Interventions used to improve control of blood pressure in patients with hypertension

Glynn, Liam; Murphy, Andrew W.; Smith, Susan M.; Schroeder, Knut; Fahey, Tom

doi:10.1002/14651858.cd005182.pub4

Cited by 427 publications

(436 citation statements)

References 148 publications

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“…Previous studies suggest that Beffective^visit frequency may be improved with the help of allied health professionals, telephone BP monitoring, and ambulatory BP monitoring. 11,[44][45][46] Our findings are consistent with previous publications demonstrating a relatively weak and inconsistent relationship between medication adherence and BP control. 7,30,41,47 Vigen and colleagues 47 compared clinic-level medication adherence and treatment intensification as potential clinical performance measures using the Cardiovascular Research Network Hypertension Registry including 162,879 patients in 89 clinics.…”

Section: Discussionsupporting

confidence: 92%

“…11,29,30 Several systematic reviews have shown that protocols that require high visit frequency with vigorous treatment intensification have the greatest impact on BP control. 11,31,32 National initiatives in the U.S aim to disseminate hypertension management protocols that primarily focus on enhancing treatment intensification in patients with BP above targets. 33 Since there are legitimate reasons why a clinician may choose not to intensify treatment for an elevated SBP measured in the office, the optimal/attainable rate of treatment intensification is unclear.…”

Section: Discussionmentioning

confidence: 99%

“…The relative importance of these different barriers is poorly understood, and is not systematically addressed by JNC 8. 9 Although many different types of interventions have been shown to improve BP control in the population, 11 there is little evidence on how population control rates can be improved most effectively and efficiently. Several clinical trials and integrated healthcare systems such as Kaiser Permanente and Veterans Health Administration have achieved high BP control rates (76-80 %) by implementing multicomponent interventions, including improved access to quality care and medication-intensification protocols.…”

Section: Introductionmentioning

confidence: 99%

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Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

et al. 2015

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BACKGROUND: Only half of hypertensive adults achieve blood pressure (BP) control in the United States, and it is unclear how BP control rates may be improved most effectively and efficiently at the population level. OBJECTIVE: We sought to compare the potential effects of system-wide isolated improvements in medication adherence, visit frequency, and higher physician prescription rate on achieving BP control at 52 weeks. DESIGN: We developed a Markov microsimulation model of patient-level, physician-level, and system-level processes involved in controlling hypertension with medications. The model is informed by data from national surveys, cohort studies and trials, and was validated against two multicenter clinical trials (ALLHAT and VALUE). SUBJECTS: We studied a simulated, nationally representative cohort of patients with diagnosed but uncontrolled hypertension with a usual source of care. INTERVENTIONS:We simulated a base case and improvements of 10 and 50 %, and an ideal scenario for three modifiable parameters: visit frequency, treatment intensification, and medication adherence. Ideal scenarios were defined as 100 % for treatment intensification and adherence, and return visits occurring within 4 weeks of an elevated office systolic BP. MAIN OUTCOME: BP control at 52 weeks of follow-up was examined. RESULTS: Among 25,000 hypothetical adult patients with uncontrolled hypertension (systolic BP ≥ 140 mmHg), only 18 % achieved BP control after 52 weeks using base-case assumptions. With 10/50 %/idealized enhancements in each isolated parameter, enhanced treatment intensification achieved the greatest BP control (19/23/71 %), compared with enhanced visit frequency (19/21/35 %) and medication adherence (19/23/26 %). When all three processes were idealized, the model predicted a BP control rate of 95 % at 52 weeks.CONCLUSION: Substantial improvements in BP control can only be achieved through major improvements in processes of care. Healthcare systems may achieve greater success by increasing the frequency of clinical encounters and improving physicians' prescribing behavior than by attempting to improve patient adherence to medications.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

et al. 2015

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“…For all subgroups [2,4,6,8,10,12,14,16,18,20,22 weeks passed since download, respectively], we tracked the number of weekly BP measurements recorded by the subject in the application. We hypothesized that there would be a precipitous "dropoff " of active users in the first 2 weeks since download, consistent with existing mHealth literature [12].…”

Section: Discussionmentioning

confidence: 99%

Improving patient engagement in self-measured blood pressure monitoring using a mobile health technology

