Stephen D. Persell

Prevalence of Resistant Hypertension in the United States, 2003–2008

The prevalence of resistant hypertension is unknown. Much previous knowledge comes from referral populations or clinical trial participants. Using data from the National Health and Nutrition Examination Survey from 2003 through 2008, nonpregnant adults with hypertension were classified as resistant if their blood pressure was ≥140/90 mm Hg and they reported using antihypertensive medications from 3 different drug classes or drugs from ≥4 antihypertensive drug classes regardless of blood pressure. Among US adults with hypertension, 8.9% (SE: 0.6%) met criteria for resistant hypertension. This represented 12.8% (SE: 0.9%) of the antihypertensive drug–treated population. Of all drug-treated adults whose hypertension was uncontrolled, 72.4% (SE: 1.6%) were taking drugs from <3 classes. Compared with those with controlled hypertension using 1 to 3 medication classes, adults with resistant hypertension were more likely to be older, to be non-Hispanic black, and to have higher body mass index (all P<0.001). They were more likely to have albuminuria, reduced renal function, and self-reported medical histories of coronary heart disease, heart failure, stroke, and diabetes mellitus (P<0.001). Most (85.6% [SE: 2.4%]) individuals with resistant hypertension used a diuretic. Of this group, 64.4% (SE: 3.2%) used the relatively weak thiazide diuretic hydrochlorothiazide. Although not rare, resistant hypertension is currently found in only a modest proportion of the hypertensive population. Among those classified here as resistant, inadequate diuretic therapy may be a modifiable therapeutic target. Cardiovascular diseases, diabetes mellitus, obesity, and renal dysfunction were all common in this population.

Distribution of 10-Year and Lifetime Predicted Risks for Cardiovascular Disease in US Adults Findings From the National Health and Nutrition Examination Survey 2003 to 2006

Background—National guidelines for primary prevention suggest consideration of lifetime risk for cardiovascular disease in addition to 10-year risk, but it is currently unknown how many US adults would be identified as having low short-term but high lifetime predicted risk if stepwise stratification were used. Methods and Results—We included 6329 cardiovascular disease–free and nonpregnant individuals ages 20 to 79 years, representing approximately 156 million US adults, from the National Health and Nutrition Examination Survey 2003 to 2004 and 2005 to 2006. We assigned 10-year and lifetime predicted risks to stratify participants into 3 groups: low 10-year (<10%)/low lifetime (<39%) predicted risk, low 10-year (<10%)/high lifetime (≥39%) predicted risk, and high 10-year (≥10%) predicted risk or diagnosed diabetes. The majority of US adults (56%, or 87 million individuals) are at low short-term but high lifetime predicted risk for cardiovascular disease. Twenty-six percent (41 million adults) are at low short-term and low lifetime predicted risk, and only 18% (28 million individuals) are at high short-term predicted risk. The addition of lifetime risk estimation to 10-year risk estimation identifies higher-risk women and younger men in particular. Conclusions—Whereas 82% of US adults are at low short-term risk, two thirds of this group, or 87 million people, are at high lifetime predicted risk for cardiovascular disease. These results provide support for use of a stepwise stratification system aimed at improving risk communication, and they provide a baseline for public health efforts aimed at increasing the proportion of Americans with low short-term and low lifetime risk for cardiovascular disease.

Prompting physicians to address a daily checklist and process of care and clinical outcomes: A single-site study

RATIONALE Checklists may reduce errors of omission for critically ill patients. OBJECTIVES To determine whether prompting to use a checklist improves process of care and clinical outcomes. METHODS We conducted a cohort study in the medical intensive care unit (MICU) of a tertiary care university hospital. Patients admitted to either of two independent MICU teams were included. Intervention team physicians were prompted to address six parameters from a daily rounding checklist if overlooked during morning work rounds. The second team (control) used the identical checklist without prompting. MEASUREMENTS AND MAIN RESULTS One hundred and forty prompted group patients were compared with 125 control and 1,283 preintervention patients. Compared with control, prompting increased median ventilator-free duration, decreased empirical antibiotic and central venous catheter duration, and increased rates of deep vein thrombosis and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared with the control group (odds ratio, 0.36; 95% confidence interval, 0.13-0.96; P = 0.041) and lower hospital mortality compared with the control group (10.0 vs. 20.8%; P = 0.014), which remained significant after risk adjustment (odds ratio, 0.34; 95% confidence interval, 0.15-0.76; P = 0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared with control (0.59 vs. 0.87; P = 0.02). Checklist availability alone did not improve mortality or length of stay compared with preintervention patients. CONCLUSIONS In this single-site, preliminary study, checklist-based prompting improved multiple processes of care, and may have improved mortality and length of stay, compared with a stand-alone checklist. The manner in which checklists are implemented is of great consequence in the care of critically ill patients.

