Managing Hypertension in Older Adults

PURPOSE OF REVIEW

The population of older adults 60-79 years globally is projected to double from 800 million to 1.6 billion between 2015 and 2050, while adults ≥ 80 years were forecast to more than triple from 125 to 430 million. The risk for cardiovascular events doubles with each decade of aging and each 20 mmHg increase of systolic blood pressure. Thus, successful management of hypertension in older adults is critical in mitigating the projected global health and economic burden of cardiovascular disease.

RECENT FINDINGS

Women live longer than men, yet with aging systolic blood pressure and prevalent hypertension increase more, and hypertension control decreases more than in men, i.e., hypertension in older adults is disproportionately a women's health issue. Among older adults who are healthy to mildly frail, the absolute benefit of hypertension control, including more intensive control, on cardiovascular events is greater in adults ≥ 80 than 60-79 years old. The absolute rate of serious adverse events during antihypertensive therapy is greater in adults ≥ 80 years older than 60-79 years, yet the excess adverse event rate with intensive versus standard care is only moderately increased. Among adults ≥ 80 years, benefits of more intensive therapy appear non-existent to reversed with moderate to marked frailty and when cognitive function is less than roughly the twenty-fifth percentile. Accordingly, assessment of functional and cognitive status is important in setting blood pressure targets in older adults. Given substantial absolute cardiovascular benefits of more intensive antihypertensive therapy in independent-living older adults, this group merits shared-decision making for hypertension targets.

Greater use of antihypertensive medications explains lower blood pressures and better control in statin-treated than statin-eligible untreated adults

OBJECTIVE

Statins appear to have greater antihypertensive effects in observational studies than in randomized controlled trials. This study assessed whether more frequent treatment of hypertension contributed to better blood pressure (BP, mmHg) control in statin-treated than statin-eligible untreated adults in observational studies.

METHODS

National Health and Nutrition Examination Surveys 2009-2020 data were analyzed for adults 21-75 years ( N  = 3814) with hypertension (BP ≥140/≥90 or treatment). The 2013 American College of Cardiology/American Heart Association Cholesterol Guideline defined statin eligibility. The main analysis compared BP values and hypertension awareness, treatment, and control in statin-treated and statin-eligible but untreated adults. Multivariable logistic regression was used to assess the association of statin therapy to hypertension control and the contribution of antihypertensive therapy to that relationship.

RESULTS

Among adults with hypertension in 2009-2020, 30.3% were not statin-eligible, 36.9% were on statins, and 32.8% were statin-eligible but not on statins. Statin-treated adults were more likely to be aware of (93.4 vs. 80.6%) and treated (91.4 vs. 70.7%) for hypertension than statin-eligible adults not on statins. The statin-treated group had 8.3 mmHg lower SBP (130.3 vs. 138.6), and 22.8% greater control (<140/<90: 69.0 vs. 46.2%; all P values <0.001). The association between statin therapy and hypertension control [odds ratio 1.94 (95% confidence interval 1.53-2.47)] in multivariable logistic regression was not significant after also controlling for antihypertensive therapy [1.29 (0.96-1.73)].

CONCLUSION

Among adults with hypertension, statin-treated adults have lower BP and better control than statin-eligible untreated adults, which largely reflects differences in antihypertensive therapy.

Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association

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.

Association of Baseline Adherence to Antihypertensive Medications With Adherence After Shelter-in-Place Guidance for COVID-19 Among US Adults

IMPORTANCE

Adherence to selected antihypertensive medications (proportion of days covered [PDC]) declined after guidance to shelter in place for COVID-19.

OBJECTIVES

To determine whether PDC for all antihypertensive medications collectively fell from the 6 months before sheltering guidance (September 15, 2019, to March 14, 2020 [baseline]) compared with the first (March 15 to June 14, 2020) and second (June 15 to September 14, 2020) 3 months of sheltering and to assess the usefulness of baseline PDC for identifying individuals at risk for declining PDC during sheltering.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included a random sample of US adults obtained from EagleForce Health, a division of EagleForce Associates Inc. Approximately one-half of the adults were aged 40 to 64 years and one-half were aged 65 to 90 years, with prescription drug coverage, hypertension, and at least 1 antihypertensive medication prescription filled at a retail pharmacy during baseline.

MAIN OUTCOMES AND MEASURES

Prescription claims were used to assess (1) PDC at baseline and changes in PDC during the first and second 3 months of sheltering and (2) the association of good (PDC ≥ 80), fair (PDC 50-79), and poor (PDC < 50) baseline adherence with adherence during sheltering.

RESULTS

A total of 27 318 adults met inclusion criteria (mean [SD] age, 65.0 [11.7] years; 50.7% women). Mean PDC declined from baseline (65.6 [95% CI, 65.2-65.9]) during the first (63.4 [95% CI, 63.0-63.8]) and second (58.9 [95% CI, 58.5-59.3]) 3 months after sheltering in all adults combined (P < .001 for both comparisons) and both age groups separately. Good, fair, and poor baseline adherence was observed in 40.0%, 27.8%, and 32.2% of adults, respectively. During the last 3 months of sheltering, PDC declined more from baseline in those with good compared with fair baseline adherence (-13.1 [95% CI, -13.6 to -12.6] vs -8.3 [95% CI, -13.6 to -12.6]; P < .001), whereas mean (SD) PDC increased in those with poor baseline adherence (mean PDC, 31.6 [95% CI, 31.3-31.9] vs 34.4 [95% CI, 33.8-35.0]; P < .001). However, poor adherence during sheltering occurred in 1034 adults (9.5%) with good baseline adherence, 2395 (31.6%) with fair baseline adherence, and 6409 (72.9%) with poor baseline adherence.

