FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W3192752601> ?p ?o ?g. }

• W3192752601 abstract "HomeCirculation: Cardiovascular Quality and OutcomesVol. 14, No. 8Helping Patients Manage Their Own Blood Pressures: A Strategy to Address Hypertension Control in the United States Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessArticle CommentaryPDF/EPUBHelping Patients Manage Their Own Blood Pressures: A Strategy to Address Hypertension Control in the United States Nancy Haff, MD, MPH and Niteesh K. Choudhry, MD, PhD Nancy HaffNancy Haff Correspondence to: Nancy Haff, MD, MPH, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, 3rd Floor, Boston, MA 02120. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8156-7137 Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Center for Healthcare Delivery Sciences, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA. Search for more papers by this author and Niteesh K. ChoudhryNiteesh K. Choudhry Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Center for Healthcare Delivery Sciences, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA. Search for more papers by this author Originally published2 Aug 2021https://doi.org/10.1161/CIRCOUTCOMES.121.008220Circulation: Cardiovascular Quality and Outcomes. 2021;14:e008220Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 2, 2021: Ahead of Print Hypertension is highly prevalent in the United States and is a leading cause of myocardial infarction, stroke, and death. Despite its importance and the widespread availability of medication treatment, less than half of patients with hypertension have controlled blood pressures.1 National efforts, such as the Million Hearts initiative, have helped, but there remains much work to be done.The prevalence of poor hypertension control is not surprising given that it is typically managed with episodic in-person visits for blood pressure measurement, laboratory checks, and medication adjustments. No-show rates for ambulatory visits can be high, and attended visits are still typically months apart. Blood pressure values are influenced by pain, exercise, and stress, which can make interpretation of office-based measurements difficult. Home blood pressure measurements can help, but systems to easily link home readings to the electronic health record are uncommon. Even with accurate blood pressure values, physicians frequently fail to intensify treatment when clinically indicated, often referred to as clinical inertia.2Given the challenges with the current model of hypertension care, alternative strategies to manage blood pressure have emerged. Interventions combining home blood pressure monitoring with systematic medication titration, for example, by a pharmacist through collaborative practice agreements with physicians, results in greater blood pressure reductions compared with usual care.3 However, establishing and maintaining these programs is still subject to human resource constraints, can be costly, and the ability for pharmacists to prescribe varies by state.Antihypertensive Self-TitrationOne approach that overcomes some of these limitations is to allow patients to manage their own blood pressures. Like insulin self-titration based on blood sugar values, hypertension management is inherently algorithmic. Self-titration of antihypertensives would involve patients checking blood pressures at home, following a limited number of preplanned steps to modify medications when indicated, and interacting with their care team when needed with questions or blood pressure values outside a safe range.There is evidence that self-titration of blood pressure mediations is effective4,5 and cost-effective.6,7 In the TASMINH2 (Telemonitoring and Self-Management in Hypertension 2) trial, conducted in the United Kingdom, patients monitored blood pressures at home each month and followed an action plan, agreed upon with their physicians, to increase medication dosage or add a new medication if their blood pressures were persistently elevated. With this intervention, patients achieved a mean systolic blood pressure 5 mm Hg lower at 12 months than patients treated with usual care.4 In the subsequent TASMIN-SR (Targets and Self-Management for the Control of Blood Pressure in Stroke and at Risk Groups) trial among patients with cardiovascular disease, diabetes, or chronic kidney disease, improvements in blood pressure control were even greater.5 More recently, parts of this process were leveraged in a related trial utilizing a digital intervention.8Follow-up qualitative studies after the TASMINH2 trial reported that patients felt more confident in their blood pressure measurements and liked having greater control. Many wanted to continue home monitoring after the trial was complete.9 Interviews with providers revealed that most were happy with patients’ increased understanding of hypertension care, the reduced in-clinic workload, and their ability to more easily identify white coat syndrome.Implementation ConsiderationsIf evidence of this intervention’s potential has existed for years, what would it take for this to become part of routine hypertension care? In addition to ensuring that a US-focused, self-management approach is based on contemporary guidelines, several factors would need to be overcome.First, >95% of participants in the UK self-management trials were White, but US patients with hypertension are dramatically more diverse. A US-based self-management approach would need to reflect this diversity, both as it relates to treatment recommendations but also the varied cultures, languages, socioeconomic factors, levels of health literacy, and patient preferences that are relevant to hypertension care in our country. Additionally, barriers to health care access are commonplace in the United States and, along with the long-standing effects of racism, have contributed to racial and ethnic disparities in blood pressure control. These factors would need to be explicitly addressed in self-management strategies. For example, the cost of home blood pressure devices and antihypertensive medications is prohibitive for many. Increased insurance coverage could help but is unlikely to be a comprehensive solution. Recommended medication intensification steps could also be based on inexpensive options; for example, only medications on the $4 list available at many pharmacies or known to be in an insurer’s least expensive tier. Implementation of a self-management strategy without directly addressing factors that contribute to health disparities could have the unintentional consequence of exacerbating these inequities. However, done correctly, self-management could have a positive impact on blood pressure disparities by making treatment more patient-centered, building self-efficacy and disease knowledge, and increasing trust in treatment decisions.Second, there are logistical considerations for the successful implementation of