Another Randomized Controlled Clinical Trial Proves Outsourced Population Health Care Management Works Hypertension

Heres another high quality randomized controlled clinical that confirms the benefits of outsourced care management.

Margolis and colleagues accessed Minnesotas HealthPartners electronic records to identify all patients who had had two sequential primary care clinic blood pressure readings that were more than 140 systolic or 90 diastolic.  These patients with hypertension were asked by letter and then phone calls to participate in the research trial.  Those who agreed were rechecked by research assistants who re-measured the blood pressures to confirm the hypertension.

16 clinics participated. 8 were assigned to the intervention group. 8 served as comparison (control) "usual care" clinics that relied on usual physician care.

In the intervention clinics, a pharmacist interviewed each patient and sought agreement to lower the blood pressure by 5 points. The patients received a home BP monitor that transmitted data to AMCHealth six times a week. The pharmacist and patient met by telephone every 2 weeks. Based on the BP monitoring and the telephone interviews, the pharmacist used a standardized medication algorithm to adjust medications until control was achieved for 6 weeks.  Telephone calls were then reduced in frequency to monthly.

The research assistants reassessed the participants blood pressures at 6, 12 and 18 months.

Over 14,000 patients were identified and 2020 agreed to be screened. 450 met criteria for persistently elevated blood pressures. 228 were cared for in the intervention clinic and 220 were cared for in the usual care. The mean age was 61 years, 45% were women, 82% were white and 48% had a college degree. The average blood pressure was 148/85.

Both groups had a similar frequency of follow-up visits. 380 patients had completed both 6 and 12 month follow-up visits with the research assistants. 

The proportion of patients with controlled BPs at both visits in the intervention clinics was 57.2% vs. 30% in the control clinics. If those patients lost to follow-up were counted as blood pressure "failures," the success rate was 48.5% vs. 25.1%. Both sets of measures were statistically significant.  The relative proportions held up at 18 months.

Unsurprisingly, intervention patients were taking more medications over the duration of the study and at 6 months were statistically more significantly more likely to report that they were taking them. 

Six patients in the intervention group vs one in the control group had "events" related to low blood pressure, dizziness and loss of consciousness.

The cost, based on pharmacist time, was $1350 per patient.

The Disease Management Care Blogs take:

This adds to a growing body of evidence that non-physicians working under clinical protocol side-by side with busy primary care physicians can achieve control of a chronic condition - in this instance, hypertension.  This is a core attribute of population health.

Another piece of good news is the emergence of the electronic health record as a means to identify patients who are program candidates.  Now thats "meaningful."

The bad news:

The cost was $1350.  It is unlikely that those direct costs were mitigated by hypertension-related "savings" within the same fiscal year.  On the other hands, thinks the DMCB, the use of other types of non-physicians with or without IT-based decision support and higher throughput could lessen that cost.  The DMCB is sure that the population health service providers are already on it.

Even with state of the art population health, the rate of hypertension control was ultimately 50%.

A small excess of participants experienced an excess of treatment side effects.  While this may be the inevitable consequence of more aggressive treatment, it could expose the program to liability.

This was Minnesota: we dont know if this would work in, say, Los Angeles.  This needs to be tested elsewhere.

Image from Wikipedia

Grapes reduce heart failure associated with hypertension

A study appearing in the Journal of Nutritional Biochemistry¹ demonstrates that grapes are able to reduce heart failure associated with chronic high blood pressure (hypertension) by increasing the activity of several genes responsible for antioxidant defense in the heart tissue. Grapes are a known natural source of antioxidants and other polyphenols, which researchers believe to be responsible for the beneficial effects observed with grape consumption. This study, funded by a grant from the National Institutes of Health (NIH), and conducted at the University of Michigan Health System, uncovered a novel way that grapes exert beneficial effects in the heart: influencing gene activities and metabolic pathways that improve the levels of glutathione, the most abundant cellular antioxidant in the heart.

An estimated 1 billion people worldwide have hypertension, which increases the risk of heart failure by 2 to 3-fold. Heart failure resulting from chronic hypertension can result in an enlarged heart muscle that becomes thick and rigid (fibrosis), and unable to fill with blood properly (diastolic dysfunction) or pump blood effectively. Oxidative stress is strongly correlated with heart failure, and deficiency of glutathione is regularly observed in both human and animal models of heart failure. Antioxidant-rich diets, containing lots of fruits and vegetables, consistently correlate with reduced hypertension.

In this study, conducted at the University of Michigan Health System, hypertensive, heart failure-prone rats were fed a grape-enriched diet for 18 weeks. The results reproduced earlier findings that grape consumption reduced the occurrence of heart muscle enlargement and fibrosis, and improved the diastolic function of the heart. Furthermore, the mechanism of action was uncovered: grape intake "turned on" antioxidant defense pathways, increasing the activity of related genes that boost production of glutathione.

"Our earlier studies showed that grapes could protect against the downward spiral of hypertensive heart failure, but just how that was accomplished – the mechanism – was not yet known," said lead investigator E. Mitchell Seymour, Ph.D. "The insights gained from our NIH study, including the ability of grapes to influence several genetic pathways related to antioxidant defense, provide further evidence that grapes work on multiple levels to deliver their beneficial effects."

