Changes in Self-Measured Blood Pressure Monitoring Use in 14 States From 2019 to 2021: Impact of the COVID-19 Pandemic.

BACKGROUND: Self-measured blood pressure monitoring (SMBP) is an important out-of-office resource that is effective in improving hypertension control. Changes in SMBP use during the Coronavirus Disease 2019 (COVID-19) pandemic have not been described previously. METHODS: Behavioral Risk Factor Surveillance System (BRFSS) data were used to quantify changes in SMBP use between 2019 (prior COVID-19 pandemic) and 2021 (during the COVID-19 pandemic). Fourteen states administered the SMBP module in both years. All data were self-reported from adults who participated in the BRFSS survey. We assessed the receipt of SMBP recommendations from healthcare professionals and actual use of SMBP among those with hypertension (n = 68,820). Among those who used SMBP, we assessed SMBP use at home and sharing BP readings electronically with healthcare professionals. RESULTS: Among adults with hypertension, there was no significant changes between 2019 and 2021 in those reporting SMBP use (57.0% vs. 55.7%) or receiving recommendations from healthcare professionals to use SMBP (66.4% vs. 66.8%). However, among those who used SMBP, there were significant increases in use at home (87.7% vs. 93.5%) and sharing BP readings electronically (8.6% vs. 13.1%) from 2019 to 2021. Differences were noted by demographic characteristics and residence state. CONCLUSIONS: Receiving a recommendation from the healthcare provider to use SMBP and actual use did not differ before and during the COVID-19 pandemic. However, among those who used SMBP, home use and sharing BP readings electronically with healthcare professional increased significantly, although overall sharing remained low (13.1%). Maximizing advances in virtual connections between clinical and community settings should be leveraged for improved hypertension management.

County-Level Disparities in Heat-Related Emergencies.

This cross-sectional study examines the distribution of emergency medical service activation across US countries during the heat wave in July 2023.

Health Care Costs Following COVID-19 Hospitalization Prior to Vaccine Availability.

BACKGROUND: Postacute sequelae of coronavirus (PASC) disease of 2019 (COVID-19) include morbidity and mortality, but little is known of the impact on medical expenditures. This study measures patients' health care costs after COVID hospitalization before vaccinations. METHODS: The Merative MarketScan database is used to track trends in medical expenditures for commercially insured patients hospitalized for COVID-19 (case subjects) compared with COVID-19 patients not hospitalized (control subjects) using a propensity score matching model. Medical expenditures were estimated from 30-, 60-, and 120-day clean periods after an initial COVID-19 encounter through the end of 2020. RESULTS: Average total medical expenditures were 96% higher for individuals hospitalized for COVID-19 starting 30 days after initial COVID-19 encounter and almost 70% higher 120 days after based on the propensity score matching. The average spending differential was $11,242 30 days after and $4959 120 days after. This effect is highest for inpatient admissions and services 60 days after at $56,862 and lowest among pharmaceuticals 120 days after at $329. The magnitude of the difference is greater for those with hypertension or diabetes where total expenditures is $14,958 30 days after, and $5962 120 days after compared with those without these chronic conditions. DISCUSSION: The results suggest both health and economic implications for COVID-19 hospitalization and supports the use of vaccinations to help mitigate these implications. PASC includes increased health care costs for hospitalized patients, particularly for those with chronic conditions. Preventing COVID-19 hospitalization has economic value in terms of reduced medical spending in addition to health benefits associated with reduced morbidity and mortality.

Age and Comorbidities Are Associated With Therapeutic Inertia Among Older Adults With Uncontrolled Blood Pressure.

BACKGROUND: Lack of initiation or escalation of blood pressure (BP) lowering medication when BP is uncontrolled, termed therapeutic inertia (TI), increases with age and may be influenced by comorbidities. METHODS: We examined the association of age and comorbidities with TI in 22,665 visits with a systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg among 7,415 adults age ≥65 years receiving care in clinics that implemented a hypertension quality improvement program. Generalized linear mixed models were used to determine the association of comorbidity number with TI by age group (65-74 and ≥75 years) after covariate adjustment. RESULTS: Baseline mean age was 75.0 years (SD 7.8); 41.4% were male. TI occurred in 79.0% and 83.7% of clinic visits in age groups 65-74 and ≥75 years, respectively. In age group 65-74 years, prevalence ratio of TI with 2, 3-4, and ≥5 comorbidities compared with zero comorbidities was 1.07 (95% confidence interval [CI]: 1.04, 1.12), 1.08 (95% CI: 1.05, 1.12), and 1.15 (95% CI: 1.10, 1.20), respectively. The number of comorbidities was not associated with TI prevalence in age group ≥75 years. After implementation of the improvement program, TI declined from 80.3% to 77.2% in age group 65-74 years and from 85.0% to 82.0% in age group ≥75 years (P < 0.001 for both groups). CONCLUSIONS: TI was common among older adults but not associated with comorbidities after age ≥75 years. A hypertension improvement program had limited impact on TI in older patients.