antihypertensive self-titration in US primary care. For example, a method for getting patients increased doses or new medications when indicated by their treatment plan would need to be established. Because most prescriptions are valid for 1 year after the date written, one option would be giving patients paper prescriptions for each intensification step to fill when needed. Patients would also need easy ways to communicate with their treatment teams about questions, concerns, and blood pressure values outside of a safe range. Existing patient portals, paired with telemedicine contact for urgent issues, could be used. Additionally, the use of telemedicine has become much more common since the start of the coronavirus disease 2019 (COVID-19) pandemic. Leveraging this care modality could make self-management interventions more scalable and may help address limitations in primary care supply and visit availability that exist in some parts of the United States.Third, given the liability concerns that are ever-present in US health care, physicians may be worried about their legal risk if, for example, patients experience side effects or deviate from the instructions. Blood pressure medications do carry risks, but significant adverse events were similar between intervention and control arms in the UK self-management trials. There are always differences when translating an intervention from a clinical trial to real-world practice, but this is not different from the implementation of other self-management approaches like home prandial insulin regimens or an asthma action plan. With the potential for significant cardiovascular risk reduction from sustained blood pressure control, for many patients, the benefits of antihypertensive self-titration would likely outweigh the risks.ConclusionsEven with thoughtful implementation, self-titration will not work for everyone. The UK trials recruited from primary care practices, and among these consented patients, adherence to the study protocol still decreased considerably over the year of follow-up.10 Thus, it would be important to include antihypertensive self-titration as one of several tools available to enable out-of-office blood pressure management, to redirect clinical time and resources liberated by patients who can titrate their own medications toward assisting patients who need more intensive support, and to identify and use strategies to enhance patient engagement over time.That said, self-titration of antihypertensives has received comparatively less attention than other out-of-office blood pressure management strategies but has the potential to allow more patient-centered care and offload our health care system. Several issues of implementation would need to be addressed, but many of these considerations are relevant to the successful implementation of most out-of-office blood pressure management strategies. None of the barriers are insurmountable, and many of the tools needed already exist. Given the failure to achieve good control of many chronic diseases in the United States with existing care models, including blood pressure, it is time to try new approaches.Disclosures Dr Choudhry reports grants/contracts from Boehringer Ingelheim, Humana, Inc, and National Institutes of Health; ownership of stock in RxAnte; and a position as a consultant to Veracity Healthcare. The other author reports no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Disclosures, see page 838.Correspondence to: Nancy Haff, MD, MPH, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, 3rd Floor, Boston, MA 02120. Email [email protected]orgReferences1. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, et al.. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2018; 138:e484–e594. doi: 10.1161/CIR.0000000000000596LinkGoogle Scholar2. Mu L, Mukamal KJ. Treatment intensification for hypertension in US Ambulatory Medical Care.J Am Heart Assoc. 2016; 5:e004188. doi: 10.1161/JAHA.116.004188LinkGoogle Scholar3. Mills KT, Obst KM, Shen W, Molina S, Zhang HJ, He H, Cooper LA, He J. Comparative effectiveness of implementation strategies for blood pressure control in hypertensive patients: a systematic review and meta-analysis.Ann Intern Med. 2018; 168:110–120. doi: 10.7326/M17-1805CrossrefMedlineGoogle Scholar4. McManus RJ, Mant J, Bray EP, Holder R, Jones MI, Greenfield S, Kaambwa B, Banting M, Bryan S, Little P, et al.. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial.Lancet. 2010; 376:163–172. doi: 10.1016/S0140-6736(10)60964-6CrossrefMedlineGoogle Scholar5. McManus RJ, Mant J, Haque MS, Bray EP, Bryan S, Greenfield SM, Jones MI, Jowett S, Little P, Penaloza C, et al.. Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial.JAMA. 2014; 312:799–808. doi: 10.1001/jama.2014.10057CrossrefMedlineGoogle Scholar6. Kaambwa B, Bryan S, Jowett S, Mant J, Bray EP, Hobbs FD, Holder R, Jones MI, Little P, Williams B, et al.. Telemonitoring and self-management in the control of hypertension (TASMINH2): a cost-effectiveness analysis.Eur J Prev Cardiol. 2014; 21:1517–1530. doi: 10.1177/2047487313501886CrossrefMedlineGoogle Scholar7. Penaloza-Ramos MC, Jowett S, Mant J, Schwartz C, Bray EP, Sayeed Haque M, Richard Hobbs FD, Little P, Bryan S, Williams B, et al.. Cost-effectiveness of self-management of blood pressure in hypertensive patients over 70 years with suboptimal control and established cardiovascular disease or additional cardiovascular risk diseases (TASMIN-SR).Eur J Prev Cardiol. 2016; 23:902–912. doi: 10.1177/2047487315618784CrossrefMedlineGoogle Scholar8. McManus RJ, Little P, Stuart B, Morton K, Raftery J, Kelly J, Bradbury K, Zhang J, Zhu S, Murray E, et al.; HOME BP investigators. Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial.BMJ. 2021; 372:m4858. doi: 10.1136/bmj.m4858CrossrefMedlineGoogle Scholar9. Jones MI, Greenfield SM, Bray EP, Baral-Grant S, Hobbs FD, Holder R, Little P, Mant J, Virdee SK, Williams B, et al.. Patients’ experiences of self-monitoring blood pressure and self-titration of medication: the TASMINH2 trial qualitative study.Br J Gen Pract. 2012; 62:e135–e142. doi: 10.3399/bjgp12X625201CrossrefMedlineGoogle Scholar10. Schwartz CL, Seyed-Safi A, Haque S, Bray EP, Greenfield S, Hobbs FDR, Little P, Mant J, Williams B, Mcmanus RJ. Do patients actually do what we ask: patient fidelity and persistence to the targets and self-management for the control of blood pressure in stroke and at risk groups blood pressure self-management intervention.J Hypertens. 2018; 36:1753–1761. doi: 10.1097/HJH.0000000000001738CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails August 2021Vol 14, Issue 8Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.121.008220PMID: 34333992 Originally publishedAugust 2, 2021 Keywordshypertensionblood pressureprevalencehealth carePDF download Advertisement SubjectsHealth ServicesHigh Blood PressureHypertensionQuality and OutcomesSocial Determinants of Health" @default.