Seymour noted that the next phase of the NIH study, which will continue into 2014, will allow his team to further define the mechanisms of grape action, and also look at the impact of whole grape intake compared to individual grape phytonutrients on hypertension-associated heart failure.

"Our hypothesis is that whole grapes will be superior to any individual grape component, in each of the areas being investigated," said Dr. Seymour. "The whole fruit contains hundreds of individual components, which we suspect likely work together to provide a synergistic beneficial effect."

The insights gained from this research will further the knowledge on grapes and heart health, but will also provide translational information on the value of dietary (whole foods) and dietary supplement approaches for prevention of heart disease stemming from chronic hypertension.

"The NIH grant is allowing the team at the University of Michigan Medical System to expand its work in this important area and further highlight the multi-faceted role of grapes in supporting heart health," said Kathleen Nave, president of the California Table Grape Commission. "This work will also provide key insights into the role of whole fruit versus individual components of a fruit, using grapes as the benchmark."

Kiwi Lower Hypertension

Kiwi Lower Hypertension - Although in general, high blood pressure or hypertension had no symptoms. However, this condition does not mean harmless. If not treated, high blood pressure overload can damage many organs and tissues.

One effort to reduce high blood pressure is to eat a varied diet with a combination of proper nutrition. The results presented in the meeting of the American Heart Association in Orlando, United States, consumption of kiwi is mentioned three times in a day is quite effective in lowering hypertension.

Research conducted by Mette Svendsen of the University Hospital Oslo, Norway, for 8 weeks to 118 people aged 55 years and suffering from hypertension were.

The respondents were divided into two groups, one which is eating three kiwi fruit per day and the rest are eating foods that contain apple once a day.

After 8 weeks, the researchers found a value of systolic pressure (the upper blood pressure number) of participants is lower than 3.6 millimeters with participants who consumed apples.

Although kiwi eaters have lower blood pressure, but researchers do not yet know whether the main cause. This can only be confirmed with more extensive research.

Passive Smokers Children Can suffer Hypertension

Children who live with parental smokers at greater risk of suffering from hypertension or high blood pressure, although they are still small. In fact, hypertension in children can continue until they grow up.

Hypertension in children is a state of systolic blood pressure and / or diastolic average is at large equal to 95 percentile for age and sex, who performed at least three times of measurement.

Hypertension in children divided into two categories, namely primary hypertension when the cause of hypertension can not be explained. Hypertension is usually associated with hereditary factors, the input of salt, stress, and obesity. Meanwhile, secondary hypertension occurs as a result of other underlying diseases, such as kidney disease.

In recent research led by Dr Giacomo D Simonetti from Childrens Hospital University of Bern, Switzerland, stated that secondhand smoke is a risk factor of hypertension in children.

In his research, Simonetti and his team examined the data on 4236 boys and girls aged 5-6 years living in the southwestern part of Germany. Approximately 29 percent of the childrens father and 21 percent of their mothers were smokers. As many as 12 percent of children also have parents who smoke.

After accounting for other heart disease factors, such as birth weight, premature birth or parental hypertension, the researchers found that parental smoking is an independent factor on the incidence of hypertension in children.

The study also found children whose mothers smoke have worse effects on blood pressure than if exposed to cigarette smoke from his father.

Prevention of cardiovascular disease in adulthood can be started from the age of the children by avoiding risk factors, including avoiding exposure to cigarette smoke. The consequences may last long term.

Black Tea Benefits Help Overcome Hypertension

Black Tea Benefits Help Overcome Hypertension - This is good news for tea lovers. A latest study conducted by researchers from Australia found that those who regularly drank black tea every day, will probably get little benefit in lowering high blood pressure (hypertension).

Although researchers can not identify the specific components of tea that play a role in lowering blood pressure, the researchers suspect that flavonoids, which are found in tea, have a vital function in preventing hypertension.

As published in the Archives of Internal Medicine, the researchers took 95 volunteers randomly from Australia who have normal blood pressure. Volunteers then divided into two groups. One group of black tea and other drinks with the same flavor and aroma with caffeine content.

Before starting the test, the volunteers blood pressure was measured first, which is about 121/72 millimeters of mercury (mm Hg). Blood pressure is normal when a person is less than 120/80 mm Hg. Meanwhile, if a persons blood pressure reaches 140/90 mm Hg or more, then it came under the category of hypertension.

After that, the researchers assigned to each group to drink black tea three times daily for six months. After six months, participants who drank black tea decreased systolic blood pressure by 2 mm Hg and their diastolic blood pressure also decreased by approximately 2 mm Hg.

Despite a decrease in blood pressure, researchers believe that the decline was not significant enough to bring someone out of danger zone associated with hypertension.

"The message is not true if one only relies on a continuous black tea," said Jonathan Hodgson, principal investigator of the University of Western Australia.

"There are small changes. This is not the same if you take blood pressure lowering drugs," continued Dr. Joseph Vita of Boston University, who was not involved with the study.