CONCLUSIONS AND RELEVANCE

These findings suggest that individuals with poor baseline adherence are candidates for adherence-promoting interventions irrespective of sheltering guidance. Interventions to prevent poor adherence during sheltering may be more useful for individuals with fair vs good baseline adherence.

Blood Pressure Control Among Non-Hispanic Black Adults Is Lower Than Non-Hispanic White Adults Despite Similar Treatment With Antihypertensive Medication: NHANES 2013-2018

BACKGROUND

Controlled blood pressure can prevent or reduce adverse health outcomes. Social and structural determinants may contribute to the disparity that despite equivalent proportions on antihypertensive medication, non-Hispanic Black (Black) adults have lower blood pressure control and more cardiovascular events than non-Hispanic White (White) adults.

METHODS

Data from 2013 to 2018 National Health and Nutrition Examination Survey were pooled to assess control among Black and White adults by antihypertensive medication use and selected characteristics using the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Blood Pressure Guideline definition (systolic blood pressure <130 mm Hg and diastolic blood pressure <80 mm Hg) among 4,739 adults.

RESULTS

Among those treated with antihypertensive medication, an estimated 34.9% of Black and 45.0% of White adults had controlled blood pressure. Control was lower for Black and White adults among most subgroups of age, sex, education, insurance status, usual source of care, and poverty-income ratio. Black adults had higher use of diuretics (28.5%-Black adults vs. 23.5%-White adults) and calcium channel blockers (24.2%-Black adults vs. 14.7%-White adults) compared with White adults. Control among Black adults was lower than White adults across all medication classes including diuretics (36.1%-Black adults vs. 47.3%-White adults), calcium channel blockers (30.2%-Black adults vs. 40.1%-White adults), and number of medication classes used.

CONCLUSIONS

Suboptimal blood pressure control rates and disparities warrant increased efforts to improve control, which could include addressing social and structural determinants along with emphasizing implementation of the 2017 ACC/AHA Blood Pressure Guideline into clinical practice.

Proceedings From a National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention Workshop to Control Hypertension

Hypertension treatment and control prevent more cardiovascular events than management of other modifiable risk factors. Although the age-adjusted proportion of US adults with controlled blood pressure (BP) defined as <140/90 mm Hg, improved from 31.8% in 1999-2000 to 48.5% in 2007-2008, it remained stable through 2013-2014 and declined to 43.7% in 2017-2018. To address the rapid decline in hypertension control, the National Heart, Lung, and Blood Institute and the Division for Heart Disease and Stroke Prevention of the Centers for Disease Control and Prevention convened a virtual workshop with multidisciplinary national experts. Also, the group sought to identify opportunities to reverse the adverse trend and further improve hypertension control. The workshop immediately preceded the Surgeon General's Call to Action to Control Hypertension, which recognized a stagnation in progress with hypertension control. The presentations and discussions included potential reasons for the decline and challenges in hypertension control, possible "big ideas," and multisector approaches that could reverse the current trend while addressing knowledge gaps and research priorities. The broad set of "big ideas" was comprised of various activities that may improve hypertension control, including: interventions to engage patients, promotion of self-measured BP monitoring with clinical support, supporting team-based care, implementing telehealth, enhancing community-clinical linkages, advancing precision population health, developing tailored public health messaging, simplifying hypertension treatment, using process and outcomes quality metrics to foster accountability and efficiency, improving access to high-quality health care, addressing social determinants of health, supporting cardiovascular public health and research, and lowering financial barriers to hypertension control.

Self-Reported Antihypertensive Medication Class and Temporal Relationship to Treatment Guidelines

The greater antihypertensive responses to initial therapy with calcium channel blockers (CCBs) or thiazide-type diuretics than renin-angiotensin system blockers as initial therapy in non-Hispanic Black (NHB) adults was recognized in the US High BP guidelines from 1988 to 2003. The 2014 Report from Panel Members Appointed to the Eighth Joint National Committee (2014 aJNC8 Report) and the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline were the first to recommend CCBs or thiazide-type diuretics rather than renin-angiotensin system blockers as initial therapy in NHB. We assessed the temporal relationship of these recommendations on self-reported CCB or thiazide-type diuretics monotherapy by NHB and NHW adults with hypertension absent compelling indications for β-blockers or renin-angiotensin system blockers in National Health and Nutrition Examination Surveys 2015 to 2018 versus 2007 to 2012 (after versus before 2014 aJNC8 Report). CCB or thiazide-type diuretics monotherapy was unchanged in NHW adults (17.1% versus 18.1%, P=0.711) and insignificantly higher after 2014 among NHB adults (43.7% versus 38.2%, P=0.204), although CCB monotherapy increased (29.5% versus 21.0%, P=0.021) and renin-angiotensin system blocker monotherapy fell (44.5% versus 31.0%, P=0.008). Although evidence-based CCB monotherapy increased among NHB adults in 2015 to 2018, hypertension control declined as untreated hypertension and monotherapy increased. While a gap between recommended and actual monotherapy persists, evidence-based monotherapy appears insufficient to improve hypertension control in NHB adults, especially given evidence for worsening therapeutic inertia. Initiating treatment with single-pill combinations and timely therapeutic intensification when required to control hypertension are evidence-based, race-neutral options for improving hypertension control among NHB adults.

