Feasibility of a Clinical Decision Support Tool to Manage Resistant Hypertension: Team-HTN, a Single-arm Pilot Study.

Abstract

Based on defining criteria, hypertension (HTN) affects 31% to 46% of the adult U.S. population and almost 20% of service members. Resistant HTN (rHTN) consumes significant resources, carries substantial morbidity and mortality risk and costs over $350 billion dollars annually. For multiple reasons, only 48.3% of people with HTN are controlled, e.g., undiagnosed secondary HTN, therapeutic or diagnostic inertia, and patient adherence. Our purpose was to determine the feasibility of a web-based clinical decision support tool (CDST) using a renin-aldosterone system (RAS) classification matrix and drug sequencing algorithm to assist providers with the diagnosis and management of uncontrolled HTN (rHTN). Outcomes were blood pressure (BP) rates of control, provider management time, and end-user satisfaction. This two-phase, prospective, non-randomized, single-arm, six-month pilot study was conducted in primary care clinics at a tertiary military medical center. Patients with uncontrolled HTN and primary care providers were recruited. Phase 1 patients checked their BP twice daily (AM and PM), three times weekly using a standardized arm cuff. Patients with rHTN were enrolled in phase 2. Phase 2 patients were managed virtually by providers using the CDST, the RAS classification matrix, and the drug sequencing algorithm which incorporated age, ethnicity, comorbidities, and renin/aldosterone levels. Medications were adjusted every 10 days until BP was at target, using virtual visits. In total, 54 patients and 16 providers were consented. One transplant patient was disqualified, 29 met phase 2 criteria for rHTN, and 6 providers completed the study. In phase 1, 45% (n = 24) of patients were identified as having apparent uncontrolled HTN using peak diurnal blood pressure (pdBP) home readings. In phase 2 (n = 29), previously undetected RAS abnormalities were identified in 69% (n = 20) of patients. Blood pressure control rates improved from 0% to 23%, 47%, and 58% at 2, 4, and 6 months, respectively. Provider management time was reduced by 17%. Using home pdBP readings identified masked HTN in almost 20% of patients that would have been missed by a single daily AM or PM home BP measurement. Feasibility and satisfaction trends were favorable. Despite significant morbidity, mortality, and existing guidelines, over half of hypertensive patients are uncontrolled. Our results suggest that this CDST used with pdBP monitoring is a feasible option to facilitate improved rates of control in rHTN, aid in overcoming therapeutic/diagnostic inertia, improve identification of secondary HTN, and potentially, access. Further research with this tool in a larger population is recommended.