Remote, Non-Physician-Led Care Cuts LDL, BP in High-Risk Patients

Patrice Wendling

November 20, 2020

A novel algorithm-based disease management program, led by pharmacists and nonlicensed navigators, optimized cholesterol and blood pressure levels in high-risk patients, according to an interim report from the first 5000 patients.

Mean low-density lipoprotein cholesterol (LDL-C) levels fell from 125 mg/dL to 73 mg/dL among those who finished active treatment titration and from 133 mg/dL to 109 mg/dL among all patients, including those who remain in active titration or dropped out (both P < .001).

The number and dosages of antihypertensive medications increased among patients, driving down the average baseline systolic blood pressure from 138 mm Hg to 124 mm Hg and diastolic pressure from 78 mm Hg to 72 mm Hg (both P < .001).

"This program provides a model to expand remote healthcare delivery and increase access to care, potentially reduce healthcare inequities, and improve healthcare quality," Benjamin Scirica, MD, said when presenting the results this week at the virtual American Heart Association Scientific Sessions.

He observed that undertreatment of hypercholesterolemia and hypertension remains a persistent clinical challenge, and that 30% to 50% of patients don't receive optimal medical treatment, despite most being generic and established in practice guidelines.

"Programs like this can improve quality metrics for value-based contracts, unburden the provider to focus on more complex care, and provide more patient education and longitudinal support," suggested Scirica, of Brigham and Women's Hospital, Boston, Massachusetts.

Between January 2018 and May 2020, the researchers screened 18,810 patients within the Mass General Brigham health system and enrolled 5000 patients with uncontrolled LDL cholesterol and/or blood pressure into either a lipid or hypertension program, or both.

Patient navigators were the primary contact with patients, ordering laboratory testing and providing education at preset intervals until treatment targets were achieved. Pharmacists prescribed and titrated medications, with supervising physicians available for additional management.

Staff were supported by an internally built software program to provide decision support, patient-relationship tasks, and communication tools like texting, Scirica explained. No in-person visits were required.

Overall, 35% of patients had established atherosclerotic cardiovascular disease (ASCVD), 25% had diabetes but no ASCVD, 32% had an LDL level greater than 190 mg/dL, and 8% were primary prevention patients at elevated cardiovascular risk. Most patients were White (71%), 55% were women, 8% didn't speak English, and 12% were older than 75 years.

At the last assessment, LDL cholesterol was reduced across all four cholesterol patient categories: ASCVD (-42 mg/dL), diabetes (-48 mg/dL), baseline LDL >190 mg/dL (-68 mg/dL), and primary prevention patients (-50 mg/dL).

Among all enrolled patients, significant gains were made from baseline in the use of any lipid-lowering therapy (from 63% to 79%), statins (60% to 75%), ezetimibe (7% to 14%), and proprotein convertase subtilisin/kexin type 9 inhibitors (1% to 2%; P < .001 for all).

Among the 1437 patients enrolled in the hypertension program, the proportion of patients on one, two, three, or four antihypertensive medications changed from 42%, 25%, 7%, and 2% at baseline to 31%, 35%, 19%, and 5% after completing active titration, according to the study, also published online in the journal Circulation.

When surveyed, more than 90% of patients said they were satisfied or very satisfied with the program, Scirica said in a press briefing.

"They just liked talking to people and it doesn't just need to be a doctor, it turns out," he said. "To have that connection, especially for a lot of the patients we seen in chronic cardiovascular disease, who many not have the greatest digital literacy, the telephone still is one of the strongest telehealth tools that we have."

Satisfaction was also high among clinicians, he observed. "Many primary care doctors were happy to have some of these management decisions taken off their plate, so they could focus on other things."

AHA president-elect Donald Lloyd-Jones, MD, ScM, Northwestern University Feinberg School of Medicine, Chicago, Illinois, pointed out that this isn't the first study to show that taking providers out of patient management results in better patient outcomes and satisfaction for everyone.

"Getting providers out of that equation really frees them up to do the more high-level work of diagnosis, setting treatment plans, and it really does allow patients more interaction with people who have the time to talk," he said during the briefing. "So it's a win-win."

Karen Joynt Maddox, MD, MPH, Washington University School of Medicine, St. Louis, Missouri, said one barrier to the program being implemented more broadly is that it's typically not paid for. "Here we have solutions where it's good for patients, it's good for the physicians, it's good for the system, but most of the ways we pay for care require a patient to be physically in a doctor's office."

Nonetheless, Joynt Maddox was excited about the potential for innovative programs like this to disrupt the traditional care model and impact health equity.

"We are developing ways to potentially reach patients who have not previously been reached by the healthcare system," said Joynt Maddox, who was not associated with the Boston team's research report. "And I don't think we can state strongly enough: If we use these things toward equity, what a crucial tool this could be for reducing inequities in healthcare."

The program was supported by Mass General Brigham and AllWays Health Partners. Scirica reports institutional grants through Brigham and Women's Hospital from Pfizer, Merck, Eisai, NovoNordisk, and Novartis; consulting fees from AbbVie, Allergan, AstraZeneca, Boehringer Ingelheim, Eisai, Esperion, Hamni, Lexicon, Medtronic, Merck, and Novo Nordisk; and has equity in Health at Scale. Joynt Maddox reports other research support from the US Department of Health and Human Services, and research grants from the National Heart, Lung, and Blood Institute, National Institute of Aging, and Commonwealth Fund. Lloyd-Jones has disclosed no relevant financial relationships.

Circulation. Published online November 17, 2020. Research Letter

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