Anna R. Bergdall

Effect of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Control: A Cluster Randomized Clinical Trial

IMPORTANCE Only about half of patients with high blood pressure (BP) in the United States have their BP controlled. Practical, robust, and sustainable models are needed to improve BP control in patients with uncontrolled hypertension. OBJECTIVES To determine whether an intervention combining home BP telemonitoring with pharmacist case management improves BP control compared with usual care and to determine whether BP control is maintained after the intervention is stopped. DESIGN, SETTING, AND PATIENTS A cluster randomized clinical trial of 450 adults with uncontrolled BP recruited from 14,692 patients with electronic medical records across 16 primary care clinics in an integrated health system in Minneapolis-St Paul, Minnesota, with 12 months of intervention and 6 months of postintervention follow-up. INTERVENTIONS Eight clinics were randomized to provide usual care to patients (n = 222) and 8 clinics were randomized to provide a telemonitoring intervention (n = 228). Intervention patients received home BP telemonitors and transmitted BP data to pharmacists who adjusted antihypertensive therapy accordingly. MAIN OUTCOMES AND MEASURES Control of systolic BP to less than 140 mm Hg and diastolic BP to less than 90 mm Hg (<130/80 mm Hg in patients with diabetes or chronic kidney disease) at 6 and 12 months. Secondary outcomes were change in BP, patient satisfaction, and BP control at 18 months (6 months after intervention stopped). RESULTS At baseline, enrollees were 45% women, 82% white, mean (SD) age was 61.1 (12.0) years, and mean systolic BP was 148 mm Hg and diastolic BP was 85 mm Hg. Blood pressure was controlled at both 6 and 12 months in 57.2% (95% CI, 44.8% to 68.7%) of patients in the telemonitoring intervention group vs 30.0% (95% CI, 23.2% to 37.8%) of patients in the usual care group (P = .001). At 18 months (6 months of postintervention follow-up), BP was controlled in 71.8% (95% CI, 65.0% to 77.8%) of patients in the telemonitoring intervention group vs 57.1% (95% CI, 51.5% to 62.6%) of patients in the usual care group (P = .003). Compared with the usual care group, systolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months (-10.7 mm Hg [95% CI, -14.3 to -7.3 mm Hg]; P<.001), at 12 months (-9.7 mm Hg [95% CI, -13.4 to -6.0 mm Hg]; P<.001), and at 18 months (-6.6 mm Hg [95% CI, -10.7 to -2.5 mm Hg]; P = .004). Compared with the usual care group, diastolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months (-6.0 mm Hg [95% CI, -8.6 to -3.4 mm Hg]; P<.001), at 12 months (-5.1 mm Hg [95% CI, -7.4 to -2.8 mm Hg]; P<.001), and at 18 months (-3.0 mm Hg [95% CI, -6.3 to 0.3 mm Hg]; P = .07). CONCLUSIONS AND RELEVANCE Home BP telemonitoring and pharmacist case management achieved better BP control compared with usual care during 12 months of intervention that persisted during 6 months of postintervention follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00781365.

TeenBP: Development and Piloting of an EHR-linked Clinical Decision Support System to Improve Recognition of Hypertension in Adolescents

Context: Blood pressure (BP) is routinely measured in children and adolescents during primary care visits. However, elevated BP or hypertension is frequently not diagnosed or evaluated further by primary care providers. Barriers to recognition include lack of clinician buy-in, competing priorities, and complexity of the standard BP tables. Case Description: We have developed and piloted TeenBP— a web-based, electronic health record (EHR) linked system designed to improve recognition of prehypertension and hypertension in adolescents during primary care visits. Major Themes: Important steps in developing TeenBP included the following: review of national BP guidelines, consideration of clinic workflow, engagement of clinical leaders, and evaluation of the impact on clinical sites. Use of a web-based platform has facilitated updates to the TeenBP algorithm and to the message content. In addition, the web-based platform has allowed for development of a sophisticated display of patient-specific information at the point of care. In the TeenBP pilot, conducted at a single pediatric and family practice site with six clinicians, over a five-month period, more than half of BPs in the hypertensive range were clinically recognized. Furthermore, in this small pilot the TeenBP clinical decision support (CDS) was accepted by providers and clinical staff. Effectiveness of the TeenBP CDS will be determined in a two-year cluster-randomized clinical trial, currently underway at 20 primary care sites. Conclusion: Use of technology to extract and display clinically relevant data stored within the EHR may be a useful tool for improving recognition of adolescent hypertension during busy primary care visits. In the future, the methods developed specifically for TeenBP are likely to be translatable to a wide range of acute and chronic issues affecting children and adolescents.