Medication Adherence and Blood Pressure Control: A Scientific Statement From the American Heart Association

The widespread treatment of hypertension and resultant improvement in blood pressure have been major contributors to the dramatic age-specific decline in heart disease and stroke. Despite this progress, a persistent gap remains between stated public health targets and achieved blood pressure control rates. Many factors may be important contributors to the gap between population hypertension control goals and currently observed control levels. Among them is the extent to which patients adhere to prescribed treatment. The goal of this scientific statement is to summarize the current state of knowledge of the contribution of medication nonadherence to the national prevalence of poor blood pressure control, methods for measuring medication adherence and their associated challenges, risk factors for antihypertensive medication nonadherence, and strategies for improving adherence to antihypertensive medications at both the individual and health system levels.

Weight-Loss Strategies for Prevention and Treatment of Hypertension: A Scientific Statement From the American Heart Association

Hypertension is a major risk factor for cardiovascular and renal diseases in the United States and worldwide. Obesity accounts for much of the risk for primary hypertension through several mechanisms, including neurohormonal activation, inflammation, and kidney dysfunction. As the prevalence of obesity continues to increase, hypertension and associated cardiorenal diseases will also increase unless more effective strategies to prevent and treat obesity are developed. Lifestyle modification, including diet, reduced sedentariness, and increased physical activity, is usually recommended for patients with obesity; however, the long-term success of these strategies for reducing adiposity, maintaining weight loss, and reducing blood pressure has been limited. Effective pharmacotherapeutic and procedural strategies, including metabolic surgeries, are additional options to treat obesity and prevent or attenuate obesity hypertension, target organ damage, and subsequent disease. Medications can be useful for short- and long-term obesity treatment; however, prescription of these drugs is limited. Metabolic surgery is effective for producing sustained weight loss and for treating hypertension and metabolic disorders in many patients with severe obesity. Unanswered questions remain related to the mechanisms of obesity-related diseases, long-term efficacy of different treatment and prevention strategies, and timing of these interventions to prevent obesity and hypertension-mediated target organ damage. Further investigation, including randomized controlled trials, is essential to addressing these questions, and emphasis should be placed on the prevention of obesity to reduce the burden of hypertensive cardiovascular and kidney diseases and subsequent mortality.

Hypertension Control in the United States 2009 to 2018: Factors Underlying Falling Control Rates During 2015 to 2018 Across Age- and Race-Ethnicity Groups

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Acute physical and mental stress resulted in an increase in fatty acids, norepinephrine, and hemodynamic changes in normal individuals: A possible pathophysiological mechanism for hypertension-Pilot study

Hypertension is often associated with metabolic changes. The sustained increase in sympathetic activity is related to increased blood pressure and metabolic changes. Environmental stimuli may be related to increased sympathetic activity, blood pressure, and metabolic changes, especially in genetically predisposed individuals. The aim of this study was to evaluate the response of fatty acids to physical and mental stress in healthy volunteers and the hemodynamic, hormonal, and metabolic implications of these stimuli. Fifteen healthy individuals with a mean age of 31 ± 7 years, of both sexes, were evaluated. They were assessed at baseline and after combined physical and mental stress (isometric exercise test, Stroop color test). Blood samples were collected at baseline and after stimulation for glucose, insulin, fatty acid, and catecholamine levels. Blood pressure, heart rate, cardiac output, systemic vascular resistance, and distensibility of the large and small arteries were analyzed. The data obtained at baseline and after stimuli were from the same individual, being the control itself. Compared to baseline, after physical and mental stress there was a statistically significant increase (p < .05) in free fatty acids, norepinephrine, diastolic blood pressure, peripheral vascular resistance, and distensibility of the large and small arteries. In conclusion, the combination of physical and mental stress raised fatty acids, norepinephrine, diastolic blood pressure, and peripheral vascular resistance in healthy individuals.

Sociodemographic Determinants of Life's Simple 7: Implications for Achieving Cardiovascular Health and Health Equity Goals

Background

Life's Simple 7 (LS7; nutrition, physical activity, cigarette use, body mass index, blood pressure, cholesterol, glucose) predicts cardiovascular health. The principal objective of our study was to define demographic and socioeconomic factors associated with LS7 to better inform programs addressing cardiovascular health and health equity.

Methods

National Health and Nutrition Examination Surveys 1999-2016 data were analyzed on non-Hispanic White [NHW], NH Black [NHB], and Hispanic adults aged ≥20 years without cardiovascular disease. Each LS7 variable was assigned 0, 1, or 2 points for poor, intermediate, and ideal levels, respectively. Composite LS7 scores were grouped as poor (0-4 points), intermediate (5-9), and ideal (10-14).

Results

32,803 adults were included. Mean composite LS7 scores were below ideal across race/ethnicity groups. After adjusting for confounders, NHBs were less likely to have optimal LS7 scores than NHW (multivariable odds ratios (OR .44; 95% CI .37-.53), whereas Hispanics tended to have better scores (1.18; .96-1.44). Hispanics had more ideal LS7 scores than NHBs, although Hispanics had lower incomes and less education, which were independently associated with fewer ideal LS7 scores. Adults aged ≥45 years were less likely to have ideal LS7 scores (.11; .09-.12) than adults aged <45 years.

Conclusions

NHBs were the least likely to have optimal scores, despite higher incomes and more education than Hispanics, consistent with structural racism and Hispanic paradox. Programs to optimize lifestyle should begin in childhood to mitigate precipitous age-related declines in LS7 scores, especially in at-risk groups. Promoting higher education and reducing poverty are also important.

