Hypertension: does “pay-for-performance” deliver quality care?

Nowadays, health care practitioners are reimbursed on a “pay-for-performance” basis also called P4P which rewards physicians financially for achieving targets and treatment goals. The financial rewards can vary from increase in percentage of reimbursements, bonuses, and grants. Even though the P4P program aims to promote better health care delivery, it can backfire when doctors may avoid patients with complex disorders (and therefore more difficult goals to achieve) and opt more for patients with simple, straightforward ailments (e.g. easy targets). As an example, patients with diabetes are also likely to present with concomitant illnesses such as high blood pressure, heart disease, and other cardiovascular disorders.

Researchers looked followed up 141,609 patients with high blood pressure from at eight Veterans Affairs (VA) hospitals in three states. They compared quality of care and patient satisfaction between patients with simple hypertension and those who are “sicker” hypertensive patients, e.g. with other co-existing conditions, from diabetes to chronic lung diseases.

According to lead author Dr. Laura A. Petersen of the VA Health Services Research and Development Center of Excellence and affiliated with the Baylor College of Medicine, in Houston, Texas

“Many clinicians are concerned that when they care for patients with multiple medical conditions, their performance on measures of health care quality is going to suffer due to that complexity. The concern is that the time spent treating other unrelated conditions would take away time from treating high blood pressure, causing performance on measures of quality to suffer.”

The results of the study show that:

• “Sicker patients” are more likely to receive high quality health care.
• Patients with multiple diseases have to take many types of medications but expressed an overall high satisfaction with the medical care they receive.
• Patient satisfaction is generally positive regardless whether patients are treated for high blood pressure only or for other conditions as well.

“Overall good quality care” was defined as:

• When doctors managed to keep blood pressure under 140/90 millimeters of mercury (mm Hg) at first visit and within the six-month follow-up period.
• When doctors are actively trying to control blood pressure (even if the patient fell short of the treatment goal) as shown by intensified follow-up care that would include change in medication, nutrition and lifestyle change counselling, etc.

The study results indicate that P4P measures do not necessarily “penalize physicians who treat patients with more complicated medical conditions”, at least in the case of hypertensive patients.

One weak point of the study is the fact that it looked only at patients under the VA system which essentially differs in a lot of ways from the civilian health care system.

However, the results of the study should be a reassurance to both health care practitioners and patients alike that indeed the P4P program seems to be also achieving its goal - quality health care.

               

R-I-N-G-G-G: your blood pressure, please?

It’s not your normal phone call. It is just like having your own assistant who reminds you to check your blood pressure and refill your prescriptions except that this is all fully automated and computerized. Researchers at the University of Montreal tried a computer-based telephone program which automatically calls hypertension patients a couple of times a week to inquire for blood pressure measurements. The readings are then recorded and passed on to the patient’s health care provider who will then analyze the data and modify the treatment regime if deemed necessary.

The study included 223 hypertension patients from different primary care clinics in Laval, Quebec. 111 of the participants were assigned to the intervention group who received “an educational booklet, a digital home blood pressure monitor, a log book and access to the telephone-linked management system.” The remaining 112 received only the booklet in addition to their usual medical care program.

The study results showed that this “simple, automated feedback system made hypertension patients more aware of their potentially fatal or disabling disease and helped them significantly lower their high blood pressure.”

The reductions in blood pressure measurements in the intervention group are:

• 11.9 millimeters of mercury (mm Hg) in systolic blood pressure
• 6.6 mm Hg in diastolic pressure

The reductions in the control group are:

• 7.1 mm Hg systolic blood pressure
• 4.5 mm Hg diastolic

The success of this computer-based phone call program can be attributed to its ease and convenience but also due to the fact that there is always someone reminding the patients what to do and as well as give feedback on how well they are doing.

In addition, this is a helpful service for those patients who aren’t too mobile and tend to be forgetful.

The next step is to find out how cost-effective is this automated intervention.

