Impact of Expanding Telephonic Codes in a State Medicaid Program During COVID-19.

Background: The recent pandemic caused by the 2019 novel coronavirus (COVID-19) resulted in declaration of a national emergency (NE) in March 2020. The Centers for Medicare and Medicaid Services quickly responded with temporary expansion of telehealth coverage policies. Aim: To determine the impact of implementing a temporary telephonic code set in a state Medicaid population by comparing the utilization patterns of telehealth claims before and after a NE announcement. Methods: This was a retrospective cohort study conducted with the Arizona Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS). Data include telehealth claims submitted to AHCCCS between January and May 2020 by contracted managed care organizations. Results: Approximately 2.3 million telehealth claims were analyzed in this study. Utilization of the audio-visual (A/V) modality increased 1,610% and telephonic visits increased 408% compared with pre-NE. Compared with pre-NE, three provider type groups increased their utilization of telephonic visits from 1.8% to 50.8% as a result of the temporary telephonic set post-NE. Rural counties had higher rates of telephonic modality adoption, whereas urban counties adopted the A/V modality more readily. Ten telephonic codes constituted 87% of all telehealth claims, with the majority of those codes used for behavioral health and established office visit types. Conclusion: The telephonic modality was adopted more frequently in rural areas and the A/V modality in urban areas. There were several new provider types utilizing telehealth as a result of the temporary telephonic code set implementation.

Antihypertensive Medication Regimens Used in the Systolic Blood Pressure Intervention Trial.

BACKGROUND: Describing the antihypertensive medication regimens used in the SPRINT (Systolic Blood Pressure Intervention Trial) would contextualize the standard and intensive systolic blood pressure (SBP) interventions and may inform future implementation efforts to achieve population-wide intensive SBP goals. METHODS: We included SPRINT participants with complete medication data at the prerandomization and 12-month visits. Regimens were categorized by antihypertensive medication class. Analyses were stratified by treatment group (standard goal SBP <140 mm Hg versus intensive goal SBP <120 mm Hg). RESULTS: Among 7860 participants (83.7% of 9361 randomized), the median number of classes used at the prerandomization visit was 2.0 and 2.0 in the standard and intensive groups (P=0.559). At 12-months, the median number of classes used was 3.0 and 2.0 in the intensive and standard groups (P<0.001). Prerandomization, angiotensin-converting enzyme inhibitor (ACE), or angiotensin-II receptor blocker (ARB) monotherapy was the most common regimen in the intensive and standard groups (12.6% versus 12.2%). At 12-months, ACE/ARB monotherapy was still the most common regimen among standard group participants (14.7%) and was used by 5.3% of intensive group participants. Multidrug regimens used by the intensive and standard participants at 12 months were as follows: an ACE/ARB with thiazide (12.2% and 7.9%); an ACE/ARB with calcium channel blocker (6.2% and 6.8%); an ACE/ARB, thiazide, and calcium channel blocker (11.4% and 4.3%); and an ACE/ARB, thiazide, calcium channel blocker, and beta-blocker (6.5% and 1.2%). CONCLUSIONS: SPRINT investigators favored combining ACEs or ARBs, thiazide diuretics, and calcium channel blockers to target SBP <120 mm Hg, compared to ACE/ARB monotherapy to target SBP <140 mm Hg. REGISTRATION: URL: https://clinicaltrials.gov; Unique identifier: NCT01206062.

Implementation of the Arizona Pain and Addiction Curriculum: Findings and Implications From a Statewide Evaluation.

Purpose: The U.S. is struggling with dual crises of chronic pain and opioid overdoses. To improve statewide pain and addiction care, the Arizona Department of Health Services and 18 health education programs collaboratively created the evidence-based, comprehensive Arizona Pain and Addiction Curriculum which includes a Toolbox for Operationalization with adult learning theory applications and an annual program survey to assess curriculum implementation. The purpose of this study is to analyze the first year's survey data to better understand the implementation of a novel curriculum across all programs in the state. Materials and Methods: Program surveys were sent 6 months after curriculum publication to all 18 health education programs in Arizona to assess the 6 Ds of curriculum implementation: Degree of implementation, Difficulty of implementation, Delivery methods, Faculty Development, Didactic dissonance and Discussion Opportunities. Results: Responses from all program types (14/18 programs) indicated that there was widespread implementation of the curriculum, with 71% reporting that all ten Core Components had been included in the past academic year. The majority of programs did not find the Components difficult to implement and had implemented them through lectures. Seventy-seven percent of programs did not have a process to ensure clinical rotation supervisors are teaching content consistent with the curriculum, 77% reported not addressing student's didactic dissonance, and 77% of programs did not report asking students about their interactions with industry representatives. Conclusion: In < 1 year after creation of the Arizona Pain and Addiction Curriculum, all program types reported wide implementation with little difficulty. This may represent a first step toward the transformation of pain and addiction education, and occurred statewide, across program types. Further focus on didactic dissonance, problem solving and faculty development is indicated, along with systematic education on pharmaceutical and industry influence on learners. Other programs may benefit from adopting this curriculum and may not experience significant challenges in doing so.

