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.

Use of unattended automated office blood pressure in Utah primary care clinics.

AIM: Unattended automated office blood pressure (BP) measurement (u-AOBP) improves office BP measurement accuracy and reduces white-coat BP elevation. u-AOBP is recommended as the preferred office BP measurement technique by multiple hypertension guidelines. This study examines utilization, performance, and potential barriers to implementation of u-AOBP in Utah primary care clinics following 5 years of promotional efforts by the Utah Million Hearts Coalition (UMHC). METHODS: An online questionnaire was administered to 285 Utah primary care clinics to evaluate self-reported use of u-AOBP and u-AOBP technique, interpretation of results, and perceived barriers to implementation. RESULTS: Seventy-nine of 285 clinics (27.7%) completed the full questionnaire. Fifty-nine clinics (74.7%) use u-AOBP. Nearly 65% first learned about u-AOBP through UMHC promotional efforts rather than from the medical literature. One-half of these clinics noted no significant barriers to u-AOBP implementation, and over 80% noted no reduction in medical staff productivity. However, important knowledge deficits concerning correct u-AOBP performance and interpretation of results were apparent from answers to the questionnaire. CONCLUSION: After 5 years of UMHC promotional efforts, at least 20% of the 285 Utah primary care clinics invited to take the questionnaire and 75% of the 79 clinics completing the survey have incorporated u-AOBP and found it feasible in a primary care setting. Ongoing promotion of u-AOBP implementation at the local and regional level is required to extend its utilization. Effective, accessible educational materials and local technical assistance from public health and community partners are needed to correct knowledge and performance deficits to optimize u-AOBP utilization in primary care.

Unattended automated office blood pressure measurement: Time efficiency and barriers to implementation/utilization.

Unattended automated office blood pressure (BP) measurement (u-AOBP) improves office BP measurement accuracy and reduces white-coat BP elevation, but there are reservations about its time efficiency in primary care. We used time-stamp methodology to measure u-AOBP procedure times performed without a rest period in 130 patients during routine clinic visits to three primary care clinics with 2.5-4.9 years u-AOBP experience. We documented the clinical activities of 30 medical assistants during the u-AOBP procedures. We also assessed MA and clinician satisfaction and knowledge about u-AOBP performance and interpretation. Median u-AOBP procedure time was <5 minutes, and MAs engaged in productive clinical activities during 83% of the procedures. Ninety-three percent of MAs and 100% of clinicians in the clinics agreed that u-AOBP is an efficient method to improve hypertension management. Barriers to effective u-AOBP implementation and ongoing utilization included initial difficulty incorporating u-AOBP into clinic workflow and medical staff knowledge deficiencies concerning correct u-AOBP performance and interpretation despite prior training and experience with the procedure. Intensive u-AOBP education and training programs are needed to facilitate effective u-AOBP implementation into primary care. The time required to perform u-AOBP can be utilized productively by staff.

Measuring and Managing Blood Pressure in a Primary Care Setting: A Pragmatic Implementation Study.

BACKGROUND: Accurate blood pressure (BP) measurement is essential to hypertension diagnosis and management. Automated office blood pressure (AOBP) and home blood pressure measurement (HBPM) may improve assessment, but barriers exist in primary care settings. METHODS: We implemented an AOBP/HBPM program in a primary care clinic in 2015 to 2016. Patients with elevated BP determined by guideline-quality observed BP measurement and/or AOBP entered the HBPM program. Patients with average home BP ≥ 135/85 mm Hg provided HBPM results for medication adjustment. Clinic staff and patients completed satisfaction questionnaires. RESULTS: Initial HBPM results in 183 patients with elevated office BP revealed white-coat BP elevation in 35% of untreated patients and in 37% of treated patients. The prevalence of white-coat BP elevation was similar whether enrollment BP was by observed BP or AOBP. Subsequent HBPM facilitated BP control in 49% of patients with elevated home BP. Most providers, staff, and patients endorsed the utility of the program. Barriers to implementation included a temporary period of incorrect AOBP technique, patients failing to provide HBPM results, and incorrect HBPM technique. DISCUSSION: Our clinic-based AOBP/HBPM program detected white-coat BP elevation in one third of enrolled patients, facilitated control of home BP, and was acceptable to staff and patients. We identified barriers to be addressed to ensure sustainability.

Diagnosing Hypertension in Primary Care Clinics According to Current Guidelines.