Abstract MP33: Hypertension Control In The U.s. 2009 To 2018: Rapidly Reversing Years Of Progress

Background: Prior reports show that blood pressure (BP, mmHg) control to <140/<90 in the U.S. rose from 32.2% in 1999-2000 to 54.5% in 2013-14, then fell to 48.0% in 2015-16. In 2014, the BP goal was raised to <150/<90 in adults ≥60 years without diabetes, then lowered to <130/<80 for all adults in 2017. We assessed if the fall in BP control to <140/<90 continued in 2017-2018 and if any decline was limited to adults ≥60 years.

Methods: BP control was assessed in adults ≥18 years in NHANES 2009-2018 (age-adjusted to 2010). BP control and its determinants were assessed by age group 18-39, 40-59, and ≥60 years in NHANES 2009-2012 and 2015-2018 (before/after 2014). Terms: Hypertension, BP ≥140 &/or ≥90 or self-reported current BP medication use (Treated); Aware, ‘Yes” to, “Have you been told you have hypertension?”; Treatment efficiency, proportion of treated adults controlled ([Cont]rolled/Treated); BP control, <140/<90.

Results: For all adults, BP control peaked in 2013-2014 at 54.5%, declining to 48.0% in 2015-2016 and 43.4% in 2017-2018 (11.1% fall, p<0.001). Comparing 2015-2018 to 2009-2012, BP control, awareness and treatment fell [Table]) in adults 40-59; BP control and treatment efficiency fell in adults ≥60 years (Table); SBP rose 3-4 mm Hg (p≤0.01) in all age groups.

Conclusion: Despite the 2017 BP goal <130/<80 in all adults, control to <140/<90 continued to fall in 2017-2018. The fall in BP control impacted adults both ≥60 years, reflecting lower treatment efficiency, and 40-59 years, reflecting less awareness and treatment. Adverse changes in BP and control could increase cardiovascular events and merit prompt attention to drivers of poor control.

Abstract P164: Self-reported Use Of Recommended Calcium Channel Blockers And Diuretics In Non-hispanic Blacks With Hypertension: An Opportunity To Improve Evidence-based Prescribing

Background: Non-Hispanic Blacks (NHBs) have a higher prevalence of hypertension and incidence of cardiovascular events than NH(W)hites and Hispanics. To improve hypertension control and outcomes in NHBs, the U.S. High Blood Pressure (BP, mmHg) Guidelines recommended calcium channel blockers (CCBs) and diuretics over other drug classes as initial therapy in 2014 and 2017. Among adults with hypertension, percentages of NHBs who reported taking CCBs and diuretic monotherapy before and after 2014 were assessed and compared to NHWs and Hispanics.

Methods: National Health and Nutrition Examination Surveys data in 2-year cycles from 2007-2012 and 2015-2018 were analyzed and included self-identified NHB, NHW, and Hispanic adults ≥18 years with recorded BP values and hypertension defined as self-reported BP medication use in the previous month, which included medication class, e.g., CCBs and diuretics. Multivariable logistic regression was used to assess the independent contribution of NHB race/ethnicity to prevalence of CCB and diuretic use as monotherapy.

Results: Self-reported CCB or diuretic monotherapy did not increase significantly from 2007-2012 to 2015-2018 among NHBs (44% vs. 50%, p=0.12) or Hispanics (22% vs 29%, p=0.12) and a non-significant decline in NHWs (26% vs 22%, p=0.14). NHBs were more likely to report taking CCBs or diuretics as monotherapy than NHWs or Hispanics in both time periods (p<0.001). In multivariable analysis, NHBs were more likely to report taking a CCB (multivariable odds ratios 3.57 [95% confidence interval 2.6-4.9]) and diuretic monotherapy (1.63 [1.2-2.3]) than NHWs.

Conclusions: NHBs had a non-significant increase in self-reported CCB or diuretic as monotherapy from 2007-2012 to 2015-2018, suggesting limited impact for this prescribing recommendation in the 2014 and 2017 High BP Guidelines. NHBs more often reported CCB or diuretic monotherapy than NHWs and Hispanics in both time periods, suggesting some clinicians were aware of evidence prior to the 2014 Guideline. Yet, half of NHBs did not report taking CCBs or diuretics as monotherapy in 2015-2018, indicating further opportunity to prescribe evidence-based initial therapy in NHBs that could improve BP control, cardiovascular outcomes and health equity.

Nicotine replacement therapy sampling for smoking cessation within primary care: results from a pragmatic cluster randomized clinical trial

BACKGROUND AND AIMS

Within the context of busy clinical settings, health-care providers need practical, evidence-based options to engage smokers in quitting. Sampling of nicotine replacement therapy [i.e. provision of nicotine replacement therapy (NRT starter kits)] is a brief, pragmatic strategy to address this need. We aimed to compare the effects of NRT sampling plus standard care (SC), relative to SC alone, provided by primary care providers during routine clinic visits.

DESIGN

Cluster-randomized clinical trial.

SETTING

Twenty-two primary care clinics in South Carolina, USA.

PARTICIPANTS

Adult smokers [n = 1245; 61% female, mean age = 50.7, standard deviation (SD) = 13.5] both motivated and unmotivated to quit, seen during routine clinical visit. Interventions were provider-delivered SC (n = 652, 12 clinics) cessation advice or SC + a 2-week supply of both nicotine patch and lozenge, with minimal instructions on use (n = 593; 10 clinics).

MEASUREMENTS

The primary outcome was 7-day point prevalence smoking abstinence at 6-month follow-up, using intent-to-treat. Additional outcomes included NRT use and quit attempts, assessed at 1, 3 and 6 months following baseline.

