Antihypertensive Medication Intensification Research Articles

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.

Evidence for Age Bias Contributing to Therapeutic Inertia in Blood Pressure Management: A Secondary Analysis of SPRINT.

Despite evidence supporting the cardiovascular and cognitive benefits of intensive blood pressure management, older adults have the lowest rates of blood pressure control. We determined the association between age and therapeutic inertia (TI) in SPRINT (Systolic Blood Pressure Intervention Trial), and whether frailty, cognitive function, or gait speed moderate or mediate these associations. We performed a secondary analysis of SPRINT of participant visits with blood pressure above randomized treatment goal. We categorized baseline age as <60, 60 to <70, 70 to <80, and ≥80 years and TI as no antihypertensive medication intensification per participant visit. Generalized estimating equations generated odds ratios for TI associated with age, stratified by treatment group based on nested models adjusted for baseline frailty index score (fit [frailty index, ≤0.10], less fit [0.10<frailty index≤0.21], and frail [0.21<frailty index]), cognitive function by Montreal cognitive assessment, and gait speed (participants ≥75 years of age), separately. Participants 60 to <70, 70 to <80, and ≥80 years of age had a higher prevalence of TI in both treatment groups versus participants <60 years of age (standard: 59.7%, 60.5%, and 60.1% versus 56.0%; 29 527 participant visits; intensive: 55.1%, 57.2%, and 57.8% versus 53.8%; 47 129 participant visits). The adjusted odds ratios for TI comparing participants ≥80 versus <60 years of age were 1.32 (95% CI, 1.14-1.53) and 1.25 (95% CI, 1.11-1.41) in the standard and intensive treatment groups, respectively. Adjustment for frailty, cognitive function, or gait speed did not attenuate the association or demonstrate effect modification (all Pinteraction, >0.10). Older age is associated with greater TI independent of physical or cognitive function, implying age bias in hypertension management.

PS-BPC11-7: SEX DIFFERENCES IN BLOOD PRESSURE CONTROL FOLLOWING REMOTE PATIENT MONITORING IMPLEMENTATION WITH AND WITHOUT CARE COORDINATION: A PROSPECTIVE COHORT STUDY

Objective: Evaluate sex and race/ethnicity subgroup differences in the effects of care coordinator-assisted implementation of remote patient monitoring (RPM) and RPM implementation alone for hypertension in primary care compared to usual care. Design and Methods: Subgroup analysis of 3-arm pragmatic pilot cohort study. At two clinics, nurse care coordinators with physician approval, offered RPM to eligible patients and assisted with initiation. At two clinics, RPM was solely at physician discretion. Twenty clinics continued with usual care. Eligible patients were aged 65–85y with Medicare insurance and had uncontrolled hypertension (last two office BP &gt; = 140/90 mm Hg). The primary outcome assessed at 6 months was controlling high blood pressure (&lt; 140/90 mm Hg) at the most recent measurement. We tested for interactions between group and sex and between group and race ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic and others) in generalized linear models adjusted for age and baseline systolic BP. Results: In this cohort (234 RPM plus care coordination, 600 RPM only, 1617 usual care), we detected effect heterogeneity by sex (p = 0.02) but not race/ethnicity (p = 0.17). In sex-stratified analyses, the odds of controlling high blood pressure at 6 months in the RPM plus care coordination compared to control were 1.62 times higher (95% CI 1.09–2.41, P = 0.02) for women and 1.17 times higher (0.65–2.13, P = 0.6) for men. Corresponding odds comparing the RPM alone to control were 1.63 (1.24–2.13, P &lt; 0.001) for women and 0.86 (0.55–1.34, P = 0.51) for men. RPM uptake in the care coordination group was 18% (27/153) for women and 14% (11/81) for men, compared with 0.7% (3/422) for women and 0% (0/178) for men in the RPM alone group. Among RPM-prescribed patients with baseline BP &gt; = 140/90 mm Hg in the care coordination plus RPM group, usage following a RPM prescription was high (90% for women and 100% in men), antihypertensive medication intensification over the course of 6 months occurred for the plurality of patients (37% and 47%). SBP decline at 6 months was substantial (mean [SD] 23.6 [27.2] and 21.1 [21.2] mmHg). Conclusions: Introducing remote patient monitoring with and without care coordination appeared to have greater effects on BP control in women. Greater rates of RPM prescribing to women compared to men may account for these findings. Larger studies are needed to explore these differences.

