Paloma Cesar de Sales, BN, RN, MS

Study Overview

Objective. To determine whether nurse-managed protocols are effective for the outpatient management of adults with diabetes, hypertension, and hyperlipidemia.

Study design. Systematic review and meta-analysis.

Data sources. The authors searched MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL for English-language peer-reviewed studies published between January 1980 and January 2014 that evaluated interventions that compared nurse-managed protocols with usual care in investigations targeting adults with chronic conditions. Two reviewers used eligibility criteria to assess titles, abstracts, and full texts, and resolved their disagreements by discussion or by consulting a third reviewer. Eligibility criteria included the involvement of an RN or LPN functioning beyond the usual scope of practice, such as adjusting medications, and conducting interventions based on a written protocol.

Main outcome measures. The effects of nurse-managed protocols on biophysical markers, patient treatment adherence, nurse protocol adherence, adverse effects, and resource use. When quantitative synthesis was feasible, dichotomous outcomes were combined using odds ratios and continuous outcomes were combined using mean differences in random-effects models. When quantitative synthesis was not feasible, the authors annualized data qualitatively, giving more weight to evidence from higher-quality studies. They evaluated overall strength of evidence (SOE) by assessing risk of bias, consistency, directness, and precision, and assigned a rating of high, moderate, or low SOE, or insufficient evidence.

Main results. Of the 2954 studies in the search results, 18 were ultimately eligible and included in the review, 16 randomized controlled trials and 2 before and after diabetes studies. Eleven were done in Western Europe and 7 in the United States. An RN or non-US equivalent was the interventionist in all studies (none used an LPN). In only 11 of the 18 studies were nurses independently allowed to initiate new medications. The meta-analysis found that hemoglobin A1c (HbA1c) level decreased by 0.4% (moderate SOE) (95% confidence interval {CI}, 0.1% to 0.7%) (n = 8), systolic and diastolic blood pressure decreased by 3.68 mm Hg (CI, 1.05 to 6.31) and 1.56 mm Hg (CI, 0.36 to 2.76), respectively (moderate SOE) (n = 12); total cholesterol level decreased by 9.37 mg/dL (20.77-mg/dL decrease to 2.02-mg/dL increase) (n = 9); and low-density-lipoprotein cholesterol level decreased by 12.07 mg/dL (CI, 28.27-mg/dL decrease to 4.13-mg/dL increase) (low SOE) (n = 6). The SOE was insufficient to estimate a treatment effect for all other outcomes.

Conclusion. A team approach that uses nurse-managed protocols may have positive effects on the outpatient management of adults with chronic conditions such as diabetes, hypertension, and hyperlipidemia.

Commentary

Hypertension, diabetes, and hyperlipidemia are major causes of morbidity and mortality worldwide and are widely prevalent in the United States. These chronic illnesses require long-term medical management, often requiring management of multiple medications and patient lifestyle changes and self-monitoring [1]. The patient-centered medical home, which involves a team approach, is increasingly being recognized as a promising model for delivering effective chronic disease care. Likewise, expanding the role of nurses as part of team care is increasingly being explored to help achieve high quality patient outcomes. The use of nurse-managed protocols can be an appropriate strategy in this scenario.

In this study, the researchers aimed to determine whether nurse-managed protocols are effective for outpatient management of adults with diabetes, hypertension, and hyperlipidemia and performed a systematic review and meta-analysis. Researchers followed a standardized procedure to conduct their search and carefully reviewed the studies, including contacting authors for missing data or clarification. They followed the approach recommended by the Agency for Healthcare Research and Quality (AHRQ) to evaluate the overall strength of the body of evidence [2].

However, some limitations must be taken into account. They acknowledge that they may have missed studies in which nurses had autonomy to practice in capacities beyond their scope of practice. In addition, the literature lacked details about the interventions and protocols used. Also, the researchers searched for studies across a 34-year range (1980–2014). Changes occurring in the nursing profession over these years may have impacted the findings.

Applications for Clinical Practice

Team-based care that includes nurse-managed protocols for titrating medications can be beneficial in the management of chronic conditions in primary care patients. With physician shortages predicted, which will impact primary care more than other specialties, team approaches using nurse-managed protocols have the potential to help lighten physician workloads and ensure quality care.