Critical observations on and suggested ways forward for healthcare communication during COVID-19: pEACH position paper.

OBJECTIVE: Communication in healthcare has influenced and been influenced by the COVID-19 pandemic. In this position paper, we share observations based on the latest available evidence and experiential knowledge that have emerged during the pandemic, with a specific focus on policy and practice. METHODS: This is a position paper that presents observations relating to policy and practice in communication in healthcare related to COVID-19. RESULTS: Through our critical observations as experts in the field of healthcare communication, we share our stance how healthcare communication has occured during the pandemic and suggest possible ways of improving policy and professional practice. We make recommendations for policy makers, healthcare providers, and communication experts while also highlighting areas that merit further investigation regarding healthcare communication in times of healthcare crises. CONCLUSION: We have witnessed an upheaval of healthcare practice and the development of policy on-the-run. To ensure that policy and practice are evidence-based, person-centred, more inclusive and equitable, we advocate for critical reflection on this symbiotic relationship between COVID-19 and the central role of communication in healthcare. PRACTICE IMPLICATIONS: This paper provides a summary of the key areas for development in communication in healthcare during COVID-19. It offers recommendations for improvement and a call to review policies and practice to build resilience and inclusive and equitable responsiveness in communication in healthcare.

FGF23, Frailty, and Falls in SPRINT.

BACKGROUND/OBJECTIVES: Chronic kidney disease (CKD) is associated with frailty. Fibroblast growth factor 23 (FGF23) is elevated in CKD and associated with frailty among non-CKD older adults and individuals with human immunodeficiency virus. Whether FGF23 is associated with frailty and falls in CKD is unknown. DESIGN: Cross-sectional and longitudinal observational study. SETTING: Systolic Blood Pressure Intervention Trial (SPRINT), a randomized trial evaluating standard (systolic blood pressure [SBP] <140 mm Hg) versus intensive (SBP <120 mm Hg) blood pressure lowering on cardiovascular and cognitive outcomes among older adults without diabetes mellitus. PARTICIPANTS: A total of 2,376 participants with CKD (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2 ). MEASUREMENTS: The exposure variable was intact FGF23. We used multinomial logistic regression to determine the cross-sectional association of intact FGF23 with frailty and Cox proportional hazards analysis to determine the longitudinal association with incident falls. Models were adjusted for demographics, comorbidities, randomization group, antihypertensives, eGFR, mineral metabolism markers, and frailty. RESULTS: After adjustment, the odds ratio for prevalent frailty versus non-frailty per twofold higher FGF23 was 1.34 (95% confidence interval [CI] = 1.01-1.77). FGF23 levels in the highest quartile versus the lowest quartile demonstrated more than a twofold increased fall risk (hazard ratio [HR] = 2.32; 95% CI = 1.26-4.26), and the HR per twofold higher FGF23 was 1.99 (95% CI = 1.48-2.68). CONCLUSION: Among SPRINT participants with CKD, FGF23 was associated with prevalent frailty and falls.

Redefining Pain and Addiction: Creation of a Statewide Curriculum.

OBJECTIVES: In response to a declared statewide public health emergency due to opioid-related overdose deaths, the Arizona Department of Health Services guided the creation of a modern, statewide, evidence-based curriculum on pain and addiction that would be relevant for all health care provider types. METHODS: The Arizona Department of Health Services convened and facilitated 4 meetings during 4 months with a workgroup comprising the deans and curriculum representatives of all 18 medical, osteopathic, physician assistant, nurse practitioner, dental, podiatry, and naturopathic programs in Arizona. During this collaborative and iterative process, the workgroup reviewed existing curricula, established a philosophical framework, and developed a flexible and practical structure for a curriculum that would suit the needs of all program types. RESULTS: The Arizona Pain and Addiction Curriculum was finalized in June 2018. The curriculum aims to redefine pain and addiction as multidimensional public health issues and is structured as 10 core components, each supported by a detailed set of evidence-based objectives. The curriculum includes a set of annual metrics to collect from both programs (focused on implementation progress and barriers) and learners (focused on knowledge, attitudes, and practice plans). CONCLUSIONS: To our knowledge, this is the first example of a statewide collaboration among diverse health professional education programs to create a single, standard curriculum. This collaborative process and the nonproprietary Arizona Pain and Addiction Curriculum may serve as a useful template for other states to enhance pain and addiction education.