Analysis of Therapeutic Inertia and Race and Ethnicity in the Systolic Blood Pressure Intervention Trial: A Secondary Analysis of a Randomized Clinical Trial

Therapeutic inertia may contribute to racial and ethnic differences in blood pressure (BP) control. To determine the association between race and ethnicity and therapeutic inertia in the Systolic Blood Pressure Intervention Trial (SPRINT). This cross-sectional study was a secondary analysis of data from SPRINT, a randomized clinical trial comparing intensive (<120 mm Hg) vs standard (<140 mm Hg) systolic BP treatment goals. Participants were enrolled between November 8, 2010, and March 15, 2013, with a median follow-up 3.26 years. Participants included adults aged 50 years or older at high risk for cardiovascular disease but without diabetes, previous stroke, or heart failure. The present analysis was restricted to participant visits with measured BP above the target goal. Analyses for the present study were performed in from October 2020 through March 2021. Self-reported race and ethnicity, mutually exclusively categorized into groups of Hispanic, non-Hispanic Black, or non-Hispanic White participants. Therapeutic inertia, defined as no antihypertensive medication intensification at each study visit where the BP was above target goal. The association between self-reported race and ethnicity and therapeutic inertia was estimated using generalized estimating equations and stratified by treatment group. Antihypertensive medication use was assessed with pill bottle inventories at each visit. Blood pressure was measured using an automated device. A total of 8556 participants, including 4141 in the standard group (22 844 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1467 women [35.4%]) and 4415 in the intensive group (35 453 participant-visits; median age, 67.0 years [IQR, 61.0-76.0 years]; 1584 women [35.9%]) with at least 1 eligible study visit were included in the present analysis. Among non-Hispanic White, non-Hispanic Black, and Hispanic participants, the overall prevalence of therapeutic inertia in the standard vs intensive groups was 59.8% (95% CI, 58.9%-60.7%) vs 56.0% (95% CI, 55.2%-56.7%), 56.8% (95% CI, 54.4%-59.2%) vs 54.5% (95% CI, 52.4%-56.6%), and 59.7% (95% CI, 56.5%-63.0%) vs 51.0% (95% CI, 47.4%-54.5%), respectively. The adjusted odds ratios in the standard and intensive groups for therapeutic inertia associated with non-Hispanic Black vs non-Hispanic White participants were 0.85 (95% CI, 0.79-0.92) and 0.94 (95% CI, 0.88-1.01), respectively. The adjusted odds ratios for therapeutic inertia comparing Hispanic vs non-Hispanic White participants were 1.00 (95% CI, 0.90-1.13) and 0.89 (95% CI, 0.79-1.00) in the standard and intensive groups, respectively. Among SPRINT participants above BP target goal, this cross-sectional study found that therapeutic inertia prevalence was similar or lower for non-Hispanic Black and Hispanic participants compared with non-Hispanic White participants. These findings suggest that a standardized approach to BP management, as used in SPRINT, may help ensure equitable care and could reduce the contribution of therapeutic inertia to disparities in hypertension. ClinicalTrials.gov identifier: NCT01206062.

Abstract 12360: A Pilot Study of Remote Patient Monitoring for Hypertension in Primary Care

Introduction: Out-of-office BP should guide hypertension care. CMS now covers remote patient monitoring (RPM). We assessed uptake and initial effects of introducing RPM. Hypothesis: At 6-months, hypertensive Medicare patients in RPM clinics would have greater antihypertensive medication intensification, better blood pressure control (NQF 0018), and lower SBP at last office visit. Methods: This was a pragmatic observational study in primary care in a single health system. We integrated Omron VitalSight TM RPM into the system’s EHR to enable transmission of BP and pulse from a BP monitor into the EHR without manual entry. We oriented two clinics [17 primary care physicians (PCPs)] using meetings and written material, leaving the decision to order RPM to PCPs. We compared their patients to controls from other clinics matched by age, sex, BP, and number of office visits in the prior year. We examined outcomes in: (P1) those with poor BP control at baseline—last two office BP ≥140/90, and (P2) all hypertensive patients (diagnosed hypertension or last office BP ≥140/90). Additional criteria included: age 65-85 years; ≥1 office visit in past year; and absence of persistent atrial fibrillation, CKD stage IV or V, or dementia. Results: RPM implementation was feasible. In P1, 207 intervention patients had mean (SD) baseline BP 151.7 (10.1) / 79.7 (8.1) mmHg, and 828 controls had BP 151.4 (10.6) / 79.5 (8.9) mmHg. In P2, 2356 intervention patients and 4712 controls had corresponding mean baseline BPs of 131.3 (14.7) / 74.9 (8.3) and 131.3 (14.7) / 74.8 (8.8) mmHg. During 6 months, PCPs ordered RPM for 14 (6.8%) P1 patients and 78 (3.3%) P2 patients. In both P1 and P2, NQF 0018 satisfaction was higher at RPM-eligible clinics (p = 0.044, 0.020 respectively) (Table). Medication intensification did not differ in P1 or P2. Conclusions: RPM uptake was modest. Controlling High Blood Pressure at 6 months favored the RPM intervention and was likely due to factors other than medication intensification.

