Telehealth intervention reduces BP in minority stroke survivors
An intervention including home BP telemonitoring plus nurse case management lowered BP more than home BP telemonitoring alone in minority stroke survivors, according to findings presented at the International Stroke Conference.
“Blacks and Hispanics have poorer stroke outcomes than Caucasians. Hypertension is a major predictor of racial disparities in stroke outcomes in the United States,” Gbenga Ogedegbe, MD, MPH, FACP, Dr. Adolph and Margaret Berger Professor of Medicine at NYU Grossman School of Medicine, said during a presentation. “Hypertension control in stroke survivors is key to secondary stroke prevention. Home BP telemonitoring and nurse case management have proven efficacy in addressing multilevel barriers to hypertension control. However, their effectiveness remains untested in stroke patients, and their implementation is suboptimal in blacks and Hispanics.”
Ogedegbe and colleagues randomly assigned 450 black and Hispanic stroke survivors (mean age, 62 years; 44% women; 51% black; 72% with annual family income less than $25,000) to home BP telemonitoring alone that consisted of home BP readings 3 days per week for 12 months — each of which were wirelessly transmitted to a secure server — plus BP reports sent to patients and physicians for 12 months, or to home BP telemonitoring plus nurse case management that consisted of 20 counseling calls with a nurse who reviewed the BP reports and offered lifestyle counseling.
All patients had systolic BP of at least 140 mm Hg on two readings prior to randomization.
Systolic BP declined in both groups at 6 and 12 months (P < .0001 for all), but the between-group difference favored the intervention group (6-month estimate, –7.32 mm Hg; standard error, 1.72; P < .0001; 12-month estimate, –9.24 mm Hg; standard error, 1.75; P < .0001), Ogedegbe said during his presentation.
Within-group systolic BP change was –6.31 mm Hg at 6 months and –5.52 mm Hg at 12 months in the control group and –13.62 mm Hg at 6 months and –14.76 mm Hg at 12 months in the intervention group (P < .05 for all), he said.
“These findings present strong empirical evidence for widespread implementation in low-income minority stroke survivors with multiple comorbidities,” Ogedegbe said during the presentation. “Policymakers and health care plans now have the needed evidence to implement these plans in minority patients with stroke and uncontrolled hypertension. Effectiveness of this intervention in secondary stroke prevention warrants further investigation.” – by Erik Swain
Reference:
Ogedegbe G, et al. LB19. Presented at: International Stroke Conference; Feb. 19-21, 2020; Los Angeles.
Disclosures: The authors report no relevant financial disclosures.
Perspective
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This randomized study of home BP telemonitoring in minority stroke survivors demonstrates that linking transmission of home BP measurements with focused nurse case management care was much more effective in lowering BP than linking home BP telemonitoring with usual hypertension care in the primary care setting. Those results are in line with now many other trials — including the Cedars-Sinai Los Angeles barbershop trial (Victor RG, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1717250) — showing that hypertension-focused care by nurses or possibly even more so by pharmacists is superior to standard hypertension treatment by primary care doctors.
The intervention effect was likely due to increased medication compliance in patients who are getting reminders and education on the importance to adhere to their BP medications, as well as because hypertension-focused care by nurses is less affected by clinical inertia — the reluctance of treating practitioners to increase antihypertensive medications in the face of uncontrolled hypertension, which is all too often seen in the primary care setting. This clinical inertia is even lower if the focused care is provided by hypertension-specialty trained practitioners, who can prescribe antihypertensive medications, such as clinical pharmacists or nurse practitioners.
We previously demonstrated in the L.A. Barbershop trial that linking BP assessment by community barbers with hypertension-specialty care provided by clinical pharmacists reduced systolic BP by more than 20 mm Hg after 6 months and was sustainable at 12 months in non-Hispanic black hypertensive men. This model, although highly effective, has not yet entered clinical practice. Until such programs are more widely available, choosing medications with few side effects that only have to be taken once per day help with compliance and hypertension control. Referral to specialized hypertension care, such as the Hypertension Center of Excellence at the Cedars-Sinai Smidt Heart Institute, will help to achieve hypertension control even in the most difficult cases.
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