Electronic Records May Help Improve BP Control
NEW YORK—New findings suggest that electronic health records (EHR) with special features for managing hypertension may be highly beneficial in improving BP control.
Numerous approaches have been employed to improve BP control, including increasing patient involvement, improving patient compliance, reversing physician inertia, improving lifestyle modifications, and optimizing pharmacologic therapy. The use of EHR has made it possible to follow large numbers of patients long term and monitor the impact of these interventions.
“Despite the proven benefits of blood pressure treatment and control, effective clinical models to control hypertension remain elusive,” said Henry Black, MD, President of the American Society of Hypertension. “This evidence-based research is crucial, but the challenge remains [as to] how can we effectively incorporate these systems into the clinic.”
In studies presented at the meeting, researchers evaluated data collected by the Veterans Administration (VA) EHR system. The system has integrated performance measures and specific automated reminders that prompt caregivers to control BP until levels below 140/90 mm Hg are achieved. All vital signs recorded in each facility are available in a common database allowing analyses to be made using actual BP readings.
In a large, eight-year study of patients from separate VA medical centers, investigators assessed the effect of organized interventions to control BP. The study population included 478,191 hypertensive patients (BP above 140/90 mm on three separate days) and 173,946 patients with normal BP.
The researchers found that overall yearly control of BP increased by 3.7% per year. At the end of the follow-up period more than 70% of hypertensives were controlled, and at some centers control rates were above 80%. The mean percentages of controlled patients increased across all ethnic groups (from 52.9% to 64.5% in African Americans; 55.4% to 73.0% in Caucasians; and 49.3% to 74.6% in Hispanics). Control rates also improved across all age groups. Control rates increased from 49.5% to 69.9% for patients younger than 55 years; 43.6% to 70.9% for patients aged 55-70 years; 43.5% to 72.3% for those aged 70-80 years; and 44% to 71.6% for subjects older than 80 years.
When closely monitoring BP control over time, comparing winter and summer readings can show misleading improvement or worsening because of seasonal variations in BP, especially among hypertensives. Accordingly, investigators specifically analyzed seasonal variation in control rates and found that the percentage of controlled patients was 6% higher on average in the summer than in the winter. While seasonal variations produce a winter dip in control, the researchers found the effect was blunted when evaluations were rapidly brought under control using revisits to clinics every two weeks.
“With the use of a uniform system for controlling blood pressure aimed at the blood pressure level itself, organized interventions produced high rates of control in all ethnic and age groups in all cities,” said study investigator Ross Fletcher, MD, Chief of Staff at the VA Medical Center in Washington, D.C. “However, while a computerized system helped evaluate the rates of control, it remains the caregiver's responsibility to determine the appropriate interventions for each individual patient.”
In a separate sub-study conducted at this medical center, researchers evaluated the impact of optimal BP control on mortality. Investigators found that a user-friendly, searchable, computerized patient record system (CPRS) could help achieve high rates of BP control and be maintained long-term to provide substantial improvement in mortality.
In the eight-year study that evaluated 42,346 patients with multiple readings, BP control increased from 44% to 79%. Investigators then divided patients based on the frequency and success of BP control into six groups to assess mortality risk (Group 1: never hypertensive (4,459 patients); group 2: hypertensive always controlled (1,305 patients); group 3: BP elevated 1%-25% of the time (8,160 patients); group 4: BP elevated 26%-50% of the time (9,444 patients); group 5: BP elevated 51%-75% of the time (8,045 patients); and group 6: BP elevated 76%-100% of time (8,045 patients).
At 90 months of follow-up, mortality rates were 2%, 6%, 9%, 9.2%, 10%, and 11.2% in groups 1, 2, 3, 4, 5, and 6, respectively. After adjusting for age, gender, BMI and the presence of heart failure and diabetes mellitus, the group with optimal BP control (group 2) had a 47% reduction in all-cause mortality compared with the poorly controlled BP group (group 6).
“We conclude that high rates of blood pressure control can be achieved in a usual clinical practice setting and can be maintained long-term,” said lead investigator Vasilios Papademetriou, MD. “Optimal blood pressure control provided substantial improvement in mortality risk and even partial blood pressure control provided significant mortality risk reduction.”
Franz Messerli, MD, Professor of Medicine at Columbia University in New York, said the findings from these studies are important because they suggest that automating health care can significantly help improve the management of hypertension. “It can help for looking at compliance by the patients, and compliance is still a major issue and many patients miss doses. This will allow us to see what the pharmacists are dispensing and what the patients are achieving.”