Limited health literacy is a barrier to medication reconciliation in ambulatory care.

BackgroundLimited health literacy may influence patients’ ability to identify medications taken; a serious concern for ambulatory safety and quality.ObjectiveTo assess the relationship between health literacy, patient recall of antihypertensive medications, and reconciliation between patient self-report and the medical record.DesignIn-person interviews, literacy assessment, medical records abstraction.ParticipantsAdults with hypertension at three community health centers.MeasurementWe measured health literacy using the short-form Test of Functional Health Literacy in Adults. Patients were asked about the medications they took for blood pressure. Their responses were compared with the medical record.ResultsOf 119 participants, 37 (31%) had inadequate health literacy. Patients with inadequate health literacy were less able to name any of their antihypertensive medications compared to those with adequate health literacy (40.5% vs 68.3%, p = 0.005). After adjusting for age and income, this difference remained (adjusted odds ratio [OR] = 2.9, 95% confidence interval [95%CI] = 1.3–6.7). Agreement between patient reported medications and the medical record was low: 64.9% of patients with inadequate and 37.8% with adequate literacy had no medications common to both lists.ConclusionsLimited health literacy was associated with a greater number of unreconciled medications. Future studies should investigate how this may impact safety and hypertension control.

ACCF/AHA/AMA-PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association-Physician Consortium for Performance Improvement.

Eric D. Peterson, MD, MPH, FACC, FAHA, Chair; Frederick A. Masoudi, MD, MSPH, FACC, FAHA[†††][1]; Elizabeth DeLong, PhD; John P. Erwin III, MD, FACC; Gregg C. Fonarow, MD, FACC, FAHA; David C. Goff, Jr., MD, PhD, FAHA, FACP; Kathleen Grady, PhD, RN, FAHA, FAAN; Lee A. Green, MD, MPH; Paul A.

Education, literacy, and health: Mediating effects on hypertension knowledge and control

OBJECTIVE To determine whether literacy mediates the association between education, hypertension knowledge and control. METHODS In-person interviews with a literacy assessment and chart review were conducted with 330 hypertensive patients from six primary care safety net clinics. Mediational analysis was used to test the role of literacy skills in explaining the relationship between education and hypertension knowledge and control. RESULTS In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. When literacy was entered into models that included education only, the association between education and knowledge was fully attenuated and no longer significant (Grades 1-8: beta=-0.30, 95% CI=-1.44-0.83), while the relationship between education and blood pressure control was only minimally reduced (AOR 2.46, 95% CI 2.10-2.88). More limited literacy skills also was associated with hypertension control in the final model (AOR 2.68, 95% CI 1.54-4.70). CONCLUSION Patient literacy mediated the relationship between education and hypertension knowledge. Literacy was a significant independent predictor of blood pressure control, but only minimally explained the relationship between education and blood pressure. PRACTICE IMPLICATIONS Health literacy is critical to the design of educational tools to improve knowledge acquisition. However, in order to impact health outcome, future health literacy studies should also address other psychosocial factors that impact motivation and capability to manage disease.

Association of Arrhythmia-Related Genetic Variants With Phenotypes Documented in Electronic Medical Records.

IMPORTANCE Large-scale DNA sequencing identifies incidental rare variants in established Mendelian disease genes, but the frequency of related clinical phenotypes in unselected patient populations is not well established. Phenotype data from electronic medical records (EMRs) may provide a resource to assess the clinical relevance of rare variants. OBJECTIVE To determine the clinical phenotypes from EMRs for individuals with variants designated as pathogenic by expert review in arrhythmia susceptibility genes. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included 2022 individuals recruited for nonantiarrhythmic drug exposure phenotypes from October 5, 2012, to September 30, 2013, for the Electronic Medical Records and Genomics Network Pharmacogenomics project from 7 US academic medical centers. Variants in SCN5A and KCNH2, disease genes for long QT and Brugada syndromes, were assessed for potential pathogenicity by 3 laboratories with ion channel expertise and by comparison with the ClinVar database. Relevant phenotypes were determined from EMRs, with data available from 2002 (or earlier for some sites) through September 10, 2014. EXPOSURES One or more variants designated as pathogenic in SCN5A or KCNH2. MAIN OUTCOMES AND MEASURES Arrhythmia or electrocardiographic (ECG) phenotypes defined by International Classification of Diseases, Ninth Revision (ICD-9) codes, ECG data, and manual EMR review. RESULTS Among 2022 study participants (median age, 61 years [interquartile range, 56-65 years]; 1118 [55%] female; 1491 [74%] white), a total of 122 rare (minor allele frequency <0.5%) nonsynonymous and splice-site variants in 2 arrhythmia susceptibility genes were identified in 223 individuals (11% of the study cohort). Forty-two variants in 63 participants were designated potentially pathogenic by at least 1 laboratory or ClinVar, with low concordance across laboratories (Cohen κ = 0.26). An ICD-9 code for arrhythmia was found in 11 of 63 (17%) variant carriers vs 264 of 1959 (13%) of those without variants (difference, +4%; 95% CI, -5% to +13%; P = .35). In the 1270 (63%) with ECGs, corrected QT intervals were not different in variant carriers vs those without (median, 429 vs 439 milliseconds; difference, -10 milliseconds; 95% CI, -16 to +3 milliseconds; P = .17). After manual review, 22 of 63 participants (35%) with designated variants had any ECG or arrhythmia phenotype, and only 2 had corrected QT interval longer than 500 milliseconds. CONCLUSIONS AND RELEVANCE Among laboratories experienced in genetic testing for cardiac arrhythmia disorders, there was low concordance in designating SCN5A and KCNH2 variants as pathogenic. In an unselected population, the putatively pathogenic genetic variants were not associated with an abnormal phenotype. These findings raise questions about the implications of notifying patients of incidental genetic findings.

