identified to have apparent treatment-resistant hypertension, representing 5.3% (95% confidence intervals [CI], 4.5% to 6.2%) of adults treated for hypertension in Canada. Respondents who had uncontrolled blood pressure with 3 or more antihypertensive drugs were more likely women (55.8% [95% CI, 41.1% to 70.4%]), 70 years of age or older (45.3% [95% CI, 32.8-57.9]), and overweight or obese (84.2% [95% CI, 72.3% to 96.1%]). Respondents with apparent treatment-resistant hypertension also had a high likelihood of chronic kidney disease (36.0% [95% CI, 21.4% to 50.6%]), diabetes (35.2% [95% CI, 21.7% to 48.7%]), dyslipidemia (68.0% [95% CI, 55.2% to 80.8%]), and previous history of heart attack (9.9% [95% CI, 4.8% to 15.1%]) or stroke (7.1% [95% CI, 0 to 14.4%]). CONCLUSIONS Despite being prescribed at least 3 antihypertensive drugs, a considerable proportion of Canadians, especially women, have difficulty achieving blood pressure control, predisposing them to a higher risk of cardiovascular complications and death.
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Affiliation(s)
- Alexander A Leung
- Department of Medicine, University of Calgary, Calgary, AB, Canada;; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada;.
| | - Jeanne V A Williams
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Karen C Tran
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raj S Padwal
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Fontil V, Pacca L, Bellows BK, Khoong E, McCulloch CE, Pletcher M, Bibbins-Domingo K. Association of Differences in Treatment Intensification, Missed Visits, and Scheduled Follow-up Interval With Racial or Ethnic Disparities in Blood Pressure Control. JAMA Cardiol 2022; 7:204-212. [PMID: 34878499 PMCID: PMC8655666 DOI: 10.1001/jamacardio.2021.4996] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 09/15/2021] [Indexed: 11/14/2022]
Abstract
Importance Black patients with hypertension often have the lowest rates of blood pressure (BP) control in clinical settings. It is unknown to what extent variation in health care processes explains this disparity. Objective To assess whether and to what extent treatment intensification, scheduled follow-up interval, and missed visits are associated with racial and ethnic disparities in BP control. Design, Setting, and Participants In this cohort study, nested logistic regression models were used to estimate the likelihood of BP control (defined as a systolic BP [SBP] level <140 mm Hg) by race and ethnicity, and a structural equation model was used to assess the association of treatment intensification, scheduled follow-up interval, and missed visits with racial and ethnic disparities in BP control. The study included 16 114 adults aged 20 years or older with hypertension and elevated BP (defined as an SBP level ≥140 mm Hg) during at least 1 clinic visit between January 1, 2015, and November 15, 2017. A total of 11 safety-net clinics within the San Francisco Health Network participated in the study. Data were analyzed from November 2019 to October 2020. Main Outcomes and Measures Blood pressure control was assessed using the patient's most recent BP measurement as of November 15, 2017. Treatment intensification was calculated using the standard-based method, scored on a scale from -1.0 to 1.0, with -1.0 being the least amount of intensification and 1.0 being the most. Scheduled follow-up interval was defined as the mean number of days to the next scheduled visit after an elevated BP measurement. Missed visits measured the number of patients who did not show up for visits during the 4 weeks after an elevated BP measurement. Results Among 16 114 adults with hypertension, the mean (SD) age was 58.6 (12.1) years, and 8098 patients (50.3%) were female. A total of 4658 patients (28.9%) were Asian, 3743 (23.2%) were Black, 3694 (22.9%) were Latinx, 2906 (18.0%) were White, and 1113 (6.9%) were of other races or ethnicities (including American Indian or Alaska Native [77 patients (0.4%)], Native Hawaiian or Pacific Islander [217 patients (1.3%)], and unknown [819 patients (5.1%)]). Compared with patients from all racial and ethnic groups, Black patients had lower treatment intensification scores (mean [SD], -0.33 [0.26] vs -0.29 [0.25]; β = -0.03, P < .001) and missed more visits (mean [SD], 0.8 [1.5] visits vs 0.4 [1.1] visits; β = 0.35; P < .001). In contrast, Asian patients had higher treatment intensification scores (mean [SD], -0.26 [0.23]; β = 0.02; P < .001) and fewer missed visits (mean [SD], 0.2 [0.7] visits; β = -0.20; P < .001). Black patients were less likely (odds ratio [OR], 0.82; 95% CI, 0.75-0.89; P < .001) and Asian patients were more likely (OR, 1.13; 95% CI, 1.02-1.25; P < .001) to achieve BP control than patients from all racial or ethnic groups. Treatment intensification and missed visits accounted for 21% and 14%, respectively, of the total difference in BP control among Black patients and 26% and 13% of the difference among Asian patients. Conclusions and Relevance This study's findings suggest that racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in BP control, and racial and ethnic differences in visit attendance may also play a role. Ensuring more equitable provision of treatment intensification could be a beneficial health care strategy to reduce racial and ethnic disparities in BP control.