PURPOSE: This descriptive study examines hypertension diagnostic practices in Utah primary care clinics relative to the 2015 US Preventive Services Task Force (USPSTF) recommendations for the accurate diagnosis of hypertension. We assessed clinic procedures in place to facilitate accurate in-office and out-of-office blood pressure (BP) measurement. METHODS: An online questionnaire was administered to 321 primary care clinics. We compared current clinic BP measurement practices with the USPTF recommendations and assessed the level of adherence to the recommendations by level of clinic integration with a hospital. RESULTS: Of the 321 primary care clinics that received the assessment, 123 (38.3%) completed the questionnaire. Clinics varied significantly in their ability to provide accurate in-office measurement, ranging from 57.5% to 93.5% of clinics complying with USPSTF recommendations. Only 25.2% of clinics reported having access to ambulatory monitoring and 36.6% had instructional materials for accurate home BP monitoring. Clinics integrated with a hospital were more likely to report adherence to recommendations than solo or independent clinics (36.4% vs 10.5%; P < .01). CONCLUSION: This assessment shows that many primary care clinics are not well prepared to implement the USPSTF guidelines for accurate diagnosis of hypertension. Most office practices will benefit from support to develop their capacities.

Evaluation of the Effectiveness of a Patient-Centered Educational Mailer Designed to Improve Statin Adherence: A Pragmatic Trial.

BACKGROUND: Patients with high total cholesterol have increased risk of cardiovascular disease. National Cholesterol Education Program (NCEP) and American Heart Association (AHA) guidelines recommend cholesterol lowering with statin medications; however, statin adherence remains poor. We hypothesized that patient-centered education on the 10-year risk for each of the major constituents of cardiovascular disease would increase statin adherence and achievement of the low-density lipoprotein cholesterol (LDL-C) goal. METHODS: Veterans within the Salt Lake City Veterans Affairs (VA) Medical Center initiating statin therapy from October 2008 to December 2011 were randomized in a pragmatic design to receive either an educational mailer or usual care. The mailer outlined their 10-year global cardiovascular risk, separated into coronary heart disease, stroke, and congestive heart failure. The study was unblinded and followed an intention-to-treat analysis where outcome measures were obtained during normal care process. The primary outcome measure was the achievement of the LDL-C goal during the 12-month follow-up. RESULTS: Two hundred and seven patients were randomly assigned to either the intervention arm (95) or the control arm (112). No differences in the proportion of patients meeting the LDL-C goal were detected during 12-months [Relative Risk (RR): 0.95 (95 percent confidence interval (CI): 0.77-1.17)] or 18-months [RR: 1.03 (95 percent CI: 0.84, 1.25)]. Patients in the intervention arm had higher adherence on average, e.g., intervention patients were more likely to have 70 percent or more days of statin therapy compared to patients who received standard care-though this did not reach statistical significance-RR: 1.33 (95 percent CI: 1.00, 1.78). There were no statistical differences in cardiovascular outcomes or mortality. CONCLUSION: Patient education mailers sent to patients starting statin treatment did not have a clear impact on LDL-C goal achievement or adherence to statin therapy.

Visual hallucinations related to angiotensin-converting enzyme inhibitor use: case reports and review.

Four patients experienced visual hallucinations that appear to have been precipitated by lisinopril. Other cases of visual hallucinations have been reported with other angiotensin-converting enzyme (ACE) inhibitors. Older patients, particularly those with a history of either dementia or mild cognitive impairment, may be at higher risk. Hallucinations resolved within 1 to 30 days after cessation of ACE inhibitors. Development of visual hallucinations after initiation of ACE inhibitors should prompt discontinuation of therapy. Visual hallucinations have been reported in one case involving an ARB. Visual hallucinations have not been associated with direct renin inhibitors. Consideration should be given to use of alternative, unrelated antihypertensive drug classes.

Peripheral neuropathy: a complication of systemic sclerosis.