Effect of the Million Hearts Cardiovascular Disease Risk Reduction Model on Initiating and Intensifying Medications

The Million Hearts Cardiovascular Disease (CVD) Risk Reduction Model pays provider organizations for measuring and reducing Medicare patients' cardiovascular risk. To assess whether the model increases the initiation or intensification of antihypertensive medications or statins among patients with blood pressure or low-density lipoprotein (LDL) cholesterol levels above guideline thresholds for treatment intensification. This prespecified secondary analysis of a cluster-randomized, pragmatic trial included primary care and cardiology practices, health care centers, and hospital-based outpatient departments across the US. Participants included Medicare patients who were enrolled into the model in 2017 by participating organizations and who were at high risk and at medium risk of a myocardial infarction or stroke in 10 years. Patient outcomes were analyzed for 1 year postenrollment (through December 2018) using an intent-to-treat design. Analysis began November 2019. US Centers for Medicare & Medicaid Services paid organizations for risk stratifying Medicare patients and reducing CVD risk among high-risk patients through discussing risk scores, developing individualized risk reduction plans, and following up with patients twice yearly. Initiating or intensifying statin or antihypertensive therapy within 1 year of enrollment, measured in Medicare Part D claims, and LDL cholesterol and systolic blood pressure levels approximately 1 year after enrollment, measured in usual care and reported to Centers for Medicare & Medicaid Services via a data registry (data complete for 51% of high-risk enrollees). The study's primary outcome (incidence of first-time myocardial infarction and stroke) is not reported because the trial is ongoing. A total of 330 primary care and cardiology practices, health care centers, and hospital-based outpatient departments and 125 436 Medicare patients were included in this analysis. High-risk patients in the intervention group had a mean (SD) age of 74 (4.1), 15 213 (63%) were male, 21 657 (90%) were receiving antihypertensive medication at baseline, and 16 558 (69%) were receiving statins. Almost all (21 791 [91%]) high-risk intervention group patients had above-threshold systolic blood pressure level (>130 mm Hg), LDL cholesterol level (>70 mg/dL), or both. Patients in the intervention group with these risk factors were more likely than control patients (8127 [37.3%] vs 4753 [32.4%]; adjusted difference in percentage points, 4.8; 95% CI, 2.9-6.7; P < .001) to initiate or intensify statins or antihypertensive medication. Centers for Medicare & Medicaid Services did not pay for CVD risk reduction for medium-risk enrollees, but initiation or intensification rates for these enrollees were also higher in the intervention vs control groups (12 668 [27.9%] vs 7544 [24.8%]; adjusted difference in percentage points, 3.1; 95% CI, 1.9-4.3; P < .001). Among high-risk enrollees with clinical data approximately 1 year after enrollment, LDL cholesterol level was slightly lower in the intervention vs control groups (mean [SD], 89 [31.8] vs 91 [32.1] mg/dL; adjusted difference in percentage points, -1.8; 95% CI, -2.9 to -0.6; P = .002), as was systolic blood pressure (mean [SD], 133 [15.7] vs 135 [16.4] mm Hg; adjusted difference in percentage points, -1.7; 95% CI, -2.8 to -0.6; P = .003). In this study, a pay-for-performance model led to modest increases in the use of CVD medications in a range of organizations, despite high medication use at baseline.