Target: BP™: A National Initiative to Improve Blood Pressure Control.

TARGET: BP™ is a national initiative launched by the American Heart Association and the American Medical Association in 2017 in response to the high prevalence of uncontrolled blood pressure (BP) in the United States. TARGET: BP™ provides support to health care organizations and health care teams, with no user fees, to improve the quality of care for adults with hypertension by providing education and resources and recognizing organizations committed to prioritizing and reporting their rate of BP control. Through Target: BP™, the American Heart Association and the American Medical Association also collaborate to align policy with evidence through federal, state, and institutional policy advocacy and raise public awareness through media campaigns. In 2022, Target: BP™ recognized 1309 health care organizations serving 8.4 million patients with hypertension for prioritizing BP control, 675 of which affirmed performance of evidence-based BP measurement activities and 551 of which reported BP control rates ≥70%. With the proportion of US adults with controlled BP falling to 48.2% from 2017 to 2020, Target: BP™ remains focused on regaining lost ground in national BP control rates by emphasizing accurate BP measurement, rapid treatment intensification, healthful lifestyle changes, and evidence-based use of self-measured BP monitoring. TARGET: BP™ also emphasizes adoption of team-based care models and prioritizing equitable health outcomes. More than 1.37 million unique users have visited https://targetbp.org/ and downloaded 98 341 Target: BP™ resources from 2017 to 2022.

Evaluation of the Conrad 30 Waiver Program's Success in Attracting International Medical Graduates to Underserved Areas.

This cross-sectional study evaluated the growth and distribution of physicians in the Conrad 30 Waiver program during the past 2 decades.

Disruption in Blood Pressure Control With the COVID-19 Pandemic: The PCORnet Blood Pressure Control Laboratory.

OBJECTIVE: To explore trends in blood pressure (BP) control before and during the COVID-19 pandemic. PATIENTS AND METHODS: Health systems participating in the National Patient-Centered Clinical Research Network (PCORnet) Blood Pressure Control Laboratory Surveillance System responded to data queries, producing 9 BP control metrics. Averages of the BP control metrics (weighted by numbers of observations in each health system) were calculated and compared between two 1-year measurement periods (January 1, 2019, through December 31, 2019, and January 1, 2020, through December 31, 2020). RESULTS: Among 1,770,547 hypertensive persons in 2019, BP control to <140/<90 mm Hg varied across 24 health systems (range, 46%-74%). Reduced BP control occurred in most health systems with onset of the COVID-19 pandemic; the weighted average BP control was 60.5% in 2019 and 53.3% in 2020. Reductions were also evident for BP control to <130/<80 mm Hg (29.9% in 2019 and 25.4% in 2020) and improvement in BP (reduction of 10 mm Hg in systolic BP or achievement of systolic BP <140 mm Hg; 29.7% in 2019 and 23.8% in 2020). Two BP control process metrics exhibited pandemic-associated disruption: repeat visit in 4 weeks after a visit with uncontrolled hypertension (36.7% in 2019 and 31.7% in 2020) and prescription of fixed-dose combination medications among those with 2 or more drug classes (24.6% in 2019 and 21.5% in 2020). CONCLUSION: BP control decreased substantially during the COVID-19 pandemic, with a corresponding reduction in follow-up health care visits among persons with uncontrolled hypertension. It is unclear whether the observed decline in BP control during the pandemic will contribute to future cardiovascular events.

Improvement in Hypertension Control Among Adults Seen in Federally Qualified Health Center Clinics in the Stroke Belt: Implementing a Program with a Dashboard and Process Metrics.