According to lead author Dr. Pavel Hamet,

“The automated blood-pressure control system could be widely accepted if it is cost-effective. The healthcare system doesn’t want to increase the cost without some benefit.”

Automated services are usually more cost-effective than manned services. In addition, if further studies can confirm that this automated phone call reminder service can prevent complications of hypertension such as stroke and kidney failure that can add to health care costs, then the health authorities might just be convinced of the system’s benefits.

               

Why African Americans are prone to hypertension

African Americans are more susceptible to stroke and other cardiovascular diseases than any other ethnic group in the US.  According to recent statistics from the American Stroke Association

• Blacks have almost twice the risk of first-ever strokes compared to whites.
• Blacks have higher death rates for stroke compared to whites.
• The prevalence of high blood pressure in African Americans in the United States is the highest in the world.
• Among non-Hispanic blacks age 20 and older, 62.9 percent of men and 77.2 percent of women are overweight or obese.
• In 2001, 27.7 percent of black or African-Americans only, used any tobacco product. Heavy cigarette smoking approximately doubles a person’s risk for stroke when compared to light smokers.
• Black women have higher prevalence rates of high blood pressure, obesity, physical inactivity, and diabetes than white women.

This recent research at the Medical College of Georgia may give us a clue to this ethnic group’s susceptibility. It seems that a natural mechanism that regulates blood pressure is missing in many African Americans who are otherwise perfectly healthy. High blood pressure is a major risk factor for cardiovascular disease. Blood pressure can be increased by stress. However, the human body has a built-in mechanism that brings down the blood pressure. This system works by excreting more salt into the urine.

According to researcher Dr. Matthew Diamond

“The way it’s supposed to work is the higher your blood pressure goes, the system is supposed to be suppressed so you urinate out more sodium and the blood pressure goes down in response.”… The renin-angiotensin-aldosterone system helps regulate blood pressure, prompting the kidneys to hold onto more salt - and fluid - if it’s too low and to get rid of salt when it’s high.

However this mechanism that regulates blood pressure does not seem to work properly in about 1 in 3 adolescent African Americans. The study looked at 168 participants aged 15 to 18 years of age. The participants were healthy, non-obese, with normal blood pressure, and were placed on diets with controlled sodium and potassium. The researchers monitored their blood pressure, urine and blood samples while the participants were exposed to environmental stress through playing video games. The results showed that the renin-angiotensin-aldosterone system worked perfectly well in adolescents who were white but was improperly suppressed in about a third of black participants.

The reason for this dysfunction cannot be easily explained but may have some genetic explanation. The researchers are now planning to “screen participants for a genetic mutation that has been linked to hypertensive kidney disease to see if that’s a factor that can be used to help identify those at risk for hypertension and kidney disease.”

May is National High Blood Pressure Education Month in the US. The results of this study may just be the key understanding why African Americans are prone to hypertension and cardiovascular disease.

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Depressed? Check your blood pressure!

The link between depression and cardiovascular health is well-known although the mechanism behind the relationship is not well-understood.

A study by Dutch researchers may just give us an idea of the complexity of that link. For one thing, contrary to the common perception that depression can lead to hypertension, depression, is, in fact, associated with low blood pressure. However, medications against depression - the so-called anti-depressants can increase blood pressure. In particular, tricyclic antidepressants (TCAs) can increase the risk for hypertension.

According lead author Carmilla Licht

“Doctors should at least be aware of a potential blood-pressure rise that could be linked to TCA use, especially for patients with cardiovascular disease or high blood pressure or others who are at risk for hypertension…They may consider meticulously monitoring these patients’ blood pressure when they prescribe one of these antidepressants or consider prescribing another antidepressant medication.”

The results of the study are somewhat controversial because they contradict the current “depression-hypertension theory.”