FINDINGS

Seven-day point prevalence abstinence rates were significantly higher in the NRT sampling group throughout follow-up, including at 6 months [12 versus 8%, odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.0-2.4]. NRT sampling increased prevalence of any use of NRT (65 versus 25%, OR = 5.8, 95% CI = 4.3-7.7), with higher prevalence of use at 6 months (25 versus 14%, OR = 2.0, 95% CI = 1.5-2.7). NRT sampling increased the rate of quit attempts in the initial month (24 versus 18%, OR = 1.5, 95% CI = 1.0-2.3) but had no significant effect on overall rate of quit attempts (48 versus 45%, OR = 1.2, 95% CI = 0.8-1.7).

CONCLUSION

Providing smokers with a free 2-week starter kit of nicotine replacement therapy increased quit attempts, use of stop smoking medications and smoking abstinence compared with standard care in a primary care setting.

Adherence in Hypertension

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Development of ethical governance framework for an mHealth platform for the management of Parkison’s

Background

The ubiquity of mobile devices promises to address the need for continuous management of chronic conditions at lower costs. Its rapid expansion, particularly in public health, is currently largely consumer-driven and lacking in acceptable frameworks for its wider adoption into the healthcare systems. The aim of this study is to identify the key parameters to consider in developing a governance framework for a Parkinson’s Disease Management MHealth platform. The Parkinson’s Disease Manager (PDM) system was developed to gather symptom information from patients with PD via wearable devices and a specially designed app and stored securely in a cloud, for use by clinicians, health researchers and policy makers.

Methodology

Twelve stakeholders were interviewed in the UK including clinicians, data managers, the public. First, the participants’ existing views about sharing personal and then specifically health data online were explored. Secondly, participants were introduced to PDM via a diagram and encouraged to explore the risks and benefits of the system with a minimum of guidance. Finally, they were asked what risks they thought might be posed by a series of specific scenarios presented through vignettes and how such issues might be addressed.

Results

Thematic analysis identified eight emerging themes which clustered around two overarching categories: 1. The key challenges of the system identified included: Establishing appropriate governance; Protecting the data; Ensuring sustainability; Building trust; 2. The proposed solutions included: Ethically informed governance; Embedded data custodians; Sustainable funding and engagement; Trust through transparency.

Conclusions

The patient’s heuristic assessment of risks and benefits is mediated by trust, which can be initially gained by association with individuals and organisations already deemed trustworthy and then consolidated and sustained through transparency and delivering on promises.

Key messages

The effective system design, must ensure that standards of transparency, data protection and informed consent are upheld if the coming eHealth revolution is ever to realise its true potential. The use of diagrams and vignettes to support qualitative interviews helped elucidate the importance of balancing protection, utility and sustainability to build and maintain trust.

Clinicians’ decision making about Parkinson’s treatment plans using self-report vs digital data

Background

An mHealth-based support systems promise to deliver objective data about the patient’s healthcare status to the clinician in a timely manner but at the same time, risks increasing ‘technical uncertainty”, by increasing the amount of available information, but not necessarily its utility in making medical decisions.The study aim was to investigate clinicians’ decision making about treatment and care plans based on the relative utility of subjective (reported by a person with Parkinson’s Disease, PwP) or objective (digital health) information.

Methodology

Clinicians completed an online questionnaire with 15 vignettes describing patient cases of PwP where information type (subjective, objective, subjective and objective) and symptoms / signs were manipulated whilst disease stage, duration and patient demographics were kept constant. Dependent variables were the likelihood of changing the care plan and the confidence in the decision. We also recorded the willingness to rely on subjective or objective information.

Results

Clinicians were equally likely to change the care plan and were equally confident in their decision when receiving information from self-reports or the digital health devices’ outcomes. The likelihood for change increased when both information sources provided consistent information. However, inconsistent information from both sources did lead to more conservative decision making, that is, clinicians were more reluctant to change the care plan.

Conclusions

Clinicians consider digital health information equally as useful and trustworthy as patients’ self-reports for their care plan decisions. This finding corroborates the potential utility of wearable technology and mobile devices for symptoms’ monitoring. Facilitating clinician’s feedback on situations where subjective and objective sources provide conflicting information is an important consideration for the development and improvement of clinical decision support systems (DSS).

Key messages

It would be important to identify conditions and mechanisms that could give rise to this conflicting information and the impact that that could have on patient care. Guidelines (e.g., more frequent appointments to monitor the situation) could then be put in place to deal with these situations.

Abstract 001: Hypertension Control to Systolic Blood Pressure <140 and <130. Implications for Hypertension Guidelines and Performance Metrics Based on Sprint Pop Data

Background: Value-based healthcare rewards quality, e.g. 90 th percentile performance, which requires more than 77% of eligible adults 18 - 85 years with hypertension have BP below 140/90 on the last visit of 2019. Systolic (S)BP (mmHg) below140 on most visits leads to fewer cardiovascular events (CVE) than less consistent control. Goal SBP was lowered to below 130 in the 2017 ACC / AHA Hypertension Guideline as treated patient groups with mean SBP 120-124 had fewer CVE than groups with higher mean SBP. Stricter treatment targets and incentives for excellent performance may lead to group mean SBP less than 120, i.e., below the evidence.

Methods: SPRINT POP Year 2 data were analyzed given more treatment adjustments in Year 01 and fewer patients active in Year 3 and later. The % of patients controlled on various % of visits and mean SBP on the last visit for each group are provided (Table). SEM for SBP less than 0.5 mmHg.

Results: Standard and intensive therapy, respectively, consistently controlled (more than 75% visits) SBP to less than 140 in 29.9% and 78.0% (mean 128.4, 117.6) and SBP to less than 130 in 5.1% and 53.8% (mean 118.5, 114.8) of SPRINT participants.

