Greater Blood Pressure Control Research Articles

P108 DIFFERENCES IN BLOOD PRESSURE CONTROL BASED ON HYPERTENSION SUBTYPE IN PATIENTS WITH A DE NOVO DIAGNOSIS: A RETROSPECTIVE COHORT STUDY

Background and Objective: Currently, the selection of antihypertensive pharmacological treatment is carried out without considering whether only systolic or diastolic hypertension is present or both pressures are elevated. It is unknown whether the selection of individualized pharmacological treatment according to arterial hypertension (AH) subtype leads to greater blood pressure (BP) control. Therefore, this study aims to evaluate the association between the selection of pharmacological treatment based on AH subtype and BP control. Methods: This was a real-world cohort study that included 1,397 Latin American subjects with a de novo diagnosis of AH who received antihypertensive pharmacological treatment following current guidelines. Retrospectively, patients were classified by AH subtype according to the pattern of systolic or diastolic predominance of AH. Also, appropriateness of the pharmacological treatment was assessed based on AH subtype and the underlying hemodynamics of each subtype. BP control at the follow-up, within the first 12 weeks after diagnosis, was defined as <140/90 mmHg. Results: Among the subjects included in the study (n=1,397), the mean age was 52.4±13.2, and body mass index 28.8±4.9 kg/m2; 56.7% were women and 50.6% achieved BP control. The median time to the follow-up after diagnosis was 55 days (IQR 32-89 days). Regarding hemodynamic variables, the mean heart rate was 76.1±7.4 beats per minute, systolic blood pressure 147±13.9 mmHg, diastolic blood pressure 86.4±11.2, mean arterial pressure 108.0±9.5 mmHg, and pulse pressure 61.1±16.1 mmHg. The most frequent AH subtype was isolated systolic hypertension (47.3%). Initiation of appropriate antihypertensive pharmacological treatment was associated with greater BP control (OR 2.17; 95% CI 1.49 to 3.15; P value <0.001) (Figure). The patients who did not reach BP control presented a higher frequency of divergent systolic-diastolic hypertension subtype, and greater hemodynamic alterations. Conclusions: Appropriate selection of pharmacological treatment based on AH subtype is associated with better BP control in patients with newly diagnosed AH.

Abstract 15333: The Addressing Hypertension Care in Africa (ADHINCRA) Study: A Multi-Level Nurse-Led, Mobile-Health Enhanced Intervention to Improve Hypertension Control in Ghana

Background: Ghana, is experiencing silent epidemics of hypertension (HTN) and cardiovascular disease (CVD). There is a dire need to implement multilevel strategies to improve HTN control in Ghana. The Addressing Hypertension Care in Africa (ADHINCRA) Study sought to test the feasibility of a multilevel, nurse-led, mobile-health enhanced intervention to improve HTN control in Ghana. Methods: Using a cluster-randomized controlled pilot trial design, we enrolled 4 hospitals in Kumasi, Ghana and recruited 240 patients with uncontrolled HTN, defined as systolic blood pressure (BP) ≥140 mm Hg. Two hospitals were randomized to the intervention and 2 to the enhanced usual care (UC) arm. Patients in the intervention arm received nurse-led task-shifting, a mobile health application and home BP monitoring. The intervention was administered for six months, after which it was withdrawn and patients were followed for 6 more months. The enhanced UC arm received usual care, plus short text messages on health. The primary outcome was change in BP control status at 6 and 12 months. We used general linear models to examine the probability of BP control, accounting for clustering within hospitals. Results: The mean age was 53 ± 9.7 years, 51% were women. After 6 months, BP control improved in the intervention arm (57.0%, 95% CI 56.8% to 57.1%) versus 18.1%, 95% CI 16.9% to 19.3%, for the UC arm), with a between-group difference of 38.9% (95% CI 37.7% to 40.1%; p<0.001). After 12 months, BP control improved in the intervention arm (80.5%, 95% CI 65.5% to 95.4%) versus 24.2%, 95% CI 10% to 38.5%, for the UC arm), with a between-group difference of 56.2% (95% CI 35.6% to 76.8%; p<0.001). ( Figure) Conclusion: A multi-level intervention nurse-led, mobile-health enhanced intervention was associated with greater BP control than enhanced UC among patients with HTN in Ghana. A larger scale study is warranted to support future scale-up of the ADHINCRA Study.