The study was part of the Netherlands Study of Depression and Anxiety, and followed up 2618 participants aged 18 to 65 years old. The study participants were divided into 3 groups:

• Control group without history of anxiety or depression
• Patient group with a major depressive disorder (MDD) but not on antidepressants
• Patients with MDD and on antidepressants

Patients were monitored for systolic blood pressure (SBP) and diastolic blood pressure (DBP) and distinction was made between different types of antidepressants, e.g. selective serotonin-reuptake inhibitors (SSRIs) vs tricyclic antidepressants (TCAs).

The study also observed that a typical patient with psychiatric disorder “were a little older, more likely to be female, less educated, less physically active, smoked more, and had a higher body-mass index and more diseases.”

The study results showed that compared with health controls, MDD patients have significantly lower blood pressure. However, MDD patients on TCA had significant higher blood pressure. The use of SSRIs doesn’t seem to be associated with blood pressure measurements.

So the next question is

Is it the depression that lowers the blood pressure or is it the low blood pressure that causes the depression?

The authors speculate that three things might influence the depression-low blood pressure link.

• Use of anti-hypertensive drugs
• Common causes of depression and low blood pressure, e.g. fluctuations in metabolites, hormones or neurotransmitters
• Low blood pressure can cause depressive symptoms, e.g. fatigue, dizziness, low tolerance to cold temperatures, and concentration problems.

While depression is associated with low blood pressure, the study shows that anxiety is linked to high blood pressure. This, the authors say, might be due to continuous stress associated with anxiety.

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The STITCH study: hypertension management made simple

“Less is better” might be the new strategy in treating high blood pressure, according a study by Canadian researchers. The study called “Simplified Treatment Intervention to Control Hypertension” (STITCH) was conducted by researchers at the Robarts Research Institute of the University of Western Ontario. The study followed up 2,104 participants with high hypertension, basically patients from 45 family practices in southwestern Ontario, Canada.

There are many different guidelines of the management of hypertension depending on the country and the medical group you are talking to. They can be complicated and confusing and can be challenging to both patients and doctors alike. Furthermore, they are frequently updated and amended.

The objective of the STITCH study is “to see if there are simpler ways to help patients (and their doctors) reduce their blood pressure to goal levels than by following national guidelines which can be complicated.”

The STITCH study came up with the following simplified treatment regime:

(1) initial therapy with a low-dose angiotensin-converting enzyme (ACE) inhibitor/diuretic or angiotensin receptor blocker/diuretic combination;

(2) up-titration of combination therapy to the highest dose;

(3) addition of a calcium channel blocker and up-titration; and

(4) addition of a non-first-line antihypertensive agent.

The results of the study suggest that starting with low doses of combination drug, then gradually increasing may actually be better for recently diagnosed hypertensive patients. “A half tablet of a single pill combination drug (e.g. an ACE-inhibitor/diuretic or angiotensin receptor blocker/diuretic combination) than the regular starting dose of a single drug” may actually be more effective. The results of the study will be published in the April edition of the journal Hypertension.

High blood pressure is a risk factor for heart disease and stroke. According to the most recent estimates (source: American Heart Association), one in three Americans have high blood pressure.

Aside from pharmacological therapy, lifestyle changes are necessary to prevent, manage and control high blood pressure. Some of these lifestyle changes are (Source: American Heart Association Scientiific Advisory):

• Weight Loss
• Dietary Salt Restriction
• Moderation of Alcohol Intake
• Increased Physical Activity
• Ingestion of a High-Fiber, Low-Fat Diet

Honestly, even the “simplified” treatment regime of the STITCH study doesn’t look that simple to me. I’d rather go for the lifestyle changes and got for prevention.

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Preeclampsia may not just be a temporary pregnancy complication

Preeclampsia belongs to a group of hypertensive disorders of pregnancy. Other related disorders are pregnancy-induced hypertension and toxaemia. These conditions can cause life-threatening pregnancy complications that endanger both the mother and the baby.

The conditions are all characterized by elevated blood pressure during the second half of pregnancy but in addition, preeclampsia is characterized by increased concentrations of proteins in the urine.

