EHR with controlled interventions can produce optimal BP control, reduce mortality

May 3 2010

Electronic health records (EHR) with controlled interventions can produce optimal blood pressure (BP) control and reduce mortality, according to data presented at the American Society of Hypertension Inc.'s 25th Annual Scientific Meeting and Exposition (ASH 2010).

As one in three American adults now have high blood pressure, improving hypertension control rates has become a top priority for healthcare organizations in the U.S. and around the world. Numerous approaches have been employed to improve blood pressure control, including increasing patient involvement, improving patient compliance, reversing physician inertia, improving life style modifications and optimizing pharmacologic therapy. The use of EHR has made it possible to follow large numbers of patients over the 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 R. Black, M.D., president of the American Society of Hypertension. "This evidence-based research is crucial, but the challenge remains how can we effectively incorporate these systems into the clinic."

In the presented studies, researchers evaluated data collected by the Veterans Health Administration EHR system. The system has integrated performance measures and specific automated reminders that prompt caregivers to control BP until levels below140/90 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.

Control of Hypertension in 15 Medical Centers from the Department of Veterans Affairs (OR-22)
In a large, eight-year study of patients from 15 separate Department of Veterans Affairs Medical Centers, researchers 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.

Investigators found that overall yearly control of BP increased by 3.7 percent per year (p <.0001; 95% CI, 3.5-4.0). At the end of the follow-up period more that 70 percent of hypertensives were controlled. At some centers control was above 80 percent. The mean percent 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: for patients <55 years of age control rates increased from 49.5% to 69.9%; for patients aged 55 to <70 from 43.6% to 70.9%; patients aged 70 to <80 increased from 43.5% to 72.3%; and patients older than 80 increased from 44.0% to 71.6% (p<0.0001 for all groups).

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 percent controlled was six percent higher in summer than winter on average (p<.0001; 95% CI, 5.7-6.5). While seasonal variation produces a winter dip in control, the effect was blunted when elevations 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 author Ross D. Fletcher, M.D., chief of staff, VA Medical Center, 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."

Optimal Blood Pressure Control and All Cause Mortality in a Clinical Practice Setting (PO-220)
A sub-study conducted in the Washington D.C. Veterans Affairs medical center 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 risk.

In the eight-year study, evaluating 42,346 patients with multiple readings, BP control (<140/90 mm Hg) increased from 44 percent to 79 percent. Investigators divided patients, based on the frequency and success of BP control, into six groups to assess mortality risk:
•G1: never hypertensive>•G2: hypertensive always controlled>•G3: BP elevated 1-25% of the time>•G4: BP elevated 26-50% of the time>•G5: BP elevated 51-75% of the time>•G6: BP elevated 76-100% of the time>

At 90 months of follow-up, mortality rates were as follows: G1: 2%, G2:6%, G3:9%, G4:9.2%, G5:10% and G6:11.2% (p<0.001 for the trend). Results were adjusted for age, sex, heart failure, diabetes mellitus, and body mass index (BMI). Comparing the optimal BP control group (G2) to poorly controlled BP control (G6), there was a 47 percent reduction in all cause mortality.

"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 researcher Vasilios Papademetriou, M.D., Veterans Affairs Medical Center, Georgetown University. "Optimal blood pressure control provided substantial improvement in mortality risk and even partial blood pressure control provided significant mortality risk reduction."

SOURCE American Society of Hypertension