Flipping the Pain Care Model: A Sociopsychobiological Approach to High-Value Chronic Pain Care.

OBJECTIVE: Much of the pain care in the United States is costly and associated with limited benefits and significant harms, representing a crisis of value. We explore the current factors that lead to low-value pain care within the United States and provide an alternate model for pain care, as well as an implementation example for this model that is expected to produce high-value pain care. METHODS: From the perspective of aiming for high-value care (defined as care that maximizes clinical benefit while minimizing harm and cost), we describe the current evidence practice gap (EPG) for pain care in the United States, which has developed as current clinical care diverges from existing evidence. A discussion of the biomedical, biopsychosocial, and sociopsychobiological (SPB) models of pain care is used to elucidate the origins of the current EPG and the unconscious factors that perpetuate pain care systems despite poor results. RESULTS: An interprofessional pain team within the Veterans Health Administration is described as an example of a pain care system that has been designed to deliver high-value pain care and close the EPG by implementing the SPB model. CONCLUSIONS: Adopting and implementing a sociopsychobiological model may be an effective approach to address the current evidence practice gap and deliver high-value pain care in the United States. The Phoenix VA Health Care System's Chronic Pain Wellness Center may serve as a template for providing high-value, evidence-based pain care for patients with high-impact chronic pain who also have medical, mental health, and opioid use disorder comorbidities.

"Do You Know What I Know?": How Communication Norms and Recipient Design Shape the Content and Effectiveness of Patient Handoffs.

BACKGROUND: Poor communication during end-of-shift transfers of care (handoffs) is associated with safety risks and patient harm. Despite the common perception that handoffs are largely a one-way transfer of information, researchers have documented that they are complex interactions, guided by implicit social norms and mental frameworks. OBJECTIVES: We investigated communication strategies that resident physicians report deploying to tailor information during face-to-face handoffs that are often based on their implicit inferences about the perceived information needs and potential harm to patients. METHODS/PARTICIPANTS: We interviewed 35 residents in Medicine and Surgery wards at three VA Medical Centers (VAMCs). MAIN MEASURES: We conducted qualitative interviews using audio-recorded semi-structured cognitive task interviews. KEY RESULTS: The effectiveness of handoff communication depends upon three factors: receiver characteristics, type of shift, and patient's condition and perceived acuity. Receiver characteristics, including subjective perceptions about an incoming resident's training or ability levels and their assumed preferences for information (e.g., detailed/comprehensive vs. minimal/"big picture"), influenced content shared during handoffs. Residents handing off to the night team provided more information about patients' medical histories and care plans than residents handing off to the day team, and higher patient acuity merited more detailed information and the medical service(s) involved dictated the types of information conveyed. CONCLUSIONS: We found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as "recipient design." Interventions should focus on raising awareness of times when information is omitted, customized, or expanded based on implicit judgments, the emerging threats such judgments pose to patient care and quality, and the competencies needed to be more explicit in handoff interactions.

Content counts, but context makes the difference in developing expertise: a qualitative study of how residents learn end of shift handoffs.

BACKGROUND: Handoff education is both formal and informal and varies widely across medical school and residency training programs. Despite many efforts to improve clinical handoffs, little evidence has shown meaningful improvement. The objective of this study was to identify residents' perspectives and develop a deeper understanding on the necessary training to conduct safe and effective patient handoffs. METHODS: A qualitative study focused on the analysis of cognitive task interviews targeting end-of-shift handoff experiences with 35 residents from three geographically dispersed VA facilities. The interview data were analyzed using an iterative, consensus-based team approach. Researchers discussed and agreed on code definitions and corresponding case examples. Grounded theory was used to analyze the transcripts. RESULTS: Although some residents report receiving formal training in conducting handoffs (e.g., medical school coursework, resident boot camp/workshops, and handoff debriefing), many residents reported that they were only partially prepared for enacting them as interns. Experiential, practice-based learning (i.e., giving handoffs, covering night shift to match common issues to handoff content) was identified as the most suited and beneficial for delivering effective handoff training. Six skills were described as critical to learning effective handoffs: identifying pertinent information, providing anticipatory guidance, applying acquired clinical knowledge, being concise, incorporating delivery strategies, and appreciating the styles/preferences of handoff recipients. CONCLUSIONS: Residents identified the immersive performance and the experience of covering night shifts as the most important aspects of learning to execute effective handoffs. Formal education alone can miss the critical role of real-time sense-making throughout the process of handing off from one trainee to another. Interventions targeting senior resident mentoring and night shift could positively influence the cognitive and performance capacity for safe, effective handoffs.