Objective: Attain 75% hypertension (HTN) control and improve racial equity in control with the American Medical Association Measure accurately, Act rapidly, Partner with patients blood pressure (AMA MAP BP™) quality improvement program, including a monthly dashboard and practice facilitation. Methods: Eight federally qualified health center clinics from the HopeHealth network in South Carolina participated. Clinic staff received monthly practice facilitation guided by a dashboard with process metrics (measure [repeat BP when initial systolic ≥140 or diastolic ≥90 mmHg; Act [number antihypertensive medication classes prescribed at standard dose or greater to adults with uncontrolled BP]; Partner [follow-up within 30 days of uncontrolled BP; systolic BP fall after medication added]) and outcome metric (BP <140/<90). Electronic health record data were obtained on adults ≥18 years at baseline and monthly during MAP BP. Patients with diagnosed HTN, ≥1 encounter at baseline, and ≥2 encounters during 6 months of MAP BP were included in this evaluation. Results: Among 45,498 adults with encounters during the 1-year baseline, 20,963 (46.1%) had diagnosed HTN; 12,370 (59%) met the inclusion criteria (67% black, 29% white; mean (standard deviation) age 59.5 (12.8) years; 16.3% uninsured. HTN control improved (63.6% vs. 75.1%, p<0.0001), reflecting positive changes in Measure, Act, and Partner metrics (all p<0.001), although control remained lower in non-Hispanic black than in non-Hispanic white adults (73.8% vs. 78.4%, p<0.001). Conclusions: With MAP BP, the HTN control goal was attained among adults eligible for analysis. Ongoing efforts aim to improve program access and racial equity in control.

Seasonal variation in blood pressure control across US health systems.

OBJECTIVE: We aimed to characterize seasonal variation in US population-based blood pressure (BP) control and BP-related metrics and evaluate the association between outdoor temperature and BP control variation. METHODS: We queried electronic health records (EHRs) from 26 health systems, representing 21 states, to summarize BP metrics by quarters of 12-month periods from January 2017 to March 2020. Patients with at least one ambulatory visit during the measurement period and a hypertension diagnosis during the first 6 months or prior to the measurement period were included. Changes in BP control, BP improvement, medication intensification, average SBP reduction after medication intensification across quarters and association with outdoor temperature were analyzed using weighted generalized linear models with repeated measures. RESULTS: Among 1 818 041 people with hypertension, the majority were more than 65 years of age (52.2%), female (52.1%), white non-Hispanic (69.8%) and had stage 1/2 hypertension (64.8%). Overall, BP control and process metrics were highest in quarters 2 and 3, and lowest in quarters 1 and 4. Quarter 2 had the highest percentage of improved BP (31.95 ±â€Š0.90%) and average SBP reduction after medication intensification (16 ±â€Š0.23 mmHg). Quarter 3 had the highest percentage of BP controlled (62.25 ±â€Š2.55%) and lowest with medication intensification (9.73 ±â€Š0.60%). Results were largely consistent in adjusted models. Average temperature was associated with BP control metrics in unadjusted models, but associations were attenuated following adjustment. CONCLUSION: In this large, national, EHR-based study, BP control and BP-related process metrics improved during spring/summer months, but outdoor temperature was not associated with performance following adjustment for potential confounders.

Improvement in Blood Pressure Control in Safety Net Clinics Receiving 2 Versions of a Scalable Quality Improvement Intervention: BP MAP A Pragmatic Cluster Randomized Trial.

Background Uncontrolled blood pressure (BP) remains a leading cause of death in the United States. The American Medical Association developed a quality improvement program to improve BP control, but it is unclear how to efficiently implement this program at scale across multiple health systems. Methods and Results We conducted BP MAP (Blood Pressure Measure Accurately, Act Rapidly, and Partner With Patients), a comparative effectiveness trial with clinic-level randomization to compare 2 scalable versions of the quality improvement program: Full Support (with support from quality improvement expert) and Self-Guided (using only online materials). Outcomes were clinic-level BP control (<140/90 mm Hg) and other BP-related process metrics calculated using electronic health record data. Difference-in-differences were used to compare changes in outcomes from baseline to 6 months, between intervention arms, and to a nonrandomized Usual Care arm composed of 18 health systems. A total of 24 safety-net clinics in 9 different health systems underwent randomization and then simultaneous implementation. BP control increased from 56.7% to 59.1% in the Full Support arm, and 62.0% to 63.1% in the Self-Guided arm, whereas BP control dropped slightly from 61.3% to 60.9% in the Usual Care arm. The between-group differences-in-differences were not statistically significant (Full Support versus Self-Guided=+1.2% [95% CI, -3.2% to 5.6%], P=0.59; Full Support versus Usual Care=+3.2% [-0.5% to 6.9%], P=0.09; Self-Guided versus Usual Care=+2.0% [-0.4% to 4.5%], P=0.10). Conclusions In this randomized trial, 2 methods of implementing a quality improvement intervention in 24 safety net clinics led to modest improvements in BP control that were not statistically significant. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03818659.

