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In an older study in Wales, the reasons given for not starting or intensifying treatment in older patients with isolated systolic hypertension were fear that side effects would decrease the quality of life (39 percent); isolated systolic hypertension was an inevitable consequence of aging (35 percent); systolic hypertension was not as great a problem as diastolic hypertension (32 percent); isolated systolic hypertension was a compensatory mechanism to force blood through arteriosclerotic arteries (28 percent); and there was no beneficial effect of treating hypertension in the elderly (14 percent) (Ekpo et al., 1993). The adjusted OR for seeing a greater number of physicians was 2.0 (p < 0.005) (Col et al., 1990). In a prospective cohort study, Hsu and colleagues (2006) reported that those whose prescriptions were capped had fewer office visits and worse physiologic outcomes (systolic blood pressure >140 mm Hg) than those whose prescriptions were not capped. However, how these interventions are implemented varies substantially. Effects of prescription drug user fees on drug and health services use and on health status in vulnerable populations: A systematic review of the evidence. These researchers observed that adherence changes were most notable among patients who were not consistently taking their medications before a value-based system was implemented.29, A simulation study conducted by Goldman et al found that implementation of a pharmacy benefit that varies copayments for cholesterol-lowering therapy based on expected therapeutic benefit will improve patient medication compliance and reduce use of other services (e.g., hospitalizations, emergency department services). There is a substantial body of literature (primarily observational studies) investigating the implications of cost sharing on medication utilization. 5.4 The committee recommends that the Division for Heart Disease and Stroke Prevention collaborate with leaders in the business community to educate them about the impact of reduced patient costs on antihypertensive medication adherence and work with them to encourage employers to leverage their health care purchasing power to advocate for reduced deductibles and copayments for antihypertensive medications in their health insurance benefits packages. 19Task Force for Community Preventive Services. 1990. SOURCE: Hyman and Pavlik, 2001. For example, inadequate screening for hypertension was 18 percent among the uninsured vs. 11 percent for the insured (adjusted OR = 1.46 [1.28-1.67]; p < 0.01) (Woolhandler and Himmelstein, 1988). Self-measured blood pressure monitoring: comparative effectiveness. Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting. Atlanta, GA: CDC, U.S. Department of Health and Human Services; 2015. MyNAP members SAVE 10% off online. New England Journal of Medicine 311(7):480-484. Medical Care 36(2):202-211. ———. A. Nelson. Higher cost sharing has been associated with delayed initiation of hypertensive therapy. 2007. Copayment level and compliance with antihypertensive medication: Analysis and policy implications for managed care. 2002. Merit-based incentive payment system. Example Evidence-based Interventions at a Glance. New England Journal of Medicine 327(11):776-781. 2006. Asians and Hispanics received the highest levels of counseling and non-Hispanic whites the least. However, familiarity with the guidelines was associated with a lower likelihood of intensifying treatment among older patients with mildly elevated SBP, particularly if they have isolated systolic hypertension (Hyman and Pavlik, 2000). Clinical Therapeutics 17(2):330-340. doi: 10.1377/hlthaff.2013.0654. Collectively, these findings from well-designed and executed clinical trials of nonpharmacologic interventions for hypertension provide encouraging evidence that carefully supervised nonpharmacologic interventions focused on African Americans will likely reduce their excess risk for serious medical complications known to be caused by uncontrolled hypertension. Lloyd-Jones, D. M., J. C. Evans, M. G. Larson, and D. Levy. SOURCE: Oliveria et al., Archives of Internal Medicine, February 25, 2002, 162:417. In a 1981 survey, a larger proportion of people with uncontrolled or moderate to severe hypertension than controlled hypertension reported economic barriers to pharmacologic and medical care. Quality Payment Program: quality measuresexternal icon. Hypertension control change package for clinicians. Systolic hypertension may be more complex to treat than diastolic pressure (SHEP Cooperative Research Group, 1991), but multiple studies show that physicians are unlikely to treat or intensify treatment for mild to moderate systolic hypertension (<165 mm Hg) if the DBP is <90 mm Hg (Figures 5-1 and 5-2) (Berlowitz et al., 1998; Hyman et al., 2000). Santa Monica, CA: RAND Corporation. 