                                                                                                                                                                                                                                    —Paloma Cesar de Sales, BN, RN, MS

Study Overview

Objective. To determine whether nurse-managed protocols are effective for the outpatient management of adults with diabetes, hypertension, and hyperlipidemia.

Study design. Systematic review and meta-analysis.

Data sources. The authors searched MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL for English-language peer-reviewed studies published between January 1980 and January 2014 that evaluated interventions that compared nurse-managed protocols with usual care in investigations targeting adults with chronic conditions. Two reviewers used eligibility criteria to assess titles, abstracts, and full texts, and resolved their disagreements by discussion or by consulting a third reviewer. Eligibility criteria included the involvement of an RN or LPN functioning beyond the usual scope of practice, such as adjusting medications, and conducting interventions based on a written protocol.

Main outcome measures. The effects of nurse-managed protocols on biophysical markers, patient treatment adherence, nurse protocol adherence, adverse effects, and resource use. When quantitative synthesis was feasible, dichotomous outcomes were combined using odds ratios and continuous outcomes were combined using mean differences in random-effects models. When quantitative synthesis was not feasible, the authors annualized data qualitatively, giving more weight to evidence from higher-quality studies. They evaluated overall strength of evidence (SOE) by assessing risk of bias, consistency, directness, and precision, and assigned a rating of high, moderate, or low SOE, or insufficient evidence.

Main results. Of the 2954 studies in the search results, 18 were ultimately eligible and included in the review, 16 randomized controlled trials and 2 before and after diabetes studies. Eleven were done in Western Europe and 7 in the United States. An RN or non-US equivalent was the interventionist in all studies (none used an LPN). In only 11 of the 18 studies were nurses independently allowed to initiate new medications. The meta-analysis found that hemoglobin A1c (HbA1c) level decreased by 0.4% (moderate SOE) (95% confidence interval {CI}, 0.1% to 0.7%) (n = 8), systolic and diastolic blood pressure decreased by 3.68 mm Hg (CI, 1.05 to 6.31) and 1.56 mm Hg (CI, 0.36 to 2.76), respectively (moderate SOE) (n = 12); total cholesterol level decreased by 9.37 mg/dL (20.77-mg/dL decrease to 2.02-mg/dL increase) (n = 9); and low-density-lipoprotein cholesterol level decreased by 12.07 mg/dL (CI, 28.27-mg/dL decrease to 4.13-mg/dL increase) (low SOE) (n = 6). The SOE was insufficient to estimate a treatment effect for all other outcomes.

Conclusion. A team approach that uses nurse-managed protocols may have positive effects on the outpatient management of adults with chronic conditions such as diabetes, hypertension, and hyperlipidemia.

Commentary

Hypertension, diabetes, and hyperlipidemia are major causes of morbidity and mortality worldwide and are widely prevalent in the United States. These chronic illnesses require long-term medical management, often requiring management of multiple medications and patient lifestyle changes and self-monitoring [1]. The patient-centered medical home, which involves a team approach, is increasingly being recognized as a promising model for delivering effective chronic disease care. Likewise, expanding the role of nurses as part of team care is increasingly being explored to help achieve high quality patient outcomes. The use of nurse-managed protocols can be an appropriate strategy in this scenario.

In this study, the researchers aimed to determine whether nurse-managed protocols are effective for outpatient management of adults with diabetes, hypertension, and hyperlipidemia and performed a systematic review and meta-analysis. Researchers followed a standardized procedure to conduct their search and carefully reviewed the studies, including contacting authors for missing data or clarification. They followed the approach recommended by the Agency for Healthcare Research and Quality (AHRQ) to evaluate the overall strength of the body of evidence [2].

However, some limitations must be taken into account. They acknowledge that they may have missed studies in which nurses had autonomy to practice in capacities beyond their scope of practice. In addition, the literature lacked details about the interventions and protocols used. Also, the researchers searched for studies across a 34-year range (1980–2014). Changes occurring in the nursing profession over these years may have impacted the findings.

Applications for Clinical Practice

Team-based care that includes nurse-managed protocols for titrating medications can be beneficial in the management of chronic conditions in primary care patients. With physician shortages predicted, which will impact primary care more than other specialties, team approaches using nurse-managed protocols have the potential to help lighten physician workloads and ensure quality care.