Effect of a Multicomponent Intervention on Antihypertensive Medication Intensification in Rural South Asia: Post Hoc Analysis of a Cluster RCT.

Inadequate treatment of hypertension is a widespread problem, especially in South Asian countries where cardiovascular disease mortality rates are high. We aimed to explore the effect of a multicomponent intervention (MCI) on antihypertensive medication intensification among rural South Asians with hypertension. A post hoc analysis of a 2-year cluster-randomized controlled trial including 2,645 hypertensives aged ≥40 years from 30 rural communities, 10 each, in Bangladesh, Pakistan, and Sri Lanka. Independent assessors collected information on participants' self-reports and physical inspection of medications. The main outcomes were the changes from baseline to 24 months in the following: (i) the therapeutic intensity score (TIS) for all (and class-specific) antihypertensive medications; (ii) the number of antihypertensive medications in all trial participants. At 24 months, the mean increase in the TIS score of all antihypertensive medications was 0.11 in the MCI group and 0.03 in the control group, with a between-group difference in the increase of 0.08 (95% confidence interval (CI, 0.03, 0.12); P = 0.002). In MCI compared with controls, a greater increase in the TIS of renin-angiotensin-aldosterone system blockers (0.05; 95% CI (0.02, 0.07); P < 0.001) and calcium channel blockers (0.03; 95% CI (0.00, 0.05); P = 0.031), and in the number of antihypertensive medications (0.11, 95% CI (0.02, 0.19); P = 0.016) was observed. In rural communities in Bangladesh, Pakistan, and Sri Lanka, MCI led to a greater increase in antihypertensive medication intensification compared with the usual care among adults with hypertension. Trial Number NCT02657746.

Medication Use Quality and Safety in Older Adults: 2019 Update.

Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital re-admission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.

Cardiovascular Disease and Mortality in Adults Aged ≥60 Years According to Recommendations by the American College of Cardiology/American Heart Association and American College of Physicians/American Academy of Family Physicians.

In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) and the American College of Physicians/American Academy of Family Physicians (ACP/AAFP) published blood pressure guidelines. Adults recommended antihypertensive medication initiation or intensification by the ACP/AAFP guideline receive the same recommendation from the ACC/AHA guideline. However, many adults ≥60 years old are recommended to initiate or intensify antihypertensive medication by the ACC/AHA but not the ACP/AAFP guideline. We compared atherosclerotic cardiovascular disease event rates according to antihypertensive treatment recommendations in the ACC/AHA and ACP/AAFP guidelines among adults ≥60 years old with systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥80 mm Hg in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) and the JHS (Jackson Heart Study). Among 4311 participants not taking antihypertensive medication at baseline, 11.4%, 61.2%, and 27.4% were recommended antihypertensive medication initiation by neither guideline, the ACC/AHA but not the ACP/AAFP guideline, and both guidelines, respectively. Atherosclerotic cardiovascular disease event rates (95% CI) for these groups were 3.4 (1.6-5.2), 18.0 (16.1-19.8), and 25.3 (21.9-28.6) per 1000 person-years, respectively. Among 7281 participants taking antihypertensive medication at baseline, 57.9% and 42.1% were recommended antihypertensive medication intensification by the ACC/AHA but not the ACP/AAFP guideline and both guidelines, respectively. Atherosclerotic cardiovascular disease event rates (95% CI) for these groups were 18.2 (16.7-19.7) and 33.0 (30.5-35.4) per 1000 person-years, respectively. In conclusion, adults recommended initiation or intensification of antihypertensive medication by the ACC/AHA but not the ACP/AAFP guideline have high atherosclerotic cardiovascular disease risk that may be reduced through treatment initiation or intensification.

Physician-pharmacist collaborative practice and telehealth may transform hypertension management.

Community pharmacists play a crucial role in hypertension management and their intervention, mainly including education, medication monitoring, and reviewing, blood pressure (BP) measurement and cardiovascular risk factors tracking, have proved to enhance BP control and adherence to antihypertensive treatment. A multidisciplinary collaborative approach with the referring physician and a patient-centered model of care have been proved to be particularly effective for improving control of hypertension and promoting patients' health. The inclusion of telehealth in such model (the so-called telepharmacy) may expand the reach of the pharmacist's intervention and provide pharmacy operations and patient care at a distance with further benefits for hypertensive patients and their managing physicians. Very few randomized controlled studies have evaluated the clinical efficacy of the implementation of telepharmacy services in the management of hypertension, with the strongest evidence limited to physician-pharmacist collaborative interventions based on home BP telemonitoring plus patient education on lifestyle, drug therapy, and cardiovascular risk factors control. The results of these trials documented a benefit of telehealth mainly in terms of improvement of BP control consequent to antihypertensive medication intensification and optimization. Although promising, these results need to be corroborated through larger, prospective, and long-term studies, which should also evaluate additional long-term benefits of telepharmacy services in hypertension management.