A substudy evaluating treatment intensification on medication adherence among hypertensive patients receiving home blood pressure telemonitoring and pharmacist management

Hypertension is a leading cause of death and major contributor to heart attacks, strokes, heart and kidney failure. Antihypertensive (HTN medication) non‐adherence contributes to uncontrolled hypertension. Effective initiatives to improve uncontrolled hypertension include a team‐based approach with home blood pressure (BP) monitoring. Our study objective was to evaluate whether objectively measured medication adherence was influenced by home BP telemonitoring and pharmacist management.

Economic evaluation of the home blood pressure telemonitoring and pharmacist case management to control hypertension (Hyperlink) trial

Pharmacist‐managed (team‐based) care for hypertension with home blood pressure monitoring support interventions has been widely studied and shown to be effective in improving rates of hypertension control and lowering blood pressure; however, few studies have evaluated the economic considerations related to bringing these programs into usual practice.

Long-term Outcomes of the Effects of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Among Adults With Uncontrolled Hypertension: Follow-up of a Cluster Randomized Clinical Trial

Key Points Question How long does blood pressure remain lower compared with usual care after a 12-month intensive intervention (home telemonitoring and pharmacist management)? Findings In this follow-up of a cluster randomized trial of 326 patients with uncontrolled hypertension, research clinic measurements showed that home blood pressure telemonitoring with pharmacist management lowered blood pressure more than usual care in the first 18 months, but this was not sustained through 54 months. The results from routine clinical measurements suggested significantly lower blood pressure in the intervention group for up to 24 months. Meaning Long-term maintenance strategies may be needed to sustain blood pressure intervention effects over several years.

CB1-02: A Comparison of Blood Pressure Measurements Derived from Primary Care Practice and Research Settings

Background/Aims Guidelines for blood pressure (BP) treatment thresholds and goals have been derived from measurements obtained in research clinics (RC), but few studies have compared BP measurements obtained in RC and routine primary care practice (PCP) settings, where decisions about BP treatment occur. Aims To compare BP obtained from RC and PCP settings using data from Hyperlink, a randomized controlled trial of home BP telemonitoring. Methods Eligible subjects included 1,138 subjects whose 2 most recent PCP BP in the last 12 months were >140/90, responded with interest to a mailed invitation, and attended a research clinic (RC) screening visit for the Hyperlink study. Of these subjects, 255 had an additional PCP BP measurement within 30 days before the RC visit and were included in this analysis. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) used for RC was the mean of 3 readings obtained using an automated blood pressure device, and for PCP was the single measurement (with sphygmomanometer as usual procedure) recorded in the electronic medical record closest to the RC visit. Results The SBP mean (SD) in mm Hg for PCP was 136.9 (15.8) and for RC was 133.5 (17.6), a mean within-person difference of 3.3, p=.005. DBP mean (SD) for PCP was 77.9 (11.1) and for RC was 75.9 (12.2), difference of −2.0, p=.005. Correlation coefficients between PCP and RC readings were 0.38 for SBP and 0.55 for DBP. Of 103 subjects with PCP SBP >=140, 52 (50%) had RC SBP <140, and the overestimation was greater at higher levels of PCP SBP (PCP SBP >150, +17 mm Hg; PCP SBP 140–149, +8 mm Hg; PCP SBP 130–139, +0.3 mm Hg; PCP SBP <130, −6 mm Hg). Discussion BP obtained in the RC setting was significantly lower than BP obtained in the PCP setting; only half of patients with uncontrolled PCP BP were confirmed in the RC. The differences could result in poorer outcomes on PCP BP performance measures and over-treatment of BP. The results support the use of better methods to more accurately assess and manage BP in the PCP setting.