Hypertension Control In Primary Care Research Articles

Blood pressure reduction in difficult-to-control patients and the effect of a nurse-led program in Bulgaria

Hypertension is a major contributor to cardiovascular morbidity and mortality. Although there has been significant improvement in blood pressure (BP) control during the last decades, it is still far from optimal. Several strategies for hypertension management have been proposed, and among all – nurse-led programs seem encouraging. AimTo evaluate the effect of a complex nurse program aiming to reduce BP in patients with uncontrolled hypertension. Patients and MethodsIn a cardiologist's office, a trained nurse included patients with uncontrolled hypertension and newly referred patients with high BP in a program for hypertension management. It consisted of patient education, assessment of quality of life, lifestyle advice, medication improvement and adherence stimulation. All patients were followed for 6 months and their BP, lifestyle indicators, and quality of life measurements were recorded. Statistical analyses included two- and one sample t-tests, chi-square test, correlation and multivariate linear regression. ResultsOverall, 47 patients, presenting with uncontrolled hypertension and with BP>140/90 mm Hg were included in this research. Their BP was reduced within 6 months by mean 30 /11 mm Hg and after 6 months, from 162/88 to 133/77 mm Hg. The drop of BP values was present at the first month with mean BP 140/82 mm Hg. Control of hypertension improved from 2% to 55% at the 1st month mark and to 79% at the 6th month, p<0.0001. The decrease in SBP was positively correlated to decrease in waist circumference, p = 0.47, p = 0.009. In multivariate linear regression analysis, the difference in BP was significantly related to self-assessment health scoring and marginally significant with renal impairment. ConclusionsThe development of a complex nurse-led program, tailored to patients with uncontrolled hypertension, leads to significant positive effect on BP decrease and improves hypertension control in primary care. This may be cost effective and improve BP control in low- to middle-income countries.

IMPLEMENTATION OF THE 2018 ESC/ESH GUIDELINES FOR THE TREATMENT AND CONTROL OF HYPERTENSION IN PRIMARY CARE IN GREECE: THE HYPEDIA STUDY

Objective: To evaluate office blood pressure (OBP) levels for antihypertensive drug treatment initiation/intensification, drug choices, and hypertension control in primary care in Greece. Design and method: A prospective nationwide non-interventional single-visit study was performed in consecutive untreated or treated hypertensives recruited by primary care doctors and hospital clinics. Participants’ characteristics, OBP measurements (triplicate; automatically transferred to PC; Microlife BPA3 PC) and treatment changes were recorded using an online cloud system. The study was supported by Menarini Hellas S.A. Results: A total of 3,122 patients were analyzed (mean age 64 ± 12.5 [SD] years, 52% males, 25% untreated). In untreated hypertensives (N = 772), drug treatment was initiated with monotherapy in 53% and with two-drug combination in 36%. ARB monotherapy was used for treatment initiation in 30%, ARB/CCB 20%, ARB/Thiazide 8%, ACEI-based 19%. Of the combinations used, single-pill were 97%. Among treated hypertensives aged &lt;65 years (N = 977), 79% had OBP &gt; = 130/80 mmHg (systolic and/or diastolic), whereas among those aged &gt; = 65 years (N = 1,373) 66% had OBP &gt; = 140/80 mmHg. ARBs were used in 69% of treated hypertensives, ACEIs 19%, CCBs 47%, diuretics 39%, b-blockers 19%. Single-pill combinations were administered in 85% of patients receiving drug combinations. Treatment intensification (mainly dose increase or drug addition) was performed in 54% of treated hypertensives aged &lt;65 years with OBP &gt; = 130/80 mmHg (systolic and/or diastolic), and in 62% of those &gt; = 65 years with OBP &gt; = 140/80 mmHg. Binary logistic regression in treated hypertensives aged &lt;65 years showed that age (OR 3.2, 95% CI 1.0–9.9), BMI (OR 7.9, 2.8–22.8), male gender (OR 1.6, 1.1–2.2) and primary care (vs. hospital) setting (OR 1.5, 1.0–1.8) predicted OBP &gt; = 130/80 mmHg. In treated hypertensives &gt; = 65 years, BMI (OR 2.5, 1.1–5.7), primary care setting (OR 1.4, 1.0–1.7) and male gender (OR 1.3, 1.0–1.6) predicted OBP &gt; = 140/80 mmHg. Conclusions: RAS blocker-based therapy, mainly ARBs, is the basis of antihypertensive drug treatment in the vast majority of patients in primary care, with single-pill combinations being widely used. In almost half of treated uncontrolled hypertensives treatment is not intensified (physician inertia), suggesting suboptimal implementation of the 2018 ESC/ESH targets in primary care.