Race-Specific Patterns of Treatment Intensification Among Hypertensive Patients Using Home Blood Pressure Monitoring: Analysis Using Defined Daily Doses in the Heart Healthy Lenoir Study.

Racial disparities in blood pressure (BP) control persist, but whether differences by race in antihypertensive medication intensification (AMI) contribute is unknown. To compare AMI by race for patients with elevated home BP readings. This prospective cohort study followed adult patients from 6 rural primary care practices who used home BP monitoring (HBPM) and recorded/reported values. For providers, AMI was encouraged when mean HBPM systolic blood pressure (SBP) values were ⩾135 mm Hg; patients received phone-based coaching on HBPM technique and sharing HBPM findings. AMI was assessed between baseline and 12 months using defined daily dose (DDD) and summed to create a total antihypertensive DDD value. A total of 217 patients (mean age = 61.4 ± 10.2 years; 66% female; 57% black) provided usable HBPM data. Among 90 (41%) intensification-eligible hypertensive patients (ie, mean HBPM SBP values for 6-months ⩾135 mm Hg), mean total antihypertensive DDD was increased in 61% at 12 months. Blacks had significantly higher mean DDD at baseline and 12 months, but intensification (+0.72 vs +0.65; P = 0.83) was similar by race. However, intensification was greater in males than females (+1.1 vs +0.39; P = 0.031). Reduction in mean SBP following intensification was greater in white versus black patients (-8.2 vs -3.9 mm Hg; P = 0.14). Conclusion/Relevance: Treatment intensification in HBPM users was similar by race, differed significantly by gender, and may produce a greater response in white patients. Differential AMI in HBPM users does not appear to contribute to persistent racial disparities in BP control.

Measure Accurately, Act Rapidly, and Partner With Patients (MAP) improves hypertension control in medically underserved patients: Care Coordination Institute and American Medical Association Hypertension Control Project Pilot Study results.

Measure Accurately, Act Rapidly, and Partner With Patients (MAP) is an evidence‐based protocol implemented to improve hypertension control in a clinic for underserved patients (49.9% Medicaid and 50.2% black). Patients with hypertension seen during the year before intervention and with at least one visit during the 6‐month intervention (N = 714) were included. If initial attended blood pressure (BP; standard aneroid manometer) was ≥140/≥90 mm Hg, unattended automated office BP was measured in triplicate and averaged (Measure Accurately) using an Omron HEM‐907XL. When automated office BP was ≥140/≥90 mm Hg, Act Rapidly included intensification of antihypertensive medications, assessed by therapeutic inertia. Partner With Patients included BP self‐monitoring, reducing pill burden, and minimizing medication costs, which was assessed by systolic BP change per therapeutic intensification. Between baseline and the last study visit, BP control to <140/<90 mm Hg increased from 61.2% to 89.9% (P < .0001). MAP rapidly and significantly improved hypertension control in medically underserved patients, largely as a result of measuring BP accurately and partnering with patients.