Effectiveness of Standard vs Enhanced Self-measurement of Blood Pressure Paired With a Connected Smartphone Application: A Randomized Clinical Trial.

Importance: Self-measured blood pressure (SMBP) with commercially available connected smartphone applications may help patients effectively use SMBP measurements. Objective: To determine if enhanced SMBP paired with a connected smartphone application was superior to standard SMBP for blood pressure (BP) reduction or patient satisfaction. Design, Setting, and Participants: This randomized clinical trial was conducted among 23 health systems participating in PCORnet, the National Patient-Centered Clinical Research Network, and included patients who reported having uncontrolled BP at their last clinic visit, a desire to lower their BP, and a smartphone. Enrollment and randomization occurred from August 3, 2019, to December 31, 2020, which was followed by 6 months of follow-up for each patient. Analysis commenced shortly thereafter. Interventions: Eligible participants were randomly assigned to enhanced SMBP using a device that paired with a connected smartphone application (enhanced) or a standard device (standard). Participants received their device in the mail, along with web-based educational materials and phone-based support as needed. No clinician engagement was undertaken, and the study provided no special mechanisms for delivering measurements to clinicians for use in BP management. Main Outcomes and Measures: Reduction in systolic BP, defined as the difference between clinic BP at baseline and the most recent clinic BP extracted from electronic health records at 6 months. Results: Enrolled participants (1051 enhanced [50.0%] vs 1050 standard [50.0%]; 1191 women [56.7%]) were mostly middle-aged or older (mean [SD] age, 58 [13] years), nearly a third were Black or Hispanic (645 [31%]), and most were relatively comfortable using technology (mean [SD], 4.1 [1.1] of 5). The mean (SD) change in systolic BP from baseline to 6 months was -10.8 (18) mm Hg vs -10.6 (18) mm Hg (enhanced vs standard: adjusted difference, -0.19 mm Hg; 95% CI, -1.83 to 1.44; P = .81). Secondary outcomes were mostly null, except for documented attainment of BP control to lower than 140/<90 mm Hg, which occurred in 32% enhanced vs 29% standard groups (odds ratio, 1.15; 95% CI, 1.01-1.34). Most participants were very likely to recommend their SMBP device to a friend (70% vs 69%). Conclusions and Relevance: This randomized clinical trial found that enhanced SMBP paired with a smartphone application is not superior to standard SMBP for BP reduction or patient satisfaction. Trial Registration: ClinicalTrials.gov Identifier: NCT03796689.

Metformin Prescription Rates for Patients with Prediabetes.

PURPOSE: Prediabetes is a serious public health concern, with 34.5% of US adults meeting the criteria for prediabetes. The American Diabetes Association has highlighted metformin therapy as a consideration for individuals with BMI ≥ 35 kg/m2, those aged < 60 years, and women with a history of gestational diabetes. We examined metformin prescription rates among a national sample of commercially insured, higher risk patients with prediabetes. METHODS: We gathered 2012 to 2018 demographic, laboratory, and prescription data for 53,551 patients with prediabetes from the IBM MarketScan research database. Our primary outcome was metformin prescription rates 1 or 3 years after a laboratory confirmation of prediabetes among patients who have a BMI ≥ 35 kg/m2 or are aged < 60 years. RESULTS: Overall, 2.4% (n = 1,124) of patients received a metformin prescription within 1 year of a laboratory confirmed prediabetes result, including 2.4% of patients aged < 60 years and 10.4% of those with BMI ≥ 35 kg/m2. By a 3 year follow-up, 4.1% (n = 1901) received a metformin prescription, including 3.9% of patients aged < 60 years and 14.0% with BMI ≥ 35 kg/m2. Patients who developed type 2 diabetes within the 1 (n = 2,769) or 3 year (n = 7,268) follow-up periods were excluded from analysis. CONCLUSIONS: Few prediabetes patients who were either obese or aged < 60 years received a metformin prescription between 2012 and 2018. Prescription rates increased slightly between 1 and 3 years after a prediabetes diagnosis, so strategies to support timely intervention among higher risk patients with prediabetes are critically needed.