2016. Hypertension quality improvement strategies, including audit and feedback on performance, provider education, patient education, self-management support, patient reminder systems (for follow-up appointments, blood pressure checks, and self-management), and care delivery system changes, have been demonstrated to reduce blood pressure and improve blood pressure.6, 28, 43 In addition, … In comparing members switched from a two-tier to a three-tier plan with those retained in the two-tier plan, Fairman and colleagues (2003) found that the two groups did not differ significantly with respect to the number of office visits, emergency department visits, or inpatient hospitalizations. 9Zedler BK, Joyce A, Murrelle L, Kakad P, Harpe SE. It also would be useful to have research on larger-scale interventions (i.e., more than 500 patients) and how these programs can be funded and continued in ways other than public grants.35, A CDC Community Guide review examining cost estimates (31 studies; search period, January 1980–May 2012) of team-based care found most cost-effectiveness estimates below the conservative threshold of $50,000 per quality-adjusted life year (QALY) saved.36, SMBP plus clinical support was more effective than usual care in lowering blood pressure and improving control among patients with hypertension.37, Pharmacists as Part of Care Coordination Teams. The results of these experiments should be shared broadly with the business community. TABLE 5-1 Proportion of Cases of Uncontrolled Hypertension in Each Population Subgroup Attributable to Identified Risk Factors, Non-Hispanic black (vs. non-Hispanic white), No physician visits in past 12 months (vs. >1 visit). Impact of generosity level of out-patient prescription drug coverage on prescription drug events and expenditure among older persons. Tamblyn, R., R. Laprise, J. 42CDC. Access to health care and the quality of health care have been areas of serious review and analysis at the Institute of Medicine. Alabama state plan amendment (SPA), 12-011 [online]. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Ahluwalia and colleagues (1997) also found that controlled hypertension was associated with having a regular place of care (OR = 7.93 [3.86-16.29]. Schneeweiss, S., A. M. Walker, R. J. Glynn, M. Maclure, C. Dormuth, and S. B. Soumerai. In addition, we Moy, E., B. According to April 2014 data from Surescripts, an e-prescription network used by the majority of community pharmacies in the United States, 7 in 10 physicians e-prescribed through an electronic health record and 96% of community pharmacies were enabled to accept e-prescriptions. In NHAMCS hospital-based clinics, 25 percent received diet counseling and 14 percent counseling for exercise. 45. Within the context of the current health care reform debate, the committee supports the recommendations by a former IOM committee for “comprehensive and affordable health care to every person residing in the United States” and that “all public and privately funded insurance include appropriate preventive services as recommended by the U.S. Preventive Services Task Force” (IOM, 2003a). New England Journal of Medicine 349(23):2224-2232. Poirier, S., and J. LeLorier. The roles and duties of CHWs tend to be similar across studies and reflect the common objective of improving blood pressure control through a range of physician- or nurse-supervised behavioral and social support interventions. Lopes et al. Effects of cost sharing on physiological health, health practices, and worry. 10.7% of blood pressure medication fills were for fixed-dose combinations of blood pressure medications. Better insurance coverage led to greater use of antihypertensive medications and purchase of a greater number of tablets (Adams et al., 2001b). Soumerai, S. B., T. J. Mclaughlin, D. Rossdegnan, C. S. Casteris, and P. Bollini. Atlanta, GA: CDC, Department of Health and Human Services; 2014. Similarly, in a survey of primary care clinicians at three VA medical centers compared with the clinical database of patients cared for by these providers, clinicians overestimated the proportion of patients who were prescribed guideline-concordant medications (75 percent perceived vs. 67 percent actual, p < 0.001) and the proportion of patients who had blood pressures levels <140/90 at their last visit (68 percent perceived vs. 43 percent actual, p < 0.001). The National Opinion Research Center at the University of Chicago. ———. IOM (Institute of Medicine). CDC. Aldana (2001) also reported significant ROI (from $2.50 to $10.00 saved for every dollar invested) related to reductions in employee absenteeism. New England Journal of Medicine 333(22):1462-1467. improved care coordination within networked primary care teams using: standardized protocols to manage blood pressure and cholesterol, electronic prescribing (e-prescribing) with 2-way information exchange between prescriber and pharmacy, medication therapy management (MTM) programs. 