Kaplan

Cohen

Zimlichman

2017

Health Inf Sci Syst

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Objective: To understand usage patterns and clinical efficacy of Hello Heart, an mHealth technology application designed to facilitate patient engagement in managing hypertension. Methods:In this single-arm observational study, all subjects with ≥2 blood pressure (BP) recordings were included. The cohort was divided into subgroups by weeks passed since download that patients were still recording measurements. Changes in BP were compared between subgroups.Results: Of 5115 eligible subjects, 3803 (74%) recorded BP for ≥2 weeks. In the 4-week subgroup, 23% achieved BP reduction of ≥10 mmHg versus 24% in the 22-week subgroup (p < 0.001). Among 783 subjects reporting baseline hypertension 57% of the 4-week and 69% of the 22-week subgroups achieved BP normalization (all p < 0.001). Conclusions:We show significant decrease in BP with improved metrics over time. Higher engagement was associated with greater BP reduction and engagement was higher among those with greater clinical need of BP control.Practice implications: Hello Heart represents an operational mHealth technology to improve patient engagement and clinical outcomes.

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“…3 4 Furthermore, clinical trials and integrated healthcare systems have achieved high BP control rates (60-80 %) 37,38 through use of stepped-care hypertension management protocols with treatment algorithms implemented by nurses or pharmacists. 39 However, while these protocols have utilized accepted therapies for stage 1 and stage 2 hypertension, guidance for resistant hypertension has been more restricted and at times not consistent with those recommended by guidelines. 40,41 Adding treatment recommendations specific to resistant hypertension in management protocols could lead to increased use of more effective medications.…”

Section: Discussionmentioning

confidence: 99%

Physician Underutilization of Effective Medications for Resistant Hypertension at Office Visits in the United States: NAMCS 2006–2010

et al. 2013

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BACKGROUND:The American Heart Association (AHA) published guidelines for treatment of resistant hypertension in 2008 recommending use of thiazide diuretics (particularly chlorthalidone), aldosterone antagonists, and fixed-dose combination medications, but it is unclear the extent to which these guidelines are being followed. OBJECTIVE: To describe trends in physician use of recommended medications for resistant hypertension and assess variations in medication use based on geography, physician specialty and patient characteristics. DESIGN: Cross-sectional analysis using the National Ambulatory Medical Care Survey from 2006 to 2010. STUDY SAMPLE: We analyzed visits of hypertension patients to family physicians, general internists, and cardiologists. Resistant hypertension was defined as concurrent use of ≥ 4 classes of blood pressure (BP) medications or elevated BP despite the use of ≥ 3 medications. Pregnant patients and visits with diagnosed heart failure or end-stage renal disease were excluded. MAIN OUTC OME: U se of A HA-r ec ommen d ed medications for management of resistant hypertension. RESULTS: Of 19,500 patient visits with hypertension, 1,567 or 7.1 % CI (6.6-7.7 %) met criteria for resistant hypertension. Thiazide diuretic use was reported in 58.9 % of visits pre-guidelines vs. 54.8 % postguidelines (p=0.37). Use of aldosterone antagonists was low and also did not change significantly after guideline publication (3.1 % vs. 4.5 %, p=0.27). Fixeddose combinations use was 42.0 % before and 37 % after guideline publication (p = 0.29). Each 10-year increase in patient age was associated with lower thiazide use (OR 0.87,, as was presence of comorbid ischemic heart disease (OR 0.62, CI 0.41-0.94). Medication use did not vary by geography or physician specialty. CONCLUSION: Use of AHA-recommended medications for resistant hypertension remains low after publication of guidelines. Healthcare systems should encourage more frequent prescribing of these medications to improve care in this high-risk population.

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Interventions used to improve control of blood pressure in patients with hypertension

Abstract: Analysis 01.01. Comparison 01 Active intervention versus control, Outcome 01 Self monitoring (systolic blood pressure) Analysis 01.02. Comparison 01 Active intervention versus control, Outcome 02 Self monitoring (diastolic blood pressure

Cited by 427 publications

References 148 publications

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

Improving patient engagement in self-measured blood pressure monitoring using a mobile health technology

Physician Underutilization of Effective Medications for Resistant Hypertension at Office Visits in the United States: NAMCS 2006–2010

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