Improve Blood Pressure Control Research Articles

Mobile Health Application and Hypertension Management in Rural, Middle-Aged Adults: A Quality Improvement Project.

Over 29% of the adult population in the United States are diagnosed with hypertension, and rates are significantly higher in those adults who live in rural areas. Hypertension is recognized as the most prevalent comorbidity and modifiable risk factor leading to premature death. The purpose of this quality improvement project was to determine if using a mobile phone-based health application called Medisafe could enhance medication adherence and improve blood pressure control in rural-dwelling adults. A small group (N = 14) of middle-aged (45-64 years old) patients with hypertension were recruited to download the free Medisafe phone-based health application. Patients utilized the Medisafe application between their initial visit and a 4- to 6-week follow-up. At the follow-up visit, 64% (n = 9) of participants improved their level of hypertension control by blood pressure classification and improved their scores on the medication adherence questionnaire. The findings from this quality improvement project suggest the Medisafe application is useful to enhance medication adherence and blood pressure control. Future research and quality improvement initiatives are necessary to determine the broader efficacy of phone-based health applications in the rural adult population.

PRESCRIPTION OF SINGLE-PILL ANTIHYPERTENSIVE COMBINATION THERAPY

Objective: The need for polytherapy is common among people affected by arterial hypertension (AH). A single-pill combination is a response to decreased medication adherence, especially in elderly people often suffering from more than one disease, which tends to improve blood pressure control and cardiovascular outcomes. The aim of our study was to determine the frequency of use of a single-pill antihypertensive combination (SPC) therapy and possible differences in presence of comorbidities. Design and method: 324 hypertensive participants on pharmacological treatment were included in this research, of which 51.2% were men, and with an overall median age of 64 years (IQR = 17). For each participant undergoing 24-hour ambulatory blood pressure measurement, data about pharmacological therapy, weight, height and comorbidities such as chronic kidney disease (CKD) and diabetes mellitus (DM) were obtained from their most recent medical records combined with self reports. Body mass index (BMI) was calculated. Results: 148 (45.7%) participants were prescribed a SPC. Participants taking a SPC had lower presence of CKD (23.7% with CKD vs. 76.3% without CKD, p<0.001). No significant difference was found in the presence of DM (p = 0.496). Another interesting finding was more frequent use of SPC therapy among patients with higher BMI (p = 0.029). Conclusions: The results show that less than half of the participants in our study were prescribed an SPC. From this we can conclude that more attention should be paid to educating people about the options for antihypertensive treatment and simplifying therapy regimen. Another point we should highlight is the limited availability of SPCs in the treatment of hypertension in patients suffering from CKD.

NOVEL TARGETED HEALTH PSYCHOLOGY CLINIC REFERRAL IMPROVES BLOOD PRESSURE: PRELIMINARY RESULTS OF A RETROSPECTIVE STUDY

Objective: Despite hypertension medications being widely available, many patients do not have adequately controlled blood pressure. Consequently, alternative interventions are required to support patients. Recently, we have established a novel health psychology clinic to provide additional support to help patients improve blood pressure control. This retrospective study compared outcomes before and after referral to a targeted health psychology clinic. Our aim was to determine the effectiveness of this novel clinic on patient outcomes with a view to improving the service and support rollout in other departments. Design and method: Patient notes referred to the Health Psychology clinic were reviewed from October 2020 to December 2022 (audit number: 11703). Patient data was linked anonymised and details reflecting key outcomes, demographics and specific psychology interventions were extracted. Results: In the preliminary findings, 11 patients were included for analysis. Patient age ranged from 28-79 years, 18% were female and 45% were White. Patients were prescribed a mean of 3.1 hypertension medications. The mean time between the first blood pressure reading and final reading was 44.1±27.8 weeks, with a mean number of 6.6±6 visits to the clinic. Interventions were tailored to each patient's need. Four patients were supported with anxiety management, three used biofeedback and three used breathing techniques. Two patients were supported with weight management, with one patient losing 31.7kg in 6 months. The mean systolic blood pressure (SBP) change was -11.55±17.78 mmHg (P = 0.0568), and diastolic blood pressure (DBP) was -5.80±13.15 mmHg (P = 0.1965). Two patients had increased blood pressure for unknown reasons. When these two cases were removed from analysis, the overall mean changes for SBP were -18.11±11.30 mmHg (P = 0.0013) and -9.88± 11.03mmHg for DBP (P = 0.0690). Of these blood pressure readings, 7 were conducted in the office, 2 at home, and 1 with 24hour ABPM. Conclusions: Our preliminary findings show that targeted psychological support for hypertensive patients experiencing difficulties with anxiety or depression may improve blood pressure. Health psychology interventions may be suitable to support patients where medication alone does not support optimum hypertension management. Further large prospective studies are needed to confirm these findings.