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Affiliation(s)
- Valy Fontil
- Division of General Internal Medicine, University of California, San Francisco, San Francisco
- UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California
| | - Lucia Pacca
- Division of General Internal Medicine, University of California, San Francisco, San Francisco
- UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California
| | - Brandon K. Bellows
- Division of General Medicine, Columbia University Irving Medical Center, New York, New York
| | - Elaine Khoong
- Division of General Internal Medicine, University of California, San Francisco, San Francisco
- UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Mark Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Kirsten Bibbins-Domingo
- Division of General Internal Medicine, University of California, San Francisco, San Francisco
- UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
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Leung AA, Bell A, Tsuyuki RT, Campbell NRC. Remettre la maîtrise de l’hypertension à l’avant-plan au Canada. CMAJ 2021; 193:E1330-E1332. [PMID: 34426456 PMCID: PMC8412423 DOI: 10.1503/cmaj.210140-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Alexander A Leung
- Départements de médecine et de santé communautaire (Leung, Campbell), Université de Calgary, Calgary, Alb.; Département de médecine familiale et communautaire (Bell), Université de Toronto, Toronto, Ont.; Départements de pharmacologie et de médecine (Tsuyuki), Université de l'Alberta, Edmonton, Alb.
| | - Alan Bell
- Départements de médecine et de santé communautaire (Leung, Campbell), Université de Calgary, Calgary, Alb.; Département de médecine familiale et communautaire (Bell), Université de Toronto, Toronto, Ont.; Départements de pharmacologie et de médecine (Tsuyuki), Université de l'Alberta, Edmonton, Alb
| | - Ross T Tsuyuki
- Départements de médecine et de santé communautaire (Leung, Campbell), Université de Calgary, Calgary, Alb.; Département de médecine familiale et communautaire (Bell), Université de Toronto, Toronto, Ont.; Départements de pharmacologie et de médecine (Tsuyuki), Université de l'Alberta, Edmonton, Alb
| | - Norman R C Campbell
- Départements de médecine et de santé communautaire (Leung, Campbell), Université de Calgary, Calgary, Alb.; Département de médecine familiale et communautaire (Bell), Université de Toronto, Toronto, Ont.; Départements de pharmacologie et de médecine (Tsuyuki), Université de l'Alberta, Edmonton, Alb
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Pasha M, Brewer LC, Sennhauser S, Alsawas M, Murad MH. Health Care Delivery Interventions for Hypertension Management in Underserved Populations in the United States: A Systematic Review. Hypertension 2021; 78:955-965. [PMID: 34397275 DOI: 10.1161/hypertensionaha.120.15946] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Maarya Pasha
- Division of General Internal Medicine (M.P.), Mayo Clinic College of Medicine, Rochester, MN
| | - LaPrincess C Brewer
- Department of Cardiovascular Medicine (L.C.B.), Mayo Clinic College of Medicine, Rochester, MN.,Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN (L.C.B.)
| | - Susie Sennhauser
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Jacksonville, FL (S.S.)
| | - Mouaz Alsawas
- Division of Preventive, Occupational and Aerospace Medicine, Rochester, MN (M.A., M.H.M.)
| | - M Hassan Murad
- Division of Preventive, Occupational and Aerospace Medicine, Rochester, MN (M.A., M.H.M.)