Field Investigation of Ambulatory Clinic Exam Room Design with respect to Computing Devices: A Pilot Study.

The Department of Veterans Affairs (VA) has developed a new exam room design standard that is intended to facilitate a greater degree of patient centeredness. This new design includes a wall-mounted monitor on an armature system and a moveable table workspace. To date, however, this design has not been formally evaluated in a field setting. We conducted observations and interviews with primary care providers and their patients from three locations within the Phoenix VA Health Care System, in a pilot study comparing the new exam room design standard with the older legacy exam rooms. When using the new exam room layout, providers spent a greater proportion of time focused on the patient, spent more time in screen-sharing activities with the patient, and had a higher degree of self-reported situation awareness. However, the legacy exam rooms were perceived as better facilitating workflow integration. Provider and patient debrief interviews were supportive of the new exam room design. Overall, our field study results suggest that the new exam room design does contribute to a greater degree of patient centeredness, though more thorough evaluations are required to support these preliminary results.

"Workin' on Our Night Moves": How Residents Prepare for Shift Handoffs.

BACKGROUND: Poor-quality handoffs have been associated with serious patient consequences. Researchers and educators have answered the call with efforts to increase system safety and resilience by supporting handoffs using increased communication standardization. The focus on strategies for formalizing the content and delivery of patient handoffs has considerable intuitive appeal; however, broader conceptual framing is required to both improve the process and develop and implement effective measures of handoff quality. METHODS: Cognitive task interviews were conducted with internal medicine and surgery residents at three geographically diverse US Department of Veterans Affairs medical centers. Thirty-five residents participated in semistructured interviews using a recent handoff as a prompt for in-depth discussion of goals, strategies, and information needs. Transcribed interview data were analyzed using thematic analysis. RESULTS: Six cognitive tasks emerged during handoff preparation: (1) communicating status and care plan for each patient; (2) specifying tasks for the incoming night shift; (3) anticipating questions and problems likely to arise during the night shift; (4) streamlining patient care task load for the incoming resident; (5) prioritizing problems by acuity across the patient census, and (6) ensuring accurate and current documentation. CONCLUSION: Our study advances the understanding of the influence of the cognitive tasks residents engage in as they prepare to hand off patients from day shift to night shift. Cognitive preparation for the handoff includes activities critical to effective coordination yet easily overlooked because they are not readily observable. The cognitive activities identified point to strategies for cognitive support via improved technology, organizational interventions, and enhanced training.

A new modeling and inference approach for the Systolic Blood Pressure Intervention Trial outcomes.

Background/aims In clinical trials with time-to-event outcomes, usually the significance tests and confidence intervals are based on a proportional hazards model. Thus, the temporal pattern of the treatment effect is not directly considered. This could be problematic if the proportional hazards assumption is violated, as such violation could impact both interim and final estimates of the treatment effect. Methods We describe the application of inference procedures developed recently in the literature for time-to-event outcomes when the treatment effect may or may not be time-dependent. The inference procedures are based on a new model which contains the proportional hazards model as a sub-model. The temporal pattern of the treatment effect can then be expressed and displayed. The average hazard ratio is used as the summary measure of the treatment effect. The test of the null hypothesis uses adaptive weights that often lead to improvement in power over the log-rank test. Results Without needing to assume proportional hazards, the new approach yields results consistent with previously published findings in the Systolic Blood Pressure Intervention Trial. It provides a visual display of the time course of the treatment effect. At four of the five scheduled interim looks, the new approach yields smaller p values than the log-rank test. The average hazard ratio and its confidence interval indicates a treatment effect nearly a year earlier than a restricted mean survival time-based approach. Conclusion When the hazards are proportional between the comparison groups, the new methods yield results very close to the traditional approaches. When the proportional hazards assumption is violated, the new methods continue to be applicable and can potentially be more sensitive to departure from the null hypothesis.