About 10% of pregnancies are affected by pregnancy-induced hypertension while preeclampsia affects 5 to8% of pregnancies. Preeclampsia is common in low-income countries, where it occurs in about 1 out of every 100 up to 1 out of 700 pregnancies. In contrast, it estimated to occur in about 1 in 1000 pregnancies (Source: Clinical Evidence BMJ).

Aside from high blood pressure, symptoms of preeclampsia also include “swelling, sudden weight gain, headaches and changes in vision“.

It has always been thought that once the baby is delivered, the condition of preeclampsia is resolved. Apparently not, according to this joint research by American and Danish researchers. The effects of preeclampsia may actually track through life and brings with it increased risk for future cardiovascular problems including hypertension, diabetes and blood clots. And the risks increase with every pregnancy.

According to lead author Dr. Michael J. Paidas, director of the Program for Thrombosis and Hemostasis in Women’s Health in the Department of Obstetrics, Gynecology & Reproductive Science at Yale University:

“The only reliable treatment for preeclampsia is delivery of the baby. But while delivery may ‘cure’ preeclampsia in the moment, these mothers are at high risk of chronic hypertension, type 2 diabetes mellitus and blood clots for the rest of their lives.”

There is therefore a great need to prevent preeclampsia not only to prevent complications that threaten both mother and baby, but also to prevent long-term health problems.

According to MayoClinic, preeclampsia may be caused by the following:

• Insufficient blood flow to the uterus
• Damage to the blood vessels
• A problem with the immune system
• Poor diet

The risk factors for the condition are

• First pregnancy
• Preeclampsia in a previous pregnancy
• Maternal age above 35
• Pregnancy with multiples
• Obesity
• Gestational diabetes
• Family of history preeclampsia
• Underlying medical conditions before pregnancy such as cardiovascular disease, diabetes, or kidney disorder.

Aside from medical management, lifestyle changes can also help prevent or manage preeclampsia. Previous studies, for example, indicate that preeclampsia can be prevented by exercise and intake of dietary fiber.

               

In the making: a vaccine against hypertension

You’ve heard of vaccines against polio, measles, small pox. What about a vaccine against hypertension? Last year, a paper presented at the American Heart Association Scientific Sessions reported about an investigational vaccine against angiotensin II. Angiotensin II is a vasoconstrictor agent - it causes constriction of blood vessels leading to increase in blood pressure. When a vaccine is investigational, it is still being tested and not yet ready for use.

However, this vaccine being tested by Cytos Biotechnology seems to be promising.

The name of the vaccine is CYT006-AngQb and is a virus-like particle-based conjugate vaccine. The vaccine is now tested in Phase II clinical trials. This means that the vaccine has passed through tests with animals and healthy humans without major safety problems. In Phase II trials, medications are tested in people showing the symptoms for which the drugs are indicated. In this case, CYT006-AngQb is intended for patients with mild to moderate hypertension.

Is the vaccine effective?

Preliminary results of the 2007 tests show that

“treatment with the high dose produced a significant reduction of daytime ambulatory blood pressure [BP] and a marked reduction in the early morning hours, when most adverse cardiovascular events occur.”

If approved, what would be the advantage of the vaccine over currently available antihypertensive drugs?

Well, antihypertensive drugs have to be taken on a daily basis because of their short half-life. CYT006-AngQb, on the other hand, produces extended antibody response because it has a half-life of about 4 months. That means, a hypertensive patient only needs to take medication 3 to 4 times a year.  In addition, currently available hypertensive drugs are not so effective in controlling early morning increases in blood pressure, the time of the day when major cardiac events such as heart attacks and stroke usually occur.

Even if the vaccine proves to be effective, will it be safe?

The study tested the vaccine in 72 patients with mild to moderate hypertension and followed-for 12 moths. During this period, the vaccine was observed to be well-tolerated by the study participants. There were side effects but they were mostly mild and the most common of these were headaches and irritation on the injection site.

