Tuesday, July 9, 2013

Another Randomized Controlled Clinical Trial Proves Outsourced Population Health Care Management Works: Hypertension

Here's another high quality randomized controlled clinical that confirms the benefits of outsourced care management.

Margolis and colleagues accessed Minnesota's HealthPartners' electronic records to identify all patients who had had two sequential primary care clinic blood pressure readings that were more than 140 systolic or 90 diastolic.  These patients with hypertension were asked by letter and then phone calls to participate in the research trial.  Those who agreed were rechecked by research assistants who re-measured the blood pressures to confirm the hypertension.

16 clinics participated. 8 were assigned to the intervention group. 8 served as comparison (control) "usual care" clinics that relied on usual physician care.

In the intervention clinics, a pharmacist interviewed each patient and sought agreement to lower the blood pressure by 5 points. The patients received a home BP monitor that transmitted data to AMCHealth six times a week. The pharmacist and patient met by telephone every 2 weeks. Based on the BP monitoring and the telephone interviews, the pharmacist used a standardized medication algorithm to adjust medications until control was achieved for 6 weeks.  Telephone calls were then reduced in frequency to monthly.

The research assistants reassessed the participants' blood pressures at 6, 12 and 18 months.

Over 14,000 patients were identified and 2020 agreed to be screened. 450 met criteria for persistently elevated blood pressures. 228 were cared for in the intervention clinic and 220 were cared for in the usual care. The mean age was 61 years, 45% were women, 82% were white and 48% had a college degree. The average blood pressure was 148/85.

Both groups had a similar frequency of follow-up visits. 380 patients had completed both 6 and 12 month follow-up visits with the research assistants. 

The proportion of patients with controlled BPs at both visits in the intervention clinics was 57.2% vs. 30% in the control clinics. If those patients lost to follow-up were counted as blood pressure "failures," the success rate was 48.5% vs. 25.1%. Both sets of measures were statistically significant.  The relative proportions held up at 18 months.

Unsurprisingly, intervention patients were taking more medications over the duration of the study and at 6 months were statistically more significantly more likely to report that they were taking them. 

Six patients in the intervention group vs one in the control group had "events" related to low blood pressure, dizziness and loss of consciousness.

The cost, based on pharmacist time, was $1350 per patient.

The Disease Management Care Blog's take:

This adds to a growing body of evidence that non-physicians working under clinical protocol side-by side with busy primary care physicians can achieve control of a chronic condition - in this instance, hypertension.  This is a core attribute of population health.

Another piece of good news is the emergence of the electronic health record as a means to identify patients who are program candidates.  Now that's "meaningful."

The bad news:

The cost was $1350.  It is unlikely that those direct costs were mitigated by hypertension-related "savings" within the same fiscal year.  On the other hands, thinks the DMCB, the use of other types of non-physicians with or without IT-based decision support and higher throughput could lessen that cost.  The DMCB is sure that the population health service providers are already on it.

Even with state of the art population health, the rate of hypertension control was ultimately 50%.

A small excess of participants experienced an excess of treatment side effects.  While this may be the inevitable consequence of more aggressive treatment, it could expose the program to liability.

This was Minnesota: we don't know if this would work in, say, Los Angeles.  This needs to be tested elsewhere.

Image from Wikipedia

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