Burden of hypertension and associated risks for cardiovascular mortality in Cuba: a prospective cohort study

SummaryBackgroundIn Cuba, hypertension control in primary care has been prioritised as a cost-effective means of addressing premature death from cardiovascular disease. However, there is little evidence from large-scale studies on the prevalence and management of hypertension in Cuba, and no direct evidence of the expected benefit of such efforts on cardiovascular mortality.MethodsIn a prospective cohort study, adults in the general population identified via local family medical practices were interviewed between Jan 1, 1996, and Nov 24, 2002, in five areas of Cuba, and a subset of participants were resurveyed between July 14, 2006, and Oct 19, 2008, in one area. During household visits, blood pressure was measured and information obtained on diagnosis and treatment of hypertension. We calculated the prevalence of hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, or receiving treatment for hypertension) and the proportion of people with hypertension in whom it was diagnosed, treated, and controlled (systolic blood pressure <140 mm Hg, diastolic blood pressure <90 mm Hg). Deaths were identified through linkage by national identification numbers to the Cuban Public Health Ministry records, to Dec 31, 2016. We used Cox regression analysis to compare cardiovascular mortality between participants with versus without uncontrolled hypertension. Rate ratios (RRs) were used to estimate the fraction of cardiovascular deaths attributable to hypertension.Findings146 556 participants were interviewed in the baseline survey in 1996–2002 and 24 345 were interviewed in the resurvey in 2006–08. After exclusion for incomplete data and age outside the range of interest, 136 111 respondents aged 35–79 years (mean age 54 [SD 12] years; 75 947 [56%] women, 60 164 [44%] men) were eligible for inclusion in the analyses. 34% of participants had hypertension. Among these, 67% had a diagnosis of hypertension. 76% of participants with diagnosed hypertension were receiving treatment and blood pressure was controlled in 36% of those people. During 1·7 million person-years of follow-up there were 5707 cardiovascular deaths. In the age groups 35–59, 60–69, and 70–79 years, uncontrolled hypertension at baseline was associated with RRs of 2·15 (95% CI 1·88–2·46), 1·86 (1·69–2·05), and 1·41 (1·32–1·52), respectively, and accounted for around 20% of premature cardiovascular deaths.InterpretationIn this Cuban population, a third of people had hypertension. Although levels of hypertension diagnosis and treatment were commensurate with those in some high-income countries, the proportion of participants whose blood pressure was controlled was low. As well as reducing hypertension prevalence, improvement in blood pressure control among people with diagnosed hypertension is required to prevent premature cardiovascular deaths in Cuba.FundingMedical Research Council, British Heart Foundation, Cancer Research UK.

Clinical Implications

Clinical Implications

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

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.

Abstract 093: Can Hypertension Control be Improved Within a Short Time Frame? - Results From Implementing the Measure Accurately, Act Rapidly and Partner With Patients (MAP) Program