PP.15.03] MEASURE ACCURATELY, ACT RAPIDLY AND PARTNER WITH PATIENTS (MAP) IMPROVES HYPERTENSION CONTROL

Objective: A quality improvement program to improve hypertension control with evidenced-based interventions for Measuring blood pressure (BP, mmHg) accurately, Acting rapidly to manage uncontrolled BP, and Partnering with patients to promote self-management of BP (MAP) was implemented in 2016 in a Family Medicine residency in South Carolina, United States. Design and method: Hypertensive patients were included in the study if they had a visit in the year before intervention (baseline period) and at least one visit during the six-month intervention period. Omron HEM-907 devices were used to measure BP with a checklist for positioning; if initial BP was > = 140/90, the automated office BP (AOBP) device was used to measure three additional BPs one minute apart with the patient alone in the examination room (measure accurately) and display the AOBP mean. When AOBP mean was > = 140/90, intensification of antihypertensive medications (act rapidly) took place and was assessed by the percent of visits with uncontrolled BP and no treatment change (therapeutic inertia). Facilitating BP self-monitoring and using affordable generic medications (partner with patients) was assessed indirectly by a reduction in systolic BP (SBP) per therapeutic change. Results: 714 hypertensive adults met inclusion criteria (mean age 54.4 years, 53.8% black, 66.0% female, 50.3% Medicaid). From baseline to the last intervention visit, BP control increased from 61.2% to 88.0% (p < 0.01). Among 277 uncontrolled hypertensive patients at baseline, mean systolic/diastolic BP fell from147/88 to 131/79 (p < 0.01/p < 0.01) and 80.5% (223/277) were controlled to < 140/90. For measuring accurately, SBP was 12.7 mmHg (p < 0.001) lower among the uncontrolled group with improved technique; while AOBP measurement showed a 2.5 mmHg (p < 0.05) lower SBP. Therapeutic inertia was unchanged (44.4% vs. 38.3%; p = 0.57); the reduction in SBP per therapeutic change increased from 8.3 mmHG to 21.6 mmHG (p < 0.01). Conclusions: MAP was associated with better hypertension control in a medically underserved population. Data indicate that measuring accurately and better patient engagement, i.e., greater decrease in SBP with each therapeutic change, accounted for improved hypertension control. Plans are in place to spread the program to 40 additional practices.

Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study

Objectives To investigate the optimal systolic blood pressure goal above which new antihypertensive medications should be added or doses of existing medications increased (“systolic intensification threshold”) and to determine the...

THERAPEUTIC INERTIA WHEN MANAGING HIGH-NORMAL BLOOD PRESSURE LEVELS IN PATIENTS AT HIGH CARDIOVASCULAR RISK. A STUDY ON PRIMARY-CARE PHYSICIANS’ ATTITUDE: PP.33.333

Objectives: 1)To asses the magnitude of clinical inertia when managing high-normal blood pressure (BP) levels in patients at high cardiovascular (CV) risk; and 2) To analyse physician and patient factors underlying clinical inertia. Design and Methods: An anonymous survey was conducted in primary-care physicians of Madrid in order to assess their attitude towards initiation or intensification of antihypertensive medications in a set of four hypothetical clinical cases. Physicians demographic features and primary-care-centres characteristics were analysed. Each case described a situation in which a patient at high CV risk had high-normal BP levels (BP:135–139/85–89 mmHg). The cases were characterised by one of the following clinical features: 1) metabolic syndrome;2) type II diabetes; 3) moderate renal insufficiency due to glomerulosclerosis; and 4) ischemic stroke. Physicians were asked to decide whether or not to initiate or intensify a previous treatment and otherwise give reasons for not modifying it. Results: Two hundred and seventy-five physicians participated. Overall, the physicians decided to initiate or intensify a previous treatment in 2.5 ± 0.7 cases. Physicians' attitude was very different depending on the clinical cases: Most physicians (87%) decided to intensify the treatment in the renal insufficiency case, while only 47% of them did so in the metabolic syndrome case. Most doctors who did not modify the previous treatment (74%) argued that clinic BP might not reflect “real life” BP. The remaining 26% doctors considered that patients' BP values were acceptable. CV Working Group membership and routine use of CV stratification risk were both associated (p < 0.05) with a more “aggressive” therapeutic attitude. Conclusions: 1) Our results suggest an important therapeutic inertia when managing high-normal BP at primary care settings. However, they might not reflect what physicians actually decide in the real clinical setting. 2) The degree of clinical inertia is influenced by physician factors (routine use to stratification risk tables and membership to CV working groups) and patient factors (specific clinical features related with CV risk).