EVALUATION IN REAL LIFE OF ‘SUIVI-HTA’, A FREE APPLICATION FOR HOME BLOOD PRESSURE MONITORING

Objective: Home Blood Pressure Monitoring (HBPM) is key to improve blood pressure control. To help hypertensive patients adopt HBPM and doctors use the results in their practice, the French ‘Fondation de Recherche en Hypertension Artérielle’ has developed the Suivi-HTA application, available since September 2020. We therefore aimed at carrying out a first real-life evaluation of the utilization of this application among hypertension specialists and their patients. Design and method: The survey was carried out in France between October 2020 and March 2021 in 8 hospitals and 2 private practices based on a standardized questionnaire assessing the acceptability and effective use of the application, as well as the doctor's opinion on patient satisfaction. Results: The survey included 135 hypertensive patients, 38% were women, 57% were over 55 years old. Only 27% regularly performed HBPM. If the application was offered, it was well accepted (women 65%, men 80%) with a more important rejection rate in hypertensives over 55 years old (26% vs. 3%, p<0.0003) and with more comorbidities (31% vs. 7%, p = 0.0005). Rejection was mainly related to digital technology (no smartphone or tablet, lack of knowledge on downloading or using applications). Among the 113 patients who agreed to test the application, 98 (87%) effectively performed HBPM, 77 (67%) did so using Suivi-HTA, of which 60 (53%) generated and transmitted a HBPM report. According to the doctor's opinion, 88% patients who have used Suivi-HTA will be future users of the application. Patient satisfaction with the application was assessed as “good” for 93% patients. Conclusions: This national survey shows that the Suivi-HTA application has a good rate of acceptance and effective use among hypertensives. It also generates a very positive opinion in the medical community. However, age and presence of comorbidities were risk factors for reduced acceptance, in connection with the difficulties to digital accessibility. It would therefore be interesting, while globally promoting the use of HBPM in hypertensive patients, to develop specific strategies targeting patients with more comorbidities and/or at higher cardiovascular risk.

Dampak Implementasi Pembayaran Berbasis Kinerja (Pay-For-Performance) Pada Fasilitas Kesehatan Tingkat Pertama (FKTP) Terhadap Kualitas Layanan Kesehatan Di Berbagai Negara

The pay-for-performance (P4P) mechanism is a strategy in the health sector to increase the availability, quality and utilization of health services. In P4P, incentives are given after achieving a series of agreed outcomes by improving the performance of health workers in health facilities. This literature review was conducted with the aim of knowing the impact of implementing pay-for-performance at primary care (FKTP) on the quality of health services in various countries. The method is carried out by searching several databases, namely Pubmed, Embase, and Proquest with the main intervention being the implementation of pay-for-performance. The results of the review focused on the impact of implementing pay-for-performance at First Level Health Facilities on the quality of health services in various countries. From this study it can be concluded that pay-for-performance has been used in various countries with different numbers and areas (domains) of indicators adapted to the characteristics of primary care in a country. Some of the benefits of implementing pay-for-performance are that it can stimulate quality improvement in clinical care and improve patient experience of the role of general practitioners and the system of care. P4P can improve the process and outcome of cardiovascular treatment. Providing incentives can have an effect on improving the quality of performance in clinical practice. Providing P4P incentives can meet the quality measures of hypertension care recommended by the guidelines. In the United States, the provision of P4P incentives can increase physician compliance to provide hypertension drugs according to guidelines. Providing incentives can also have an impact on improving blood pressure control in hypertensive patients.

Effect of Adapted Mindfulness Training in Participants With Elevated Office Blood Pressure: The MB-BP Study: A Randomized Clinical Trial.