Objective: Evaluate a multifaceted quality improvement program with evidenced-based interventions for Measuring blood pressure (BP, mm Hg) accurately, Acting rapidly to manage uncontrolled BP, and Partnering with patients to promote BP self-management (MAP) in primary care. Methods: Study design : Quasi-experimental, pre-post intervention, design. BP control and BPs of uncontrolled patients were compared at baseline, February 2015[A1] to May 2016, at the last visit of the next 6 months.. Measure accurately included training staff in BP measurement. If attended BP was ≥140/90, unattended, automated office (AO) BP was obtained. Act rapidly included intensification of BP meds when unattended AOBP was ≥140/90 assessed by percent of visits with uncontrolled BP and no treatment change (therapeutic inertia). Partner with patients including BP self-monitoring and using low-priced generic BP meds assessed indirectly by the fall in systolic BP (SBP) per therapeutic intensification. Population Studied: Hypertensive patients (21,035) from 16 practices who had a visit during the baseline period and either no visit (4,691) or at least one visit (16,344) during the program. Results: BP control rose from 65.6% (13,790 of 21,035) to 74.8% (12,234 of 16,344) (p&lt;.001); 12 of 16 practices had significant increases in BP control. In uncontrolled patients at baseline, mean SBP/DBP fell from 149/85 to 139/80 (p&lt;.001/p&lt;.001). Measure accurately lowered SBP 12.8 mm Hg (p&lt;.001) in uncontrolled patients with better technique in attended BP reducing SBP ≥6.5 mm Hg per practice; while unattended AOBP lowered SBP 8.6 mm Hg (p&lt;.001). Therapeutic inertia was unchanged (50.2% vs. 48.4%; p=.10); the mean fall in SBP per therapeutic change increased from 5.4 to 14.0 mm Hg (p&lt;.001). Conclusions: MAP was associated with significant improvement in hypertension control in primary care during a six-month period. The decrease in SBP and improved control were largely explained by Measure accurately and Partner with patients as therapeutic inertia (Act rapidly) did not change. Evidence-based strategies in MAP provide opportunities for primary care practices to quickly improve hypertension control toward the national goals of 80%, and importantly to reduce cardiovascular risk.

On the transition from a nurse-led hypertension clinic to hypertension control in primary care: identifying barriers to and factors acting against continuous hypertension control

Many hypertensive patients are not treated to target and hence do not benefit fully from the blood pressure-related improvements in cardiovascular health. Hypertensive patients who had primarily been treated to a target goal in a nurse-led hypertension clinic were re-examined to evaluate whether their target goal blood pressure was maintained after their discharge from the hypertension clinic for further control in primary care, and to evaluate potential barriers to and factors acting against continuous hypertension control. The median observation time was 3.6 years (range 3 months to 7.9 years). Only 45.2% of the patients were well controlled at the time of re-examination. No patient-related factors (age, body mass index, gender, attitudes towards medication) predicted the outcome. Two factors were significant in the reduction in continuous hypertension control: the cooperation between the patient and health personnel and the shared commitment towards the target goal were discontinued; and many patients did not make control visits to the general practitioner’s office. In conclusion, maintained strict control of hypertension requires both continued close collaboration between the patient and health personnel, with an emphasis on treatment goals, and systematic control visits.

Capsule Commentary on Margolis et al., A Successful Multifaceted Trial to Improve Hypertension Control in Primary Care: Why did it Work?

M argolis et al. 1 conducted a comparative effectiveness research trial to assess whether blood pressure (BP) telemonitoring improved systolic BP over a 6-month period compared to standard care. Using a two-group cluster randomized trial design (eight sites served as controls and eight as intervention arms), the intervention group received home BP telemonitoring with the aid of a pharmacist, who called patients periodically to ensure they were checking their BP regularly. The authors hypothesized that greater medication intensification, greater adherence to medication and healthy lifestyle behaviors, and effective patient–pharmacist relationship—consisting of educational counseling sessions about hypertension and the health benefits of adherence and positive lifestyles changes—would yield improved BP, mediated by either: 1) home BP monitor use; 2) number of BP medication classes; 3) patient-reported adherence to BP medications; 4) physical activity; 5) salt intake; 6) alcohol use; or 7) weight change. Findings indicate that home BP telemonitoring and medication intensification, over the 12-month duration of the study, accounted for 42 % of the intervention effect. Despite the innovativeness of this approach, the lack of clarity as to how adding an educational component to the pharmacist's role can be translated into a scalable intervention calls into question the study’s feasibility. In fact, the authors made no mention of why pharmacists were most suited to deliver this behavioral intervention, nor did they identify a theoretical grounding as to how education and frequent home BP monitoring led to greater BP control. Additionally, the authors did not control for two significant clinical confounders, participants with obstructive sleep apnea and participants with resistant hypertension requiring a medication regimen beyond intensification. Despite these limitations, the current findings are consistent with previous studies which suggest that task-shifting is a viable method of improving BP management. Future work should investigate the effectiveness of this treatment model with patients who have sleep apnea or resistant hypertension.

A Successful Multifaceted Trial to Improve Hypertension Control in Primary Care: Why Did it Work?

