Effect of intensive structured care on individual blood pressure targets in primary care: multicentre randomised controlled trial

Stewart, Simon; Carrington, Melinda; Swemmer, C.; Anderson, Craig S.; Kurstjens, N.; Amerena, John; Brown, Alex; Burrell, Louise M.; Looze, Ferdinandus J. de; Harris, Mark F; Hung, Joseph; Krum, Henry; Nelson, Mark; Schlaich, Markus P.; Stocks, Nigel; Jennings, Garry

doi:10.1136/bmj.e7156

Cited by 32 publications

(28 citation statements)

References 18 publications

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“…Arguably general practice is an ideal setting to bridge the gap between detection and management allowing intervention strategies to be implemented by physicians or practice nurses, to target biomedical risk factors. [34][35][36][37] Consistent with relevant systematic reviews, 3,12 no differences in total mortality are found in the review. However, mortality was not the primary outcome for the majority of the practice-based studies.…”

Section: Comparison With Existing Literaturesupporting

confidence: 80%

Effectiveness of general practice-based health checks: a systematic review and meta-analysis

Si¹,

et al. 2013

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Section: Comparison With Existing Literaturesupporting

confidence: 80%

Effectiveness of general practice-based health checks: a systematic review and meta-analysis

Si¹,

et al. 2013

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“…17,[34][35][36][37] The large impact of treatment intensification on population BP control seen in our model argues for large-scale adoption of interventions that have been shown to increase treatment intensification rates. 36,[38][39][40][41] Our results suggest that visit frequency is an important parameter in the management of hypertension. Although BP blood pressure BP control = proportion of patients with systolic BP < 140 mmHg JNC 8 9 did not address visit frequency, our simulation of ideal visit frequency is based on the JNC 7 guideline that patients are followed up within a month when an elevated BP is noted.…”

Section: Discussionmentioning

confidence: 99%

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

et al. 2015

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BACKGROUND: Only half of hypertensive adults achieve blood pressure (BP) control in the United States, and it is unclear how BP control rates may be improved most effectively and efficiently at the population level. OBJECTIVE: We sought to compare the potential effects of system-wide isolated improvements in medication adherence, visit frequency, and higher physician prescription rate on achieving BP control at 52 weeks. DESIGN: We developed a Markov microsimulation model of patient-level, physician-level, and system-level processes involved in controlling hypertension with medications. The model is informed by data from national surveys, cohort studies and trials, and was validated against two multicenter clinical trials (ALLHAT and VALUE). SUBJECTS: We studied a simulated, nationally representative cohort of patients with diagnosed but uncontrolled hypertension with a usual source of care. INTERVENTIONS:We simulated a base case and improvements of 10 and 50 %, and an ideal scenario for three modifiable parameters: visit frequency, treatment intensification, and medication adherence. Ideal scenarios were defined as 100 % for treatment intensification and adherence, and return visits occurring within 4 weeks of an elevated office systolic BP. MAIN OUTCOME: BP control at 52 weeks of follow-up was examined. RESULTS: Among 25,000 hypothetical adult patients with uncontrolled hypertension (systolic BP ≥ 140 mmHg), only 18 % achieved BP control after 52 weeks using base-case assumptions. With 10/50 %/idealized enhancements in each isolated parameter, enhanced treatment intensification achieved the greatest BP control (19/23/71 %), compared with enhanced visit frequency (19/21/35 %) and medication adherence (19/23/26 %). When all three processes were idealized, the model predicted a BP control rate of 95 % at 52 weeks.CONCLUSION: Substantial improvements in BP control can only be achieved through major improvements in processes of care. Healthcare systems may achieve greater success by increasing the frequency of clinical encounters and improving physicians' prescribing behavior than by attempting to improve patient adherence to medications.

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“…36 However, system-level and clinic-level interventions, such as providing feedback to physicians regarding their patterns of medication use, have successfully promoted more rapid adoption of guideline-recommended therapies. 3 4 Furthermore, clinical trials and integrated healthcare systems have achieved high BP control rates (60-80 %) 37,38 through use of stepped-care hypertension management protocols with treatment algorithms implemented by nurses or pharmacists. 39 However, while these protocols have utilized accepted therapies for stage 1 and stage 2 hypertension, guidance for resistant hypertension has been more restricted and at times not consistent with those recommended by guidelines.…”

Section: Discussionmentioning

confidence: 99%

Physician Underutilization of Effective Medications for Resistant Hypertension at Office Visits in the United States: NAMCS 2006–2010

et al. 2013

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BACKGROUND:The American Heart Association (AHA) published guidelines for treatment of resistant hypertension in 2008 recommending use of thiazide diuretics (particularly chlorthalidone), aldosterone antagonists, and fixed-dose combination medications, but it is unclear the extent to which these guidelines are being followed. OBJECTIVE: To describe trends in physician use of recommended medications for resistant hypertension and assess variations in medication use based on geography, physician specialty and patient characteristics. DESIGN: Cross-sectional analysis using the National Ambulatory Medical Care Survey from 2006 to 2010. STUDY SAMPLE: We analyzed visits of hypertension patients to family physicians, general internists, and cardiologists. Resistant hypertension was defined as concurrent use of ≥ 4 classes of blood pressure (BP) medications or elevated BP despite the use of ≥ 3 medications. Pregnant patients and visits with diagnosed heart failure or end-stage renal disease were excluded. MAIN OUTC OME: U se of A HA-r ec ommen d ed medications for management of resistant hypertension. RESULTS: Of 19,500 patient visits with hypertension, 1,567 or 7.1 % CI (6.6-7.7 %) met criteria for resistant hypertension. Thiazide diuretic use was reported in 58.9 % of visits pre-guidelines vs. 54.8 % postguidelines (p=0.37). Use of aldosterone antagonists was low and also did not change significantly after guideline publication (3.1 % vs. 4.5 %, p=0.27). Fixeddose combinations use was 42.0 % before and 37 % after guideline publication (p = 0.29). Each 10-year increase in patient age was associated with lower thiazide use (OR 0.87,, as was presence of comorbid ischemic heart disease (OR 0.62, CI 0.41-0.94). Medication use did not vary by geography or physician specialty. CONCLUSION: Use of AHA-recommended medications for resistant hypertension remains low after publication of guidelines. Healthcare systems should encourage more frequent prescribing of these medications to improve care in this high-risk population.

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Effect of intensive structured care on individual blood pressure targets in primary care: multicentre randomised controlled trial

Abstract: Objective To determine the effectiveness of intensive structured care to optimise blood pressure control based on individual absolute risk targets in primary care.

Cited by 32 publications

References 18 publications

Effectiveness of general practice-based health checks: a systematic review and meta-analysis

Effectiveness of general practice-based health checks: a systematic review and meta-analysis

Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model

Physician Underutilization of Effective Medications for Resistant Hypertension at Office Visits in the United States: NAMCS 2006–2010

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