Changes in Performance After Implementation of a Multifaceted Electronic-Health-Record-Based Quality Improvement System

Background:Electronic health record (EHR) systems have the potential to revolutionize quality improvement (QI) methods by enhancing quality measurement and integrating multiple proven QI strategies. Objectives:To implement and evaluate a multifaceted QI intervention using EHR tools to improve quality measurement (including capture of contraindications and patient refusals), make point-of-care reminders more accurate, and provide more valid and responsive clinician feedback (including lists of patients not receiving essential medications) for 16 chronic disease and preventive service measures. Design:Time series analysis at a large internal medicine practice using a commercial EHR. Subjects:All adult patients eligible for each measure (range approximately 100–7500). Measures:The proportion of eligible patients who satisfied each measure after removing those with exceptions from the denominator. Results:During the year before the intervention, performance improved significantly for 8 measures. During the year after the intervention, performance improved significantly for 14 measures. For 9 measures, the primary outcome improved more rapidly during the intervention year than during the previous year (P < 0.001 for 8 measures, P = 0.02 for 1). Four other measures improved at rates that were not significantly different from the previous year. Improvements resulted from increases in patients receiving the service, documentation of exceptions, or a combination of both. For 5 drug-prescribing measures, more than half of physicians achieved 100% performance. Conclusions:Implementation of a multifaceted QI intervention using EHR tools to improve quality measurement and the accuracy and timeliness of clinician feedback improved performance and/or accelerated the rate of improvement for multiple measures simultaneously.

ACCF/AHA/AMA–PCPI 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension

Developed in Collaboration With the American Academy of Family Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation, American Association of Clinical Endocrinologists, American College of Emergency Physicians, American College of Radiology, American Nurses Association, American Society of Health-System Pharmacists, Society of Hospital Medicine, and Society of Thoracic Surgeons

Increased Blood Pressure in the Emergency Department : Pain, Anxiety, or Undiagnosed Hypertension?

STUDY OBJECTIVE We determine the proportion of patients with increased emergency department (ED) blood pressure and no history of hypertension who have persistently increased blood pressure at home, describe characteristics associated with sustained blood pressure increase, and examine the relationship between pain and anxiety and the change in blood pressure after ED discharge. METHODS This was a prospective cohort study. Patients with no history of hypertension and 2 blood pressure measurements of at least 140/90 mm Hg who were treated in an urban ED were enrolled, provided with home blood pressure monitors, and asked to take their blood pressure twice a day for 1 week. Outcome measures were increased mean home blood pressure (140/90 mm Hg or greater), and correlations between ED anxiety (Spielberger State Anxiety Scale) or pain (10-point scale) and the change in blood pressure after discharge. Potential relevant predictors were recorded and a multivariate model was constructed to assess the relationship between these predictors and increased home blood pressure. RESULTS 189 patients were enrolled and 156 returned the monitors and completed the protocol. Increased mean home blood pressure was present in 79 of 156 (51%) patients and was associated with older age and being black. Of patients with ED blood pressures meeting criteria for stage I hypertension, 6% had home blood pressures meeting stage II hypertension, 36% stage I, and 52% prehypertension, and 6% had normal blood pressure For patients with ED blood pressures meeting stage II criteria, the corresponding percentages were 28%, 31%, 33%, and 8%, respectively. The difference between home and ED systolic blood pressures was not associated with anxiety (r=-.03; P=.69) and showed a slight association with pain in the opposite direction from what was expected (r=.18; P=.03). CONCLUSION Patients without diagnosed hypertension and increased ED blood pressures often have persistently increased home blood pressures, which does not appear to be related to pain or anxiety in the ED.