                                                                                                                                                                                                                                    —Paloma Cesar de Sales, BN, RN, MS

Study Overview

Objective. To determine whether nurse-managed protocols are effective for the outpatient management of adults with diabetes, hypertension, and hyperlipidemia.

Study design. Systematic review and meta-analysis.

Data sources. The authors searched MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL for English-language peer-reviewed studies published between January 1980 and January 2014 that evaluated interventions that compared nurse-managed protocols with usual care in investigations targeting adults with chronic conditions. Two reviewers used eligibility criteria to assess titles, abstracts, and full texts, and resolved their disagreements by discussion or by consulting a third reviewer. Eligibility criteria included the involvement of an RN or LPN functioning beyond the usual scope of practice, such as adjusting medications, and conducting interventions based on a written protocol.

Main outcome measures. The effects of nurse-managed protocols on biophysical markers, patient treatment adherence, nurse protocol adherence, adverse effects, and resource use. When quantitative synthesis was feasible, dichotomous outcomes were combined using odds ratios and continuous outcomes were combined using mean differences in random-effects models. When quantitative synthesis was not feasible, the authors annualized data qualitatively, giving more weight to evidence from higher-quality studies. They evaluated overall strength of evidence (SOE) by assessing risk of bias, consistency, directness, and precision, and assigned a rating of high, moderate, or low SOE, or insufficient evidence.

Main results. Of the 2954 studies in the search results, 18 were ultimately eligible and included in the review, 16 randomized controlled trials and 2 before and after diabetes studies. Eleven were done in Western Europe and 7 in the United States. An RN or non-US equivalent was the interventionist in all studies (none used an LPN). In only 11 of the 18 studies were nurses independently allowed to initiate new medications. The meta-analysis found that hemoglobin A1c (HbA1c) level decreased by 0.4% (moderate SOE) (95% confidence interval {CI}, 0.1% to 0.7%) (n = 8), systolic and diastolic blood pressure decreased by 3.68 mm Hg (CI, 1.05 to 6.31) and 1.56 mm Hg (CI, 0.36 to 2.76), respectively (moderate SOE) (n = 12); total cholesterol level decreased by 9.37 mg/dL (20.77-mg/dL decrease to 2.02-mg/dL increase) (n = 9); and low-density-lipoprotein cholesterol level decreased by 12.07 mg/dL (CI, 28.27-mg/dL decrease to 4.13-mg/dL increase) (low SOE) (n = 6). The SOE was insufficient to estimate a treatment effect for all other outcomes.

Conclusion. A team approach that uses nurse-managed protocols may have positive effects on the outpatient management of adults with chronic conditions such as diabetes, hypertension, and hyperlipidemia.

Commentary

Hypertension, diabetes, and hyperlipidemia are major causes of morbidity and mortality worldwide and are widely prevalent in the United States. These chronic illnesses require long-term medical management, often requiring management of multiple medications and patient lifestyle changes and self-monitoring [1]. The patient-centered medical home, which involves a team approach, is increasingly being recognized as a promising model for delivering effective chronic disease care. Likewise, expanding the role of nurses as part of team care is increasingly being explored to help achieve high quality patient outcomes. The use of nurse-managed protocols can be an appropriate strategy in this scenario.

In this study, the researchers aimed to determine whether nurse-managed protocols are effective for outpatient management of adults with diabetes, hypertension, and hyperlipidemia and performed a systematic review and meta-analysis. Researchers followed a standardized procedure to conduct their search and carefully reviewed the studies, including contacting authors for missing data or clarification. They followed the approach recommended by the Agency for Healthcare Research and Quality (AHRQ) to evaluate the overall strength of the body of evidence [2].

However, some limitations must be taken into account. They acknowledge that they may have missed studies in which nurses had autonomy to practice in capacities beyond their scope of practice. In addition, the literature lacked details about the interventions and protocols used. Also, the researchers searched for studies across a 34-year range (1980–2014). Changes occurring in the nursing profession over these years may have impacted the findings.

Applications for Clinical Practice

Team-based care that includes nurse-managed protocols for titrating medications can be beneficial in the management of chronic conditions in primary care patients. With physician shortages predicted, which will impact primary care more than other specialties, team approaches using nurse-managed protocols have the potential to help lighten physician workloads and ensure quality care.