We performed bedside testing for peripheral neuropathy in our systemic sclerosis (SSc) population to determine whether foot care guidelines should be developed for SSc. Twenty consecutive SSc patients and 20 healthy control (HC) patients were evaluated for peripheral neuropathy in both feet using the 10-g Semmes-Weinstein monofilament examination (SWME) and 128 Hz vibration sensation using the on-off method. Independent, blinded, vibratory sensation, and SWME evaluations were performed on each subject by two investigators who had completed a training session to standardize each exam. An additional consecutive 20 patients with type 2 diabetes mellitus (DM) were examined by a diabetologist to compare with peripheral neuropathy prevalence in SSc patients. We examined the inter-rater variability using Cohen's kappa. We compared SWME and vibratory sensation in SSc to HC using Fisher's exact. The t test was used to compare duration of disease and modified Rodnan skin score (mRSS) for those with abnormal SWME or vibratory sensation. Two of 20 SSc patients reported sensory foot symptoms consistent with peripheral neuropathy prior to the examination. Inter-rater agreement for both SWME and vibratory sensation was strong (kappa: 0.72 and 0.83, respectively). Two HC and 12 SSc patients demonstrated abnormal vibratory sense (one-sided Fishers' exact, p < 0.002). No HC and four SSc patients had abnormal monofilament exams (one-sided Fisher's exact, p = 0.053). Neither mRSS (p = 0.28) nor duration of non-Raynauds (p = 0.07) symptoms differed between those with peripheral neuropathy and those without. Duration of Raynaud's symptoms were clinically significantly associated with presence of peripheral neuropathy (p = 0.04). The prevalence of sensory loss to monofilament in SSc was identical to DM patients (4/20). SSc patients have a considerable prevalence of pedal peripheral neuropathy as detected by loss of vibratory sensation or inability to sense the 10-g SWME. Further studies are indicated to determine if routine screening for neuropathy and subsequent podiatric care for SSc patients with abnormalities can reduce pedal complications.

The prevalence and clinical correlates of an auscultatory gap in systemic sclerosis patients.

Introduction. Accurate blood pressure (BP) measurement is essential to the diagnosis and management of hypertension in patients with systemic sclerosis (SSc) to help prevent renal and cardiovascular complications. The presence of an auscultatory gap during manual BP measurement-the temporary disappearance of the Korotkoff sounds during cuff deflation-leads to a potentially important underestimate of systolic BP if undetected. Objectives. Since the presence of an auscultatory gap is frequently associated with increased vascular stiffness, we investigated its presence and correlates in 50 consecutive SSc patients. Methods. For each patient, BP was measured sequentially using three different approaches performed in the same order. Results. Sixteen of 50 patients (32%) had an auscultatory gap which if undetected would have resulted in clinically important underestimates of systolic BP in 4 patients. The presence of an auscultatory gap was statistically associated with the presence of antibodies to RNA polymerase III (P<0.0068) and SSc diagnosis type (P<0.01). Conclusions. Our study demonstrates that auscultatory gaps are relatively common in SSc and correlate with markers for SSc vasculopathy. If undetected auscultatory gaps may result in clinically important underestimation of BP. Thus, electronic oscillometric BP may be preferred in SSc patients.

Clinical decision support and appropriateness of antimicrobial prescribing: a randomized trial.

CONTEXT: The impact of clinical decision support systems (CDSS) on antimicrobial prescribing in ambulatory settings has not previously been evaluated. OBJECTIVE: To measure the added value of CDSS when coupled with a community intervention to reduce inappropriate prescribing of antimicrobial drugs for acute respiratory tract infections. DESIGN, PARTICIPANTS AND SETTING: Cluster randomized trial that included 407,460 inhabitants and 334 primary care clinicians in 12 rural communities in Utah and Idaho (6 with 1 shared characteristic and 6 with another), and a third group of 6 communities that served as nonstudy controls. The preintervention period was January to December 2001 and the postintervention period was January 2002 to September 2003. Acute respiratory tract infection diagnoses were classified into groups based on indication for antimicrobial use. Multilevel regression methods were applied to account for the clustered design. INTERVENTION: Six communities received a community intervention alone and 6 communities received community intervention plus CDSS that were targeted toward primary care clinicians. The CDSS comprised decision support tools on paper and a handheld computer to guide diagnosis and management of acute respiratory tract infection. MAIN OUTCOME MEASURE: Community-wide antimicrobial usage was assessed using retail pharmacy data. Diagnosis-specific antimicrobial use was compared by chart review. RESULTS: Within CDSS communities, 71% of primary care clinicians participated in the use of CDSS. The prescribing rate decreased from 84.1 to 75.3 per 100 person-years in the CDSS arm vs 84.3 to 85.2 in community intervention alone, and remained stable in the other communities (P = .03). A total of 13,081 acute respiratory tract infection visits were abstracted. The relative decrease in antimicrobial prescribing for visits in the antibiotics "never-indicated" category during the post-intervention period was 32% in CDSS communities and 5% in community intervention-alone communities (P = .03). Use of macrolides decreased significantly in CDSS communities but not in community intervention-alone communities. CONCLUSION: CDSS implemented in rural primary care settings reduced overall antimicrobial use and improved appropriateness of antimicrobial selection for acute respiratory tract infections. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00235703.