Background Hypertension is a leading risk factor for cardiovascular disease. Despite availability of effective lifestyle and medication treatments, blood pressure (BP) is poorly controlled in the United States. Mindfulness training may offer a novel approach to improve BP control. The objective was to evaluate the effects of Mindfulness-Based Blood Pressure Reduction (MB-BP) versus enhanced usual care control on unattended office systolic BP. Methods and Results Methods included a parallel-group phase 2 randomized clinical trial conducted from June 2017 to November 2020. Follow-up time was 6 months. Outcome assessors and data analyst were blinded to group allocation. Participants had elevated unattended office BP (≥120/80 mm Hg). We randomized 201 participants to MB-BP (n=101) or enhanced usual care control (n=100). MB-BP is a mindfulness-based program adapted for elevated BP. Loss-to-follow-up was 17.4%. The primary outcome was change in unattended office systolic BP at 6 months. A total of 201 participants (58.7% women; 81.1% non-Hispanic White race and ethnicity; mean age, 59.5 years) were randomized. Results showed that MB-BP was associated with a 5.9-mm Hg reduction (95% CI, -9.1 to -2.8 mm Hg) in systolic BP from baseline and outperformed the control group by 4.5 mm Hg at 6 months (95% CI, -9.0 to -0.1 mm Hg) in prespecified analyses. Plausible mechanisms with evidence to be impacted by MB-BP versus control were sedentary activity (-350.8 sitting min/wk [95% CI, -636.5 to -65.1] sitting min/wk), Dietary Approaches to Stop Hypertension diet (0.32 score [95% CI, -0.04 to 0.67]), and mindfulness (7.3 score [95% CI, 3.0-11.6]). Conclusions A mindfulness-based program adapted for individuals with elevated BP showed clinically relevant reductions in systolic BP compared with enhanced usual care. Mindfulness training may be a useful approach to improve BP. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT03256890 and NCT03859076.

The association between social functioning and health literacy among rural Southeastern African Americans with hypertension.

African Americans living in low socioeconomic circumstances are at high risk of poor health outcomes; this is particularly true for those with hypertension. Many African Americans with chronic hypertension living in the rural impoverished Southeastern USA have low health literacy and are socially isolated. These factors are known to have a negative impact on health outcomes, but it is possible that social support may overcome some of the effect of low health literacy. Since little has been reported about this association, we examined the association between social functioning and health literacy in a rural African American population in the Southeast USA. We used baseline data from participants in the Southeastern Collaboration to Improve Blood Pressure Control, a pragmatic trial that recruited rural African Americans with persistently uncontrolled hypertension and collected survey data. Overall, 33.5% of the 1221 person sample reported social isolation, 26.0% reported low instrumental support, 36.0% reported low emotional support, and 63.4% had inadequate health literacy. All three domains of low social functioning were significantly associated with low health literacy, and this effect was robust to multivariable adjustment for sociodemographics and cognitive functioning for social isolation (adjusted odds ratio 1.62, 95% confidence intervals 1.20-2.20). In conclusion, the majority of this sample living in the NC and AL Black Belt had high social functioning but inadequate health literacy. Tests of interventions to improve social support, especially social isolation, may be warranted to overcome low health literacy in this high-risk rural population.

Mixed effects logistic regression analysis of blood pressure among Ghanaians and associated risk factors

