Remote Non-Physician Care Helps BP,
LDL Control

Marlene Busko

November 29, 2021

An ongoing remote digital care program to manage hypertension and hypercholesterolemia delivered by non-physicians can be effective, results from the first 10,000 patients demonstrate.

Lead investigator Alexander J. Blood, MD, reported these study findings in a late-breaking session at the virtual American Heart Association (AHA) 2021 Scientific Sessions.

Researchers delivered promising interim results in 5000 patients at last year's meeting, as previously reported and published.

Patients were identified by electronic health record (EHR) screening or primary care clinician referral. They were given home blood pressure cuffs and received phone calls from non-licensed patient "navigators" who provided educational information and ordered lab tests; pharmacists initiated and titrated medicines — all without in-person patient visits.

In the current study, at 3 months, 40% of patients in the lipid management program and 44% of patients in the hypertension management program had attained maintenance levels of low-density lipoprotein cholesterol (LDL-C) and blood pressure; 92% of these patients were at their target levels and the rest were close.  

"The program effectively improves hypertension and LDL-cholesterol in high-risk patients [and] reduces the need for in-person visits and physician time," Blood, a research fellow at Brigham and Women's Hospital in Boston, Massachusetts concluded.

The findings also reaffirm difficulties in maintaining patients in a long-term program, even if it's free, he added. At the same time, this remote program was equally effective in patients who were not tech savvy or English speaking.

"The program has the potential to expand remote healthcare delivery, increase access to care, reduce health inequities, and improve healthcare quality," Blood said.

High Satisfaction Among Patients, Physicians

Among the patients who reached maintenance levels, average blood pressure dropped from 145/84 mm Hg to 135/78 mm Hg, and average LDL-C decreased from 140 mg/dL to 70 mg/dL, from baseline to 3 months.

"Starting a high-intensity statin will lower LDL by 50% and up-titrating and adding blood pressure medications will lower blood pressure by this amount," so these findings were not surprising, senior author Benjamin M. Scirica, MD, MPH, explained to | Medscape Cardiology in an email.

This study confirms that "we have incredible therapies, mostly generic, that can substantially lower cardiovascular risk," said Scirica, director of quality initiatives at Brigham and Women's Hospital's Cardiovascular Division, and associate professor, Harvard School of Medicine, Boston.

"The challenge," he added, "is the 'last mile' dilemma of all medical therapy: how do we identify, engage, motivate, and treat these patients more effectively with guideline-directed therapies?"

With this program, "we receive high patient satisfaction scores from patients and their primary care providers who are relieved to receive help in managing chronic diseases," he said.

Shared Decision-Making

The study showed that "the use of information technology may be a beneficial means of controlling risk factors, especially in patients with limited access to ongoing medical care," assigned discussant Keith C. Ferdinand, MD, told | Medscape Cardiology in an interview.

"The main barrier will be ensuring that devices such as blood pressure monitors will be cost-effective for disadvantaged persons," said Ferdinand, professor of medicine and endowed chair in preventive cardiology at Tulane University School of Medicine, New Orleans, Louisiana.

"Shared decision-making is the best means of ensuring adherence to pharmacotherapy in the general community," he added.

"This is a very nice response in the patients who participated — the issue was that it took a number of calls," some 100,000 calls for 10,000 patients, "and patients did not stay in as long as we would have liked to see," Donald M. Lloyd-Jones, MD, incoming president of the American Heart Association, told | Medscape Cardiology in an email.

"It is a good approach with use of the EHR to identify potentially eligible patients and then use of pharmacists and patient navigators to assist patients with control of BP and cholesterol," added Lloyd-Jones, chair of preventive medicine and professor at Northwestern University Feinberg School of Medicine, Chicago, Illinois.

"It is replicable, but obviously labor intensive and patients may not stick with it," as they observed, he said. "Still, it is better than what physicians achieve given their many distractions, so this warrants further attempts and refinement as an approach."

Tech Savvy Not Required

About 30% to 50% of patients do not receive optimal medical treatment for hypertension and hypercholesterolemia, even though most treatments are generic, Blood noted.

Their program aimed to improve this while ensuring equitable access to care.

"Many patients are not comfortable with apps and smartphones and for them we use standard telephone calls and the cellular BP devices that don't require any setup," Scirica said.

"For more tech-savvy patients, we use text, emails, or secure patient messaging, based on their preference."

Navigators who spoke Spanish or Creole and translators who spoke other languages were available. The educational materials were multilingual.

"With this approach," he said, "we can (and do) reach a broad spectrum of the population including the elderly, non-English speakers, and traditionally underserved communities."

Between January 2018 and October 2021, the researchers screened 28,473 patients and enrolled 6887 of these in the lipid program and 3367 patients in the hypertension program (some patients were enrolled in both). Participants did not have to pay for the program.

A total of 12% of the patients were older than age 75 years, 55% were female, 29% were non-White, and 8% were non-English speaking.

In the lipid group, patients either had established atherosclerotic cardiovascular disease (ASCVD), diabetes (no ASCVD), LDL >190 mg/dL (no ASCVD or diabetes) or were being given primary prevention because they were at high risk — with roughly 25% of patients in each of the four categories.

The navigators and pharmacists followed treatment titration algorithms and goals based on current AHA/American College of Cardiology (ACC) guidelines.

At 3 months, 40% - 44% of patients reached maintenance; and the rest were still in active titration (15% - 23%), or were unreachable, had withdrawn, or had been referred to a specialist (37% - 41%).

The findings were similar in the non-White and non-English speaking subgroups.

Care for 10,000 patients involved making more than 100,000 phone calls, obtaining more than 424,000 blood pressure values, doing greater than 74,000 LDL-C lab tests, and issuing close to 28,000 new prescriptions. "Patients are asked to send 8 to 12 blood pressure readings per week during titration and they often send more," said Scirica.

Looking Ahead

"The remote digital care program is ongoing in several different areas in our health system and through our insurance partner, Always Health Partners Insurance, who markets this as iHeartChampion." Scirica explained.

There are a few similar programs from other healthcare providers (Oschner, Mount Sinai) and many commercial products. "Our ability to use multiple communication channels lowers the 'digital divide' and expands access to a broad population," he added.

"We are dedicated, and actively working, to expand our program outside of our health system as we feel it offers a valuable solution for the national healthcare crisis of underdiagnosis and undertreatment of chronic cardiovascular diseases," Scirica concluded. "Currently, all our patients are Massachusetts residents, but we are looking to expand."

The program was funded by Mass General Brigham and Always Health Partners Insurance. Blood received a grant from the National Institutes of Health. Scirica discloses receiving grants from Pfizer, Merck, Eisai, NovoNordisk, and Novartis; consulting fees from AbbVie, Allergan, AstraZeneca, Boehringer Ingelheim, Eisai, Esperion, Hamni, Lexicon, Medtronic, Merck, and NovoNordisk; and has equity in Heath at Scale and Doximity. Ferdinand discloses that he is a consultant for Novartis, Medtronic, Eli Lilly, and was part of the National Hypertension Control Initiative (NHCI) Advisory Group, and the Data and Safety Monitoring Board of the LA Barbershop Study.

American Heart Association (AHA) 2021 Scientific Sessions: Session LBS.02. Abstract. Presented November 13, 2021.

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