2008. Atlanta, GA: CDC, Department of Health and Human Services; 2014. The researchers found that antihypertensive therapy was not intensified in 86.9 percent of visits when blood pressure was ≥140/90. Once these factors are better understood, strategies should be developed to increase the likelihood that primary providers will screen for and treat hypertension appropriately, especially in elderly patients. For example, Fairman and colleagues (2003) compared an intervention group of members switched from a two-tier to a three-tier plan with a comparison group retained in the two-tier plan (tiered plans employ formularies with differential copayments to encourage the use of generic drugs, or brand drugs that have been made available at a discounted rate). The toolkit includes a check list to help employers choose and negotiate health benefit packages that fit the needs of their employees. Further, the First National Report Card on Quality of Health Care in America published by the RAND Corporation in 2004 documented that patients with hypertension received less than 65 percent of recommended care (RAND, 2006). These interventions include change concepts such as providing blood pressure checks without appointment or co-payment, flowcharts for how hypertensive patients can be tracked and managed, the systematic use of evidence-based hypertension treatment protocols, and the use of direct care staff to facilitate patient self-management. The Million Hearts® ABCS include: Aspirin use when appropriate, Blood pressure control, Cholesterol management, and Smoking cessation . The impact of increasing patient prescription drug cost sharing on therapeutic classes of drugs received and on the health status of elderly HMO members. “Undiagnosed hypertension and treated but uncontrolled hypertension occurs largely under the watchful eye of the health care system”. ———. The chapter also considers community health workers as a potential strategy to increase treatment adherence among individuals with hypertension. New England Journal of Medicine 314(19):1266-1268. Journal of the American Medical Association 284(16):2061-2069. For non-Hispanic whites, the hazard ratio for hypertensives vs. normotensives was 1.70 (95% CI: 1.09-2.65); however, when non-Hispanic white hypertensives with controlled blood pressure were compared to their normotensive counterparts, the excess CVD mortality risk was no longer statistically significant (hazard ratio = 1.17, 95% CI: 0.72-1.91). 5.3 The committee recommends that the Division for Heart Disease and Stroke Prevention should encourage the Centers for Medicare & Medicaid Services to recommend the elimination or reduction of deductibles for antihypertensive medications among plans participating under Medicare Part D, and work with state Medicaid programs and encourage them to eliminate deductibles and copayment for antihypertensive medications. 52Department of Health and Human Services. Patient noncompliance with prescribed antihypertensive medications is also a problem that contributes to suboptimal rates of blood pressure control. It is prevalent in adults and endemic in the older adult population. 43CDC. 2000. 2004. 35The Community Guide. 5.5 The committee recommends that the Division for Heart Disease and Stroke Prevention work with state partners to leverage opportunities to ensure that existing community health worker programs include a focus on the prevention and control of hypertension. Pharmacist-delivered patient care services evidence examples. 07-0047-EF [online]. A 2012 comparative effectiveness review by the Agency for Healthcare Research and Quality (AHRQ) examined the effectiveness of usual care compared with SMBP plus additional clinical support. In a 2002 nationally. Clinical advisory statement. 1991. The researchers found that most of the quality improvement strategies contributed to some improvement in the detection and control of high blood pressure, but it was difficult to determine which strategy was superior. Cost sharing is not always consistent with decrease in utilization. Use of medical care in the Rand Health Insurance Experiment. Izzo, J. L., Jr., D. Levy, and H. R. Black. Among the 5 studies that addressed adherence to medications, 2 RCTs saw significant improvement in the intervention groups that included CHWs compared to the control group. For example, a program might provide lower copayments for hyperten-. 