Blood pressure (BP) control is a global health issue with an increase in BP beyond the normal BP leading to different stages of hypertension in humans and hence the need to identify risk factors of BP for efficient and effective control. Multiple BP measurement have proven to provide BP readings close to the true BP status of the individual. In this study, we used multiple BP measurement data on 3809 Ghanaians to determine risk factors associated with BP. The data were obtained from World Health Organization study on Global AGEing and Adult Health. We defined high blood pressure (HBP) as ge 130/80 mmHg or normal as le 130/80 mmHg. We provide summary statistics and also used the Chi-Square test to assess significance of association between HBP versus risk factors of HBP. The aim of this study is to identify risk factors of BP using the mixed effects logistic regression model. Data were analyzed using R version 4.2.2. The results showed that the risk of high blood pressure (HBP) decreases across the three measurement periods. There is reduced risk (OR = 0.274, 95% CI = 0.2008, 0.405) of HBP among male participants relative to female participants. The risk (OR = 2.771, 95% CI = 1.8658, 4.1145) of HBP increased by 2.771-folds among those who are 60 years and above relative to those below the age of 60 years. Those whose work involves/requires vigorous exercise has 1.631-fold increase in the risk (OR = 1.631, 95% CI = 1.1151, 2.3854) of HBP relative to those whose work does not involve vigorous exercise. There is approximately 5-folds increased in the risk (OR = 4.896, 95% CI = 1.9535, 12.2268) of among those who have ever been diagnosed with diabetes. The results also revealed high risk (OR = 1.649, 95%CI = 1.1108, 2.4486) of HBP among those who have formal education. The risk (OR = 1.009, 95% CI = 1.0044, 1.0137) of HBP increases with increasing weight and a reduced risk (OR = 0.996, 95% CI = 0.9921, 0.9993) of HBP with increasing height. We found that sad experience, either mild, moderate or severe, is associated with a reduced risk of HBP. Those who have vegetable servings at least 2 cups per day have increased risk of HBP and those who have fruits servings at least 2 cups per day is associated with a reduced risk of HBP, however this is not statistically significant. To achieve success in BP control, programs should be designed with the aim of reducing weight, educate those with formal eduction on issues relating to HBP. Those whose work requires vigorous exercise are recommended to have regular check-ups to ensure that pressure build-up in the lungs is cleared. SBP is lower for women at young age but continue to increase after menopause as their BP increase becomes salt-sensitive. Hence there is need to give more attention to menopausal women so as to improve BP. Both young and old individuals are recommended to practice regular exercise since this has shown to reduce risk of being overweight or becoming diabetic and reduces the risk of HBP at yong age and old age. Also, to improve blood pressure control, programs for management of blood pressure or hypertension should focus more short stature individuals since such people are more likely to experience HBP.

Antihypertensive Medication Regimens Used by US Adults With Hypertension and the Potential for Fixed-Dose Combination Products: The National Health and Nutrition Examination Surveys 2015 to 2020.

Background Fixed-dose combination (FDC) antihypertensive products improve blood pressure control and adherence among patients with hypertension. It is unknown to what degree commercially available FDC products meet the current hypertension management prescription patterns in the United States. Methods and Results This cross-sectional analysis of the National Health and Nutrition Examination Surveys 2015 to March 2020 included participants with hypertension taking ≥2 antihypertensive medications (N=2451). After constructing each participant's regimen according to antihypertensive classes used, we estimated the extent to which the 7 class-level FDC regimens available in the United States as of January 2023 would match the regimens used. Among a weighted population of 34.1 million US adults (mean age, 66.0 years; 52.8% women; 69.1% non-Hispanic White race and ethnicity), the proportions using 2, 3, 4, and ≥5 antihypertensive classes were 60.6%, 28.2%, 9.1%, and 1.6%, respectively. The 7 FDC regimens were among 189 total regimens used (3.7%), and 39.2% of the population used one of the FDC regimens (95% CI, 35.5%-43.0%; 13.4 million US adults); 60.8% of the population (95% CI, 57.0%-64.5%; 20.7 million US adults) were using a regimen not available as a class-equivalent FDC product. Conclusions Three in 5 US adults with hypertension taking ≥2 antihypertensive classes are using a regimen that is not commercially available as a class-equivalent FDC product as of January 2023. To maximize the potential benefit of FDCs to improve medication adherence (and thus blood pressure control) among patients taking multiple antihypertensive medications, use of FDC-compatible regimens and improvements in the product landscape are needed.

