Remote, algorithm-driven program improves hypertension, LDL in high-risk patients
A remote care program that utilizes phone calls, text messaging and electronic health records improved BP and LDL levels in high-risk and underserved patients, while reducing the need for in-person visits, researchers reported.
Undertreatment of hypertension and hypercholesterolemia is a persistent clinical challenge, and up to half of patients do not receive optimal treatment despite many generic options, Alexander J. Blood, MD, cardiologist and critical care fellow in medicine at Brigham and Women’s Hospital, told Healio. A shift to remote health care delivery has the potential to revolutionize care, but raises concerns about deepening a “digital health divide” that could exacerbate inequities, Blood said.
“One major finding from this initiative was that across racial, ethnic and primary language subgroups, our outcomes remain robust,” Blood told Healio. “All patients benefit: We engaged, enrolled and got participants through to program completion at similar rates across all traditionally underrepresented groups, and we were able to help them reach their clinical targets at similar rates.”
Using digital tools
Blood and colleagues analyzed data from 10,803 patients participating in an ongoing remote, algorithmically driven disease-management program within the Massachusetts General Brigham Health System, initiated in January 2018. Patients were identified by provider referral and electronic health record screenings for hypertension or LDL optimization to achieve guideline-recommended targets.
“Around 10% of these patients chose to participate only in education about their disease state and receive dietary and lifestyle recommendations,” Blood said. “Over 9,500 patients who were engaged agreed to proceed with medication management.”
Nonphysician patient navigators acted as the primary point-of-contact with the patients, engaging via phone, text or email in a “high-touch” model to provide education and gather data, Blood said. As part of a collaborative drug treatment management program, pharmacists independently prescribed and titrated antihypertensive and lipid-lowering therapy.
Program participants had significant reductions in systolic and diastolic BP, with a mean change of 10 mm Hg systolic/6 mm Hg diastolic for all enrolled patients (P < .0001 for all BP measurement types), Blood said. Outcomes were more pronounced in the 1,492 patients who completed the program, who achieved a mean reduction of 12 mm Hg systolic/7 mm Hg diastolic (P < .0001 for all BP measurement types). Among completers, 92% reached their guideline-recommended BP goals.
In the lipids program, researchers observed a mean 45 mg/dL reduction in LDL for all enrolled patients (P < .0001). For those who completed the program, there was a mean 70 mg/dL reduction in LDL, representing a 50% reduction from baseline to program exit (P < .0001), Blood said.
Among participants in the LDL analysis who completed the study, between baseline and study exit, use of high-intensity statins, ezetimibe and PCSK9 inhibitors increased and the percentage taking no LDL-lowering medication decreased (P for all < .001), according to the researchers.
BP and LDL results were consistent by race, ethnicity and language spoken.
At 3 months, 23% of patients in the lipids program and 15% of patients in the hypertension program remained in active medication management.
“We achieved these results by making 100,663 phone calls, integrating 424,482 BP values, ordering and reviewing 74,027 laboratory results, and making 27,885 prescriptions,” Blood told Healio.
In both programs, more than 40% of patients completed their recommended medication management steps to optimize therapy and reached maintenance, whereas 37% and 41% of patients in the lipid and hypertension programs, respectively, only completed partial therapy, became unreachable, or withdrew.
“There is room for improvement there, for certain,” Blood told Healio. “However, it really does highlight or reaffirm the difficulties in maintaining patients in longitudinal care, whether that is in-person or remote.”
Blood called the program a model for managing disease states effectively and safely with a non-physician and non-primary provider team.
“What we demonstrated here is once the disease state has been appropriately identified or screened for, we can accomplish that in a team-based approach, remotely, without the need for inpatient visits, unburdening the provider teams to integrate clinically relevant data on BP and cholesterol monitoring to help them reach their targets without the need for excessive in-person appointments, which burden the patient, the provider and the health care system as a whole,” Blood said.
Room for improvement
Blood said the intervention, while successful, could likely benefit from different patient and provider engagement strategies, as well as technology improvements to improve participant retention over time — even if a patient only participates in the dietary and lifestyle education modules.
“Life gets in the way,” Blood said. “It is not that these people don’t care. People do not spend 24/7 thinking about their health. We are hoping with a platform like this, we can make it more of a part of everyone’s thought process.”
Perspective
Back to Top
The BP intervention worked. A 10 mm Hg systolic/6 mm Hg diastolic BP reduction is huge. However, more than half of the patients did not go into the maintenance phase, and the benefits were much greater in the people that stayed in the maintenance program. We need better tools to help us maintain people longitudinally in these programs.
The intervention worked remarkably well in lipids, too. Those enrolled had about a 45 mg/dL reduction in LDL, and those that stayed in the maintenance phase had an even greater 70 mg/dL reduction. These are meaningful changes that should translate to reduction in risk for stroke and major adverse CV outcomes.
Though there was a lifestyle coaching component, which is important, achievement of these results was largely accomplished through initiation and titration of pharmacotherapy.
A program like this does work to improve two major risk factors and can decrease the number of in-person visits and clinician time, and can translate across diverse populations. However, the study still involved 100,000 calls to make all these changes. Just giving someone a BP cuff for monitoring on their own is not enough; you need to have someone to help facilitate making these changes. That leads to questions of how we can deploy the framework in our health care system. Who covers the costs of these 100,000 calls?
Overall, this appears it will be effective in reducing major events on a large scale, but questions remain about who pays for it, how it can be implemented in the health care system and what to do about the patients who did not stick with the maintenance phase.
Inertia is a major reason why patients are not at lipid goal and BP goal. There is tremendous inertia with the traditional model of how we deliver care. Having this model with remote monitoring at home and an allied health professional like a pharmacist following the guidelines that we know work and following these algorithms can have meaningful impact on getting large numbers of patients to these desired goals.
Collapse
Blood AJ, et al. LBS.02. Hypertension: Local, Global and Pandemic Impacts. Presented at: American Heart Association Scientific Sessions; Nov. 13-15, 2021 (virtual meeting).
Read more about