Laboratory monitoring to reduce adverse drug-related events: a mixed methods study.

BACKGROUND: Therapy with angiotensinconverting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) requires laboratory monitoring to avoid hyperkalemia and acute kidney failure. OBJECTIVE: To assess the frequency of recommended annual serum potassium and creatinine monitoring and determine potential factors associated with care gaps among adults dispensed an ACEI or ARB. METHODS: This mixed-methods study integrated findings from a retrospective cohort study and individual patient interviews. Adults aged 21 years and over within Kaiser Permanente Southern California with at least 180 treatment days of an ACEI and/or ARB in 2015 were included. Patients invited for qualitative interviews included those who did and did not complete the recommended laboratory tests. We assessed the proportion of patients completing both recommended laboratory tests, factors associated with not receiving laboratory monitoring, and patients' insights into barriers and facilitators of recommended monitoring. RESULTS: Of 437,544 patients who received an ACEI or ARB, 9.0% did not receive both a serum potassium and creatinine laboratory test during treatment (defined as a care gap). Lower risk of a care gap was observed for patients with increasing age (rate ratio [RR] per 10-year increase = 0.78, 95% CI = 0.77-0.79); diabetes mellitus (RR = 0.62, 95% CI = 0.60-0.64); hypertension (RR = 0.71, 95% CI = 0.71-0.74); Charlson Comorbidity Index score of at least 2 (RR = 0.62, 95% CI = 0.60-0.64); those who changed medication classes (RR = 0.53, 95% CI = 0.51-0.56); and patients with a cardiologist (RR = 0.81, 95% CI = 0.73-0.90) or nephrologist (RR = 0.60, 95% CI = 0.52-0.69) as their prescribing provider. Twenty-five patients completed the qualitative interviews. Patients often lacked knowledge about the need for laboratory monitoring, cited logistical barriers to accessing the laboratory, and deemed the reminders they received through an outpatient safety program as a facilitator to completing tests. CONCLUSIONS: Given the large patient population on ACEI and ARB medications, monitoring and support strategies such as electronic clinical surveillance could be important in addressing care gaps and potentially reducing adverse drug effects. DISCLOSURES: This project was supported by grant number R01HS024437 from the Agency for Healthcare Research and Quality. The funder had no role in the design of the study; collection, analyses, or interpretation of the data, or decision to submit this manuscript for publication. Harrison, Reynolds, Hahn, Munoz-Plaza, Yi, Fischer, Luong, Sim, Brettler, Handler, and Mittman are employees of the Southern California Permanente Medical Group. Danworth was employed by the Southern California Permanente Medical Group at the time of this study. Singh was partially supported by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN13-413). Reynolds reports grants from Novartis, Amgen Inc., and Vital Strategies, Resolve to Save Lives, unrelated to this work. Yi reports grants from Novartis unrelated to this work. Kanter has nothing to disclose.

Nocturia as an Unrecognized Symptom of Uncontrolled Hypertension in Black Men Aged 35 to 49 Years.

Background Hypertension is assumed to be asymptomatic. Yet, clinically significant nocturia (≥2 nightly voids) constitutes a putative symptom of uncontrolled hypertension. Black men with hypertension may be prone to nocturia because of blunted nocturnal blood pressure ( BP ) dipping, diuretic drug use for hypertension, and comorbidity that predisposes to nocturia. Here, we test the hypothesis that nocturia is a common and potentially reversible symptom of uncontrolled hypertension in black men. Methods and Results We determined the strength of association between nocturia (≥2 nightly voids) and high BP (≥135/85 mm Hg) by conducting in-person health interviews and measuring BP with an automated monitor in a large community-based sample of black men in their barbershops. Because nocturia is prevalent and steeply age-dependent after age 50 years, we studied men aged 35 to 49 years. Among 1673 black men (mean age, 43±4 years [ SD ]), those with hypertension were 56% more likely than men with normotension to have nocturia after adjustment for diabetes mellitus and sleep apnea (adjusted odds ratio, 1.56; 95% CI , 1.25-1.94 [ P<0.0001]). Nocturia prevalence varied by hypertension status, ranging from 24% in men with normotension to 49% in men whose hypertension was medically treated but uncontrolled. Men with untreated hypertension were 39% more likely than men with normotension to report nocturia ( P=0.02), whereas men whose hypertension was treated and controlled were no more likely than men with normotension to report nocturia ( P=0.69). Conclusions Uncontrolled hypertension was an independent determinant of clinically important nocturia in a large cross-sectional community-based study of non-Hispanic black men aged 35 to 49 years. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unqiue identifier: NCT 02321618.