2003. Medical Care 24(9 Suppl):S1-S87. BCBSA supports Million Hearts Campaign with heart health programs for federal workersexternal icon. Hypertension 40(5):640-646. Health objectives for the nation: Adults taking action to control their blood pressure—United States, 1990. (1994) study of a well-insured population, 71 percent of individuals with hypertension were aware of their hypertension, only 49 percent were being treated, and only 12 percent of these were controlled (<140/90 mm Hg), despite frequent utilization of the health care system. To measure your blood pressure, your doctor or a specialist will usually place an inflatable arm cuff around your arm and measure your blood pressure using a pressure-measuring gauge.A blood pressure reading, given in millimeters of mercury (mm Hg), has two numbers. All rights reserved. Cardiovascular disease prevention and control: self-measured blood pressure monitoring interventions for improved blood pressure control [online]. 2016. Studies that have shown improvement in care include data from multiple surveys. Introduction: While behavioral interventions may be viewed as important strategies to improve blood pressure (BP), an evidence-based review of studies evaluating these interventions may help to guide clinical practice. Hypertension 2010;55:399–407. Comparative Effectiveness Review No. Factors associated with hypertension control in the general population of the United States. 2017. 2005. The JNC8 recommends 4 pharmacologic classes of medications to manage hypertension. To err is human: Building a safer health system. Insurance coverage was not significantly associated with the number of tablets purchased in the unadjusted analysis, but in the multivariate analysis, medication coverage increased the number of tablets purchased per year by 37 (p = 0.02) (Blustein, 2000). Pharmacist-delivered patient care services evidence examplespdf iconexternal icon. 13Centers for Medicare & Medicaid Services. Hypertension 47(3):345-351. health care accounts for a relatively low proportion of poor awareness or poor control of hypertension. (2008) observed a 3.86 greater risk (hazard ratio = 3.86, 95 percent confidence interval [95% CI]: 1.60-9.32) of CVD deaths among individuals with hypertension under age 65 compared to similar-age individuals with normal blood pressure levels. In a cross-sectional study of Medstat’s 1999 MarketScan database, Kamal-Bahl and Briesacher (2004) noted that the average annual use of antihypertensive medication was lower in the two- or three-tier plans with higher copayments, but not in single-tier plans. Effects of a 3-tier pharmacy benefit design on the prescription purchasing behavior of individuals with chronic disease. In the early 2000s, the IOM produced a series of reports on the general benefits of having health insurance and the adverse health consequences when insurance is lacking (IOM, 2001a, 2002a,b, 2003b,d, 2004). London: BMJ Books, 2001. When patients have to pay a share of drug costs: Effects on frequency of physician visits, hospital admissions and filling of prescriptions. Noncompliance with antihypertensive medication is associated with increased hospital admissions (Maronde et al., 1989). 36The Community Guide. antihypertensive medication is an important and efficient way to increase medication adherence. Although there is a simple test to diagnose hypertension and relatively inexpensive drugs to treat it, the disease is often undiagnosed and uncontrolled. They estimated that improvement of 20 percent in the percentage of visits in which treatment is intensified, blood pressure control could increase from the study’s observed 46.2 percent to a projected 65.9 percent in one year. 2003. Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population. Bethesda, MD: U.S. Department of Health and Human Services. Hypertension is a major contributor to cardiovascular morbidity and disability. hypertension screening, follow-up care, and the use of medication (Moy et al., 1995). Diet counseling rates were also higher for patients with co-occurring diabetes, obesity, or dyslipidemia. Lexchin, J., and P. Grootendorst. Diet counseling did not differ by payment provider. Some studies have assessed the relationship between insurance coverage and control of hypertension (Ahluwalia et al., 1997). Another study found that one of the factors associated with a hospitalization due to noncompliance with medication (medications included an ACE [angiotensin-converting enzyme] inhibitor) was the number of physicians seen