                                                                                                                                                                                                                                    —Paloma Cesar de Sales, BN, RN, MS

Study Overview

Objective. To identify the prevalence and characteristics of patients identified with high blood pressure (BP) in nonprimary care compared with primary care visits.

Design. Longitudinal population-based study.

Setting and participants. This study was conducted at Kaiser Permanente Southern California (KPSC) after implementation of a system-wide change to improve hypertension care, which included comprehensive decision support tools embedded in the EHR system, including BP measurement flag alerts. Patient eligible for the study were normotensive members (BP < 140/90 mm Hg), older than 18 years, and enrolled in a KPSC health plan for at least 12 months on January of 2009. A gap of < 3 months in health care coverage in the year prior was allowed. Excluded were patients with a history of elevated BP during an outpatient visit, an inpatient or outpatient diagnosis code for hypertension, prescription for any antihypertensive medication within 24 months prior to 1 January 2009, missing BP information or whose only BP measurements were from a visit indicating fever or in preparation for a surgery or pain management. Pregnant patients, patients with missing sex information, and missing visit specialty information were also excluded. The study period was from January 2009 to March 2011.

Measurement. BP was measured routinely at the beginning of almost every primary and nonprimary outpatient visit. Nurses and medical assistants were trained according to a standard KPSC protocol using automated sphygmomanometer digital devices. According to the study protocol, in cases in which BP was elevated (≥ 140/90 mm Hg), a second measurement was obtained. At KPSC, all staff members including those in primary and nonprimary care are certified in BP measurement during their initial staff orientation and recertified annually.

Main outcome measure. An initial BP ≥ 140/90 mm Hg during a primary or nonprimary care outpatient visit.

Results. The mean ages of patients at baseline and at end of follow-up for the primary outcome were 39.7 (SD, 13.9) and 41.5 (SD, 14.0) years, respectively. The total cohort (n = 1,075,522) was nearly equally representative of both men (48.6%) and women (51.4%). The majority of the patients (91.7%) were younger than 60 years. A large proportion of the cohort belonged to racial/ethnic minorities with 33.1% Hispanic, 6.5% black, and 8.4% Asian/Pacific Islander.

The total cohort had 4,903,200 office visits, of which 3,996,190 were primary care visits, 901,275 nonprimary care visits, and 5735 visits of unknown specialty. During a mean follow-up of 1.6 years (SD, 0.8) 111,996 patients had a BP measurement ≥ 140/90 mm Hg. Of these, 92,577 (82.7%) were measured during primary care visits and 19,419 (17.3%) during nonprimary care visits. Of 15,356 patients with confirmed high BP, 12,587 (82%) were measured during primary care visits and 2769 (18.0%) patients during nonprimary care visits. Patients with a BP ≥ 140/90 mm Hg measured during nonprimary care visits were older, more likely to be male and non-Hispanic white, less likely to be obese, but more likely to smoke or have a Framingham risk score ≥ 20%. Ophthalmology/optometry, neurology, and dermatology were the main specialties to identify a first BP ≥ 140/90 mm Hg.

The follow-up after a first elevated BP was marginally higher in patients identified in nonprimary care than in primary care. Among patients with a first BP ≥ 140/90 mm Hg measured during a primary care visit, 60.6% had a follow-up BP within 3 months of the first high BP, 22.9% after 3 months or more, and 16.5% did not have a follow-up BP. Among individuals with a first BP ≥ 140/90 mm Hg measured during a nonprimary care visit, 64.7% had a follow-up BP within 3 months of the first high BP, 22.6% after 3 months or more, and 12.7% did not have a follow-up BP measurement.

The proportion of false-positives, defined as individuals with an initial BP ≥ 140/90 mm Hg who had a follow-up visit with a normal BP within 3 months, was the same for patients identified in primary and nonprimary care. False-positives were most frequent in individuals identified during visits in other specialty care, rheuma-tology, and neurology fields.

Conclusion. Expanding screening for hypertension to nonprimary care settings may improve the detection of hypertension and may contribute to better hypertension control. However, an effective system to ensure appropriate follow-up if high BP is detected is needed. Elderly, non-Hispanic, white male patients and those with very high BP are more likely to benefit from this screening.

Commentary

Hypertension is a common and costly health problem [1]. BP screening can identify adults with hypertension, who are at increased risk of cardiovascular and other diseases. Effective treatments are available to control high BP and reduce associated morbidity and mortality [2], but the first step is to identify patients with this largely asymptomatic disorder.