Discussion: Group mean SBP falls as the (% visits and patients at goal rise. Consistent control to SBP less than 140 likely requires group mean SBP 118-128 on the last yearly visit. Consistent control to SBP less than 130 likely requires group mean SBP 115-119, which is below the evidence of 120-124. BP variability, the impact of single point assessment, and incentives for excellent control are items to consider in hypertension guideline and performance metrics as mean SBP below the evidence may be attained.

A cluster-based approach for integrating clinical management of Medicare beneficiaries with multiple chronic conditions

Background

Approximately 28% of adults have ≥3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress.

Methods and findings

To determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, ‘other’). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R² = 0.36) in claims paid/beneficiary.

Conclusions

Identifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.

Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association

Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.

Improving Hypertension Control in Primary Care With the Measure Accurately, Act Rapidly, and Partner With Patients Protocol

Supplemental Digital Content is available in the text.

Better blood pressure (BP; mm Hg) control is a pivotal national strategy for preventing cardiovascular events. Measure accurately, Act rapidly, and Partner with patients (MAP) with practice facilitation improved BP control (<140/<90 mm Hg) from 61.2% to 89.8% during a 6-month pilot study in one primary care clinic. Current study objectives included evaluating the 6-month MAP framework in 16 Family Medicine Clinics and then withdrawing practice facilitation and determining whether better hypertension control persisted at 12 months since short-term improvements often decline by 1 year. Measure accurately included staff training in attended (intake) BP measurement and unattended automated office BP when intake BP was ≥140/≥90 mm Hg. Act rapidly (therapeutic inertia) included protocol-guided escalation of antihypertensive medications when office BP was ≥140/≥90 mm Hg. Partner with patients (systolic BP decline/therapeutic intensification) included shared decision making, BP self-monitoring, and affordable medications. Study data were obtained from electronic records. In 16 787 hypertensive adults (mean, 61.2 years; 54.1% women; 46.0% Medicare) with visits at baseline and first 6 months, BP control improved from 64.4% at baseline to 74.3% (P<0.001) at 6 and 73.6% (P<0.001) at 12 months. At the first MAP visit, among adults with uncontrolled baseline BP and no medication changes (n=3654), measure accurately resulted in 11.1/5.1 mm Hg lower BP. During the first 6 months of MAP, therapeutic inertia fell (52.0% versus 49.5%; P=0.01), and systolic BP decreased more per therapeutic intensification (−5.4 to −12.7; P<0.001). MAP supports a key national strategy for cardiovascular disease prevention through rapid and sustained improvement in hypertension control, largely reflecting measuring accurately and partnering with patients.

Hypertensive heart disease: Benefit of carvedilol in hemodynamic, left ventricular remodeling, and survival

Objectives

The aim of this study was to determine if carvedilol improved structural and functional changes in the left ventricle and reduced mortality in patients with hypertensive heart disease.

Methods

Blood pressure, heart rate, echocardiographic parameters, and laboratory variables, were assessed pre and post treatment with carvedilol in 98 eligible patients.

Results

Carvedilol at a median dose of 50 mg/day during the treatment period in hypertensive heart disease lowered blood pressure 10/10 mmHg, heart rate 10 beats/min, improved left ventricular ejection fraction from baseline to follow-up (median: 6 years) (36%-47%)) and reduced left ventricular end-diastolic and end-systolic dimensions (62 vs 56 mm; 53 vs 42 mm, respectively, all p-values <0.01). Left ventricular ejection fraction increased in 69% of patients. Patients who did not have improved left ventricular ejection fraction had nearly six-fold higher mortality than those that improved (relative risk; 5.7, 95% confidence interval: 1.3-25, p = 0.022).

Conclusion

Carvedilol reduced cardiac dimensions and improved left ventricular ejection fraction and cardiac remodeling in patients with hypertensive heart disease. These treatment-related changes had a favorable effect on survival.

Differences in primary cardiovascular disease prevention between the 2013 and 2016 cholesterol guidelines and impact of the 2017 hypertension guideline in the United States

The US Preventive Services Task Force cholesterol guideline recommended statins for fewer adults than the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline by setting a higher 10-year atherosclerotic cardiovascular disease threshold (≥10.0% vs ≥7.5%) and requiring concomitant diabetes mellitus, hypertension, dyslipidemia, or cigarette smoking. The 2017 ACC/AHA hypertension guideline lowered the hypertension threshold, increasing 2016 guideline statin-eligible adults. Cross-sectional data on US adults aged 40 to 75 years enabled estimated numbers for the 2013 guideline and 2016 guideline with hypertension thresholds of ≥140/≥90 mm Hg and ≥130/80 mm Hg, respectively, on: (1) untreated, statin-eligible adults for primary atherosclerotic cardiovascular disease prevention (25.40, 14.72, 15.35 million); (2) atherosclerotic cardiovascular disease events prevented annually (124 000, 70 852, 73 199); (3) number needed to treat (21, 21, 21); and (4) number needed to harm (38, 143, 143) per 1000 patient-years for incident diabetes mellitus (42 800, 6700, 7100 cases per year). Despite the lower hypertension threshold, the 2013 cholesterol guideline qualifies approximately 10 million more adults for statins and prevents approximately 50 600 more primary atherosclerotic cardiovascular disease events but induces approximately 35 700 more diabetes mellitus cases annually than the 2016 guideline.

