Protocol design and preliminary evaluation of the REAL-Health Triple Aim, an open-cohort CVD-care optimisation initiative

Introduction

Effective treatment of cardiovascular disease (CVD) in primary care could be improved. We aim to assess the efficacy of a scalable treatment optimisation programme in unselected community populations in South East England, with the triple aim of improved blood pressure control in people with hypertension, increased high-intensity statin use in people with CVD and reduced gastrointestinal bleeding in patients on antithrombotic medication.

Method

This observational study comprises an open cohort of approximately 200,000 adults at high cardiovascular risk registered with general practitioners in five South East England Clinical Commissioning Groups (CCGs). An intervention programme is planned in four of these CCGs with a further non-intervention CCG acting as a control group. The intervention will consist of: clinical guidelines and educational outreach; virtual patient-reviews software; peer-performance “dashboards” and, where available, financial incentives.

The study will examine 3 primary outcomes: 1. Diagnosed hypertension with a blood pressure <140/90mmHg; 2. Diagnosed CVD on a high-intensity statin; 3. A cardiovascular indication for antithrombotic therapy with one or more factors for increased risk of gastrointestinal bleeding (e.g. age ≥65) on gastroprotection. A further 17 secondary outcomes related to these three aims will be assessed.

Analysis

We will use an interrupted time series analysis over 18 months, representing the pre-implementation, implementation and the post-implementation phases with comparison to the control CCG and applicable national Quality and Outcomes Framework and national prescribing statistics (e.g. OpenPrescribing). Secondary outcomes include an equity impact analysis with results stratified by age, gender, ethnic group and index of deprivation.

Preliminary data

We present preliminary data on Key Performance Indicators (KPIs) collected from 191 GP practices including [percentage achievement on 01/09/2019, on 01/09/2020]: 1. Patients with hypertension and most recent blood pressure ≤140/90mmHg [68.7%, 60.6%]. 2. Patients eligible for treatment with a high-intensity statin on such treatment [53.8%, 55.8%]. 3. Patients on antithrombotics with ≥1 risk factors for gastrointestinal bleeding on gastroprotection [59.0%, 60.1%]. We also present our virtual patient-review software tool and outcome visualisation dashboard.

Conclusion

The REAL-Health Triple Aim initiative is a large-scale primary care cardiovascular risk reduction initiative which was launched almost contemporaneously with the United Kingdom's first SARS-CoV-2 related lockdown. Preliminary data justify the need for the Triple Aim initiative and give us an insight on the impact of the pandemic on its implementation.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Barts CharityBritish Heart Foundation

How to give home BP monitoring patients the correct cuff: using BMI as a surrogate estimate of arm circumference

Background

The key role of patient self-monitoring, already well established by large-scale forward planning initiative such the British National Health Service's (NHS) long-term plan, has been emphasised by the COVID19 pandemic. In the management of hypertension, much can be achieved through the provision of blood pressure monitors to patients, along with appropriate education and online blood pressure (BP) recording facilities. However, it is important to ensure that patients have the correct equipment to reliably measure their own blood pressures and to ensure they purchase or are supplied with validated monitors and, as undersized cuffs yield artefactually elevated BP readings, with correctly sized cuffs.

Purpose

To demonstrate the use of Body Mass Index (BMI) as an estimate of Middle Upper Arm Circumference (MUAC) for purposes of blood pressure monitor cuff size requirement estimation and the application of this strategy to a national Home Blood Pressure Monitoring (HBPM) programme.

Methods

The relationship between MUAC and BMI is well established; MUAC is used surrogate measure of BMI particularly in identifying underweight patients especially in environments where accurate recording of weight and height is challenging. Here, we reverse this relationship to use the BMI (one of the most commonly recorded datum in primary care patient records) to estimate patient MUACs. First, using manufacturer recommended cuff arm-circumference ranges and aggregate pre-established MUAC to BMI linear equations, we generate a simplified BMI to cuff-size scheme. Second, we apply this scheme to a UK Integrated Care System (a regional NHS organisation supporting 1.7 million adult patients in an English city) to estimate cuff requirement under NHS England's BPM@h HBPM initiative (in which patients with poorly controlled hypertension are allocated free home BP monitors). Lastly, we propose a patient-level tool for BP monitor cuff size prediction.

Results

Our simplified scheme proposes the following cuff predictions: Small (S: 17–22cm): BMI <18kg/m2; Medium (M: 22–32cm): BMI ≥18 and <28kg/m2; Large (M: 32–42cm): BMI ≥28 and <38kg/m2 and Extra-large (X: 42–50cm): BMI ≥38kg/m2. In our population of approximately 157,000 adult hypertensive patients, 6,039 were eligible for a BP monitor under the NHS England's BPM@h HBPM initiative. Using our simplified scheme, we predict cuff requirements as follows: S: 2%, M: 32%, L: 46%, X: 19%.

Conclusion

Patient BMIs are a useful predictor of BP monitor cuff size requirement. They are readily available or calculatable from primary care records and their application to cuff size identification will improve accuracy of BP readings in HBPM initiatives. Our preliminary results suggest that the most commonly supplied “standard” cuff may be unsittable for well over 50% of patients and that extra-large cuff may be required for nearly 1 in 5 patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Barts CharityHealth Data Research UK

The Mycobacterium tuberculosis Rv1099c gene encodes a GlpX-like class II fructose 1,6-bisphosphatase

There are now abundant data indicating that Mycobacterium tuberculosis uses fatty acids as a carbon source in vivo. A key enzyme in gluconeogenesis, missing in the original annotation of the M. tuberculosis genome, is fructose 1,6-bisphosphatase (FBPase; EC 3.1.3.11). The authors have shown that M. tuberculosis Rv1099c, a glpX homologue, can complement Escherichia coli mutants lacking FBPase. The protein encoded by Rv1099c was shown to have FBPase activity. Rv1099c was expressed at significant levels in M. tuberculosis, and may encode the major FBPase of this pathogen.

The Mycobacterium tuberculosis dosRS two-component system is induced by multiple stresses

Induction of the Mycobacterium tuberculosis dosR gene, which is known to respond to hypoxia, was measured using RTq-PCR following exposure to different stresses. Increased expression was seen after exposure to S-nitrosoglutathione (GSNO), ethanol and (to a lesser extent) H2O2, but not heat- or cold-shock. We also demonstrated that hspX, which is dependent on dosR for expression, is induced when cultures are left standing for 30 min, while significant but minor induction was seen following a 10 min centrifugation. Microarray analysis was used to compare gene expression in wild-type and deltadosR strains following 30 min standing. Fifty-two genes were significantly up-regulated, and 19 genes were down-regulated. These included genes that had previously been reported as being part of the dosR regulon, and also some novel ones.