BP measurement is standard practice in primary care. However, many people do not regularly see a primary care clinician. In this study, researchers aimed to identify the prevalence and characteristics of patients identified with high BP in nonprimary care compared with primary care visits in a large integrated health care system that had implemented a system-level, multifaceted quality improvement program to improve hypertension care. Of the patients who were found to have high BP, 83% were diagnosed in a primary care setting and 17% in a specialty care setting, and the number of false-positive results were comparable.

In general, the study was well conducted and a strength of the study was the large sample size. Limitations included the fact that the study was conducted as part of a quality improvement project in an integrated health system, and there were no control clinics.

The authors noted that a high BP reading requires adequate follow-up, and nonprimary care detected elevated BP patients had lower follow-up rates. Also, some specialties had higher false-positive rates. Quality of measurement can be maximized with regular staff training.

Applications for Clinical Practice

Expanding routine screening for hypertension to non-primary care can potentially improve rates of detection, capturing patients who might otherwise have been missed. An effective system to ensure appropriate follow-up attention if high BP is detected is essential, and it is important that staff be well trained in using standard technique to minimize false-positives, which could lead to unnecessary resource use.

—Paloma Cesar de Sales, BN, RN, MS

Study Overview

Objective. To identify the prevalence and characteristics of patients identified with high blood pressure (BP) in nonprimary care compared with primary care visits.

Design. Longitudinal population-based study.

Setting and participants. This study was conducted at Kaiser Permanente Southern California (KPSC) after implementation of a system-wide change to improve hypertension care, which included comprehensive decision support tools embedded in the EHR system, including BP measurement flag alerts. Patient eligible for the study were normotensive members (BP < 140/90 mm Hg), older than 18 years, and enrolled in a KPSC health plan for at least 12 months on January of 2009. A gap of < 3 months in health care coverage in the year prior was allowed. Excluded were patients with a history of elevated BP during an outpatient visit, an inpatient or outpatient diagnosis code for hypertension, prescription for any antihypertensive medication within 24 months prior to 1 January 2009, missing BP information or whose only BP measurements were from a visit indicating fever or in preparation for a surgery or pain management. Pregnant patients, patients with missing sex information, and missing visit specialty information were also excluded. The study period was from January 2009 to March 2011.

Measurement. BP was measured routinely at the beginning of almost every primary and nonprimary outpatient visit. Nurses and medical assistants were trained according to a standard KPSC protocol using automated sphygmomanometer digital devices. According to the study protocol, in cases in which BP was elevated (≥ 140/90 mm Hg), a second measurement was obtained. At KPSC, all staff members including those in primary and nonprimary care are certified in BP measurement during their initial staff orientation and recertified annually.

Main outcome measure. An initial BP ≥ 140/90 mm Hg during a primary or nonprimary care outpatient visit.

Results. The mean ages of patients at baseline and at end of follow-up for the primary outcome were 39.7 (SD, 13.9) and 41.5 (SD, 14.0) years, respectively. The total cohort (n = 1,075,522) was nearly equally representative of both men (48.6%) and women (51.4%). The majority of the patients (91.7%) were younger than 60 years. A large proportion of the cohort belonged to racial/ethnic minorities with 33.1% Hispanic, 6.5% black, and 8.4% Asian/Pacific Islander.

The total cohort had 4,903,200 office visits, of which 3,996,190 were primary care visits, 901,275 nonprimary care visits, and 5735 visits of unknown specialty. During a mean follow-up of 1.6 years (SD, 0.8) 111,996 patients had a BP measurement ≥ 140/90 mm Hg. Of these, 92,577 (82.7%) were measured during primary care visits and 19,419 (17.3%) during nonprimary care visits. Of 15,356 patients with confirmed high BP, 12,587 (82%) were measured during primary care visits and 2769 (18.0%) patients during nonprimary care visits. Patients with a BP ≥ 140/90 mm Hg measured during nonprimary care visits were older, more likely to be male and non-Hispanic white, less likely to be obese, but more likely to smoke or have a Framingham risk score ≥ 20%. Ophthalmology/optometry, neurology, and dermatology were the main specialties to identify a first BP ≥ 140/90 mm Hg.