It is important to understand which components of successful multifaceted interventions are responsible for study outcomes, since some components may be more important contributors to the intervention effect than others. We conducted a mediation analysis to determine which of seven factors had the greatest effect on change in systolic blood pressure (BP) after 6months in a trial to improve hypertension control. The study was a preplanned secondary analysis of a cluster-randomized clinical trial. Eight clinics in an integrated health system were randomized to provide usual care to their patients (n = 222), and eight were randomized to provide a telemonitoring intervention (n = 228). Four hundred three of 450 trial participants completing the 6-month follow-up visit were included. Intervention group participants received home BP telemonitors and transmitted measurements to pharmacists, who adjusted medications and provided advice to improve adherence to medications and lifestyle modification via telephone visits. Path analytic models estimated indirect effects of the seven potential mediators of intervention effect (defined as the difference between the intervention and usual care groups in change in systolic BP from baseline to 6months). The potential mediators were change in home BP monitor use, number of BP medication classes, adherence to BP medications, physical activity, salt intake, alcohol use, and weight. The difference in change in systolic BP was 11.3mmHg. The multivariable mediation model explained 47% (5.3mmHg) of the intervention effect. Nearly all of this was mediated by two factors: an increase in medication treatment intensity (24%) and increased home BP monitor use (19%). The other five factors were not significant mediators, although medication adherence and salt intake improved more in the intervention group than in the usual care group. Most of the explained intervention effect was attributable to the combination of self-monitoring and medication intensification. High adherence at baseline and the relatively low intensity of resources directed toward lifestyle change may explain why these factors did not contribute to the improvement in BP.

Quality Improvement Initiative for Rapid Induction of Hypertension Control in Primary Care

Hypertension affects 1 of every 4 adults, including two thirds of those over 60 years of age in the United States.1,2 Despite improvements in hypertension awareness and access to care, rates of blood pressure (BP) control remain below 50% in most population studies.1,3,–,5 The Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) in Houston, Texas, is one of the largest regional health centers within the national VA system, handling more than 900 000 outpatient visits in 2006, including 50 000 patients enrolled in primary care. MEDVAMC serves as the main referral center for specialized care for veterans in Southeast Texas and Louisiana. From October 1, 2004, to May 31, 2005, 21 794 patients were treated for chronic hypertension within primary care at the MEDVAMC. Rates of control were 54% in 2005 for all hypertensive patients without diabetes receiving primary care at the MEDVAMC and 30% among patients with comorbid diabetes.6 Under the guidance of the primary care clinic director (J.K.) and nurse manager (D.T.), selected clinicians and staff of the primary care clinic initiated a quality improvement (QI) program to specifically address the quality issues related to the care of patients with persistent, uncontrolled hypertension despite regular follow-up and treatment. The persistence of uncontrolled hypertension among patients with access to health insurance and treatment from a regular provider has been well characterized.7 The cause of treated but uncontrolled hypertension is often attributed to clinical inertia, the failure to initiate or intensify therapy.8,9 Clinical inertia in hypertension care may reflect uncertainty about whether the BP measurement merits intensification (clinical uncertainty) and/or preoccupation with the patient's other problems (competing demands).10,11 The primary care providers (PCPs) at the MEDVAMC adapted a model of frequent, shared …

Cardiovascular risk management and its impact on hypertension control in primary care in low-resource settings: a cluster-randomized trial

To evaluate a simple cardiovascular risk management package for assessing and managing cardiovascular risk using hypertension as an entry point in primary care facilities in low-resource settings. Two geographically distant regions in two countries (China and Nigeria) were selected and 10 pairs of primary care facilities in each region were randomly selected and matched. Regions were then randomly assigned to a control group, which received usual care, or to an intervention group, which applied the cardiovascular risk management package. Each facility enrolled 60 consecutive patients with hypertension. Intervention sites educated patients about risk factors at baseline and initiated treatment with hydrochlorothiazide at 4 months in patients at medium risk of a cardiovascular event, according to a standardized treatment algorithm. Systolic blood pressure change from baseline to 12 months was the primary outcome measure. The study included 2397 patients with baseline hypertension: 1191 in 20 intervention facilities and 1206 in 20 control facilities. Systolic and diastolic blood pressure decreased more in intervention patients than in controls. However, at 12 months more than half of patients still had uncontrolled hypertension (systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg). Behavioural risk factors had improved among intervention patients in Nigeria but not in China. Only about 2% of hypertensive patients required referral to the next level of care. Even in low-resource settings, hypertensive patients can be effectively assessed and managed in primary care facilities.