Blood pressure outcomes at 12 months in primary care patients prescribed remote physiological monitoring for hypertension: a prospective cohort study

Remote patient monitoring (RPM) for hypertension enables automatic transmission of blood pressure (BP) and pulse into the electronic health record (EHR), but its effectiveness in primary care is unknown. This pragmatic matched cohort study using EHR data compared BP outcomes between individuals prescribed RPM and temporally-matched controls from six primary care practices. We retrospectively created a cohort of 288 Medicare-enrolled patients prescribed BP RPM (cases) and 1152 propensity score-matched controls (1:4). Matching was based on age, sex, systolic blood pressure (SBP), marital status, and other characteristics. Outcomes at 3, 6, 9 and 12 months were: controlling high BP (most recent BP < 140/90 mm Hg), antihypertensive medication intensification, and most recent SBP assessed using: all measurements, and office measurements only. At baseline, RPM-prescribed patients and controls had similar ages and systolic BP. BP control diverged at 3 months (RPM: 72.2%, control: 51%, p < 0.001). This difference persisted but decreased over follow-up. After 12 months, the RPM-prescribed cohort had greater BP control (RPM: 71.5%, control: 58.1%, p < 0.001) and lower SBP (132.3 versus 136.5 mm Hg, p = 0.003) using all measurements, but they did not differ using only office measurements (12 month BP control: 60.8% versus 58.1%, p = 0.44; SBP: 135.9 versus 136.5 mm Hg, p = 0.91). At 12 months, the most recent BP measurements were more current for RPM-prescribed patients (median [IQR] 8 [0–109] versus 134 [56–239] days). Net increases in antihypertensive medications by 12 months were similar. Implementation of RPM in primary care could inform hypertension management strategies and increase hypertension control. Registration: ClinicalTrials.gov identifier: NCT05562921.

Implementation Support for a Social Risk Screening and Referral Process in Community Health Centers

Summary Evidence is needed about how to effectively support health care providers in implementing screening for social risks (adverse social determinants of health) and providing related referrals meant to address identified social risks. This need is greatest in underresourced care settings. The authors tested whether an implementation support intervention (6 months of technical assistance and coaching study clinics through a five-step implementation process) improved adoption of social risk activities in community health centers (CHCs). Thirty-one CHC clinics were block-randomized to six wedges that occurred sequentially. Over the 45-month study period from March 2018 to December 2021, data were collected for 6 or more months preintervention, the 6-month intervention period, and 6 or more months postintervention. The authors calculated clinic-level monthly rates of social risk screening results that were entered at in-person encounters and rates of social risk-related referrals. Secondary analyses measured impacts on diabetes-related outcomes. Intervention impact was assessed by comparing clinic performance based on whether they had versus had not yet received the intervention in the preintervention period compared with the intervention and postintervention periods. In assessing the results, the authors note that five clinics withdrew from the study for various bandwidth-related reasons. Of the remaining 26, a total of 19 fully or partially completed all 5 implementation steps, and 7 fully or partially completed at least the first 3 steps. Social risk screening was 2.45 times (95% confidence interval [CI], 1.32–4.39) higher during the intervention period compared with the preintervention period; this impact was not sustained postintervention (rate ratio, 2.16; 95% CI, 0.64–7.27). No significant difference was seen in social risk referral rates during the intervention or postintervention periods. The intervention was associated with greater blood pressure control among patients with diabetes and lower rates of diabetes biomarker screening postintervention. All results must be interpreted considering that the Covid-19 pandemic began midway through the trial, which affected care delivery generally and patients at CHCs particularly. Finally, the study results show that adaptive implementation support was effective at temporarily increasing social risk screening. It is possible that the intervention did not adequately address barriers to sustained implementation or that 6 months was not long enough to cement this change. Underresourced clinics may struggle to participate in support activities over longer periods without adequate resources, even if lengthier support is needed. As policies start requiring documentation of social risk activities, safety-net clinics may be unable to meet these requirements without adequate financial and coaching/technical support.