The follow-up after a first elevated BP was marginally higher in patients identified in nonprimary care than in primary care. Among patients with a first BP ≥ 140/90 mm Hg measured during a primary care visit, 60.6% had a follow-up BP within 3 months of the first high BP, 22.9% after 3 months or more, and 16.5% did not have a follow-up BP. Among individuals with a first BP ≥ 140/90 mm Hg measured during a nonprimary care visit, 64.7% had a follow-up BP within 3 months of the first high BP, 22.6% after 3 months or more, and 12.7% did not have a follow-up BP measurement.

The proportion of false-positives, defined as individuals with an initial BP ≥ 140/90 mm Hg who had a follow-up visit with a normal BP within 3 months, was the same for patients identified in primary and nonprimary care. False-positives were most frequent in individuals identified during visits in other specialty care, rheuma-tology, and neurology fields.

Conclusion. Expanding screening for hypertension to nonprimary care settings may improve the detection of hypertension and may contribute to better hypertension control. However, an effective system to ensure appropriate follow-up if high BP is detected is needed. Elderly, non-Hispanic, white male patients and those with very high BP are more likely to benefit from this screening.

Commentary

Hypertension is a common and costly health problem [1]. BP screening can identify adults with hypertension, who are at increased risk of cardiovascular and other diseases. Effective treatments are available to control high BP and reduce associated morbidity and mortality [2], but the first step is to identify patients with this largely asymptomatic disorder.

BP measurement is standard practice in primary care. However, many people do not regularly see a primary care clinician. In this study, researchers aimed to identify the prevalence and characteristics of patients identified with high BP in nonprimary care compared with primary care visits in a large integrated health care system that had implemented a system-level, multifaceted quality improvement program to improve hypertension care. Of the patients who were found to have high BP, 83% were diagnosed in a primary care setting and 17% in a specialty care setting, and the number of false-positive results were comparable.

In general, the study was well conducted and a strength of the study was the large sample size. Limitations included the fact that the study was conducted as part of a quality improvement project in an integrated health system, and there were no control clinics.

The authors noted that a high BP reading requires adequate follow-up, and nonprimary care detected elevated BP patients had lower follow-up rates. Also, some specialties had higher false-positive rates. Quality of measurement can be maximized with regular staff training.

Applications for Clinical Practice

Expanding routine screening for hypertension to non-primary care can potentially improve rates of detection, capturing patients who might otherwise have been missed. An effective system to ensure appropriate follow-up attention if high BP is detected is essential, and it is important that staff be well trained in using standard technique to minimize false-positives, which could lead to unnecessary resource use.

—Paloma Cesar de Sales, BN, RN, MS

Study Overview

Objective. To identify the prevalence and characteristics of patients identified with high blood pressure (BP) in nonprimary care compared with primary care visits.

Design. Longitudinal population-based study.

Setting and participants. This study was conducted at Kaiser Permanente Southern California (KPSC) after implementation of a system-wide change to improve hypertension care, which included comprehensive decision support tools embedded in the EHR system, including BP measurement flag alerts. Patient eligible for the study were normotensive members (BP < 140/90 mm Hg), older than 18 years, and enrolled in a KPSC health plan for at least 12 months on January of 2009. A gap of < 3 months in health care coverage in the year prior was allowed. Excluded were patients with a history of elevated BP during an outpatient visit, an inpatient or outpatient diagnosis code for hypertension, prescription for any antihypertensive medication within 24 months prior to 1 January 2009, missing BP information or whose only BP measurements were from a visit indicating fever or in preparation for a surgery or pain management. Pregnant patients, patients with missing sex information, and missing visit specialty information were also excluded. The study period was from January 2009 to March 2011.

Measurement. BP was measured routinely at the beginning of almost every primary and nonprimary outpatient visit. Nurses and medical assistants were trained according to a standard KPSC protocol using automated sphygmomanometer digital devices. According to the study protocol, in cases in which BP was elevated (≥ 140/90 mm Hg), a second measurement was obtained. At KPSC, all staff members including those in primary and nonprimary care are certified in BP measurement during their initial staff orientation and recertified annually.

Main outcome measure. An initial BP ≥ 140/90 mm Hg during a primary or nonprimary care outpatient visit.