Examination of Acupuncture and Acupressure as an Integrative Treatment for Preeclampsia With Severe Features [ID: 1354672

INTRODUCTION: This study assessed whether acupuncture (AQ) and acupressure (AP) in conjunction with routine care are associated with improved blood pressure control or obstetric outcomes in hospitalized preeclampsia patients. METHODS: This is a retrospective matched cohort study (2010–2020) of patients with preterm preeclampsia with severe features admitted for expectant management. Integrative medicine services including AQ or AP were offered to antepartum patients starting in 2010. Patients receiving AQ/AP were matched with controls who received only routine care. Matching criteria included gestational age on admission, maternal age, parity, multiple gestation, chronic hypertension, and other clinical features. Controls were eligible for matching if their pregnancy continued at least 12 hours after the matched case received their first AQ/AP treatment. RESULTS: Among 416 patients admitted for preeclampsia, 146 had AQ/AP treatment, of which 104 were matched to controls for a final sample of 208 patients. Mean gestational age at admission was 30.6 weeks. Mean latency period from admission to delivery was 9.6 days (±7.6) in the treatment group and 7.3 days (±7.5) in the control group (P=.006). Changes in mean arterial pressure (MAP) from 12, 8, and 6 hours before and after the first treatment were not significantly different between the matched pairs. CONCLUSION: Among patients hospitalized for preeclampsia with severe features, AQ/AP treatment was associated with significant prolongation of the latency period from admission to delivery, but was not associated with changes in MAP over the 12–24 hours surrounding the first treatment.

Daily Versus Twice-Daily Dosing of Nifedipine for Blood Pressure Control in Pregnancy and Postpartum [ID: 1375881

INTRODUCTION: Hypertensive disorders of pregnancy (HDP) may be managed with oral antihypertensives; however, pregnancy-induced changes in the hormonal milieu and volume of distribution make it difficult to determine optimal dosing regimens. Nifedipine is a first-line therapy for treatment of HDP. The purpose of this study is to compare 60 mg daily (QD) of extended released (XR) nifedipine to 30 mg twice daily (BID) for blood pressure (BP) control antepartum and postpartum. METHODS: This was a retrospective chart review conducted in Mount Sinai Health System. Patients admitted from January 1, 2015 to April 30, 2021, who were diagnosed with a HDP and received nifedipine XR 30 mg BID or 60 mg QD for intrapartum or postpartum BP control were included. The primary outcome was need for dose adjustment of nifedipine or addition of another antihypertensive agent. Patients were excluded if they had preexisting renal disease or were already taking oral antihypertensives. RESULTS: Two hundred thirty-seven patients were included, 139 (59%) received 30 mg BID and 98 (41%) 60 mg QD. There was no statistically significant difference in the need for increase in nifedipine dose or addition of another oral antihypertensive between those receiving 30 mg BID versus 60 mg QD (33.8% versus 35.7%, adjusted odds ratio [95% CI], 0.90 [0.50, 1.60]; P=.71). Additionally, there was no difference in need for emergency hypertensive treatment after reaching study dose (P=.19) or readmission for BP control between the two groups (P>.99). CONCLUSION: These findings suggest that BID versus QD dosing of nifedipine XR does not improve blood pressure control in the antepartum or postpartum periods; thus, daily dosing is reasonable and may be preferable for patient convenience and compliance.

Development and Initial Use of an Evidence-Based Home Blood Pressure Monitoring mHealth Platform.

Home blood pressure monitoring (HBPM) has been shown to provide a more reliable assessment of blood pressure (BP) than in-office measurement and may lead to improved BP control. While many mHealth apps are available to help users track their blood pressure (BP), no apps incorporate the full set of evidence-based HBPM recommendations for ensuring accurate measurement at home. Through an agile development approach employing user stories, we translated an evidence-based standardized protocol for BP measurement and monitoring over a recommended 3-7day monitoring period into a mHealth app and corresponding clinician portal. We then pilot tested this platform to assess its feasibility for guiding users to measure BP over multiple days according to this protocol. During this pilot testing, one hundred and twenty five users created an app account; 75 (60.0%) of these users recorded at least one BP reading and 47 (37.6%) completed at least one monitoring period. Through this work, we have demonstrated how a series of guidelines can be systematically translated into a mHealth platform for HBPM. Such platforms may be accessible resources to facilitate standardized HBPM and sharing of readings with providers.

Social Determinants of Health and Uncontrolled Blood Pressure in a National Cohort of Black and White US Adults: the REGARDS Study.