• W3192752601 created "2021-08-16" @default.
• W3192752601 creator A5012495023 @default.
• W3192752601 creator A5091282674 @default.
• W3192752601 date "2021-08-01" @default.
• W3192752601 modified "2023-09-27" @default.
• W3192752601 title "Helping Patients Manage Their Own Blood Pressures: A Strategy to Address Hypertension Control in the United States" @default.
• W3192752601 cites W2121607038 @default.
• W3192752601 cites W2157488387 @default.
• W3192752601 cites W2165202379 @default.
• W3192752601 cites W2167145056 @default.
• W3192752601 cites W2176765011 @default.
• W3192752601 cites W2535390099 @default.
• W3192752601 cites W2777811290 @default.
• W3192752601 cites W2806447893 @default.
• W3192752601 cites W3048383434 @default.
• W3192752601 cites W4238968220 @default.
• W3192752601 doi "https://doi.org/10.1161/circoutcomes.121.008220" @default.
• W3192752601 hasPubMedCentralId "https://www.ncbi.nlm.nih.gov/pmc/articles/8366532" @default.
• W3192752601 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/34333992" @default.
• W3192752601 hasPublicationYear "2021" @default.
• W3192752601 type Work @default.
• W3192752601 sameAs 3192752601 @default.
• W3192752601 citedByCount "1" @default.
• W3192752601 countsByYear W31927526012023 @default.
• W3192752601 crossrefType "journal-article" @default.
• W3192752601 hasAuthorship W3192752601A5012495023 @default.
• W3192752601 hasAuthorship W3192752601A5091282674 @default.
• W3192752601 hasBestOaLocation W31927526011 @default.
• W3192752601 hasConcept C126322002 @default.
• W3192752601 hasConcept C154945302 @default.
• W3192752601 hasConcept C164705383 @default.
• W3192752601 hasConcept C177713679 @default.
• W3192752601 hasConcept C2775924081 @default.
• W3192752601 hasConcept C41008148 @default.
• W3192752601 hasConcept C71924100 @default.
• W3192752601 hasConcept C84393581 @default.
• W3192752601 hasConceptScore W3192752601C126322002 @default.
• W3192752601 hasConceptScore W3192752601C154945302 @default.
• W3192752601 hasConceptScore W3192752601C164705383 @default.
• W3192752601 hasConceptScore W3192752601C177713679 @default.
• W3192752601 hasConceptScore W3192752601C2775924081 @default.
• W3192752601 hasConceptScore W3192752601C41008148 @default.
• W3192752601 hasConceptScore W3192752601C71924100 @default.
• W3192752601 hasConceptScore W3192752601C84393581 @default.
• W3192752601 hasIssue "8" @default.
• W3192752601 hasLocation W31927526011 @default.
• W3192752601 hasLocation W31927526012 @default.
• W3192752601 hasLocation W31927526013 @default.
• W3192752601 hasOpenAccess W3192752601 @default.
• W3192752601 hasPrimaryLocation W31927526011 @default.
• W3192752601 hasRelatedWork W2011347913 @default.
• W3192752601 hasRelatedWork W2049397185 @default.
• W3192752601 hasRelatedWork W2073151595 @default.
• W3192752601 hasRelatedWork W2074833529 @default.
• W3192752601 hasRelatedWork W2125804349 @default.
• W3192752601 hasRelatedWork W2159512267 @default.
• W3192752601 hasRelatedWork W2304633692 @default.
• W3192752601 hasRelatedWork W2355498105 @default.
• W3192752601 hasRelatedWork W2399063111 @default.
• W3192752601 hasRelatedWork W2414320482 @default.
• W3192752601 hasVolume "14" @default.
• W3192752601 isParatext "false" @default.
• W3192752601 isRetracted "false" @default.
• W3192752601 magId "3192752601" @default.
• W3192752601 workType "article" @default.