Blood Pressure Control Among US Adults, 2009 to 2012 Through 2017 to 2020.

BACKGROUND: The National Health and Nutrition Examination Survey data indicate that the proportion of US adults with hypertension that had controlled blood pressure (BP) declined from 2013 to 2014 through 2017 to 2018. We analyzed data from National Health and Nutrition Examination Survey 2009 to 2012, 2013 to 2016, and 2017 to 2020 to confirm this finding. METHODS: Hypertension was defined as systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg or antihypertensive medication use. BP control among those with hypertension was defined as systolic BP <140 mm Hg and diastolic BP <90 mm Hg. RESULTS: The age-adjusted prevalence of hypertension was 31.5% (95% CI, 30.3%-32.8%), 32.0% (95% CI, 30.6%-33.3%), and 32.9% (95% CI, 31.0%-34.7%) in 2009 to 2012, 2013 to 2016, and 2017 to 2020, respectively (P trend=0.218). The age-adjusted prevalence of hypertension increased among non-Hispanic Asian adults from 27.0% in 2011 to 2012 to 33.5% in 2017 to 2020 (P trend=0.003). Among Hispanic adults, the age-adjusted prevalence of hypertension increased from 29.4% in 2009 to 2012 to 33.2% in 2017 to 2020 (P trend=0.029). In 2009 to 2012, 2013 to 2016, and 2017 to 2020, 52.8% (95% CI, 50.0%-55.7%), 51.3% (95% CI, 47.9%-54.6%), and 48.2% (95% CI, 45.7%-50.8%) of US adults with hypertension had controlled BP (P trend=0.034). Among US adults taking antihypertensive medication, 69.9% (95% CI, 67.8%-72.0%), 69.3% (95% CI, 66.6%-71.9%), and 67.7% (95% CI, 65.2%-70.3%) had controlled BP in 2009 to 2012, 2013 to 2016, and 2017 to 2020, respectively (P trend=0.189). Among all US adults with hypertension and those taking antihypertensive medication, a decline in BP control between 2009 to 2012 and 2017 to 2020 occurred among those ≥75 years, women, and non-Hispanic black adults. CONCLUSIONS: These data confirm that the proportion of US adults with hypertension who have controlled BP has declined.

Prescription Smoking-Cessation Medication Fills and Spending, 2009-2019.

INTRODUCTION: Smoking is the leading cause of preventable disease and death. However, effective medicines, including prescription medications often covered by health insurance, are available to aid cessation. METHODS: Trends of 7 U.S. Food and Drug Administration-approved prescription medications for smoking cessation during 2009-2019 (before and during Affordable Care Act implementation), including fill counts and spending (total and patient, adjusted to 2019 U.S. dollars), were assessed among U.S. adults aged ≥18 years. Symphony Health's Integrated Dataverse combines data on >90% of outpatient prescription fills with market purchasing data to create national estimates. Analyses were conducted in 2021. RESULTS: Annually, total fills (spending) decreased from 3.7 million ($577 million) in 2009 to 2.5 million ($465 million) in 2013 and increased to 4.5 million ($1.279 billion) in 2019; patient spending decreased from $174 million (30% of total annual spending) in 2009 to $54 million (4%) in 2019. Comparing 2009 with 2019, the total spending per fill increased by 80% (from $157 to $282), whereas patient spending per fill decreased by 75% (from $47 to $12). The total spending per fill for branded products increased by 175% (from $166 to $459) and decreased by 41% (from $75 to $44) for generic products. Branded product percentage decreased from 89% to 57%. CONCLUSIONS: Total fills and spending decreased from 2009 to 2013 and then increased through 2019, whereas patient spending decreased. Earlier studies suggest possible reasons for these trends, such as gradual implementation of federal requirements for insurance coverage of cessation medications and reduced cost sharing and financial barriers.