Sustainability of Blood Pressure Reduction in Black Barbershops.

BACKGROUND: We developed a new model of hypertension care for non-Hispanic black men that links health promotion by barbers to medication management by American Society of Hypertension-certified pharmacists and demonstrated efficacy in a 6-month cluster-randomized trial. The marked reduction in systolic blood pressure (BP) seen at 6 months warranted continuing the trial through 12 months to test sustainability, a necessary precondition for implementation research. METHODS: We enrolled a cohort of 319 black male patrons with systolic BP ≥140 mm Hg at baseline. Fifty-two Los Angeles County barbershops were assigned to either a pharmacist-led intervention or an active control group. In the intervention group, barbers promoted follow-up with pharmacists who prescribed BP medication under a collaborative practice agreement with patrons' primary care providers. In the control group, barbers promoted follow-up with primary care providers and lifestyle modification. After BP assessment at 6 months, the intervention continued with fewer in-person pharmacist visits to test whether the intervention effect could be sustained safely for 1 year while reducing pharmacist travel time. Final BP and safety outcomes were assessed in both groups at 12 months. RESULTS: At baseline, mean systolic BP was 152.4 mm Hg in the intervention group and 154.6 mm Hg in the control group. At 12 months, mean systolic BP fell by 28.6 mm Hg (to 123.8 mm Hg) in the intervention group and by 7.2 mm Hg (to 147.4 mm Hg) in the control group. The mean reduction was 20.8 mm Hg greater in the intervention (95% CI, 13.9-27.7; P<0.0001). A BP <130/80 mm Hg was achieved by 68.0% of the intervention group versus 11.0% of the control group ( P<0.02). These new 12-month efficacy data are statistically indistinguishable from our previously reported 6-month data. No treatment-related serious adverse events occurred in either group over 12 months. Cohort retention at 12 months was 90% in both groups. CONCLUSIONS: Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in large and sustained BP reduction over 12 months when coupled with medication management by American Society of Hypertension-certified pharmacists. Broad-scale implementation research is both justified and warranted. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT 02321618.

Low Systolic Blood Pressure From Treatment and Association With Serious Falls/Syncope.

INTRODUCTION: With the growing emphasis on intensive blood pressure control, the potential for overtreatment and treatment-related adverse outcomes has become an area of interest. A large representative population within a real-world clinical environment with successful hypertension control rates was used to evaluate serious falls and syncope in people with low-treated systolic blood pressure (SBP). METHODS: A cross-sectional study among medically treated hypertensive individuals within the Kaiser Permanente Southern California health system (2014-2015) was performed. Serious fall injuries and syncope were identified using ICD codes based on emergency department and hospitalization diagnoses. SBPs in a 1-year window were used to compare serious falls and syncope among individuals with SBP <110 mmHg vs ≥110 mmHg. Logistic regression was used to evaluate the association between low minimum and mean SBP and serious falls/syncope after adjustment for demographics, comorbidities, and medications. RESULTS: In 477,516 treated hypertensive individuals, the mean age was 65 (SD=13) years and the mean SBP was 129 (SD=10) mmHg, with 27% having a minimum SBP <110 mmHg and 3% having mean SBP <110 mmHg. A total of 15,419 (3.2%) individuals experienced a serious fall or syncope or both during the observation window (5.7% among minimum SBP <110 mmHg and 5.4% among mean SBP <110 mmHg). The multivariable ORs for serious falls/syncope were 2.18 (95% CI=2.11, 2.25) for minimum SBP <110 mmHg and 1.54 (95%CI=1.43, 1.66) for mean SBP <110 mmHg compared with SBP ≥110 mmHg. CONCLUSIONS: Among treated hypertensive patients, both minimum and mean SBP less than 110 mmHg were associated with serious falls and syncope. Low treatment-related blood pressures deserve consideration given the emphasis on intensive blood pressure control.

A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops.