Ambulatory Clinic Exam Room Design with respect to Computing Devices: A Laboratory Simulation Study.

BACKGROUND: Challenges persist regarding how to integrate computing effectively into the exam room, while maintaining patient-centered care. PURPOSE: Our objective was to evaluate a new exam room design with respect to the computing layout, which included a wall-mounted monitor for ease of (re)-positioning. METHODS: In a lab-based experiment, 28 providers used prototypes of the new and older "legacy" outpatient exam room layouts in a within-subject comparison using simulated patient encounters. We measured efficiency, errors, workload, patient-centeredness (proportion of time the provider was focused on the patient), amount of screen sharing with the patient, workflow integration, and provider situation awareness. RESULTS: There were no statistically significant differences between the exam room layouts for efficiency, errors, or time spent focused on the patient. However, when using the new layout providers spent 75% more time in screen sharing activities with the patient, had 31% lower workload, and gave higher ratings for situation awareness (14%) and workflow integration (17%). CONCLUSIONS: Providers seemed to be unwilling to compromise their focus on the patient when the computer was in a fixed position in the corner of the room and, as a result, experienced greater workload, lower situation awareness, and poorer workflow integration when using the old "legacy" layout. A thoughtful design of the exam room with respect to the computing may positively impact providers' workload, situation awareness, time spent in screen sharing activities, and workflow integration.

Teaching and assessment of clinical communication skills: Lessons learned from a SWOT analysis of Portuguese Angolan and Mozambican Medical Education.

HIGHLIGHTS: CCS training lacks a formal structure with substantial variation of the teaching process.The interviews promoted, amongst important stakeholders, a rise in awareness of this situation and how these skills can enhance the quality of clinical practice, encouraging curricular change.A communication skills teaching model: CoSTProMed is suggested for curriculum integration. BACKGROUND: The importance of clinical communication skills (CCS) teaching and assessment is increasingly recognized in medical education. There is a lack of outcome-based research about CCS teaching and assessment processes in Portuguese medical education. Our goal is to conduct a SWOT analysis of this process in Portugal, Angola and Mozambique in order to contribute to the establishment of an action plan for more effective CCS teaching and assessment in medical curricula. METHODS: Between 2010 and 2012, semi-structured interviews focused on the state of the art of teaching and assessment of clinical communication skills were conducted with key stakeholders of medical courses in Portugal, Angola and Mozambique. The design corresponds to an exploratory, descriptive and cross-sectional study, with the analysis of the recorded interviews. Interview transcripts were analyzed to identify salient themes/coding template in their discussions of the CCS teaching process. The coding and analysis of the surveys is qualitative. RESULTS: 87 interviews were performed at the 8 Portuguese, 1 Angolan and 1 Mozambican medical schools. Results indicate that the teaching and assessment process of CCS is in the beginning stages with these commonalities noted: (i) Variability amongst faculty in the teaching and assessment methods, (ii) disconnection of CCS between basic and clinical cycles, (iii) content and process skills and (iv) faculty development. CONCLUSIONS: CCS training lacks a formal structure with considerable variation of the CCS teaching process in these countries. The interviews promoted a rise in awareness of this situation and how these skills can enhance the quality of curricular change. Some important opportunities for the development and implementation of a framework of an integrated communication skills curriculum such as curricular reforms and well-established cooperation and networks were identified. The acknowledgement of the importance of integrating these skills in ME by key stake-holders and students in institutions and the identification of champions motivated to commit to the effort are strengths that should be considered to integrate and enhance CCS in the medical curricula.

Systolic Blood Pressure Control Among Individuals With Type 2 Diabetes: A Comparative Effectiveness Analysis of Three Interventions.