Blood Pressure Control Among Non-Hispanic Black Adults Is Lower Than Non-Hispanic White Adults Despite Similar Treatment With Antihypertensive Medication: NHANES 2013-2018.

BACKGROUND: Controlled blood pressure can prevent or reduce adverse health outcomes. Social and structural determinants may contribute to the disparity that despite equivalent proportions on antihypertensive medication, non-Hispanic Black (Black) adults have lower blood pressure control and more cardiovascular events than non-Hispanic White (White) adults. METHODS: Data from 2013 to 2018 National Health and Nutrition Examination Survey were pooled to assess control among Black and White adults by antihypertensive medication use and selected characteristics using the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Blood Pressure Guideline definition (systolic blood pressure <130 mm Hg and diastolic blood pressure <80 mm Hg) among 4,739 adults. RESULTS: Among those treated with antihypertensive medication, an estimated 34.9% of Black and 45.0% of White adults had controlled blood pressure. Control was lower for Black and White adults among most subgroups of age, sex, education, insurance status, usual source of care, and poverty-income ratio. Black adults had higher use of diuretics (28.5%-Black adults vs. 23.5%-White adults) and calcium channel blockers (24.2%-Black adults vs. 14.7%-White adults) compared with White adults. Control among Black adults was lower than White adults across all medication classes including diuretics (36.1%-Black adults vs. 47.3%-White adults), calcium channel blockers (30.2%-Black adults vs. 40.1%-White adults), and number of medication classes used. CONCLUSIONS: Suboptimal blood pressure control rates and disparities warrant increased efforts to improve control, which could include addressing social and structural determinants along with emphasizing implementation of the 2017 ACC/AHA Blood Pressure Guideline into clinical practice.

The Affordable Care Act Medicaid Expansion, Social Disadvantage, and the Practice Location Choices of New General Internists.

BACKGROUND: A recent study found that states that expanded Medicaid under the Affordable Care Act (ACA) gained new general internists who were establishing their first practices, whereas nonexpansion states lost them. OBJECTIVE: The objective of this study was to examine the level of social disadvantage of the areas of expansion states that gained new physicians and the areas of nonexpansion states that lost them. RESEARCH DESIGN: We used American Community Survey data to classify commuting zones as high, medium, or low social disadvantage. Using 2009-2019 data from the AMA Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following the expansion to where they located during the 5 years preceding the expansion. SUBJECTS: A total of 32,102 new general internists. RESULTS: Compared with preexpansion patterns, new general internists were more likely to locate in expansion states after the expansion, a finding that held for high, medium, and low disadvantage areas. We estimated that, between 2014 and 2019, nonexpansion states lost 371 new general internists (95% confidence interval, 203-540) to expansion states. However, 62.5% of the physicians lost by nonexpansion states were lost from high disadvantage areas even though these areas only accounted for 17.9% of the population of nonexpansion states. CONCLUSIONS: States that opted not to expand Medicaid lost new general internists to expansion states. A highly disproportionate share of the physicians lost by nonexpansion states were lost from high disadvantage areas, potentially compromising access for all residents irrespective of insurance coverage.

Using web-based training to improve accuracy of blood pressure measurement among health care professionals: A randomized trial.

Accurate blood pressure measurement is crucial for proper screening, diagnosis, and monitoring of high blood pressure. However, providers are not aware of proper blood pressure measurement skills, do not master all the appropriate skills, or miss key steps in the process, leading to inconsistent or inaccurate readings. Training in blood pressure measurement for most providers is usually limited to a one-time brief demonstration during professional education coursework. The American Medical Association and the American Heart Association developed a 30-minute e-Learning module designed to refresh and improve existing blood pressure measurement knowledge and clinical skills among practicing providers. One hundred seventy-seven practicing providers, which included medical assistants, nurses, advanced practice providers, and physicians, participated in a multi-site randomized educational study designed to assess the effect of this e-Learning module on blood pressure measurement knowledge and skills. Participants were randomized 1:1 to either the intervention or control group. The intervention group followed a pre-post assessment approach, and the control group followed a test-retest approach. The initial assessment showed that participants in both the intervention and control groups correctly performed less than half of the 14 skills considered necessary to obtain an accurate blood pressure measurement (mean scores 5.5 and 5.9, respectively). Following the e-Learning module, the intervention group performed on average of 3.4 more skills correctly vs 1.4 in the control group (P < .01). Our findings reinforce existing evidence that errors in provider blood pressure measurements are highly prevalent and provide novel evidence that refresher training improves measurement accuracy.