BACKGROUND: Uncontrolled hypertension is a major problem among non-Hispanic black men, who are underrepresented in pharmacist intervention trials in traditional health care settings. METHODS: We enrolled a cohort of 319 black male patrons with systolic blood pressure of 140 mm Hg or more from 52 black-owned barbershops (nontraditional health care setting) in a cluster-randomized trial in which barbershops were assigned to a pharmacist-led intervention (in which barbers encouraged meetings in barbershops with specialty-trained pharmacists who prescribed drug therapy under a collaborative practice agreement with the participants' doctors) or to an active control approach (in which barbers encouraged lifestyle modification and doctor appointments). The primary outcome was reduction in systolic blood pressure at 6 months. RESULTS: At baseline, the mean systolic blood pressure was 152.8 mm Hg in the intervention group and 154.6 mm Hg in the control group. At 6 months, the mean systolic blood pressure fell by 27.0 mm Hg (to 125.8 mm Hg) in the intervention group and by 9.3 mm Hg (to 145.4 mm Hg) in the control group; the mean reduction was 21.6 mm Hg greater with the intervention (95% confidence interval, 14.7 to 28.4; P<0.001). A blood-pressure level of less than 130/80 mm Hg was achieved among 63.6% of the participants in the intervention group versus 11.7% of the participants in the control group (P<0.001). In the intervention group, the rate of cohort retention was 95%, and there were few adverse events (three cases of acute kidney injury). CONCLUSIONS: Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in larger blood-pressure reduction when coupled with medication management in barbershops by specialty-trained pharmacists. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT02321618 .).

ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

BACKGROUND: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. OBJECTIVES: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. METHODS: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. RESULTS: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). CONCLUSION: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

BACKGROUND: In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. OBJECTIVES: Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. METHODS: This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. RESULTS: Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). CONCLUSION: The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.

Population Care Management and Team-Based Approach to Reduce Racial Disparities among African Americans/Blacks with Hypertension.

OBJECTIVES: At Kaiser Permanente, national Equitable Care Health Outcomes (ECHO) Reports with a baseline measurement of 16 Healthcare Effectiveness Data and Information Set measures stratified by race and ethnicity showed a disparity of 8.1 percentage points in blood pressure (BP) control rates between African- American/black (black) and white members. The aims of this study were to describe a population care management team-based approach to improve BP control for large populations and to explain how a culturally tailored, patient-centered approach can address this racial disparity. METHODS: These strategies were implemented through: 1) physician-led educational programs on treatment intensification, medication adherence, and consistent use of clinical practice guidelines; 2) building strong care teams by defining individual roles and responsibilities in hypertension management; 3) redesign of the care delivery system to expand access; and 4) programs on culturally tailored communication tools and self-management. RESULTS: At a physician practice level where 65% of patients with hypertension were black, BP control rates (< 140/90 mmHg) for blacks improved from 76.6% to 81.4%, and control rates for whites increased from 82.9% to 84.2%. The racial gap narrowed from 6.3% to 2.8%. As these successful practices continue to spread throughout the program, the health disparity gap in BP control has decreased by 50%, from 8.1% to 3.9%. CONCLUSION: A sustainable program to collect self-reported race, ethnicity, and language preference data integrated with successful population care management programs provided the foundation for addressing health disparities. Cultural tailoring of a multilevel team-based approach closed the gap for blacks with hypertension.

An Age-Adjusted D-dimer Threshold for Emergency Department Patients With Suspected Pulmonary Embolus: Accuracy and Clinical Implications.

STUDY OBJECTIVE: We determine the accuracy of an age-adjusted D-dimer threshold to detect pulmonary embolism in emergency department (ED) patients older than 50 years and describe current ED practices when evaluating possible pulmonary embolism. METHODS: This was a retrospective study of ED encounters for suspected pulmonary embolism from 2008 to 2013. We used structured data to calculate the sensitivity, specificity, negative predictive value, and positive predictive value of different D-dimer thresholds. We describe the incidence of pulmonary embolism, the proportion of patients receiving imaging concordant with D-dimer levels, and the number of "missed" pulmonary embolisms. These findings were used to estimate patient outcomes based on different D-dimer thresholds. RESULTS: Among 31,094 encounters for suspected pulmonary embolism, there were 507 pulmonary embolism diagnoses. The age-adjusted D-dimer threshold was more specific (64% versus 54%) but less sensitive (93% versus 98%) than the standard threshold of 500 ng/dL; 11,999 imaging studies identified 507 pulmonary embolisms (4.2%); of these, 1,323 (10.6%) were performed with a D-dimer result below the standard threshold. Among patient encounters without imaging, 17.6% had D-dimer values above the threshold, including 5 missed pulmonary embolisms. Among patients who received imaging, 10.6% had a negative D-dimer result. Applying an age-adjusted D-dimer threshold to our sample would avert 2,924 low-value imaging tests while resulting in 26 additional cases of missed pulmonary embolism. CONCLUSION: An age-adjusted D-dimer limit has the potential to reduce chest imaging among older ED patients and is more accurate than a standard threshold of 500 ng/dL. Our findings support the adoption of an age-adjusted D-dimer cutoff in community EDs.