Results. The mean ages of patients at baseline and at end of follow-up for the primary outcome were 39.7 (SD, 13.9) and 41.5 (SD, 14.0) years, respectively. The total cohort (n = 1,075,522) was nearly equally representative of both men (48.6%) and women (51.4%). The majority of the patients (91.7%) were younger than 60 years. A large proportion of the cohort belonged to racial/ethnic minorities with 33.1% Hispanic, 6.5% black, and 8.4% Asian/Pacific Islander.

The total cohort had 4,903,200 office visits, of which 3,996,190 were primary care visits, 901,275 nonprimary care visits, and 5735 visits of unknown specialty. During a mean follow-up of 1.6 years (SD, 0.8) 111,996 patients had a BP measurement ≥ 140/90 mm Hg. Of these, 92,577 (82.7%) were measured during primary care visits and 19,419 (17.3%) during nonprimary care visits. Of 15,356 patients with confirmed high BP, 12,587 (82%) were measured during primary care visits and 2769 (18.0%) patients during nonprimary care visits. Patients with a BP ≥ 140/90 mm Hg measured during nonprimary care visits were older, more likely to be male and non-Hispanic white, less likely to be obese, but more likely to smoke or have a Framingham risk score ≥ 20%. Ophthalmology/optometry, neurology, and dermatology were the main specialties to identify a first BP ≥ 140/90 mm Hg.

The follow-up after a first elevated BP was marginally higher in patients identified in nonprimary care than in primary care. Among patients with a first BP ≥ 140/90 mm Hg measured during a primary care visit, 60.6% had a follow-up BP within 3 months of the first high BP, 22.9% after 3 months or more, and 16.5% did not have a follow-up BP. Among individuals with a first BP ≥ 140/90 mm Hg measured during a nonprimary care visit, 64.7% had a follow-up BP within 3 months of the first high BP, 22.6% after 3 months or more, and 12.7% did not have a follow-up BP measurement.

The proportion of false-positives, defined as individuals with an initial BP ≥ 140/90 mm Hg who had a follow-up visit with a normal BP within 3 months, was the same for patients identified in primary and nonprimary care. False-positives were most frequent in individuals identified during visits in other specialty care, rheuma-tology, and neurology fields.

Conclusion. Expanding screening for hypertension to nonprimary care settings may improve the detection of hypertension and may contribute to better hypertension control. However, an effective system to ensure appropriate follow-up if high BP is detected is needed. Elderly, non-Hispanic, white male patients and those with very high BP are more likely to benefit from this screening.

Commentary

Hypertension is a common and costly health problem [1]. BP screening can identify adults with hypertension, who are at increased risk of cardiovascular and other diseases. Effective treatments are available to control high BP and reduce associated morbidity and mortality [2], but the first step is to identify patients with this largely asymptomatic disorder.

BP measurement is standard practice in primary care. However, many people do not regularly see a primary care clinician. In this study, researchers aimed to identify the prevalence and characteristics of patients identified with high BP in nonprimary care compared with primary care visits in a large integrated health care system that had implemented a system-level, multifaceted quality improvement program to improve hypertension care. Of the patients who were found to have high BP, 83% were diagnosed in a primary care setting and 17% in a specialty care setting, and the number of false-positive results were comparable.

In general, the study was well conducted and a strength of the study was the large sample size. Limitations included the fact that the study was conducted as part of a quality improvement project in an integrated health system, and there were no control clinics.

The authors noted that a high BP reading requires adequate follow-up, and nonprimary care detected elevated BP patients had lower follow-up rates. Also, some specialties had higher false-positive rates. Quality of measurement can be maximized with regular staff training.

Applications for Clinical Practice

Expanding routine screening for hypertension to non-primary care can potentially improve rates of detection, capturing patients who might otherwise have been missed. An effective system to ensure appropriate follow-up attention if high BP is detected is essential, and it is important that staff be well trained in using standard technique to minimize false-positives, which could lead to unnecessary resource use.

—Paloma Cesar de Sales, BN, RN, MS

Study Overview

Objective. To investigate national trends in hospital admissions for malignant hypertension and hypertensive encephalopathy.

Study design. Retrospective cohort study. The Nation-wide Inpatient Sample [1] was used to identify all hospitalizations between January 2000 and December 2011 during which a primary diagnosis of malignant hypertension, hypertensive encephalopathy, or essential hypertension occurred. Time series models were estimated for these diagnoses and also for the combined series. A piecewise linear regression analysis was done to investigate whether there were changes in the trends of these series. In addition, the researchers compared patient characteristics.