The author, Prof. Juerg Nussberger

“Despite the fact that effective drugs are available to treat hypertension, only about one out of four hypertensive patients has the blood pressure successfully controlled. Once people are aware of the often symptomless hypertension, they have to take their medications daily, and many are apparently unable or unwilling to take pills every day for the rest of their lives. The major remaining medical need in this important therapeutic area is thus improved patient compliance. If we could support or substitute the oral therapy with a vaccine that would need to be given just every few months, I think we could achieve a better control of high blood pressure.”

The results of the study were later published in the journal Lancet.

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Risk factors for hypertension: men vs women

The National Heart Lung and Blood Institute and MayoClinic list the following as the most common risk factors for hypertension:

• Older age
• Race or ethnicity
• Overweight or obesity
• Gender
• Stress
• Lack of physical activity
• Use of tobacco
• Family history of hypertension
• High alcohol consumption
• High sodium in the diet
• Low vitamin D levels
• Low potassium in the diet

This latest study by Chinese researchers reports that risk factors can contribute differentially to the developing hypertension depending on individual’s gender. The researchers studied 834 men and 835 women aged 15 to 84 years old in an ethnically isolated group and assessed their risk factors by collecting data on lifestyle, diet, and demographics as well as performing blood tests, genotyping, and blood pressure measurements.

The differences they observed were as follows:

Prevalence of hypertension	lower in women
Awareness	lower in women
Treatment	lower in women
Mean blood pressure	lower in women (116/72 vs 119/75)

Lifestyle risk factors

As expected, age is a common risk factor both gender that cannot be altered. However, several lifestyle risk factors seem to be strongly linked to males.

Lifestyle risk factors which are specific for males are:

• Physical activity
• Alcohol consumption
• Body weight and body mass index (BMI)
• Waist circumference

A lifestyle risk factor which is specific for females is calcium intake in the diet.

Other lifestyle risk factors common to both males and females are:

• education level
• plasma lipid profile (e.g. cholesterols and triglycerides)
• dietary intakes of energy, fat, sodium, and potassium

Genetic risk factors

Gene markers also varied between males and females. Genetic polymorphisms affecting the following genes encoding:

• calpastatin
• lipoprotein lipase
• thyrotropin-releasing hormone receptor
• Willebrand factor

are specific for women.

Conversely, polymorphisms in the genes encoding the following:

• angiotensin-converting enzyme
• aldehyde dehydrogenase
• hepatic lipase

 are specific for men.

Since this study was conducted on an ethnically isolated group of people and it is not clear how the results can be extrapolated to the general population. The researchers themselves are a bit cautious with the interpretation of the data and conclude that

“Sex differences in the prevalence of hypertension in the Hei Yi Zhuang population may be mainly attributed to the differences in dietary habits, lifestyle choices, sodium and potassium intakes, physical activity level, and some genetic polymorphisms.”

Whatever future studies will show, they wouldn’t change the fact that an unhealthy lifestyle is a strong factor in getting hypertension - whether you are male or female!

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Birth weight and cardiovascular health - where is the connection?

How much did you weigh at birth? Your baby/babies? Does it matter?

A new study by British researchers published in the European Heart Journal shows that there is a link between low birth weight and predisposition to hypertension later in life.

Increasing evidence suggests that adverse prenatal environments, as indicated by low birth weight, cause long-term changes in cardiovascular physiology that predispose to circulatory disease.

The study followed up 140 healthy children aged 7 to 9 years old who were born at full-term, had a wide-range of birth weights though still considered normal. Blood pressure and heart rate (by ECG) were regularly monitored. In addition, the children were also subjected to psychological stress tests (e.g. speaking in public, mental arithmetic task) and the response in the form of cardiac impedance was measured.

The results show that there birth weight is linked to certain cardiovascular response to stress. However, the relationship is different depending on gender. Boys with low birth weights are more like to have higher vascular resistance and higher blood pressure during the stress test. In girls, this link is not evident. However girls with low birth weight tended to have higher activity of the sympathetic nervous system in response to stress. This is the part of the nervous system usually located in the spinal cord and is responsible for regulation of many processes in the body, including stress response. Both responses translate to a predisposition to cardiovascular problems later in life.