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Leung AA, Bell A, Tsuyuki RT, Campbell NRC. Refocusing on hypertension control in Canada. CMAJ 2021; 193:E854-E855. [PMID: 34099471 PMCID: PMC8203261 DOI: 10.1503/cmaj.210140] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander A Leung
- Department of Medicine (Leung, Campbell) and of Community Health Sciences (Leung, Campbell), University of Calgary, Calgary, Alta.; Department of Family and Community Medicine (Bell), University of Toronto, Toronto, Ont.; Department of Pharmacology (Tsuyuki) and of Medicine (Tsuyuki), University of Alberta, Edmonton, Alta.
| | - Alan Bell
- Department of Medicine (Leung, Campbell) and of Community Health Sciences (Leung, Campbell), University of Calgary, Calgary, Alta.; Department of Family and Community Medicine (Bell), University of Toronto, Toronto, Ont.; Department of Pharmacology (Tsuyuki) and of Medicine (Tsuyuki), University of Alberta, Edmonton, Alta
| | - Ross T Tsuyuki
- Department of Medicine (Leung, Campbell) and of Community Health Sciences (Leung, Campbell), University of Calgary, Calgary, Alta.; Department of Family and Community Medicine (Bell), University of Toronto, Toronto, Ont.; Department of Pharmacology (Tsuyuki) and of Medicine (Tsuyuki), University of Alberta, Edmonton, Alta
| | - Norman R C Campbell
- Department of Medicine (Leung, Campbell) and of Community Health Sciences (Leung, Campbell), University of Calgary, Calgary, Alta.; Department of Family and Community Medicine (Bell), University of Toronto, Toronto, Ont.; Department of Pharmacology (Tsuyuki) and of Medicine (Tsuyuki), University of Alberta, Edmonton, Alta
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Anderson TS, Odden MC, Penko J, Kazi DS, Bellows BK, Bibbins‐Domingo K. Characteristics of Populations Excluded From Clinical Trials Supporting Intensive Blood Pressure Control Guidelines. J Am Heart Assoc 2021; 10:e019707. [PMID: 33754796 PMCID: PMC8174340 DOI: 10.1161/jaha.120.019707] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background Only one third of patients recommended intensified treatment by the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline for high blood pressure would have been eligible for the clinical trials on which recommendations were largely based. We sought to identify characteristics of adults who would have been trial-ineligible in order to inform clinical practice and research priorities. Methods and Results We examined the proportion of adults diagnosed with hypertension who met trial inclusion and exclusion criteria, stratified by age, diabetes mellitus status, and guideline recommendations in a cross-sectional study of the National Health and Nutrition Examination Survey, 2013-2016. Of the 107.7 million adults (95% CI, 99.3-116.0 million) classified as having hypertension by the ACC/AHA guideline, 23.1% (95% CI, 20.8%-25.5%) were below the target blood pressure of 130/80 mm Hg, 22.2% (95% CI, 20.1%-24.4%) would be recommended nonpharmacologic treatment, and 54.6% (95% CI, 52.5%-56.7%) would be recommended additional pharmacotherapy. Only 20.6% (95% CI, 18.8%-22.4%) of adults with hypertension would be trial-eligible. The majority of adults <50 years were excluded because of low cardiovascular risk and lack of access to primary care. The majority of adults aged ≥70 years were excluded because of multimorbidity and limited life expectancy. Reasons for trial exclusion were similar for patients with and without diabetes mellitus. Conclusions Intensive blood pressure treatment trials were not representative of many younger adults with low cardiovascular risk and older adults with multimorbidity who are now recommended more intensive blood pressure goals.
