Racial Differences and Social Determinants of Health in Achieving Hypertension Control.

OBJECTIVE: To investigate whether specific social determinants of health could be a "health barrier" toward achieving blood pressure (BP) control and to further evaluate any differences between Black patients and White patients. PATIENTS AND METHODS: We conducted a retrospective cohort study of 3305 patients with elevated BP who were enrolled in a hypertension digital medicine program for at least 60 days and followed up for up to 1 year. Patients were managed virtually by a dedicated hypertension team who provided guideline-based medication management and lifestyle support to achieve goal BP. RESULTS: Compared with individuals without any health barriers, the addition of 1 barrier was associated with lower probability of control at 1 year from 0.73 to 0.60 and to 0.55 in those with 2 or more barriers. Health barriers were more prevalent in Black patients than in those who were White (44.6% [482 of 1081] vs 31.3% [674 of 2150]; P<.001). There was no difference at all in BP control between Black individuals and those who were White if 2 or more barriers were present. CONCLUSION: Patient-related health barriers are associated with BP control. Black patients with poorly controlled hypertension have a higher prevalence of health barriers than their White counterparts. When 2 or more health barriers were present, there was no differences in BP control between White and Black individuals.

Improving Management of Type 2 Diabetes Using Home-Based Telemonitoring: Cohort Study.

BACKGROUND: Diabetes is present in 10.5% of the US population and accounts for 14.3% of all office-based physician visits made by adults. Despite this established office-based approach, the disease and its adverse outcomes including glycemic control and clinical events tend to worsen over time. Available home technology now provides accurate, reliable data that can be transmitted directly to the electronic medical record. OBJECTIVE: This study aims to evaluate the impact of a virtual, home-based diabetes management program on clinical measures of diabetes control compared to usual care. METHODS: We evaluated glycemic control and other diabetes-related measures after 1 year in 763 patients with type 2 diabetes enrolled into a home-based digital medicine diabetes program and compared them to 794 patients matched for age, sex, race, BMI, hemoglobin A1c (HbA1c), creatinine, estimated glomerular filtration rate, and insulin use in a usual care group after 1 year. Digital medicine patients completed questionnaires online, received medication management and lifestyle recommendations from a clinical pharmacist or advanced practice provider and a health coach, and were asked to submit blood glucose readings using a commercially available Bluetooth-enabled glucose meter that transmitted data directly to the electronic medical record. RESULTS: After 1 year, usual care patients demonstrated no significant changes in HbA1c (mean 7.3, SE 1.7 to mean 7.3, SE 1.6; P=.41) or changes in the proportion of patients with HbA1c≥9.0 (n=117, 15% to n=113, 14%; P=.51). Digital medicine patients demonstrated improvements in HbA1c (mean 7.3, SE 1.5 to mean 6.9, SE 1.2; P<.001) and significant changes in the proportion of patients with HbA1c≥9.0 (n=107, 14% to n=49, 6%; P<.001), diabetes distress (n=198, 26% to n=122, 16%; P<.001), and hypoglycemic episodes (n=313, 41.1% to n=91, 11.9%; P<.001). CONCLUSIONS: A digital diabetes program is associated with significant improvement in glycemic control and other diabetes measures. The use of a virtual health intervention using connected devices was widely accepted across a broad range of ethnic diversity, ages, and levels of health literacy.

The emerging clinical role of wearables: factors for successful implementation in healthcare.

Wearable technologies promise to redefine assessment of health behaviors, yet their clinical implementation remains a challenge. To address this gap, two of the NIH's Big Data to Knowledge Centers of Excellence organized a workshop on potential clinical applications of wearables. A workgroup comprised of 14 stakeholders from diverse backgrounds (hospital administration, clinical medicine, academia, insurance, and the commercial device industry) discussed two successful digital health interventions that involve wearables to identify common features responsible for their success. Seven features were identified including: a clearly defined problem, integration into a system of healthcare delivery, technology support, personalized experience, focus on end-user experience, alignment with reimbursement models, and inclusion of clinician champions. Health providers and systems keen to establish new models of care inclusive of wearables may consider these features during program design. A better understanding of these features is necessary to guide future clinical applications of wearable technology.

Digital Management of Hypertension Improves Systolic Blood Pressure Variability.