Automated Outreach for Cardiovascular-Related Medication Refill Reminders.

The objective of this study was to evaluate the effectiveness of an automated telephone system reminding patients with hypertension and/or cardiovascular disease to obtain overdue medication refills. The authors compared the intervention with usual care among patients with an overdue prescription for a statin or lisinopril-hydrochlorothiazide (lisinopril-HCTZ). The primary outcome was refill rate at 2 weeks. Secondary outcomes included time to refill and change in low-density lipoprotein cholesterol and blood pressure. Significantly more patients who received a reminder call refilled their prescription compared with the usual-care group (statin cohort: 30.3% vs 24.9% [P<.0001]; lisinopril-HCTZ cohort: 30.7% vs 24.2% [P<.0001]). The median time to refill was shorter in patients receiving the reminder call (statin cohort: 29 vs 36 days [P<.0001]; lisinopril-HCTZ cohort: 24 vs 31 days [P<.0001]). There were no statistically significant differences in mean low-density lipoprotein cholesterol and blood pressure. These findings suggest the need for interventions that have a longer-term impact.

Clinical challenges in diagnosing and managing adult hypertension.

Although there is still no consensus on how to diagnose hypertension, opinion is moving toward incorporating out-of-office blood pressure measurements into the process. The SPRINT trial poses potential opportunities and challenges. Simplified antihypertensive drug regimens incorporating single pill combinations are very effective.

2014 Hypertension Guideline: Recommendation for a Change in Goal Systolic Blood Pressure.

The 2014 Kaiser Permanente Care Management Institute National Hypertension Guideline was developed to assist primary care physicians and other health care professionals in the outpatient treatment of uncomplicated hypertension in adult men and nonpregnant women aged 18 years and older. A major practice change is the recommendation for goal systolic blood pressure less than 150 mmHg in patients aged 60 years and older who are treated for hypertension in the absence of diabetes or chronic kidney disease. This article describes the reasons for, evidence for, and consequences of the change, and includes the guideline.

Screening for High Blood Pressure in Adults During Ambulatory Nonprimary Care Visits: Opportunities to Improve Hypertension Recognition.

Visits with nonprimary care providers such as optometrists may be missed opportunities for the detection of high blood pressure (BP). For this study, normotensive adults with at least 12 months of health plan membership on January 1, 2009 (n=1,075,522) were followed-up for high BP through March 14, 2011. Of 111,996 patients with a BP measurement ≥140/90 mm Hg, 82.7% were measured during primary care visits and 17.3% during nonprimary care visits. Individuals with a BP ≥140/90 mm Hg measured during nonprimary care visits were older and more likely to be male and non-Hispanic white. The proportion of patients with follow-up and false-positives were comparable between primary and nonprimary care. The main nonprimary care specialty to identify a first BP ≥140/90 mm Hg was ophthalmology/optometry with 24.5% of all patients. Results suggest that expanding screening for hypertension to nonprimary care settings may improve the detection of hypertension.

Improving blood pressure control in a large multiethnic California population through changes in health care delivery, 2004-2012.

The Kaiser Permanente Southern California (Kaiser) health care system succeeded in improving hypertension control in a multiethnic population by adopting a series of changes in health care delivery. Data from the Healthcare Effectiveness Data and Information Set (HEDIS) was used to assess blood pressure control from 2004 through 2012. Hypertension control increased overall from 54% to 86% during that period, and 80% or more in every subgroup, regardless of race/ethnicity, preferred language, or type of health insurance plan. Health care delivery changes improved hypertension control across a large multiethnic population, which indicates that health care systems can achieve a clinical target goal of 70% for hypertension control in their populations.