BACKGROUND: The relative effectiveness of 3 approaches to blood pressure control-(i) an intensive lifestyle intervention (ILI) focused on weight loss, (ii) frequent goal-based monitoring of blood pressure with pharmacological management, and (iii) education and support-has not been established among overweight and obese adults with type 2 diabetes who are appropriate for each intervention. METHODS: Participants from the Action for Health in Diabetes (Look AHEAD) and the Action to Control Cardiovascular Risk in Diabetes (ACCORD) cohorts who met criteria for both clinical trials were identified. The proportions of these individuals with systolic blood pressure (SBP) <140 mm Hg from annual standardized assessments over time were compared with generalized estimating equations. RESULTS: Across 4 years among 480 Look AHEAD and 1,129 ACCORD participants with baseline SBPs between 130 and 159 mm Hg, ILI (OR = 1.46; 95% CI = [1.18-1.81]) and frequent goal-based monitoring with pharmacotherapy (OR = 1.51; 95% CI = [1.16-1.97]) yielded higher rates of blood pressure control compared to education and support. The intensive behavioral-based intervention may have been more effective among individuals with body mass index >30 kg/m2, while frequent goal-based monitoring with medication management may be more effective among individuals with lower body mass index (interaction P = 0.047). CONCLUSIONS: Among overweight and obese adults with type 2 diabetes, both ILI and frequent goal-based monitoring with pharmacological management can be successful strategies for blood pressure control. CLINICAL TRIALS REGISTRY: clinicaltrials.gov identifiers NCT00017953 (Look AHEAD) and NCT00000620 (ACCORD).

You and me and the computer makes three: variations in exam room use of the electronic health record.

Challenges persist on how to effectively integrate the electronic health record (EHR) into patient visits and clinical workflow, while maintaining patient-centered care. Our goal was to identify variations in, barriers to, and facilitators of the use of the US Department of Veterans Affairs (VA) EHR in ambulatory care workflow in order better to understand how to integrate the EHR into clinical work. We observed and interviewed 20 ambulatory care providers across three geographically distinct VA medical centers. Analysis revealed several variations in, associated barriers to, and facilitators of EHR use corresponding to different units of analysis: computer interface, team coordination/workflow, and organizational. We discuss our findings in the context of different units of analysis and connect variations in EHR use to various barriers and facilitators. Findings from this study may help inform the design of the next generation of EHRs for the VA and other healthcare systems.

Plasma Renin test-guided drug treatment algorithm for correcting patients with treated but uncontrolled hypertension: a randomized controlled trial.

BACKGROUND: Undefined pathophysiologic mechanisms likely contribute to unsuccessful antihypertensive drug therapy. The renin test-guided therapeutic (RTGT) algorithm is based on the concept that, irrespective of current drug treatments, subnormal plasma renin activity (PRA) (<0.65 ng/ml/h) indicates sodium-volume excess "V" hypertension, whereas values >or=0.65 indicate renin-angiotensin vasoconstriction excess "R" hypertension. METHODS: The RTGT algorithm was applied to treated, uncontrolled hypertensives and compared to clinical hypertension specialists' care (CHSC) without access to PRA. RTGT protocol: "V" patients received natriuretic anti-"V" drugs (diuretics, spironolactone, calcium antagonists, or alpha(1)-blockers) while withdrawing antirenin "R" drugs (converting enzyme inhibitors, angiotensin receptor antagonists, or beta-blockers). Converse strategies were applied to "R" patients. Eighty-four ambulatory hypertensives were randomized and 77 qualified for the intention-to-treat analysis including 38 in RTGT (63.9 +/- 1.8 years; baseline blood pressure (BP) 157.0 +/- 2.6/87.1 +/- 2.0 mm Hg; PRA 5.8 +/- 1.6; 3.1 +/- 0.3 antihypertensive drugs) and 39 in CHSC (58.0 +/- 2.0 years; BP 153.6 +/- 2.3/91.9 +/- 2.0; PRA 4.6 +/- 1.1; 2.7 +/- 0.2 drugs). RESULTS: BP was controlled in 28/38 (74% (RTGT)) vs. 23/39 (59% (CHSC)), P = 0.17, falling to 127.9 +/- 2.3/73.1 +/- 1.8 vs. 134.0 +/- 2.8/79.8 +/- 1.9 mm Hg, respectively. Systolic BP (SBP) fell more with RTGT (-29.1 +/- 3.2 vs. -19.2 +/- 3.2 mm Hg, P = 0.03), whereas diastolic BP (DBP) declined similarly (P = 0.32). Although final antihypertensive drug numbers were similar (3.1 +/- 0.2 (RTGT) vs. 3.0 +/- 0.3 (CHSC), P = 0.73) in "V" patients, 60% (RTGT) vs. 11% (CHSC) of "R" drugs were withdrawn and BP medications were reduced (-0.5 +/- 0.3 vs. +0.7 +/- 0.3, P = 0.01). CONCLUSIONS: In treated but uncontrolled hypertension, RTGT improves control and lowers BP equally well or better than CHSC, indicating that RTGT provides a reasonable strategy for correcting treated but uncontrolled hypertension.