Measure Accurately, Act Rapidly, and Partner With Patients (MAP) improves hypertension control in medically underserved patients: Care Coordination Institute and American Medical Association Hypertension Control Project Pilot Study results

Measure Accurately, Act Rapidly, and Partner With Patients (MAP) is an evidence‐based protocol implemented to improve hypertension control in a clinic for underserved patients (49.9% Medicaid and 50.2% black). Patients with hypertension seen during the year before intervention and with at least one visit during the 6‐month intervention (N = 714) were included. If initial attended blood pressure (BP; standard aneroid manometer) was ≥140/≥90 mm Hg, unattended automated office BP was measured in triplicate and averaged (Measure Accurately) using an Omron HEM‐907XL. When automated office BP was ≥140/≥90 mm Hg, Act Rapidly included intensification of antihypertensive medications, assessed by therapeutic inertia. Partner With Patients included BP self‐monitoring, reducing pill burden, and minimizing medication costs, which was assessed by systolic BP change per therapeutic intensification. Between baseline and the last study visit, BP control to <140/<90 mm Hg increased from 61.2% to 89.9% (P < .0001). MAP rapidly and significantly improved hypertension control in medically underserved patients, largely as a result of measuring BP accurately and partnering with patients.

Cholesterol Control Among Uninsured Adults Did Not Improve From 2001-2004 to 2009-2012 as Disparities With Both Publicly and Privately Insured Adults Doubled

BACKGROUND

Low-density lipoprotein cholesterol (LDL-C) control is higher among insured than uninsured adults, but data on time trends and contributing factors are incomplete and important for improving health equity.

METHODS AND RESULTS

Awareness, treatment, and control of elevated LDL-C were compared among insured versus uninsured and publicly versus privately insured adults, aged 21 to 64 years, in National Health and Nutrition Examination Surveys from 2001 to 2004, 2005 to 2008, and 2009 to 2012 using Adult Treatment Panel-3 criteria. Compared with insured adults, uninsured adults were younger; were more often minority; reported lower incomes, less education, and fewer healthcare encounters; and had lower awareness and treatment of elevated LDL-C (P<0.0001). LDL-C control was higher among insured than uninsured adults in 2001 to 2004 (mean±SEM, 21.4±1.6% versus 10.5±2.6%; P<0.01), and the gap widened by 2009 to 2012 (35.1±1.9% versus 11.3±2.2%; P<0.0001). Despite more minorities (P<0.01), greater poverty, and less education (P<0.001), publicly insured adults had more healthcare visits/year than privately insured adults (P<0.001) and similar awareness, treatment, and control of LDL-C from 2001 to 2012. In multivariable logistic regression, significant positive predictors of cholesterol awareness, treatment, and control included more frequent health care (strongest), increasing age, private healthcare insurance versus uninsured, and hypertension. Public insurance (versus uninsured) was a significant positive predictor of LDL-C control, whereas income <200% versus ≥200% of federal poverty was a significant negative predictor.

CONCLUSIONS

LDL-C control improved similarly over time in publicly and privately insured adults but was stagnant among the uninsured. Healthcare insurance largely addresses socioeconomic barriers to effective LDL-C management, yet poverty retains an independent adverse effect.

Abstract P443: Multiple Chronic Conditions in Older Adults: Implications for Clinical Trials & Guidelines in Hypertension

Background: Multiple chronic conditions ([M]CCs), including hypertension (HTN) and clinical CVD, increase sharply with age and account for most U.S. healthcare costs. In 2001, the Institute of Medicine recommended integrated clinical guidelines for MCC. The dearth of integrated guidelines reflects limited inclusion of complex patients in clinical trials and continued focus on individual diseases.

Methods: To explore implications of MCC for clinical trials and HTN guidelines in older adults, hierarchical clustering was used to segregate beneficiaries in one large Medicare Shared Savings Program into clusters with similar groups of MCC. Clusters were named for the most prevalent CC and described by number of CCs, prevalent HTN, CVD, behavioral health diagnoses and paid claims.

Results: The 50,627 beneficiaries (mean 72 yrs) segregated into 12 clusters; 36,533 (72.2%) had HTN. A total of 33,262 beneficiaries (65.7%) segregated into 6 complex clusters (CHF, CKD, Diabetes, Cancer, COPD, Vascular) with a high prevalence of CVD; 27,324 (82.1%) had HTN. The CHF and CKD clusters had the highest mean number of CCs (9.8, 7.5, respectively), HTN prevalence (94.3%, 91.9%), and yearly costs ($37,700, $26,700/beneficiary). Diabetes, cancer, COPD and vascular disease clusters also had a large burden of CCs (5.9, 5.8, 5.1, 5.4) and HTN (88.3%, 73.6%, 70.7%, 83.9%) with annual healthcare costs from $19,500 (cancer) to $12,900 (COPD); more than 1/3 of patients in the CHF, CKD, diabetes and vascular clusters had a behavioral health diagnosis, most often depression. Of 17,365 (34.3%) beneficiaries in less complex clusters, 9,209 (54%) had HTN, 90+% were candidates for primary CVD prevention, less than 10% had behavioral health diagnoses, and costs were lower.

Conclusions: HTN impacts ~82% of older adults with a higher burden of MCC, and ~75% (27,324/36,533) of Medicare beneficiaries with HTN have a large burden of MCCs. Behavioral health diagnosis, associated with adverse outcomes and costs, are common with MCCs. Clinical care, outcomes and costs for older adults with HTN and MCCs could improve with more representative inclusion in clinical trials and translation through integrated clinical guidelines developed by multi-specialty/disciplinary teams.