Comparison of Information Content of Structured and Narrative Text Data Sources on the Example of Medication Intensification

ObjectiveTo compare information obtained from narrative and structured electronic sources using anti-hypertensive medication intensification as an example clinical issue of interest. DesignA retrospective cohort study of 5,634 hypertensive patients with diabetes from 2000 to 2005. MeasurementsThe authors determined the fraction of medication intensification events documented in both narrative and structured data in the electronic medical record. The authors analyzed the relationship between provider characteristics and concordance between intensifications in narrative and structured data. As there is no gold standard data source for medication information, the authors clinically validated medication intensification information by assessing the relationship between documented medication intensification and the patients' blood pressure in univariate and multivariate models. ResultsOverall, 5,627 (30.9%) of 18,185 medication intensification events were documented in both sources. For a medication intensification event documented in narrative notes the probability of a concordant entry in structured records increased by 11% for each study year (p < 0.0001) and decreased by 19% for each decade of provider age (p = 0.035). In a multivariate model that adjusted for patient demographics and intraphysician correlations, an increase of one medication intensification per month documented in either narrative or structured data were associated with a 5–8 mm Hg monthly decrease in systolic and 1.5–4 mm Hg decrease in diastolic blood pressure (p < 0.0001 for all). ConclusionNarrative and structured electronic data sources provide complementary information on anti-hypertensive medication intensification. Clinical validity of information in both sources was demonstrated by correlation with changes in blood pressure.

Importance of Therapy Intensification and Medication Nonadherence for Blood Pressure Control in Patients With Coronary Disease

Despite the importance of blood pressure (BP) control in secondary prevention, a significant proportion of patients with coronary disease have uncontrolled BP. This retrospective cohort study of patients with coronary disease (N = 10 447) evaluated the impact of medication nonadherence and therapy intensification on reaching target BP goals. Medication adherence was calculated as the proportion of days covered for filled prescriptions of antihypertensive medications. Therapy intensification included dosage increase or increase in number of antihypertensive medications. The primary outcome was uncontrolled systolic BP (SBP) over time, using a latent class model that incorporated longitudinal SBP data and assigned patients to SBP trajectory groups. Multivariable regression evaluated the association between medication nonadherence (ie, proportion of days covered, <0.80) and therapy intensification with SBP control over time, with adjustment for demographics and clinical characteristics. Three SBP trajectory groups were identified: (1) patients with BP that remained controlled (ie, SBP, <or=140 mm Hg) over time (n = 9114 [87.2%]); (2) patients with high BP that became controlled (n = 779 [7.5%]); and (3) patients with BP that remained high over time (n = 554 [5.3%]). In multivariable analyses, therapy intensification (odds ratio, 1.31; 95% confidence interval, 1.01-1.70) and medication nonadherence (odds ratio, 1.73; 95% confidence interval, 1.34-2.24) were associated with uncontrolled BP compared with high SBP that became controlled over time. These findings suggest that medication nonadherence can help explain why BP levels remained elevated despite intensification of antihypertensive medications. Successful BP control is seen with a combination of intensification and adherence, suggesting that therapy intensification must be coupled with interventions to enhance medication adherence.

Failure to Intensify Antihypertensive Treatment by Primary Care Providers: A Cohort Study in Adults with Diabetes Mellitus and Hypertension

Although tight blood pressure control is crucial in reducing vascular complications of diabetes, primary care providers often fail to appropriately intensify antihypertensive medications. To identify novel visit-based factors associated with intensification of antihypertensive medications in adults with diabetes. Non-concurrent prospective cohort study. A total of 254 patients with type 2 diabetes and hypertension enrolled in an academically affiliated managed care program. Over a 24-month interval (1999-2001), we identified 1,374 visits at which blood pressure was suboptimally controlled (systolic BP >/= 140 mmHg or diastolic BP >/= 90 mmHg). Intensification of antihypertensive medications at each visit was the primary outcome. Primary care providers intensified antihypertensive treatment in only 176 (13%) of 1,374 visits at which blood pressure was elevated. As expected, higher mean systolic and mean diastolic blood pressures were important predictors of intensification. Treatment was also more likely to be intensified at visits that were "routine" odds ratio (OR) 2.08; 95% Confidence Interval [95% CI] 1.36-3.18), or that paired patients with their usual primary care provider (OR 1.84; 95% CI 1.11-3.06). In contrast, several factors were associated with failure to intensify treatment, including capillary glucose >150 mg/dL (OR 0.54; 95% CI 0.31-0.94) and the presence of coronary heart disease (OR 0.61; 95% CI 0.38-0.95). Co-management by a cardiologist accounted partly for this failure (OR 0.65; 95% CI 0.41-1.03). Failure to appropriately intensify antihypertensive treatment is common in diabetes care. Clinical distractions and shortcomings in continuity and coordination of care are possible targets for improvement.