Abstract P382: Blood Pressure Outcomes After 12 Months in Primary Care: A Prospective Cohort Study in Electronic Health Records Using Propensity Score Matching for Remote Patient Monitoring for Hypertension

Introduction: In primary care (PC) settings, more hands-on hypertension management may be enabled by remote patient monitoring (RPM) for blood pressure (BP), leading to greater BP control over time Hypothesis: Individuals prescribed RPM will have better BP control (BP &lt;140/90 mmHg) and lower office SBP after 12 months, compared with temporally-matched controls. Methods: We conducted a pragmatic matched cohort study in Medicare-enrolled patients with Hypertension at six PC practices, 288 of whom participated in pilot studies of a Omron VitalSight TM RPM system that enabled automatic transmission of BP and pulse into the electronic health record (EHR). We used 1:4 propensity score matching to identify 1152 contemporary matches for these patients from the same PC practices, based on age, sex, systolic BP (SBP), marital status, and several other clinical and healthcare visit characteristics. Outcomes after 12 months included controlling high blood pressure (most recent BP &lt;140/90 mm Hg), and most recent systolic BP and diastolic BP, assessed 1) using PC office measurements only and 2) incorporating RPM measurements. Results: The matched cohort of 1152 patients was, on average, 74 (SD 8) years old, 71% female, and 71% non-Hispanic white. Average baseline systolic BP (SD) was similar between groups: 142.7 (19.5) and 141.2 (18.7) mm Hg in RPM-prescribed patients and controls, respectively (Table). Compared with matched controls, after 12 months the RPM-prescribed cohort had greater BP control (72.6% versus 65.6%) and lower systolic BP (132.3 versus 136.6 mm Hg) when including RPM measurements. However, these metrics were similar when using PC office measurements only. Conclusions: Greater BP control and lower SBP were observed after 12 months in RPM-prescribed patients when considering RPM measurements. Further studies will assess the contributions of adherence to RPM use to observed declines in BP. The EHR can be used to prospectively construct and conduct cohort studies.

Combination Antihypertensive Therapy Prescribing and Blood Pressure Control in a Real-World Setting.

Specific combinations of two drug classes are recommended in a variety of clinical situations in the management of hypertension. These preferred combinations are based on complimentary blood pressure (BP) lowering mechanisms or benefit for a concomitant disease. Using electronic health records (EHRs) data from 27,579 ambulatory hypertensive patients, we investigated antihypertensive therapy prescribing patterns and associations of preferred two drug classes with BP control. Overall, BP control, defined as BP <140/90 mm Hg, was 65% among treated patients. Preferred dual antihypertensive therapy was prescribed in 55% of patients with uncomplicated hypertension, 49% of patients with diabetes, and 47% of patients with a history of myocardial infarction (MI); these prescribing frequencies of preferred combinations were not explained by worse BP control on those combinations. In fact, we found suggestive evidence of association between prescribing of preferred two drug classes and improved BP control among post-MI (OR: 1.21, 95% CI: 0.99-1.48, P = 0.061) and uncomplicated hypertensive (OR: 1.11, 95% CI: 0.98-1.26, P = 0.089) patients. Prescribing of guideline-recommended antihypertensive drug classes for concomitant diseases is suboptimal and prescribing of preferred/optimized drug class combinations was moderate. We did not find a clear association between the use of optimized drug class combinations and greater BP control. Overall, using EHR data, we identified potential opportunities for re-examining prescribing practices with implications for clinical decision support and healthcare improvement at the community and health system-wide levels.

Cluster Randomized Clinical Trial of FAITH (Faith-Based Approaches in the Treatment of Hypertension) in Blacks.