BACKGROUND: Higher systolic blood pressure variability has been shown to be a better predictor of all-cause and cardiovascular disease mortality, stroke, and cardiac disease compared with average systolic blood pressure. METHODS: We evaluated the impact of a digital hypertension program on systolic blood pressure variability in 803 consecutive patients with long-standing hypertension who had been under the care of a primary care physician for a minimum of 12 months prior to enrollment (mean 4.7 years). Blood pressure readings were transmitted directly from home using a digitally connected blood pressure unit. Medication adjustments and lifestyle coaching was performed virtually via a dedicated team of pharmacists and health coaches. Systolic blood pressure variability was grouped by quartile and measured using the standard deviation (SD) of all systolic blood pressure values per individual. RESULTS: The mean age was 67 ± 12 years, 41% were male, submitting 3.3 ± 3.7 blood pressures per week. Under usual care, only 30% of patients were in the lowest-risk quartile, and 21% of patients were in the highest risk. After 24 months, the mean systolic blood pressure variability progressively fell from 12.8 ± 4.3 mm Hg to 9.9 ± 5.1 mm Hg (P <0.0001) with 57% of patients achieving the lowest-risk quartile. CONCLUSIONS: The majority of patients with hypertension under usual care have elevated systolic blood pressure variability exposing them to higher risk of cardiovascular disease events. Digital management of hypertension that includes weekly submission of home readings leads to improvement in average systolic blood pressure as well as systolic blood pressure variability over time, which should improve cardiovascular prognosis.

Reducing inappropriate outpatient antibiotic prescribing: normative comparison using unblinded provider reports.

Importance: Antibiotic resistance is a global health issue. Up to 50% of antibiotics are inappropriately prescribed, the majority of which are for acute respiratory tract infections (ARTI). Objective: To evaluate the impact of unblinded normative comparison on rates of inappropriate antibiotic prescribing for ARTI. Design: Non-randomised, controlled interventional trial over 1 year followed by an open intervention in the second year. Setting: Primary care providers in a large regional healthcare system. Participants: The test group consisted of 30 primary care providers in one geographical region; controls consisted of 162 primary care providers located in four other geographical regions. Intervention: The intervention consisted of provider and patient education and provider feedback via biweekly, unblinded normative comparison highlighting inappropriate antibiotic prescribing for ARTI. The intervention was applied to both groups during the second year. Main outcomes and measures: Rate of inappropriate antibiotic prescription for ARTI. Results: Baseline inappropriate antibiotic prescribing for ARTI was 60%. After 1 year, the test group rate of inappropriate antibiotic prescribing decreased 40%, from 51.9% to 31.0% (p<0.0001), whereas controls decreased 7% (61.3% to 57.0%, p<0.0001). In year 2, the test group decreased an additional 47% to an overall prescribing rate of 16.3%, and the control group decreased 40% to a prescribing rate of 34.5% after implementation of the same intervention. Conclusions and relevance: Provider and patient education followed by regular feedback to provider via normative comparison to their local peers through unblinded provider reports, lead to reductions in the rate of inappropriate antibiotic prescribing for ARTI and overall antibiotic prescribing rates.

Reducing Hospital Toxicity: Impact on Patient Outcomes.

BACKGROUND: Circadian rhythms are endogenous 24-hour oscillations in biologic processes that drive nearly all physiologic and behavioral functions. Disruption in circadian rhythms can adversely impact short- and long-term health outcomes. Routine hospital care often causes significant disruption in sleep-wake patterns that is further compounded by loss of personal control of health information and health decisions. We wished to evaluate measures directed at improving circadian rhythm and access to daily health information on hospital outcomes. METHODS: We evaluated 3425 consecutive patients admitted to a medical-surgical unit comprised of an intervention wing (n = 1185) or standard control wing (n = 2240) over a 2.5-year period. Intervention patients received measures to improve sleep that included reduction of nighttime noise, delay of routine morning phlebotomy, passive vital sign monitoring, and use of red-enriched lighting after sunset, as well as access to daily health information utilizing an inpatient portal. RESULTS: Intervention patients accessed the inpatient portal frequently during hospitalization seeking personal health and care team information. Measures impacting the quality and quantity of sleep were significantly improved. Length of stay was 8.6hours less (P = .04), 30- and 90-day readmission rates were 16% and 12% lower, respectively (both P ≤ .02), and self-rated emotional/mental health was higher (69.2% vs 52.4%; P = 0.03) in the intervention group compared with controls. CONCLUSIONS: Modest changes in routine hospital care can improve the hospital environment impacting sleep and access to health knowledge, leading to improvements in hospital outcomes. Sleep-wake patterns of hospitalized patients represent a potential avenue for further enhancing hospital quality and safety.

New Concepts in Hypertension Management: A Population-Based Perspective.

Hypertension (HTN) is the most common chronic disease in the U.S., and the standard model of office-based care delivery has yielded suboptimal outcomes, with approximately 50% of affected patients not achieving blood pressure (BP) control. Poor population-level BP control has been primarily attributed to therapeutic inertia and low patient engagement. New models of care delivery utilizing patient-generated health data, comprehensive assessment of social health determinants, computerized algorithms generating tailored interventions, frequent communication and reporting, and non-physician providers organized as an integrated practice unit, have the potential to transform population-based HTN control. This review will highlight the importance of these elements and construct the rationale for a reengineered model of care delivery for populations with HTN.