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Affiliation(s)
- Timothy S. Anderson
- Division of General MedicineBeth Israel Deaconess Medical CenterBostonMA
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyBeth Israel Deaconess Medical CenterBostonMA
| | - Michelle C. Odden
- Department of Epidemiology and Population HealthStanford UniversityStanfordCA
| | - Joanne Penko
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCA
| | - Dhruv S. Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyBeth Israel Deaconess Medical CenterBostonMA
- Division of CardiologyBeth Israel Deaconess Medical CenterBostonMA
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General HospitalSan FranciscoCA
| | | | - Kirsten Bibbins‐Domingo
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCA
- Division of General Internal MedicineZuckerberg San Francisco General HospitalSan FranciscoCA
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General HospitalSan FranciscoCA
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Muntner P, Hardy ST, Fine LJ, Jaeger BC, Wozniak G, Levitan EB, Colantonio LD. Trends in Blood Pressure Control Among US Adults With Hypertension, 1999-2000 to 2017-2018. JAMA 2020; 324:1190-1200. [PMID: 32902588 PMCID: PMC7489367 DOI: 10.1001/jama.2020.14545] [Citation(s) in RCA: 535] [Impact Index Per Article: 133.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Controlling blood pressure (BP) reduces the risk for cardiovascular disease. OBJECTIVE To determine whether BP control among US adults with hypertension changed from 1999-2000 through 2017-2018. DESIGN, SETTING, AND PARTICIPANTS Serial cross-sectional analysis of National Health and Nutrition Examination Survey data, weighted to be representative of US adults, between 1999-2000 and 2017-2018 (10 cycles), including 18 262 US adults aged 18 years or older with hypertension defined as systolic BP level of 140 mm Hg or higher, diastolic BP level of 90 mm Hg or higher, or use of antihypertensive medication. The date of final data collection was 2018. EXPOSURES Calendar year. MAIN OUTCOMES AND MEASURES Mean BP was computed using 3 measurements. The primary outcome of BP control was defined as systolic BP level lower than 140 mm Hg and diastolic BP level lower than 90 mm Hg. RESULTS Among the 51 761 participants included in this analysis, the mean (SD) age was 48 (19) years and 25 939 (50.1%) were women; 43.2% were non-Hispanic White adults; 21.6%, non-Hispanic Black adults; 5.3%, non-Hispanic Asian adults; and 26.1%, Hispanic adults. Among the 18 262 adults with hypertension, the age-adjusted estimated proportion with controlled BP increased from 31.8% (95% CI, 26.9%-36.7%) in 1999-2000 to 48.5% (95% CI, 45.5%-51.5%) in 2007-2008 (P < .001 for trend), remained stable and was 53.8% (95% CI, 48.7%-59.0%) in 2013-2014 (P = .14 for trend), and then declined to 43.7% (95% CI, 40.2%-47.2%) in 2017-2018 (P = .003 for trend). Compared with adults who were aged 18 years to 44 years, it was estimated that controlled BP was more likely among those aged 45 years to 64 years (49.7% vs 36.7%; multivariable-adjusted prevalence ratio, 1.18 [95% CI, 1.02-1.37]) and less likely among those aged 75 years or older (37.3% vs 36.7%; multivariable-adjusted prevalence ratio, 0.81 [95% CI, 0.65-0.97]). It was estimated that controlled BP was less likely among non-Hispanic Black adults vs non-Hispanic White adults (41.5% vs 48.2%, respectively; multivariable-adjusted prevalence ratio, 0.88; 95% CI, 0.81-0.96). Controlled BP was more likely among those with private insurance (48.2%), Medicare (53.4%), or government health insurance other than Medicare or Medicaid (43.2%) vs among those without health insurance (24.2%) (multivariable-adjusted prevalence ratio, 1.40 [95% CI, 1.08-1.80], 1.47 [95% CI, 1.15-1.89], and 1.36 [95% CI, 1.04-1.76], respectively). Controlled BP was more likely among those with vs those without a usual health care facility (48.4% vs 26.5%, respectively; multivariable-adjusted prevalence ratio, 1.48 [95% CI, 1.13-1.94]) and among those who had vs those who had not had a health care visit in the past year (49.1% vs 8.0%; multivariable-adjusted prevalence ratio, 5.23 [95% CI, 2.88-9.49]). CONCLUSIONS AND RELEVANCE In a series of cross-sectional surveys weighted to be representative of the adult US population, the prevalence of controlled BP increased between 1999-2000 and 2007-2008, did not significantly change from 2007-2008 through 2013-2014, and then decreased after 2013-2014.