Determining the contribution of social determinants of health (SDOH) to the higher proportion of Black adults with uncontrolled blood pressure (BP) could inform interventions to improve BP control and reduce cardiovascular disease. We analyzed data from 7306 White and 7497 Black US adults taking antihypertensive medication from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study (2003-2007). SDOH were defined using the Healthy People 2030 domains of education, economic stability, social context, neighborhood environment, and health care access. Uncontrolled BP was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg. Among participants taking antihypertensive medication, 25.4% of White and 33.7% of Black participants had uncontrolled BP. The SDOH included in the current analysis mediated the Black-White difference in uncontrolled BP by 33.0% (95% CI, 22.1%-46.8%). SDOH that contributed to excess uncontrolled BP among Black compared with White adults included low annual household income (percent-mediated 15.8% [95% CI, 10.8%-22.8%]), low education (10.5% [5.6%-15.4%]), living in a health professional shortage area (10.4% [6.5%-14.7%]), disadvantaged neighborhood (11.0% [4.4%-18.0%]), and high-poverty zip code (9.7% [3.8%-15.5%]). Together, the neighborhood-domain accounted for 14.1% (95% CI, 5.9%-22.9%), the health care domain accounted for 12.7% (95% CI, 8.4%-17.3%), and the social-context-domain accounted for 3.8% (95% CI, 1.2%-6.6%) of the excess likelihood of uncontrolled BP among Black compared with White adults, respectively. SDOH including low education, low income, living in a health professional shortage area, disadvantaged neighborhood, and high-poverty zip code contributed to the excess likelihood of uncontrolled BP among Black compared with White adults.

Long-Term Adherence in Overweight Patients with Obstructive Sleep Apnea and Hypertension—A Pilot Prospective Cohort Study

Obstructive sleep apnea (OSA) is associated with increased cardiovascular risk, sedentarism, depression, anxiety and impaired quality of life. The long-term effectiveness of positive airway pressure (PAP) is insufficiently studied and limited by poor patient compliance. The aim of this pilot prospective cohort study was to evaluate long-term adherence in overweight patients with moderate-severe OSA and hypertension and to analyze changes in weight, sleepiness and quality of life. We performed a prospective study that included overweight patients with moderate-severe OSA and hypertension who had not undergone previous PAP therapy. All subjects received a standard physical examination, education regarding lifestyle changes and free PAP therapy for 2 months. After five years, the patients were invited to participate in a telephone-based interview regarding PAP compliance and completed standard questionnaires assessing adherence to medication, physical activity, diet, anxiety and quality of life (QoL). Only 39.58% of the patients were adherent to PAP 5 years (58.42 ± 3.70 months) after being diagnosed with moderate-severe OSA. Long-term PAP use results in sustained weight loss; improved blood pressure control, sleepiness and QOL; and lower anxiety and depression scores. PAP compliance was not associated with a higher level of daily physical activity or a healthier diet.

The design and rationale of a multicenter real-world trial: The Southeastern Collaboration to Improve Blood Pressure Control in the US Black Belt – Addressing the Triple Threat

BackgroundImpoverished African Americans (AA) with hypertension face poor health outcomes. PurposeTo conduct a cluster-randomized trial testing two interventions, alone and in combination, to improve blood pressure (BP) control in AA with persistently uncontrolled hypertension. MethodsWe engaged primary care practices serving rural Alabama and North Carolina residents, and in each practice we recruited approximately 25 AA adults with persistently uncontrolled hypertension (mean systolic BP >140 mmHg over the year prior to enrollment plus enrollment day BP assessed by research assistants ≥140/90 mmHg). Practices were randomized to peer coaching (PC), practice facilitation (PF), both PC and PF (PC + PF), or enhanced usual care (EUC). Coaches met with participants from PC and PC + PF practices weekly for 8 weeks then monthly over one year, discussing lifestyle changes, medication adherence, home monitoring, and communication with the healthcare team. Facilitators met with PF and PC + PF practices monthly to implement ≥1 quality improvement intervention in each of four domains. Data were collected at 0, 6, and 12 months. ResultsWe recruited 69 practices and 1596 participants; 18 practices (408 participants) were randomized to EUC, 16 (384 participants) to PF, 19 (424 participants) to PC, and 16 (380 participants) to PC + PF. Participants had mean age 57 years, 61% were women, and 56% reported annual income <$20,000. LimitationsThe PF intervention acts at the practice level, possibly missing intervention effects in trial participants. Neither PC nor PF currently has established clinical reimbursement mechanisms. ConclusionsThis trial will fill evidence gaps regarding practice-level vs. patient-level interventions for rural impoverished AA with uncontrolled hypertension.