Therapeutic lifestyle change (TLC) is a recommended treatment for patients with hypertension, but its effectiveness in community-based settings remains untested, particularly in black churches-an influential institution for health promotion in black communities. The FAITH study (Faith-Based Approaches in the Treatment of Hypertension) evaluated the comparative effectiveness of a TLC intervention plus motivational interviewing (MINT) sessions versus health education (HE) alone, on blood pressure (BP) reduction among blacks with uncontrolled hypertension. Data were collected on 373 participants meeting eligibility criteria (self-identification as black, age ≥18 years, self-reported diagnosis of hypertension, and uncontrolled BP [BP ≥140/90 or ≥130/80 mm Hg with diabetes mellitus or chronic kidney disease]) from 32 New York City churches. The MINT-TLC intervention plus motivational interviewing treatment comprised 11 weekly group sessions on TLC plus 3 MINT sessions delivered monthly by lay health advisors. The HE control group received 1 TLC session plus 10 sessions on health topics delivered by local experts. The outcomes were BP reduction at 6 months (primary) and BP control and BP reduction at 9 months (secondary). The sample mean age was 63 years; 76% women, with mean BP of 153/87 mm Hg. Using linear mixed-effects regression models, the MINT-TLC intervention plus motivational interviewing group had a significantly greater systolic BP reduction of 5.79 mm Hg compared with the HE group at 6 months ( P=0.029). The treatment effect on systolic BP persisted at 9 months but had reduced significance (5.21 mm Hg; P=0.068). The between-group differences in diastolic BP reduction (0.41 mm Hg) and mean arterial pressure (2.24 mm Hg) at 6 months were not significant. Although the MINT-TLC intervention plus motivational interviewing group had greater BP control than the HE group at 9 months, the difference was not statistically significant (57.0% versus 48.8%; odds ratio, 1.43; 95% CI, 0.90-2.28). A community-based lifestyle intervention delivered in churches led to significantly greater reduction in systolic BP in hypertensive blacks compared with HE alone. URL: https://www.clinicaltrials.gov . Unique identifier: NCT01065831.

Patient characteristics associated with greater blood pressure control in a randomized trial of home blood pressure telemonitoring and pharmacist management

This paper reports subgroup analysis of a successful cluster-randomized trial to identify attributes of hypertensive patients who benefited more or less from an intervention combining blood pressure (BP) telemonitoring and pharmacist management. The end point was BP < 140/90 mm Hg at 6-month follow-up. Fourteen baseline patient characteristics were selected a priori as subgroup variables. Among the 351 trial participants, 44% were female, 84% non-Hispanic white, mean age was 60.9 years, and mean BP was 149/86 mm Hg. The overall adjusted odds ratio for BP control in the intervention versus usual care group was 3.64 (P < .001). The effect of the intervention was significantly larger in patients who were younger (interaction P = .02), did not have diabetes (P = .005), had high baseline diastolic BP (P = .02), added salt less than daily in food preparation (P = .007), and took 0–2 (rather than 3–6) antihypertensive medication classes at baseline (P = .02). These findings may help prioritize patients for whom the intervention is most effective.

Counseling African Americans to Control Hypertension

Background— Data are limited on the implementation of evidence-based multilevel interventions targeted at blood pressure (BP) control in hypertensive blacks who receive care in low-resource primary care practices. Methods and Results— Counseling African Americans to Control Hypertension is a cluster-randomized clinical trial in which 30 community health centers were randomly assigned to the intervention condition (IC) or usual care (UC). Patients at the IC sites received patient education, home BP monitoring, and monthly lifestyle counseling, whereas physicians attended monthly hypertension case rounds and received feedback on their patients’ home BP readings and chart audits. Patients and physicians at the UC sites received printed patient education material and hypertension treatment guidelines, respectively. The primary outcome was BP control, and secondary outcomes were mean changes in systolic and diastolic BPs at 12 months, assessed with an automated BP device. A total of 1059 patients (mean age, 56 years; 28% men, 59% obese, and 36% with diabetes mellitus) were enrolled. The BP control rate was similar in both groups (IC=49.3% versus UC=44.5%; odds ratio, 1.21 [95% confidence interval, 0.90–1.63]; P =0.21). In prespecified subgroup analyses, the intervention was associated with greater BP control in patients without diabetes mellitus (IC=54.0% versus UC=44.7%; odds ratio, 1.45 [confidence interval, 1.02–2.06]); and small-sized community health centers (IC=51.1% versus UC=39.6%; odds ratio, 1.45 [confidence interval, 1.04–2.45]). Conclusions— A practice-based, multicomponent intervention was no better than UC in improving BP control among hypertensive blacks. Future research on the implementation of behavioral modification strategies for hypertension control in low-resource settings should focus on the development of more efficient and tailored interventions in this high-risk population. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00233220.