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Affiliation(s)
- Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham
| | - Shakia T. Hardy
- Department of Epidemiology, University of Alabama at Birmingham
| | - Lawrence J. Fine
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Byron C. Jaeger
- Department of Biostatistics, University of Alabama at Birmingham
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Margolis KL, Crain AL, Bergdall AR, Beran M, Anderson JP, Solberg LI, O'Connor PJ, Sperl-Hillen JM, Pawloski PA, Ziegenfuss JY, Rehrauer D, Norton C, Haugen P, Green BB, McKinney Z, Kodet A, Appana D, Sharma R, Trower NK, Williams R, Crabtree BF. Design of a pragmatic cluster-randomized trial comparing telehealth care and best practice clinic-based care for uncontrolled high blood pressure. Contemp Clin Trials 2020; 92:105939. [PMID: 31981712 DOI: 10.1016/j.cct.2020.105939] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Uncontrolled hypertension is the largest single contributor to all-cause and cardiovascular mortality in the U.S. POPULATION Nurse- and pharmacist-led team-based care and telehealth care interventions have been shown to result in large and lasting improvements in blood pressure (BP); however, it is unclear how successfully these can be implemented at scale in real-world settings. It is also uncertain how telehealth interventions impact patient experience compared to traditional clinic-based care. AIMS/OBJECTIVES To compare the effects of two evidence-based blood pressure care strategies in the primary care setting: (1) best-practice clinic-based care and (2) telehealth care with home BP telemonitoring and management by a clinical pharmacist. To evaluate implementation using mixed-methods supported by the RE-AIM framework and Consolidated Framework for Implementation Research. METHODS The design is a cluster-randomized comparative effectiveness pragmatic trial in 21 primary care clinics (9 clinic-based care, 12 telehealth care). Adult patients (age 18-85) with hypertension are enrolled via automated electronic health record (EHR) tools during primary care encounters if BP is elevated to ≥150/95 mmHg at two consecutive visits. The primary outcome is change in systolic BP over 12 months as extracted from the EHR. Secondary outcomes are change in key patient-reported outcomes over 6 months as measured by surveys. Qualitative data are collected at various time points to investigate implementation barriers and help explain intervention effects. CONCLUSION This pragmatic trial aims to inform health systems about the benefits, strengths, and limitations of implementing home BP telemonitoring with pharmacist management for uncontrolled hypertension in real-world primary care settings.
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Affiliation(s)
- Karen L Margolis
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America.