Practice facilitation for scale up of clinical decision support for hypertension management: study protocol for a cluster randomized control trial

BackgroundOnly half of patients with hypertension have adequately controlled blood pressure. Clinical decision support (CDS) has the potential to overcome barriers to delivering guideline-recommended care and improve hypertension management. However, optimal strategies for scaling CDS have not been well established, particularly in small, independent primary care practices which often lack the resources to effectively change practice routines. Practice facilitation is an implementation strategy that has been shown to support process changes. Our objective is to evaluate whether practice facilitation provided with hypertension-focused CDS can lead to improvements in blood pressure control for patients seen in small primary care practices. Methods/designWe will conduct a cluster randomized control trial to compare the effect of hypertension-focused CDS plus practice facilitation on BP control, as compared to CDS alone. The practice facilitation intervention will include an initial training in the CDS and a review of current guidelines along with follow-up for coaching and integration support. We will randomize 46 small primary care practices in New York City who use the same electronic health record vendor to intervention or control. All patients with hypertension seen at these practices will be included in the evaluation. We will also assess implementation of CDS in all practices and practice facilitation in the intervention group. DiscussionThe results of this study will inform optimal implementation of CDS into small primary care practices, where much of care delivery occurs in the U.S. Additionally, our assessment of barriers and facilitators to implementation will support future scaling of the intervention.ClinicalTrials.gov Identifier: NCT05588466

Engagement in Self-measured Blood Pressure Monitoring Among Medically Underresourced Participants (the Reach Out Trial): Digital Framework Qualitative Study.

Mobile health (mHealth) interventions serve as a scalable opportunity to engage people with hypertension in self-measured blood pressure (SMBP) monitoring, an evidence-based approach to lowering blood pressure (BP) and improving BP control. Reach Out is an SMS text messaging-based SMBP mHealth trial that aims to reduce BP among hypertensive patients recruited from the emergency department of a safety net hospital in a low-income, predominately Black city. As the benefits of Reach Out are predicated on participants' engagement with the intervention, we sought to understand participants' determinants of engagement via prompted SMBP with personalized feedback (SMBP+feedback). We conducted semistructured telephone interviews based on the digital behavior change interventions framework. Participants were purposively sampled from 3 engagement categories: high engagers (≥80% response to SMBP prompts), low engagers (≤20% response to BP prompts), and early enders (participants who withdrew from the trial). We conducted interviews with 13 participants, of whom 7 (54%) were Black, with a mean age of 53.6 (SD 13.25) years. Early enders were less likely to be diagnosed with hypertension prior to Reach Out, less likely to have a primary care provider, and less likely to be taking antihypertensive medications than their counterparts. Overall, participants liked the SMS text messaging design of the intervention, including the SMBP+feedback. Several participants across all levels of engagement expressed interest in and identified the benefit of enrolling in the intervention with a partner of their choice. High engagers expressed the greatest understanding of the intervention, the least number of health-related social needs, and the greatest social support to engage in SMBP. Low engagers and early enders shared a mixed understanding of the intervention and less social support compared to high engagers. Participation decreased as social needs increased, with early enders sharing the greatest amount of resource insecurity apart from a notable exception of a high engager with high health-related social needs. Prompted SMBP+feedback was perceived favorably by all participants. To enhance SMBP engagement, future studies could consider greater support in the initiation of SMBP, evaluating and addressing participants' unmet health-related social needs, as well as strategies to cultivate social norms.

Using Renin Activity to Guide Mineralocorticoid Receptor Antagonist Therapy in Patients with Low Renin and Hypertension.