PM259 Potential impact of structured care and percutaneous transluminal renal denervation to provide greater blood pressure control in those with persistent/resistant hypertension

PM259 Potential impact of structured care and percutaneous transluminal renal denervation to provide greater blood pressure control in those with persistent/resistant hypertension

Analysis of care given to patients with hypertension in Belo Horizonte, according to telephone survey.

To examine the care given to patients with hypertension in the Brazilian public and private health services in the population of Belo Horizonte, Minas Gerais. Telephone interviews were conducted in a sample of hypertensive adults in the year 2009, in Belo Horizonte (n = 100). We compared the care provided to hypertensive users of the Unified Health System (SUS) and of the Supplementary Health (SS), using the χ² test or Fisher's exact test. The prevalence ratio was calculated by the Poisson regression model, adjusted for the variables age, education and skin color. In the descriptive analysis, hypertensive users of private health plans had a higher frequency of physician referral and greater blood pressure control. Unified Health System users were the ones who participated in health promotion groups the most. The acquisition of antihypertensive medications by beneficiaries of private health insurance was more frequent in private pharmacies, and in Health Centers among users of the Unified Health System. The differences disappeared when adjusting the variables for age, race and education. There was no difference regarding the guidance received for a change of habits, or regarding the incorporation of these healthy practices promotion by hypertensive patients. A healthier diet, the practice of physical activity, and the non-use of alcohol and tobacco have been incorporated by hypertensive patients, whether owning private health insurance or not. Promotion practices, proper use of medication a clinical follow-up are important for the control of blood pressure levels.

Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care

Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory. To test the effect of explicit financial incentives to reward guideline-recommended hypertension care. Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists). Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports. Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension. Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout. Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings. clinicaltrials.gov Identifier: NCT00302718.

Blood pressure control and cardiovascular outcomes in high-risk Hispanic patients—Findings From the International Verapamil SR/Trandolapril Study (INVEST)

People of Hispanic origin are the fastest growing ethnic minority in the United States and often have hypertension and other comorbidities which increase the risk associated with coronary artery disease (CAD). An analysis of the 8045 Hispanic patients enrolled in INVEST was conducted, and comparisons were made to the 14,531 non-Hispanic patients. INVEST was a prospective, randomized, open, blinded end point study in CAD patients with hypertension. After 61,835 patient-years of follow-up, treatment with either a verapamil sustained release (SR) or atenolol antihypertensive strategy resulted in greater blood pressure control in Hispanic patients, and Hispanic patients were at significantly lower risk of experiencing a nonfatal myocardial infarction, nonfatal stroke, or death (hazard ratio [HR] 0.87, 95% CI 0.78-0.97). Hispanic ethnicity was associated with an increase (HR 1.19, 95% CI 1.04-1.36), and randomization to the verapamil SR strategy was associated with a decrease (HR 0.85, 95% CI 0.76-0.95), in the risk of new-onset diabetes. Use of trandolapril in the verapamil SR strategy was associated with reduced risk of new-onset diabetes, whereas increasing doses of atenolol and hydrochlorothiazide in the atenolol strategy were associated with increased risk of new-onset diabetes. The Hispanic cohort of INVEST had better blood pressure control and lower risk of adverse cardiovascular outcomes compared with the non-Hispanic cohort. A verapamil SR strategy is an alternative to an atenolol strategy for the treatment of Hispanic patients with hypertension and CAD and can reduce the risk of new-onset diabetes.