regularly (p = 0.007). For 93 percent of visits in which the physician reported being satisfied with the BP level, SBP was >140 mm Hg; 35 percent had a blood pressure >150 mm Hg; and the DBP was >90 mm Hg at 22 percent of these visits. Treatment and control of hypertension in the community: A prospective analysis. How do incentive-based formularies influence drug selection and spending for hypertension? Health Affairs 27(5):1429-1441. Underutilization of antihypertensive drugs and associated hospitalization. Million Hearts® Cardiovascular Risk Reduction Model. ———. Providing full coverage had no effect on clinical outcomes and costs for white patients. All rights reserved. Kotchen, J. M., B. Shakoor-Abdullah, W. E. Walker, T. H. Chelius, R. G. Hoffmann, and T. A. Kotchen. 2001. The CPSTF has related findings for self-measured blood pressure monitoring interventions when combined with additional support (recommended). 2000. E-prescribing [online].2014. Of those on medication (61 percent), 49 percent were controlled to a systolic blood pressure goal compared with 90 percent to a diastolic blood pressure goal (Lloyd-Jones et al., 2000). Physician adherence to guidelines for nonpharmacological strategies to manage hypertension is also problematic. 1990. 44Siu AL, USPSTF: Screening for High Blood Pressure in Adults: U.S. Preventive Services Task Force Recommendation Statement. Oliveria, S. A., P. Lapuerta, B. D. McCarthy, G. J. L’Italien, D. R. Berlowitz, and S. M. Asch. 1997. 2012. Evidence-based interventions use a continuum of integrated policies, strategies, activities, and services whose effectiveness has been proven or informed by research and evaluation. Do you want to take a quick tour of the OpenBook's features? Physician role in lack of awareness and control of hypertension. It offers several recommendations that embody a population-based approach grounded in the principles of measurement, system change, and accountability. Similarly, in an analysis of the NHANES (National Health and Nutrition Examination Survey) III, He et al. 47Centers for Medicare & Medicaid Services. American Elder Care Research Organization. 50Siu AL, USPSTF: Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. A time-series study and a before-and-after study also noted improvement with CHW interventions. Data are somewhat mixed, however, about whether hypertension control is improved if patients have a regular source of care (Ahluwalia et al., 1997; Col et al., 1990; Fihn and Wicher, 1988; He et al., 2002). Bray and colleagues, in an analysis of the effects of the DASH diet and three dietary sodium levels on blood pressure, also reported that the lower the sodium level, the greater the mean reduction in blood pressure. The effect of a $2 co-payment on prescription refill rates of Quebec elderly and its relationship to socioeconomic status. A. In another survey, the long-term uninsured (19.5 percent) and short-term uninsured (8.6 percent) were less likely than the insured (5.8 percent) to have been screened for hypertension in the previous 2 years (both were statistically significant differences) (Ayanian et al., 2000). 60CDC. Findings suggest that generous coverage did not lead to significant changes in medical spending by patients and insurers. These organizations include specific performance measures for care of hypertension (Table 5-2). Two years after value-based payments were started, patient medication adherence showed an additional 2.1% gain, increasing to 5.2%. Characteristics of patients with uncontrolled hypertension in the United States. 99.5% of blood pressure medication fills had a copayment of $5 or less. E-prescribing trends in the United States. 27 Community Preventive Services Task Force. The latter typically include measuring and monitoring blood pressure; providing health education to patients and families about behavioral risk factors for hypertension; recommending changes in diet and physical activity; explaining treatment protocols, health insurance matters, and the importance of adhering to medication regimens; providing help with obtaining transportation to medical appointments; serving as mediators between patients and health care and social service systems; arranging for translation services; and finally, listening to patients and their family members, motivating them, reducing their isolation, and leading self-help groups. Isolated systolic hypertension was also the majority subtype of uncontrolled hypertension among those >50 years of age. 220. cation among those with no prescription coverage compared to those with such coverage (Piette et al., 2004). Advancing care information [online]. 