Mineralocorticoid receptor antagonists (MRAs) are often empirically used for patients with low-renin hypertension (LRH) or probable primary aldosteronism (PA) who decline surgery. However, the optimal approach to MRA therapy is unknown. Studies have shown that a rise in renin is an effective biomarker of prevention of cardiovascular complications of PA. This study aimed to determine whether empiric MRA therapy in patients with LRH or probable PA targeting unsuppressed renin is associated with a decrease in blood pressure and/or proteinuria. Retrospective single-center cohort study from 2005 to 2021 included adults with LRH or probable PA (renin activity <1.0 ng/ml/h and detectable aldosterone levels). All patients were empirically treated with an MRA, targeting renin ≥1.0 ng/ml/h. Out of 39 patients studied, 32 (82.1%) achieved unsuppressed renin. Systolic and diastolic blood pressure decreased from 148.0 and 81.2 to 125.8 and 71.6 mm Hg, respectively (P < 0.001 for both). Similar blood pressure reductions were seen whether patients had high (>10 ng/dl) or low (<10 ng/dl) aldosterone levels. The majority (24/39; 61.5%) of patients had at least one baseline anti-hypertensive medication stopped. Among the six patients who had detectable proteinuria and albumin-to-creatinine (ACR) measurements post-treatment, the mean ACR decreased from 179.0 to 36.1 mg/g (P = 0.03). None of the patients studied had to completely stop treatment due to adverse reactions. Empiric MRA therapy in patients with LRH or probable PA targeting unsuppressed renin can safely and effectively improve blood pressure control and reduce proteinuria.

Hypertension control in the Tunisian elderly

Background : Hypertension is a major public health problem. Despite therapeutic progress, blood pressure control remains insufficient particularly in the elderly. Purpose: The aim of our study was to identify the factors associated with poor blood pressure control in the elderly in Tunisia. Material and methods: We conducted a descriptive study including 101 Tunisian treated hypertensive patients, aged 65 years and over, followed on an outpatient basis between November and December 2019. Results: Median age was 73 and sex ratio was 0.57. The major cardiovascular risk factor was diabetes in 60.4% of cases, followed by dyslipidaemia (48.5%) and smoking (40.6%). About 33% of the hypertensive patients realized regular physical activity and 31% had a high-sodium diet. Our patients were completely dependent in 4% of cases and among those aged 80 and over, 68.2% were frail. The prevalence of poor blood pressure control was 59%. Adherence to treatment was satisfactory in 75.2% of cases. In multivariate analysis, the factors associated with poor blood pressure control were: non-compliance with treatment [odds ratio (OR) = 0.19; p = 0.013], frailty (OR = 7.194; p = 0.004), the number of antihypertensive tablets (OR = 0.382; p = 0.008), non-use of thiazide diuretics (OR = 25.903; p = 0.001) and the patient's lack of knowledge of antihypertensive treatment (OR = 0.56; p = 0.008). Conclusion: Detection of the risk of non-compliance, the use of combined treatments screening for frailty and informing the patient about his/her treatment are necessary to improve blood pressure control in our Tunisian context.

Community health volunteer for blood pressure control in rural people with stroke in India: Pilot randomised trial

ObjectiveTo test the hypothesis that an Accredited social health activist (ASHA), a community health volunteer in a task-sharing model can help in sustained control of systolic blood pressure (BP) in rural people with Stroke and hypertension at 6 months follow up. MethodsIn this randomized trial two rural areas (Pakhowal and Sidhwan bet) with 70 and 94 villages respectively were screened for people with stroke and hypertension. They were assigned to either ASHA-assisted BP control in addition to standard-of-care (Pakhowal-intervention Group) or standard-of-care alone (Sidhwan bet- Control Group). Assessors blinded to intervention conducted the baseline and 6 months follow-up visits to measure risk factors in both the rural areas. ResultsA total of 140 people with stroke with mean age of 63.7 ± 11.5 years and 44.3% females were randomised. The baseline systolic BP was higher in the intervention group (n = 65,173.5 ± 22.9 mmHg) compared to the control group (n = 75,163 ± 18.7 mmHg, p = 0.004). The follow-up systolic BP was lower in the intervention group compared to the control group 145 ± 17.2 mmHg and 166.6 ± 25.7 mmHg respectively (p < 0.0001). According to the intention-to-treat analysis a total of 69.2% of patients in the intervention group achieved systolic BP control compared to 18.9% in the control group patients (OR 9, 95% CI 3.9-20.3; p < 0.0001). ConclusionTask sharing with ASHA a community health volunteer can improve BP control in rural people with stroke and hypertension. They can also help in the adoption of healthy behaviour. Clinical trial registration numberctri.nic.in, CTRI/2018/09/015709.