Systemic implementation strategies to improve hypertension: the Kaiser Permanente Southern California experience.

The past decade has seen hypertension improving in the United States where control is approximately 50%. Kaiser Permanente has mirrored and exceeded these national advances in control. Integrated models of care such as Kaiser Permanente and the Veterans Administration health systems have demonstrated the greatest hypertension outcomes. We detail the story of Kaiser Permanente Southern California (KPSC) to illustrate the success that can be achieved with an integrated health system model that uses implementation, dissemination, and performance feedback approaches to chronic disease care. KPSC, with a large ethnically diverse population of more than 3.6 million, has used a stepwise approach to achieve control rates greater than 85% in those recognized with hypertension. This was accomplished through systemic implementations of specific strategies: (1) capturing hypertensive members into a hypertension registry; (2) standardization of blood pressure measurements; (3) drafting and disseminating an internal treatment algorithm that is evidence-based and is advocating of combination therapy; and (4) a multidisciplinary approach using medical assistants, nurses, and pharmacists as key stakeholders. The infrastructure, support, and involvement across all levels of the health system with rapid and continuous performance feedback have been pivotal in ensuring the follow-through and maintenance of these strategies. The KPSC hypertension program is continually evolving in these areas. With these high control rates and established infrastructure, they are positioned to take on different innovations and study models. Such potential projects are drafting strategies on resistant hypertension or addressing the concerns about overtreatment of hypertension.

2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).

Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

Commentary in support of a highly effective hypertension treatment algorithm.

A simple hypertension treatment algorithm has contributed to the achievement of control rates greater than 85% for more than 1 million adults with hypertension across the United States. It is built on the fixed-dose combination drug lisinopril/hydrochlorothiazide, which is maximized in three steps before adding amlodipine. Spironolactone is the preferred fourth drug.

A randomized controlled trial of an automated telephone intervention to improve blood pressure control.

The objective of this study was to evaluate the effectiveness of a telephonic outreach program to improve blood pressure (BP) control among patients with hypertension. The authors identified adults 18 years and older with uncontrolled BP within the previous 12 months. Patients received either an automated telephone call advising them to have a walk-in BP check (n=31,619) or usual care (n=33,154). The primary outcome was BP control at 4 weeks. Significantly more patients who received the intervention achieved BP control compared with the usual care group (32.5% vs 23.7%; P<.0001). Patients in the intervention arm with cardiovascular disease, chronic kidney disease, or diabetes mellitus achieved better BP control. Older age, female sex, and having a household income above the median were associated with BP control. When designing quality-improvement interventions to increase BP control rates, health care organizations should consider utilizing an automated telephone outreach campaign.

Impact of the number of blood pressure measurements on blood pressure classification in US adults: NHANES 1999-2008.

Clinical guidelines recommend averaging ≥ 2 blood pressure (BP) measurements on each visit. Only one BP is measured on many clinical visits, especially if the value is <120/<80 mm Hg, ie, normal. The impact of this practice on accurate assignment of BP category is incompletely defined. Data were analyzed from 22,641 adults 18 years and older who had 3 BP readings in the National Health and Nutrition Examination Surveys 1999-2008. BP category defined by initial measurement was compared with the category determined by mean of the first and second, first through third, and second and third readings. Among 8553 nonhypertensive patients with initial BP <120/<80 mm Hg, 2.9%, 3.3%, and 6.7%, respectively, were reclassified as prehypertensive, ie, BP 120-139/80-89 mm Hg, and two patients as stage 1 hypertension (140-159/90-99 mm Hg). In 733 treated hypertensive patients with initial BP <120/<80 mm Hg, 5.1%-8.9% were reclassified as prehypertensive and only one patient as hypertensive. Among nonhypertensive and hypertensive patients with initial BP in the prehypertensive range, 8.0%-23.6% were reclassified as normal. Among stage 1 and 2 hypertensive patients based on initial BP, 18.2%-33.5% were reclassified to lower BP categories. By multivariable logistic regression, older age and higher systolic and diastolic BP were associated with reclassification to a lower BP category. In nonhypertensive and hypertensive patients with normal initial BP values, one BP measurement appears adequate as <10% are re-classified as prehypertensive and <0.5% as hypertensive. In contrast, patients with an initial BP above normal are often reclassified to a lower category, which supports recommendations for additional measurements.