32Choudhry N, Bykov K, Shrank WH, et al. Data from the 2000 Health and Retirement Study showed that going from full coverage to partial coverage and from partial coverage to no coverage reduced compliance with antihypertensive medications (adjusted OR = 0.46; p < 0.001). Introduction The aim of this review is to evaluate the effectiveness of educational interventions on improving the control of blood pressure in patients with hypertension. Effects of regular exercise on blood-pressure and left-ventricular hypertrophy in African-American men with severe hypertension. Evidence-Based Hypertension has successfully achieved its goal to be a “practice-based textbook” that provides primary care practitioners with an evidence-based approach to the management of hypertension. Controlling for health status, financial burden (out-of-pocket costs compared to income) has been shown to be significantly greater for persons with chronic conditions such as hypertension (Rogowski et al., 1997). Similarly, South Carolina and its partner, the American Society of Hypertension, Inc., provide continuing medical education to health professionals on evidence-based treatment of hypertension. [cited 2015 Apr 22]. In a survey of low-income African Americans, those having no insurance were significantly more likely to have uncontrolled hypertension (Pavlik et al., 1997). Show this book's table of contents, where you can jump to any chapter by name. Shea, S., D. Misra, M. H. Ehrlich, L. Field, and C. K. Francis. More work is needed to understand barriers to achieving better control and to develop evidence-based interventions. Programs that have the greatest effect on patient outcomes Col et al., 1997 ) Information management 2014 ; (... Jernigan, S. Yoon, and R. J. Glynn, M. B., R. H. Brook [ comment... National workforce study: U.S. Department of health care system ” improving compliance and increasing control systolic! Brogan, a counseling for patients with uncontrolled although there is a substantial body of literature ( observational., worksite health handbook-2nd edition: a resource guide for pharmacists ambulatory care setting, myocardial,. A hypertensive population average ROI of $ 3.48 in health care and the use of agents... But no cost savings Opinion in Cardiology 21 ( 4 ):296-300 approaches to treating hypertension in that group... Buy this book, type in a hypertensive population contribute to the previous chapter or to. Interventions for improving the efficiency and accuracy of prescribing in the guide oliveria and colleagues also identified with... 29Farley JF, Wansink D, Lindquist JH, Parker JC, Maciejewski ML E. Z.,! A printable version of this evidence summary herepdf icon or less of incentive-based formularies prescription-drug... The AHRQ ( 2004 ) commissioned a review of the american Medical Association 268 ( 17 ):2388-2394 the ill.! On admission to hospitals and nursing homes those of lower socioeconomic status ( SES ) Payment... 15 ( 5 ) evidence-based interventions for hypertension was mild systolic hypertension among Middle-Aged and elderly US Hypertensives for II! Elective hospitalization were not diagnosed with hypertension: needs of special hypertensive populations the majority subtype of hypertension. Evaluated outcomes at 12 months, more evidence is needed on programs evaluated over a time. Started, patient medication adherence showed an additional 2.1 % gain, to... Association 259 ( 19 ):1266-1268 CDC ( Centers for disease control and access to hypertension care.. Seeing a greater number of physicians was 2.0 ( p < 0.005 ) ( Col et al. 2002... C. Gatsonis, and R. R. Henderson to Medical care in America should be shared with... In care include data from multiple surveys your areas of serious review and.... With specific nursing process components on the use of medication has been identified the. ) found that lack of blood pressure control, cholesterol management, this is important... Impacts and health healthy people 2010 blood pressure control monitoring: action steps for health Statistics ; 2015 JNC8! ) 2014 ; 33 ( 5 ):265–74 objectives for the chronically ill. Journal of the U.S. population T.,! That have shown improvement in care include data from multiple surveys Uninsurance in America applied study! Strategies for improving hypertension control may be furnished by pharmacists or others Avorn... 15 ( 5 ): home blood pressure control 160 ( 15:2281-2286! Of pharmacies to send Information back to the care of hypertension in the 21st century one co-occurring.! N. D. Wong, F. M. Sacks, E. C. Roemer health 88 ( 11 ):776-781 high... Furthermore, high levels of uncontrolled hypertension blood pressure—United States, 1990 ) addressed in the adult.

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