The scope of remote healthcare in hypertension and hyperlipidaemia

 

A remote, algorithm-driven programme with over 10,000 enrolled participants was able to reduce hypertension and LDL cholesterol in patients with a high risk for cardiovascular events. The programme may reduce the need for in-person visitations. Moreover, the remote programme could provide equitable care across underserved populations. Physician’s Weekly spoke with Dr Alexander Blood (Brigham and Women’s Hospital, MA, USA), the first author of the current study. The results of the remote healthcare programme were presented as a late-breaking abstract during the 2021 virtual meeting of the American Heart Association Scientific Sessions, 13–15 November [1].

Dr Blood and colleagues developed a remote programme to improve hypertension and lipid control, with an emphasis on equal healthcare distribution across subgroups. Patient navigators, pharmacists, and digital technology were integrated into the programme’s model using a remote care delivery platform. In total, 6,887 patients were included in the lipid programme and 3,367 patients entered the hypertension programme. Approximately 40% of participants in either group completed the programme.

Systolic blood pressure (BP), in mmHg, was reduced at the last measurement of the study (mean 135) compared with baseline (mean 145; P<0.0001) in all patients who were enrolled in the hypertension programme. This effect was more pronounced in patients who completed the programme (mean 125 vs mean 137; P<0.0001). Similarly, diastolic BP was significantly decreased at the latest BP measurement of the study compared with baseline. In addition, 92% of the patients who completed the programme reached their guideline-recommended BP goals. Subgroup analysis demonstrated that the effect was consistent across ethnic groups, with equal proportions of subgroup populations achieving study completion. This result suggests that traditionally underserved subgroups benefit equally from the current programme.

The lipid programme showed a reduction of LDL cholesterol, in mg/dL, at the latest performed measurement (mean 100) compared with baseline (mean 145; P<0.0001). Again, this effect was more pronounced in patients who completed the programme (mean 70 vs mean 140; P<0.0001). Reductions in LDL cholesterol were also similar across subgroups.

Physician’s Weekly interviewed Dr Blood to discuss the possibilities of this novel algorithm-driven healthcare programme.

Physician’s Weekly: Could you explain the remote healthcare programme that was developed for the current study?

We were aiming to provide an end-to-end service model to move the needle for a large population of patients with hypertension or hyperlipidaemia. The model managed patients with these chronic diseases remotely, on a large scale. We consider our study to be a clinical implementation study, analogous to a warfarin clinic or dialysis clinic, in which information is communicated back to primary care.

Patients received a connected blood pressure cuff, via which data was sent to their electronic health record. Subsequently, patients received the best recommendation based on lab values, demographics, and medical history. If needed, therapy could be initiated, intensified, and monitored. For safety reasons, lab values were continuously monitored. Besides this, the process was fairly flexible.

We could initiate a new line of therapy for a couple of weeks and monitor adverse events and blood pressure. The data was integrated, and the effectiveness of the therapy was analysed. Subsequent decisions were made based on these results. In addition, regular follow-up was important to make sure that patients were adherent to therapy and optimised the use of combination pills. By prescribing generic medicine and using our patients' preferred pharmacies we reduced the costs and effort for our patients. In addition, diet and lifestyle recommendations were part of the package. We provided advice for every patient that entered the programme. The overall goal was to help patients reduce their overall cardiovascular risk and help them to achieve their guideline-directed targets.

Physician’s Weekly: What are the main advantages and disadvantages of this approach?

Importantly, our approach was not onerous on the patients or the providers. One of the major challenges for patients is getting to a healthcare facility. It takes time, effort, and money. With the current approach, we met patients where they were. If a patient had given permission to use emails or text messages, the appropriate healthcare could be delivered almost completely asynchronously. Patients measured their blood pressure when they were able, at home, or at the workplace. That data automatically gets integrated and sent over to us.

Next, approximately 80–90% of the people who completed our programme reached their guideline-recommended targets. In addition, when we monitor these patients in maintenance, they may remain at their targets in the long term. I think our study has shown that we can unburden the system and manage a large volume of patients with our approach. Moreover, since most individuals around the world have access to a mobile phone and telephone calls have been our default communication option, this approach could be scaled up to a much greater capacity. Notably, I think that our approach can deliver guideline-directed care to patients with limited access to healthcare facilities, thereby reducing barriers and disparities in care.

On the downside, our system is not the perfect solution for a hundred percent of the patients. Not all patients are comfortable using text messages, secure patient gateway email, or telephones. In 5–10% of the cases, we need to rely on traditional outpatient visitations.

Physician’s Weekly: What was the role of the so-called navigators that were part of the programme?

The navigators were unlicensed, mostly college-educated individuals with an interest in medicine. They received a tailored training from pharmacists and clinicians to answer the most frequently asked questions by our patients. There was always a pharmacist or clinician available to answer the complicated or unfrequently asked questions, but the navigators were the first line of contact.

Physician’s Weekly: Were there other control mechanisms installed in the programme?

Next to the navigator-pharmacist-clinician axis, the software we used is designed to detect irregular patterns in a patient’s profile. The pharmacist or clinician can respond to these signs if needed. Furthermore, weekly meetings were organised to review all patients who were in the system and getting therapy. All the prescriptions, lab values, and adverse events were addressed and controlled. Finally, a daily report was conducted on the approximately 420,000 blood pressure measurements that came in. A nurse practitioner monitored this report and controlled for divergent blood pressures. Subsequently, outlying values could be addressed by the clinician.

 

1. Blood AJ, et al. Digital Care Transformation: Report from the First 10,000 Patients Enrolled in a Remote Algorithm-based Cardiovascular Risk Management Program to Improve Lipid and Hypertension Control. LBS02, AHA Scientific Sessions 2021, 13–15 November.

Posted on 30 November, 202124 January, 2022