| | - A Lauren Crain
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Anna R Bergdall
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - MarySue Beran
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Jeffrey P Anderson
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Leif I Solberg
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Patrick J O'Connor
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Pamala A Pawloski
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Jeanette Y Ziegenfuss
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Dan Rehrauer
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Christine Norton
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Patricia Haugen
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Av, Seattle, WA 98101, United States of America
| | - Zeke McKinney
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Amy Kodet
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Deepika Appana
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Rashmi Sharma
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Nicole K Trower
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - RaeAnn Williams
- HealthPartners, Mailstop 31100A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, New Brunswick, NJ 08901, United States of America
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Lewis CL, Chrastil HJ, Schorr-Ratzlaff W, Lam H, McCord M, Williams L, Drake L, Kozloski M, Lebduska E, Dashiell-Earp C. Achieving 70% Hypertension Control: How Hard Can It Be? Jt Comm J Qual Patient Saf 2020; 46:335-341. [PMID: 32418805 DOI: 10.1016/j.jcjq.2020.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although decades of research support hypertension treatment, studies guiding the successful implementation of programs to control blood pressure (BP) in real-world primary care settings are sparse. METHODS In this study a multicomponent intervention was implemented, with the following goals: (1) achieve 70% control of hypertension within 18 months, (2) use the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to evaluate the implementation of the program, and (3) assess additional actions that could have been undertaken to achieve control among those who remained uncontrolled. RESULTS Of 786 patients, 597 achieved BP control (75.9%; improvement of 20.9 percentage points). For RE-AIM outcomes, (1) staff performed outreach for all uncontrolled patients, with 75.3% making follow-up appointments, and 61.3% attending at least one appointment; (2) the proportion of faculty with at least 70% control increased from 26.7% to 87.5%, indicating significant physician adoption; (3) implementation outcomes were mixed, with four of six medical assistant BP training sessions completed, outreach calls performed in 16 of 18 months, but only 24 patients referred to the patient counseling and medication management program. For maintenance, 70% control was maintained for a 7-month observation period. The research team determined that 16.8% of those uncontrolled could have had additional actions taken to achieve control. CONCLUSION The goal of 70% control was achieved, improving control by 20.9 percentage points over 18 months. The RE-AIM framework evaluation demonstrated successful implementation and likely contributed to achievement of the target. The chart review findings revealed that a minority of patients could have additional interventions provided by the primary care practice.
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Betjemann J, Hemphill JC, Sarkar U. We Dropped the Reflex Hammer on Hypertension 20 Years Ago-Reply. JAMA Neurol 2020; 77:526-527. [PMID: 32119033 DOI: 10.1001/jamaneurol.2020.0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John Betjemann
- Department of Neurology, University of California, San Francisco, San Francisco.,Web Editor
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, San Francisco
| | - Urmimala Sarkar
- Zuckerberg San Francisco General Hospital, Division of General Internal Medicine and Center for Vulnerable Populations, University of California, San Francisco, San Francisco
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Du M, Luo J, Wang S, Liu S. Genetic algorithm combined with BP neural network in hospital drug inventory management system. Neural Comput Appl 2019. [DOI: 10.1007/s00521-019-04379-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Bhat S, Kroehl M, Maniga B, Navarro A, Thompson AM, Lam HM, Trinkley KE. Patient Outreaches for Clinical Pharmacy Services: A Population Health Management Program Assessment. J Pharm Pract 2019; 34:58-63. [PMID: 31238771 DOI: 10.1177/0897190019857396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pharmacists in ambulatory care can utilize population health approaches to identify patients needing disease management and improve outcomes. However, population health is only effective when identified patients are successfully outreached and show to appointments. OBJECTIVE Describe a population health approach utilized by pharmacists in primary care, report outcomes of outreach attempts and scheduled appointments, and determine whether patient and referral characteristics predict no-show appointments. METHODS Retrospective cohort study of patients referred for pharmacist management of hypertension or chronic pain through population health between 2013-2016. Outreach attempt and appointments outcomes were collected. Patient and referral characteristics were analyzed to determine whether predictive of no-show appointments using logistic regression. RESULTS Of 450 outreach attempts, 250 (56%) patients were not reached, 164 (36%) scheduled appointments, and 36 (8%) were reached but declined an appointment. Of 164 patients with appointments, 71 (43%) no-showed. Patients with higher systolic blood pressure were more likely to no-show (OR: 1.02, 95% CI: 1.00-1.04). Other characteristics were not predictive of no-show appointments. CONCLUSION Successful outreach and showed appointments are essential components of successful population health programs. Using multiple outreach modalities and further identifying factors predictive of no-show appointments to refine the current approach may lead to increased efficiency.