Cost-Effectiveness of Recommendations From the Surgeon General's Call-to-Action to Control Hypertension.

In response to high prevalence of hypertension and suboptimal rates of blood pressure (BP) control in the United States, the Surgeon General released a Call-to-Action to Control Hypertension (Call-to-Action) in the fall of 2020 to address the negative consequences of uncontrolled BP. In addition to morbidity and mortality associated with hypertension, hypertension has an annual cost to the US healthcare system of $71 billion. The Call-to-Action makes recommendations for improving BP control, and the purpose of this review was to summarize the literature on the cost-effectiveness of these strategies. We identified a number of studies that demonstrate the cost saving or cost-effectiveness of recommendations in the Call-to-Action including strategies to promote access to and availability of physical activity opportunities and healthy food options within communities, advance the use of standardized treatment approaches and guideline-recommended care, to promote the use of healthcare teams to manage hypertension, and to empower and equip patients to use self-measured BP monitoring and medication adherence strategies. While the current review identified numerous cost-effective methods to achieve the Surgeon General's recommendations for improving BP control, future work should determine the cost-effectiveness of the 2017 American College of Cardiology and American Heart Association Hypertension guidelines, interventions to lower therapeutic inertia, and optimal team-based care strategies, among other areas of research. Economic evaluation studies should also be prioritized to generate more comprehensive data on how to provide efficient and high value care to improve BP control.

Controlling High Blood Pressure: An Evidence-Based Blueprint for Change.

Recently published national data demonstrate inadequate and worsening control of high blood pressure (HBP) in the United States, outcomes that likely have been made even worse by the coronavirus disease 2019 (COVID-19) pandemic. This major public health crisis exposes shortcomings of the US health care delivery system and creates an urgent opportunity to reduce mortality, major cardiovascular events, and costs for 115 million Americans. Ending this crisis will require a more coherent and systemic change to traditional patterns of care. The authors present an evidence-based Blueprint for Change for comprehensive health delivery system redesign based on current national clinical practice guidelines and quality measures. This innovative model includes a systems-based approach to ensuring proper BP measurement, assessment of cardiovascular risk, effective patient-centered team-based care, addressing social determinants of health, and shared decision-making. The authors also propose building on current national quality improvement initiatives designed to better control HBP.

Self-Reported Antihypertensive Medication Class and Temporal Relationship to Treatment Guidelines.

The greater antihypertensive responses to initial therapy with calcium channel blockers (CCBs) or thiazide-type diuretics than renin-angiotensin system blockers as initial therapy in non-Hispanic Black (NHB) adults was recognized in the US High BP guidelines from 1988 to 2003. The 2014 Report from Panel Members Appointed to the Eighth Joint National Committee (2014 aJNC8 Report) and the 2017 American College of Cardiology/American Heart Association High Blood Pressure Guideline were the first to recommend CCBs or thiazide-type diuretics rather than renin-angiotensin system blockers as initial therapy in NHB. We assessed the temporal relationship of these recommendations on self-reported CCB or thiazide-type diuretics monotherapy by NHB and NHW adults with hypertension absent compelling indications for ß-blockers or renin-angiotensin system blockers in National Health and Nutrition Examination Surveys 2015 to 2018 versus 2007 to 2012 (after versus before 2014 aJNC8 Report). CCB or thiazide-type diuretics monotherapy was unchanged in NHW adults (17.1% versus 18.1%, P=0.711) and insignificantly higher after 2014 among NHB adults (43.7% versus 38.2%, P=0.204), although CCB monotherapy increased (29.5% versus 21.0%, P=0.021) and renin-angiotensin system blocker monotherapy fell (44.5% versus 31.0%, P=0.008). Although evidence-based CCB monotherapy increased among NHB adults in 2015 to 2018, hypertension control declined as untreated hypertension and monotherapy increased. While a gap between recommended and actual monotherapy persists, evidence-based monotherapy appears insufficient to improve hypertension control in NHB adults, especially given evidence for worsening therapeutic inertia. Initiating treatment with single-pill combinations and timely therapeutic intensification when required to control hypertension are evidence-based, race-neutral options for improving hypertension control among NHB adults.