A remotely delivered, home-based hypertension and lipid program using nonlicensed navigators and licensed pharmacists led to reductions in blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) in a single-center cohort study of more than 10,000 patients.
A few of the study findings were surprising, Benjamin M. Scirica, MD, MPH, of Brigham and Women’s Hospital and Harvard Medical School in Boston, told theheart.org | Medscape Cardiology.
“First, patients want to engage in conversations about their health and talk about treatment options, but it doesn’t have to be with a doctor. Our nonlicensed navigators, mostly recent college graduates, are the ‘face’ of our program and able to form therapeutic relationships with patients to help them improve their care.”
It was also very important to minimize technology requirements for patients, he said. “We specifically did not require any patient-facing apps but relied on technology patients were used to using ― telephone, texting, or email ― and in their preferred language to ensure easier communications.
“Clinically, it was encouraging to see how effective generic drugs [are] across multiple populations,” he added. “And it is just amazing all that advanced-practice pharmacists can do — they were the cornerstones of the program.”
Nevertheless, many patients dropped out of the program during the 1-year follow-up period, he acknowledged. “Like all implementation programs, maintaining continued engagement is a challenge that will require more study and ingenuity.”
The study was published online November 9 in JAMA Cardiology.
Education Alone Not Effective
The team enrolled 10,803 patients (mean age, 65; 58% women) in the remote hypertension and cholesterol management program: 3658 with hypertension, 8103 with hypercholesterolemia, and 958 with both conditions.
Seventy-two percent of patients identified as White; 12% as Black; 11% as Hispanic; and 16% as another or multiple races. Eleven percent reported a preferred language other than English.
The remote program included education, a home BP device that automatically sent measurements, and medication titration. Nonlicensed navigators and pharmacists, supported by cardiovascular clinicians, coordinated care using standardized algorithms, task management and automation software, omnichannel communication, and active BP monitoring.
A total of 1266 participants (about 12%) requested education only.
Altogether, 424,482 BP readings and 139,263 laboratory reports were collected.
The mean office BP prior to enrollment was 150/83 mm Hg, and the mean home BP was 145/83 mm Hg.
For those who consented to remote medication management, the mean clinic BP decreased by 8.7/3.8 mm Hg at 6 months and by 9.7/5.2 mm Hg at 12 months.
For those who received education only, BP changed by a mean -1.5/-0.7 mm Hg at 6 months and by +0.2/-1.9 mm Hg at 12 months.
The median time in the hypertension program was 103 days. At the time of data lock, 524 patients remained active in the program, 1064 were unreachable, 302 had returned to their primary care physician because of adherence problems or communication challenges, 276 had dropped out, and 1492 had achieved their goal and had entered maintenance.
In the lipids program, patients enrolled in remote medication management experienced a mean reduction in LDL-C of 35.4 mg/dL at 6 months and 37.5 mg/dL at 12 months. Education-only patients experienced a mean LDL-C reduction of 9.3 mg/dL at 6 months and 10.2 mg/dL at 12 months.
The median time in the lipids program was 131 days. At the time of data lock, 1572 patients remained in the program, 2528 were unreachable, 817 had dropped out of remote management, 433 had returned to their primary care physician because of adherence problems or communication challenges, and 2753 had achieved their goal and had entered maintenance.
Rates of BP and LDL-C reductions were similar across racial, ethnic, and primary language groups.
“We built our care-delivery platform with the goal that it can scale inside and outside the Mass General Brigham health system,” Scirica noted. “All can be done without technology, but to be able to scale effectively, we developed a technology platform outside our EHR [electronic health record system] that includes customer-relationship software and omnichannel communication tools to allow better tracking, communication, and analytics.”
Beth Abramson, MD, co-chair of the American College of Cardiology’s Hypertension Work Group and the Paul Albrechtsen Professor in Cardiac Prevention and Women’s Health at St. Michael’s Hospital, University of Toronto, commented on the study for theheart.org | Medscape Cardiology.
“This is an exciting opportunity for us to address the challenge of treating hypertension in our patients because it’s looking at it from a broader systems approach,” she said. “We have to think about working as a team in treating high blood pressure. While individual clinicians are important, we need to think beyond that and work with pharmacists and healthcare navigators to really realize reductions and, ultimately, cardiovascular events.”
Although the study was not randomized, “it is a very pragmatic evaluation that provides useful real-world information,” she said. However, the findings may be “slightly more magnified” because the patients self-selected, in comparison with what the findings might have shown had the program been offered to the population at large.
Challenges to implementation will be how to appropriately involve navigators and pharmacists in patient care and how to fund such programs, Abramson said. “How will we move from fee-for-service or private payer to paying for effective care that uses a team approach? That will be a larger challenge that we’re all going to have to deal with as we rethink how to provide best practices in preventive cardiology.”
Similarly, Neha J. Pagidipati, MD, MPH, of Duke University, in Durham, North Carolina, and Eric D. Peterson, MD, MPH, of UT Southwestern, in Dallas, Texas, write in a related editorial, “It remains to be seen whether clinicians in community- and private-practice settings will accept a program that may lower professional compensation (from fewer in-person visits) in exchange for lessening care responsibilities (and perhaps achieve better control rates in their patients).”
Operational costs for the study were supported by Mass General Brigham and Allways Health Plan. No relevant commercial relationshps were reported.
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