Medicare reimbursement policy for ambulatory blood pressure monitoring: A qualitative analysis of public comments to the Centers for Medicare and Medicaid Services.

Ambulatory blood pressure monitoring (ABPM) is considered the best means of diagnosing hypertension. However, it is rarely used and is reimbursed only under narrow conditions. We sought to gain insight into the perceived value of ABPM among stakeholders who responded to the Centers for Medicare and Medicaid Services' (CMS) request for comments to inform the first revision of ABPM reimbursement policy in over 15 years. We found that most comments were classifiable in two main themes, current coverage and future coverage. Individuals and institutions representing multiple disciplines and specialties were highly supportive of expanding the current CMS coverage of ABPM, including for a wide range of clinical indications and populations. It is clear from the comments reviewed that there is wide support for expanding CMS coverage for ABPM. Broad support for a change in ABPM reimbursement policy may lead to changes in the way this technology is used in the United States.

For what factors should we normalize urinary extracellular mRNA biomarkers?

mRNA is a critical biomolecule involved in the manifestation of the genetic code into functional protein molecules. Its critical role in the central dogma has made it a key target in many studies to determine biomarkers and drug targets for numerous diseases. Currently, there is a growing body of evidence to suggest that RNA molecules around the size of full-length mRNA transcripts can be assayed in the supernatant of human urine and urinary extracellular mRNA could provide information about transcription in cells of urogenital tissues. However, the optimal means of normalizing these signals is unclear. In this paper, we describe relevant first principles as well as research findings from our lab and other labs toward normalization of urinary extracellular mRNA.

Patient knowledge of blood pressure target is associated with improved blood pressure control in chronic kidney disease.

OBJECTIVE: To describe patient hypertension knowledge and associations with blood pressure measurements. METHODS: Patients with chronic kidney disease (CKD) were asked about the impact of high blood pressure on kidneys and their target blood pressure goal. Systolic blood pressure was measured using automated sphygmomanometers. RESULTS: In 338 adults with hypertension and pre-dialysis CKD, the median [IQR] age was 59 [47,68] years, 45% [n = 152] were women, and 18% [n = 62] were non-white. Lower systolic blood pressure (SBP) was associated with female sex (SBP mmHg median [IQR] 132 [117,149] women vs. 137 [124,152] men; p = 0.04), less advanced CKD (SBP 134 [122,147] stages 1-2 vs. 132 [118,148] stage 3 vs. 140 [125,156] stages 4-5; p = 0.01), and patient ability to correctly identify SBP goal (SBP 134 [119,150] correct vs. 141 [125,154] incorrect; p = 0.05). In adjusted analysis, knowledge of blood pressure goal remained independently associated with lower SBP (-9.96 mmHg [-19.97, -1.95] in correct respondents vs. incorrect; p<0.001). CONCLUSION: Patient knowledge of goal blood pressure is independently associated with improved blood pressure control. PRACTICE IMPLICATIONS: Interventions to improve patient knowledge of specific blood pressure targets may have an important role in optimizing blood pressure management.

The renin-angiotensin-aldosterone system and glucose homeostasis.

The renin-angiotensin-aldosterone system (RAAS) is inappropriately activated in obesity. In individuals at risk for diabetes, RAAS inhibition protects against kidney and heart disease, and also reduces the incidence of diabetes in large clinical trials. At a cellular level, angiotensin II (Ang II) and aldosterone induce insulin resistance by increasing oxidative stress and altering insulin signaling, leading to decreased glucose transport. Ang II also contributes to oxidative stress, inflammation, and apoptosis in pancreatic ß cells. Aldosterone diminishes glucose-stimulated insulin secretion in vivo and in vitro from isolated pancreatic islets and cultured ß cells through a mineralocorticoid receptor (MR)-independent mechanism. We review these findings in the context of pharmacological strategies interrupting the RAAS to highlight the potential application of these strategies to the prevention of diabetes progression.