Conference Coverage

Can case management cut hypertension’s consequences?



A 4% drop in all-cause mortality occurred in case-managed patients with hypertension who received phone calls, care coordination, and coaching from a nurse case manager, according to a retrospective population-based cohort study of almost 85,000 patients with hypertension.

The reduction yielded a hazard ratio for all-cause mortality of 0.504, with a number needed to treat (NNT) of 25 (P less than .05).

Dr. Esther Yu of the University of Hong Kong Kari Oakes/Frontline Medical News

Dr. Esther Yu

Significant reductions were also seen in the rates of end-stage renal disease and cardiovascular disease (HR, 0.710 and 0.836, and NNT, 222 and 46, respectively; P less than .05 for all), said Esther Yu, MD, presenting 3 years’ worth of data from the Hong Kong–based study during the annual meeting of the North American Primary Care Research Group (NAPCRG).

Service utilization also decreased for those participating in the intervention, compared with those receiving usual care: Hospitalizations fell by 7 per 100 patient-years, with greater reductions seen in emergency department, specialist, and primary care utilization (P less than .05 for all).

At the time the study was conceived, the Hong Kong Hospital Authority cared for about 200,000 hypertensive patients, of whom more than 40% hadn’t achieved the target blood pressure of less than 140/90 mm Hg, said Dr. Yu.

Dr. Yu of the department of family medicine and primary care at the University of Hong Kong said there are challenges in bringing more hypertension patients into good blood pressure control in Hong Kong. These include the “idiosyncratic practice” of some frontline physicians, who also often have limited time for patient consultations and only limited access to the services of allied health professionals to help them in their work. Patient adherence, she said, is also an issue.

To tackle these persistent high rates of patients whose blood pressures remained too high, Dr. Yu and her colleagues at the Hospital Authority launched the Risk Assessment and Management Program – Hypertension (RAMP-HT) in 2011. The program, she said, is an “evidence-based, structured, protocol-driven, multidisciplinary program” that includes risk assessment and screening for complications, and uses a risk-guided management approach.

Patients in RAMP-HT received interventions according to a matrix for risk management of patients with hypertension. Patients with a blood pressure between 140/90 and 160/100 mm Hg who were assessed as being low and medium risk according to the Joint British Societies guidelines for cardiovascular risk continued to receive management from their primary care physician. High-risk patients with blood pressure in this range also received a statin if their low-density lipoprotein cholesterol level was suboptimal.

Patients whose blood pressure was at least 160/100 mm Hg were followed by a RAMP-HT nurse. For those with this degree of blood pressure elevation who were already on at least three antihypertensive medications, specialty appointments were also arranged.

Other targeted interventions were also available to participants, including the services of dietitians and physical therapists for those with a body mass index (BMI) of at least 27.5 kg/m2; smoking cessation and mental health services were also available, as appropriate.

After 3 years, those participating in the RAMP-HT program (n = 79,116) were compared with those in the usual care group (n = 43,901). In both arms, adult patients with complete data and without preexisting cardiovascular disease, diabetes, or end-stage renal disease were included. In each group, about 58% of participants were female, and the mean age was about 65 years.

Primary outcome measures included the incidence of cardiovascular disease, an outcome that included coronary heart disease, heart failure, and stroke; end-stage renal disease; and all-cause mortality. The significant reductions in these measures for the RAMP-HT group remained after multivariable analysis accounted for sex, age, smoking status, renal function, lipid values, BMI, comorbidities, and antihypertensive and lipid-lowering medication use.

The reduced care utilization seen among RAMP-HT participants also persisted after multivariable analysis for these potential confounders.

Dr. Yu said the systematic, protocol-driven program was a primary strength of RAMP-HT. The key to the program was use of nurses to provide patient education and physicians and allied health resources only as needed, she said; the program reinforced the importance of self-management and adherence because patients heard a unified message from many different health care professionals.

However, lifestyle factors such as diet and exercise weren’t tracked, and the retrospective study design introduced the potential for some bias, she said. In ongoing work, the long-term efficacy and cost-effectiveness of the RAMP-HT program are being tracked.

Dr. Yu reported that the study was funded by the Hong Kong Health and Medical Research Fund. She reported no relevant conflicts of interest.

SOURCE: Yu, Esther et al. NAPCRG 2017, Abstract HY33.

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