Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis
Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis
Background: The prevalence of hypertension is high and is increasing worldwide, whereas the proportion of controlled hypertension is low.
Purpose: To assess the comparative effectiveness of 8 implementation strategies for blood pressure (BP) control in adults with hypertension.
Data sources: Systematic searches of MEDLINE and Embase from inception to September 2017 with no language restrictions, supplemented with manual reference searches.
Study selection: Randomized controlled trials lasting at least 6 months comparing the effect of implementation strategies versus usual care on BP reduction in adults with hypertension.
Data extraction: Two investigators independently extracted data and assessed study quality.
Data synthesis: A total of 121 comparisons from 100 articles with 55 920 hypertensive patients were included. Multilevel, multicomponent strategies were most effective for systolic BP reduction, including team-based care with medication titration by a nonphysician (-7.1 mm Hg [95% CI, -8.9 to -5.2 mm Hg]), team-based care with medication titration by a physician (-6.2 mm Hg [CI, -8.1 to -4.2 mm Hg]), and multilevel strategies without team-based care (-5.0 mm Hg [CI, -8.0 to -2.0 mm Hg]). Patient-level strategies resulted in systolic BP changes of -3.9 mm Hg (CI, -5.4 to -2.3 mm Hg) for health coaching and -2.7 mm Hg (CI, -3.6 to -1.7 mm Hg) for home BP monitoring. Similar trends were seen for diastolic BP reduction.
Limitation: Sparse data from low- and middle-income countries; few trials of some implementation strategies, such as provider training; and possible publication bias.
Conclusion: Multilevel, multicomponent strategies, followed by patient-level strategies, are most effective for BP control in patients with hypertension and should be used to improve hypertension control.
Routes to diagnosis of heart failure: observational study using linked data in England
Routes to diagnosis of heart failure: observational study using linked data in England
Objective Timely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care. We describe the journey of people with HF in primary care from presentation through to diagnosis and initial management.
Methods We used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis.
Results 36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March 2013. For 29 113 (79.2%) patients, this was first recorded in hospital. In the 5 years prior to diagnosis, 15 057 patients (41.0%) had a primary care consultation with one of three key HF symptoms recorded, 17 724 (48.2%) attended for another reason and 3967 (10.8%) did not see their general practitioner. Only 24% of those with recorded HF symptoms followed a pathway aligned with guidelines (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral.
Conclusions Patients follow various pathways to the diagnosis of HF. However, few appear to follow a pathway supported by guidelines for investigation and referral. There are likely to be missed opportunities for earlier HF diagnosis in primary care.
Remote Monitoring In A Fee For Service World
Politico | November 6, 2017
Excerpt:
“The reason this is going to facilitate more use of remote patient monitoring is most medical providers want their patients to get better, and they realize that most care happens outside the medical facility,” Krista Drobac, executive director of the Alliance for Connected Care, told Morning eHealth. “Viewing data digitally transmitted from a patient’s home gives the provider a clearer picture of what’s happening, and providers want that for purposes of good care.”
Drobac said Medicare’s policy shift will also make it easier for doctors to convince unwilling hospital CFOs to follow suit.
The mortality risk of deferring optimal medical therapy in heart failure: a systematic comparison against norms for surgical consent and patient information leaflets
The mortality risk of deferring optimal medical therapy in heart failure: a systematic comparison against norms for surgical consent and patient information leaflets
Aims: The prescription of optimal medical therapy for heart failure is often delayed despite compelling evidence of a reduction in mortality. We calculated the absolute risk resulting from delayed prescription of therapy. For comparison, we established the threshold applied by clinicians when discussing the risk for death associated with an intervention, and the threshold used in official patient information leaflets.
Methods and results: We undertook a meta-analysis of randomized controlled trials to calculate the excess mortality caused by deferral of medical therapy for 1 year. Risk ratios for angiotensin-converting enzyme inhibitors, beta-blockers and aldosterone antagonists were 0.80, 0.73 and 0.77, respectively. In patients who might achieve a 1-year survival rate of 90% if treated, a 1-year deferral of treatment reduced survival to 78% (i.e. an annual absolute increase in mortality of 12 in 100 patients). This corresponds to an additional absolute mortality risk per month of 1%. A survey of clinicians carried out to establish the risk threshold at which they would obtain written consent showed the majority (85%) sought written consent for interventions associated with a 12-fold lower mortality risk: one in 100 patients. A systematic review of UK patient information leaflets to establish the magnitude of risk considered sufficient to be stated explicitly showed that leaflets begin to mention death at a ∼18 000-fold lower mortality risk of just 0.0007 in 100 patients.
Conclusions: Deferring heart failure treatment for 1 year carries far greater risk than the level at which most doctors seek written consent, and 18 000 times more risk than the level at which patient information leaflets begin to mention death.
Remote management of heart failure using implantable electronic devices
Remote management of heart failure using implantable electronic devices
Aims: Remote management of heart failure using implantable electronic devices (REM-HF) aimed to assess the clinical and cost-effectiveness of remote monitoring (RM) of heart failure in patients with cardiac implanted electronic devices (CIEDs).
Methods and results: Between 29 September 2011 and 31 March 2014, we randomly assigned 1650 patients with heart failure and a CIED to active RM or usual care (UC). The active RM pathway included formalized remote follow-up protocols, and UC was standard practice in nine recruiting centres in England. The primary endpoint in the time to event analysis was the 1st event of death from any cause or unplanned hospitalization for cardiovascular reasons. Secondary endpoints included death from any cause, death from cardiovascular reasons, death from cardiovascular reasons and unplanned cardiovascular hospitalization, unplanned cardiovascular hospitalization, and unplanned hospitalization. REM-HF is registered with ISRCTN (96536028). The mean age of the population was 70 years (range 23-98); 86% were male. Patients were followed for a median of 2.8 years (range 0-4.3 years) completing on 31 January 2016. Patient adherence was high with a drop out of 4.3% over the course of the study. The incidence of the primary endpoint did not differ significantly between active RM and UC groups, which occurred in 42.4 and 40.8% of patients, respectively [hazard ratio 1.01; 95% confidence interval (CI) 0.87-1.18; P = 0.87]. There were no significant differences between the two groups with respect to any of the secondary endpoints or the time to the primary endpoint components.
Conclusion: Among patients with heart failure and a CIED, RM using weekly downloads and a formalized follow up approach does not improve outcomes.
Remote Monitoring of Patients With Heart Failure: An Overview of Systematic Reviews
Remote Monitoring of Patients With Heart Failure: An Overview of Systematic Reviews
Background
Many systematic reviews exist on the use of remote patient monitoring (RPM) interventions to improve clinical outcomes and psychological well-being of patients with heart failure. However, research is broadly distributed from simple telephone-based to complex technology-based interventions. The scope and focus of such evidence also vary widely, creating challenges for clinicians who seek information on the effect of RPM interventions
Objective
The aim of this study was to investigate the effects of RPM interventions on the health outcomes of patients with heart failure by synthesizing review-level evidence.
Results
A total of 19 systematic reviews met our inclusion criteria. Reviews consisted of RPM with diverse interventions such as telemonitoring, home telehealth, mobile phone–based monitoring, and videoconferencing. All-cause mortality and heart failure mortality were the most frequently reported outcomes, but others such as quality of life, rehospitalization, emergency department visits, and length of stay were also reported. Self-care and knowledge were less commonly identified.
Conclusions
Telemonitoring and home telehealth appear generally effective in reducing heart failure rehospitalization and mortality. Other interventions, including the use of mobile phone–based monitoring and videoconferencing, require further investigation.