Cost-accuracy and patient experience assessment of blood pressure monitoring methods to diagnose hypertension: A comparative effectiveness study.

Objectives: Studies of the diagnosis of hypertension have emphasized long-term cost-effectiveness analysis, but the patient experience and costs of blood pressure monitoring methods at the diagnosis stage remain unclear. We studied four diagnostic methods: a new 1 h-automated office blood pressure (BP) monitoring, office BP measurement, home BP monitoring, and awake-ambulatory BP monitoring. Methods: We carried out a comparative effectiveness study of four methods of diagnosing hypertension in 500 participants with a clinical suspicion of hypertension from three primary healthcare (PHC) centers in Barcelona city (Spain). We evaluated the time required and the intrinsic and extrinsic costs of the four methods. The cost-accuracy ratio was calculated and differences between methods were assessed using ANOVA and Tukey's honestly significant difference (HSD) post-hoc test. Patient experience data were transformed using Rasch analysis and re-scaled from 0 to 10. Results: Office BP measurement was the most expensive method (€156.82, 95% CI: 156.18-157.46) and 1 h-automated BP measurement the cheapest (€85.91, 95% CI: 85.59-86.23). 1 h-automated BP measurement had the best cost-accuracy ratio (€ 1.19) and office BP measurement the worst (€ 2.34). Home BP monitoring (8.01, 95% CI: 7.70-8.22), and 1 h-automated BP measurement (7.99, 95% CI: 7.80-8.18) had the greatest patient approval: 66.94% of participants would recommend 1 h-automated BP measurement as the first or second option. Conclusion: The relationship between the cost-accuracy ratio and the patient experience suggests physicians could use the new 1 h-automated BP measurement as the first option and awake-ambulatory BP monitoring in complicated cases and cease diagnosing hypertension using office BP measurement.

Integración entre cardiología y atención primaria: impacto sobre la práctica clínica / Integration between cardiology and primary care: impact on clinical practice

Introducción y objetivos. Evaluar el impacto de un programa de integración entre cardiología y atención primaria en la práctica clínica, comparado con la atención convencional. La integración consiste en un cardiólogo hospitalario en cada centro de atención primaria, historia clínica común, guías clínicas consensuadas, sesiones de consultoría y otras herramientas de coordinación. Métodos. Estudio observacional de dos muestras transversales sobre prevalencias en periodos antes y después de la intervención: atención convencional y atención integrada. Se analiza: distribución de pacientes atendidos, impacto en indicadores de buena práctica clínica en los pacientes con cardiopatía isquémica, insuficiencia cardiaca y fibrilación auricular, satisfacción de atención primaria y uso de recursos. Resultados. Se incluyó a 3.194 pacientes (1.572 en atención convencional y 1.622 en integrada). La integración redistribuyó a los pacientes y aumentó el control del cardiólogo sobre enfermedades graves y el control desde primaria de los factores de riesgo y pacientes estables. En cardiopatía isquémica, mejoró el control de colesterolemia, presión arterial, optimización del tratamiento y documentación de la función ventricular. En insuficiencia cardiaca, aumentó el tratamiento con bloqueadores beta y la valoración funcional. En fibrilación auricular, mejoró el estudio con ecocardiografía e indicación de anticoagulación. El uso de recursos no aumentó. La satisfacción de los médicos de primaria se incrementó con la integración. Conclusiones. Tras la integración, mejoró el control y el tratamiento crónico de los pacientes con cardiopatía isquémica, insuficiencia cardiaca y fibrilación auricular, se redistribuyó a los pacientes crónicos entre atención primaria y cardiología, y aumentó la satisfacción de los médicos de familia, sin objetivarse incremento en el uso de recursos (AU)

Introduction and objectives. To assess the impact of a program integrating cardiology and primary care in clinical practice, compared with usual care. The integrated care consists of a hospital cardiologist in each primary care clinic, shared clinical history, joint practice guidelines, consultation sessions, and other coordinating tools. Methods. Observational, cross-sectional study of 2 series of chronic outpatients: conventional and integrated care. We analyzed patient distribution and the impact on good clinical practice indicators in patients with ischemic heart disease, heart failure and atrial fibrillation, along with primary care practitioner satisfaction and use of resources. Results. We included 3194 patients (1572 usual care, 1622 integrated care). Integrated care changed the patient distribution, allowing the cardiologist to focus on serious pathologies while cardiovascular risk factors and stable patients were monitored in primary care. In ischemic heart disease, improvement was observed in cholesterol management and blood pressure control; optimal medical treatment was more frequently prescribed and ventricular function evaluated more often. In heart failure, Beta-blockers treatment increased and functional class was assessed more often. In atrial fibrillation, an increase in anticoagulation prescription and echocardiography evaluation was observed. Satisfaction parameters improved with integrated care. The use of resources was not increased. Conclusions. Using our integration model, follow-up and chronic treatment of patients with ischemic heart disease, heart failure, and atrial fibrillation were improved. Monitoring of chronic patients was redistributed between primary care and cardiology, and family physicians¡¯ satisfaction levels improved. There was no increase in use of resources (AU)

[Integration between cardiology and primary care: impact on clinical practice]. / Integración entre cardiología y atención primaria: impacto sobre la práctica clínica.

INTRODUCTION AND OBJECTIVES: To assess the impact of a program integrating cardiology and primary care in clinical practice, compared with usual care. The integrated care consists of a hospital cardiologist in each primary care clinic, shared clinical history, joint practice guidelines, consultation sessions, and other coordinating tools. METHODS: Observational, cross-sectional study of 2 series of chronic outpatients: conventional and integrated care. We analyzed patient distribution and the impact on good clinical practice indicators in patients with ischemic heart disease, heart failure and atrial fibrillation, along with primary care practitioner satisfaction and use of resources. RESULTS: We included 3194 patients (1572 usual care, 1622 integrated care). Integrated care changed the patient distribution, allowing the cardiologist to focus on serious pathologies while cardiovascular risk factors and stable patients were monitored in primary care. In ischemic heart disease, improvement was observed in cholesterol management and blood pressure control; optimal medical treatment was more frequently prescribed and ventricular function evaluated more often. In heart failure, ß-blockers treatment increased and functional class was assessed more often. In atrial fibrillation, an increase in anticoagulation prescription and echocardiography evaluation was observed. Satisfaction parameters improved with integrated care. The use of resources was not increased. CONCLUSIONS: Using our integration model, follow-up and chronic treatment of patients with ischemic heart disease, heart failure, and atrial fibrillation were improved. Monitoring of chronic patients was redistributed between primary care and cardiology, and family physicians' satisfaction levels improved. There was no increase in use of resources. Full English text available from: www.revespcardiol.org.