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A cohort study assessing feasibility of an entirely remote hypertension and hypercholesterolemia management program conducted by nonlicensed navigators and pharmacists supported by cardiovascular clinicians, results provide evidence demonstrating such a program can contribute to optimization of guideline-directed therapy at scale, reduce cardiovascular risk, and reduce need for in-person visits.
“The findings in this study indicated an association between remote health delivery at scale and improvements in chronic disease metrics in a large urban and suburban outpatient cohort and across racial, ethnic, and language populations historically underserved by health care,” wrote investigators. “We believe that this program may serve as a model for health care professionals and systems aiming to enhance access, patient engagement, and health outcomes.”
Despite the marked advances in therapies and technologies, hypertension and lipid management has persisted as a challenge for cardiologists and public health. With an interest in addressing these issues, a team from Harvard Medical School and Brigham and Women’s Hospital designed the current research endeavor with the intent of exploring avenues for improving hypertension and dyslipidemia on a population level given the current bandwidth issues impact cardiologists in the US. To assesses the feasibility of an entirely remote hypertension and hypercholesterolemia program, investigators recruited and enrolled patients monitored by a physician within the Massachusetts General Brigham healthcare system aged 26-80 years, and with blood pressure and/or LDL-C exceeding guideline-directed targets.
Qualified patients were subsequently contacted by a patient navigator to confirm eligibility and interest in participation. These navigators were responsible for being the primary communicator with enrolled patients and also served an integral role in collecting data and conveying dietary, lifestyle, and medication recommendations made by the clinical team to optimize risk reduction in study participants. All patients enrolled in the study received education, home blood pressure device integration, and medication titration from the patient navigator team, which included nonlicensed navigators and pharmacists who, with the support of cardiovascular clinicians, coordinated care using standardized algorithms, task management and automation software, and omnichannel communication.
From January 1, 2018-July 1, 2021, a total of 20,454 patients were screened. Of these 18,444 were contacted and 10,803 were enrolled in the remote hypertension and lipids medication management programs. Of these 10,803 included in the overall study, 3658 were enrolled in the hypertension program alone, 8103 were enrolled in the cholesterol management program alone, and 958 were enrolled in both. Investigators pointed out 1266 patients request education only without medication titration. The study cohort had a mean age of 65 (SD, 11.4) years, 56% were female, 12% identified as Black, 11% identified as Hispanic, 72% identified as White, and 16% identified as another or multiple races. Overall, 11% of the population reported preferred language other than English. During the study period, a total of 424,482 blood pressure readings and 139,263 laboratory reports were collected.
Results of the investigators’ baseline analyses indicate the mean office blood pressure was 150/83 (SD, 18/10) mmHg and mean home blood pressure was prior to enrollment in the hypertension program. Among those engaged in remote medication management for hypertension, the mean office blood pressure was reduced by 8.7/3.8 (21.4/12.4) and 9.7/5.2 (22.2/12.6) mmHg at 6 and 12 months, respectively. Among those who opted to only receive education, the mean changes in blood pressure at 6 and 12 months were −1.5/−0.7 (SD, 23.0/11.1) and by +0.2/−1.9 (SD, 30.3/11.2) mmHg, respectively (P <.001 for between cohort difference).
For those opting to take part in remote medication titration as part of the lipid management program, the mean reduction in LDL-C was 35.4 (SD, 43.1) and 37.5 (SD, 43.9) mg/dL at 6 and 12 months, respectively. In the education-only cohort, the mean reduction in LDL-C achieved at 6 and 12 months was 9.3 (SD, 34.3) and 10.2 (SD, 35.5) mg/dL, respectively (P <.001). Investigators highlighted subgroup analyses indicated similar rates of enrollment and reductions in both blood pressure and LDL-C were observed across different racial, ethnic, and primary language groups included in the study.
In an invited commentary, Neha J. Pagidipati, MD, MPH, of the Duke Clinical Research Institute, and Eric D. Peterson, MD, MPH, of UT Southwestern, wrote about the public health failure to address blood pressure and hyperlipidemia, but went on to applaud investigators and their research endeavor for adding important new information for outlining the potential for such an intervention strategy to be delivered in real-world settings.
“The investigators (and their health system) should be congratulated for designing and implementing a thoughtful, comprehensive, system-based intervention to help reduce cardiovascular risk among all patient types. The authors demonstrated that a BP and lipid intervention strategy can be delivered at scale by nonphysician health care professionals using algorithmic care and achieved an impressive result,” wrote the pair. “Moving forward, this study should provide motivation for others to explore system-level interventions of a similar type. We now have an important example that a broken system can be fixed!”
This study, “Results of a Remotely Delivered Hypertension and Lipid Program in More Than 10 000 Patients Across a Diverse Health Care Network,” was published in JAMA Cardiology.