Opportunities for improving cardiovascular health outcomes in adults younger than 65 years with guideline-recommended statin therapy

The impact of age, race/ethnicity, healthcare insurance, and selected clinical variables on statin-preventable ASCVD were quantified in adults aged 21 to 79 years from National Health and Nutrition Examination Surveys 2007-2012 using the 2013 American College of Cardiology/American Heart Association guideline on the treatment of cholesterol. Among ≈42.4 million statin-eligible, untreated adults, 52.6% were hypertensive and 71% were younger than 65 years. Of ≈232 000 statin-preventable ASCVD events annually, most occur in individuals younger than 65 years, with higher proportions in blacks and Hispanics than whites (73.0% and 69.2% vs 56.9%, respectively; P<.01). Among adults younger than 65 years, the ratio of statin-eligible but untreated to statin-treated adults was higher in blacks and Hispanics than whites (3.0 and 2.9 vs 1.3, respectively; P<.01), and blacks, men, hypertensives, and cigarette smokers were more likely to be statin eligible than their statin-ineligible counterparts by multivariable logistic regression. Two thirds of untreated statin-eligible adults had two or more healthcare visits per year. Identifying and treating more statin-eligible adults in the healthcare system could improve cardiovascular health equity.

Chaos to complexity: leveling the playing field for measuring value in primary care

RATIONALE, AIMS AND OBJECTIVES

Develop a risk-stratification model that clusters primary care patients with similar co-morbidities and social determinants and ranks 'within-practice' clusters of complex patients based on likelihood of hospital and emergency department (ED) utilization.

METHODS

A retrospective cohort analysis was performed on 10 408 adults who received their primary care at the Medical University of South Carolina University Internal Medicine clinic. A two-part generalized linear regression model was used to fit a predictive model for ED and hospital utilization. Agglomerative hierarchical clustering was used to identify patient subgroups with similar co-morbidities.

RESULTS

Factors associated with increased risk of utilization included specific disease clusters {e.g. renal disease cluster [rate ratio, RR = 5.47; 95% confidence interval (CI; 4.54, 6.59) P < 0.0001]}, low clinic visit adherence [RR = 0.33; 95% CI (0.28, 0.39) P < 0.0001] and census measure of high poverty rate [RR = 1.20; 95% CI (1.11, 1.28) P < 0.0001]. In the cluster model, a stable group of four clusters remained regardless of the number of additional clusters forced into the model. Although the largest number of high-utilization patients (top 20%) was in the multiple chronic condition cluster (1110 out of 4728), the largest proportion of high-utilization patients was in the renal disease cluster (67%).

CONCLUSIONS

Risk stratification enhanced with disease clustering organizes a primary care population into groups of similarly complex patients so that care coordination efforts can be focused and value of care can be maximized.

Low Blood Pressure Is Associated With Greater Risk for Cardiovascular Events in Treated Adults With and Without Apparent Treatment-Resistant Hypertension

Apparent treatment-resistant hypertension (aTRH) may confound the reported relationship between low blood pressure (BP) and increased cardiovascular disease (CVD) in treated hypertensive patients. Incident CVD was assessed in treated hypertensive patients with and without aTRH (BP ≥140 and/or ≥90 mm Hg on ≥3 medications or <140/<90 mm Hg on ≥4 BP medications) at three BP levels: 1: <120 and/or <70 mm Hg and <140/<90 mm Hg; 2: 120-139/70-89 mm Hg; and 3: ≥140 and/or ≥90 mm Hg. Electronic health data were matched to emergency and hospital claims for incident CVD in 118 356 treated hypertensive patients. In adults with and without aTRH, respectively, CVD was greater in level 1 versus level 2 (multivariable hazard ratio, 1.88 [95% confidence interval [CI], 1.70-2.07]; 1.71 [95% CI, 1.59-1.84]), intermediate in level 1 versus level 3 (hazard ratio, 1.32 [95% CI, 1.21-1.44]; 0.99, [95% CI, 0.92-1.07]), and lowest in level 2 versus level 3 (hazard ratio, 0.70 [95% CI, 0.65-0.76]; 0.58, [95% CI, 0.54-0.62]). Low treated BP was associated with more CVD than less stringent BP control irrespective of aTRH.

Relationship between risk factor control and vascular events in the SAMMPRIS trial

OBJECTIVE

The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study is the first stroke prevention trial to include protocol-driven intensive management of multiple risk factors. In this prespecified analysis, we aimed to investigate the relationship between risk factor control during follow-up and outcome of patients in the medical arm of SAMMPRIS.

METHODS

Data from SAMMPRIS participants in the medical arm (n = 227) were analyzed. Risk factors were recorded at baseline, 30 days, 4 months, and then every 4 months for a mean follow-up of 32 months. For each patient, values for all risk factor measures were averaged and dichotomized as in or out of target.

RESULTS

Participants who were out of target for systolic blood pressure and physical activity, as well as those with higher mean low-density lipoprotein cholesterol and non-high-density lipoprotein, were more likely to have a recurrent vascular event (stroke, myocardial infarction, or vascular death) at 3 years compared to those who had good risk factor control. In the multivariable analysis, greater physical activity decreased the likelihood of a recurrent stroke, myocardial infarction, or vascular death (odds ratio 0.6, confidence interval 0.4-0.8).

CONCLUSIONS

Raised blood pressure, cholesterol, and physical inactivity should be aggressively treated in patients with intracranial atherosclerosis to prevent future vascular events. Physical activity, which has not received attention in stroke prevention trials, was the strongest predictor of a good outcome in the medical arm in SAMMPRIS.

CLINICALTRIALSGOV IDENTIFIER

NCT00576693.