The study concludes

Smaller size at birth is associated with sex-specific alterations in cardiac physiology; boys had higher systemic vascular resistance and girls had increased cardiac sympathetic activation.

The results of this study are based on children with birth weights considered to be low, nevertheless still within a range considered normal.

Can you imagine what possible health problems premature babies with below normal birth weights can have? A baby is considered premature when born before the 37th week of gestation. Premature babies - preemies for short - tend to be smaller and weigh less than full-term babies. Several studies have shown that preemies are more likely to have health problems ranging from respiratory problems to autism

This doesn’t mean that preemies are doomed to be ill for the rest of their lives. My twins were born 5 weeks early but I didn’t resign myself to the fact that they will be just as healthy as their peers just because they were small babies. I strongly believe in the power of prevention through a healthy lifestyle. Exercise, proper nutrition, and the right attitude can make a lot of difference and I can to attest this when I look at how my boys can outrun and outcycle other kids of their age.

Still, now that the health consequences of low birth weight are known, pregnant and wanna-be pregnant women should pay closer attention to factors that can affect a fetus’ growth in the womb - and these include maternal nutrition, smoking, and alcohol consumption.

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There’s no place like home: home monitoring program for cardiovascular patients

Is home monitoring by patients with heart disease and/or hypertension a feasible alternative? According to experts and results of recent studies, there’s actually no place like home for monitoring cardiovascular patients.

 

Hypertension patients

In a recent joint scientific statement by the American Heart Association (AHA), American Society of Hypertension (ASH), and Preventive Cardiovascular Nurses Association (PCNA), experts push for more home monitoring programs of hypertension patients.

“Given the amount of accumulated evidence about the value of home blood-pressure monitoring (HBPM), it is time to make HBPM a part of routine management of hypertensive patients, especially those with diabetes, coronary heart disease, chronic kidney disease, substantial nonadherence, or a substantial white-coat effect.”

according Dr Thomas Pickering, who is a member of the scientific committee who write the statement, as quoted by heartwire.

HBPM is recommended to be a routine part of the management of hypertension, be it known or suspected. It is also recommended for those with the so-called “white-coat hypertension” because routine monitoring may detect “masked hypertension” before it becomes critical.

The committee notes that regular use of home monitoring will improve the quality as lower the cost of health care to the 72 million people with some form of hypertension. It urges the reimbursement of HBPM costs by health insurance.

The use of HBPM has gained popularity in recent years as people’s health literacy improved. According to a recent Gallup poll:

The number of patients monitoring their BP at home has increased steadily over the past 5 years, being 38% in 2000 and 55% in 2005, an increase of 17%. 

The proportion of patients owning a monitor has increased from 49% in 2000 to 64% in 2005.

Of patients who do not own monitors, 14% said that expense was the reason.

Heart failure patients

According to another study, home monitoring programs of heart failure patients may actually be more beneficial than initially thought, Health Day News reports

110 patients at the Massachusetts General Hospital in Boston were randomly divided into 2 groups. One group of 68 patients received the usual follow-up care for heart failure patients. Another group of 42 patients were monitored remotely while they stayed at home. The patients in the remote care group had remote monitoring equipment attached that measured vital signs such as heart rate, pulse and blood pressure. They also measured their weight daily and answered a questionnaire about their general well-being. When any of the remote care patients show abnormal values, a health care professional makes a house visit to make a proper assessment. The remote care program is called the Connected Cardiac Care program and was conducted by the Center for Connected Health.

After 3 months of follow-up, patients in the remote care group had much lower hospital readmission rates (31%) compared to the control group (38%). The remote care group also had lower incidence of heart-failure related admissions and emergency room visits.

In a future resource post, I will go into detail about different home monitoring programs available.

Source:

Pickering TG, Houston-Miller N, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring. Hypertension 2008.

Health Day News, 1 May 2008

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