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Affiliation(s)
- Shubha Bhat
- Department of Clinical Pharmacy, 12226University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Miranda Kroehl
- Department of Biostatistics and Informatics, Colorado School of Public Health, 12226University of Colorado, Aurora, CO, USA
| | - Brian Maniga
- Department of Clinical Pharmacy, 12226University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Alina Navarro
- Department of Clinical Pharmacy, 12226University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Angela M Thompson
- Department of Clinical Pharmacy, 12226University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - H Mindy Lam
- Department of Clinical Pharmacy, 12226University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Katy E Trinkley
- Department of Clinical Pharmacy, 12226University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Bellows BK, Ruiz-Negrón N, Bibbins-Domingo K, King JB, Pletcher MJ, Moran AE, Fontil V. Clinic-Based Strategies to Reach United States Million Hearts 2022 Blood Pressure Control Goals. Circ Cardiovasc Qual Outcomes 2019; 12:e005624. [PMID: 31163981 DOI: 10.1161/circoutcomes.118.005624] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Centers for Disease Control and Prevention's Million Hearts initiative includes an ambitious ≥80% blood pressure control goal in US adults with hypertension by 2022. We used the validated Blood Pressure Control Model to quantify changes in clinic-based hypertension management processes needed to attain ≥80% blood pressure control. METHODS AND RESULTS The Blood Pressure Control Model simulates patient blood pressures weekly using 3 key modifiable hypertension management processes: office visit frequency, clinician treatment intensification given uncontrolled blood pressure, and continued antihypertensive medication use (medication adherence rate). We compared blood pressure control rates (using the Seventh Joint National Committee on hypertension targets) achieved over 4 years between usual care and the best-observed values for management processes identified from the literature (1-week return visit interval, 20%-44% intensification rate, and 76% adherence rate). We determined the management process values needed to achieve ≥80% blood pressure control in US adults. In adults with uncontrolled blood pressure, usual care achieved 45.6% control (95% uncertainty interval, 39.6%-52.5%) and literature-based best-observed values achieved 79.7% control (95% uncertainty interval, 79.3%-80.1%) over 4 years. Increasing treatment intensification rates to 62% of office visits with an uncontrolled blood pressure resulted in ≥80% blood pressure control, even when the return visit interval and adherence remained at usual care values. Improving to best-observed values for all 3 management processes would achieve 78.1% blood pressure control in the overall US population with hypertension, approaching the ≥80% Million Hearts 2022 goal. CONCLUSIONS Achieving the Million Hearts blood pressure control goal by 2022 will require simultaneously increasing visit frequency, overcoming therapeutic inertia, and improving patient medication adherence. As the relative importance of each of these 3 processes will depend on local characteristics, simulation models like the Blood Pressure Control Model can help local healthcare systems tailor strategies to reach local and national benchmarks.
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Affiliation(s)
- Brandon K Bellows
- Columbia University, Division of General Medicine, New York, NY (B.K.B., A.E.M.)
| | - Natalia Ruiz-Negrón
- University of Utah, Department of Pharmacotherapy, Salt Lake City, UT (N.R.-N.).,SelectHealth, Murray, UT (N.R.-N.)
| | - Kirsten Bibbins-Domingo
- Department of Epidemiology and Biostatistics, University of California at San Francisco (K.B.-D., M.J.P.)
| | - Jordan B King
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT (J.B.K.)
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California at San Francisco (K.B.-D., M.J.P.)
| | - Andrew E Moran
- Columbia University, Division of General Medicine, New York, NY (B.K.B., A.E.M.)
| | - Valy Fontil
- Division of General Medicine, University of California at San Francisco (V.F.)
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