Results. There was a gradual increase in the number of hypertension-related hospitalizations from 2000 to 2011. However, after 2007, the number of admissions for malignant hypertension and hypertensive encephalopathy increased dramatically, whereas diagnoses for essential hypertension fell (P < 0.001). Mortality for malignant hypertension significantly fell after the change point of 2007 (–36%, P = 0.02) but there was no significant difference in mortality for hypertensive encephalopathy or essential hypertension. The number of diagnoses and the adjusted average charges significantly increased after the change point for all hypertension series, although the increase in malignant hypertension and hypertensive encephalopathy was higher than in essential hypertension. Length of stay significantly decreased after 2007 for all series. Mean patient age and number of procedures for all series were similar before and after the change point.

Conclusion. Since the dramatic increase in the number of hospital admissions did not result in dramatic increases in morbidity, which would have been expected, the increase was most likely related to a change in coding practices that was implemented in 2007 and not actual changes in disease incidence.

Commentary

Hypertension is a major public health problem associated with significant morbidity and mortality [2]. In general, hypertension is asymptomatic; however, life-threatening manifestations of hypertension can develop. A hypertensive emergency is a situation in which uncontrolled hypertension is associated with acute end-organ damage.  Most patients presenting with hypertensive emergency have chronic hypertension, although the disorder can present in previously normotensive individuals [3]. The 2 major emergency syndromes are malignant hypertension and hypertensive encephalopathy. They usually require hospitalization, and therefore monitoring trends in admissions for these conditions is a reasonable population-based indicator for failures related to hypertension management.

In this epidemiologic study by Polgreen et al, the authors found a increasing trend in admissions for malig-nant hypertension and hypertensive emergencies, with a substantial increase after 2007. Although the authors considered the possibility that their findings represented a true change in the epidemiology of hypertensive emergencies, they concluded that this appears unlikely, as the diagnoses of essential hypertension fell, and in addition, an expected associated increase in morbidity was not seen. They attribute the shift to a change in assignment of administrative billing codes. In 2007, DRG codes were changed to medical severity DRG codes [4]. The authors acknowledge that there was a recession from 2007 to 2009 that led to an increase in the number of uninsured Americans [5]. However, they noted that the uninsured were no more likely to be diagnosed with malignant hypertension or hypertensive encephalopathy than essential hypertension and there is no reason to think that a change provider’s management of hypertension could have been responsible.

Limitations to this study were the use of administrative data only and the lack of data on outpatient medication use.

Applications for Clinical Practice

As the authors suggest, the study raised questions regarding the use of administrative data for monitoring hypertension outcomes. Future studies are needed to examine whether the rise in diagnoses for malignant hypertension and hypertensive encephalopathy are related to coding practices or other variables.

—Paloma Cesar de Sales, BN, RN, MS

Study Overview

Objective. To investigate national trends in hospital admissions for malignant hypertension and hypertensive encephalopathy.

Study design. Retrospective cohort study. The Nation-wide Inpatient Sample [1] was used to identify all hospitalizations between January 2000 and December 2011 during which a primary diagnosis of malignant hypertension, hypertensive encephalopathy, or essential hypertension occurred. Time series models were estimated for these diagnoses and also for the combined series. A piecewise linear regression analysis was done to investigate whether there were changes in the trends of these series. In addition, the researchers compared patient characteristics.

Results. There was a gradual increase in the number of hypertension-related hospitalizations from 2000 to 2011. However, after 2007, the number of admissions for malignant hypertension and hypertensive encephalopathy increased dramatically, whereas diagnoses for essential hypertension fell (P < 0.001). Mortality for malignant hypertension significantly fell after the change point of 2007 (–36%, P = 0.02) but there was no significant difference in mortality for hypertensive encephalopathy or essential hypertension. The number of diagnoses and the adjusted average charges significantly increased after the change point for all hypertension series, although the increase in malignant hypertension and hypertensive encephalopathy was higher than in essential hypertension. Length of stay significantly decreased after 2007 for all series. Mean patient age and number of procedures for all series were similar before and after the change point.

Conclusion. Since the dramatic increase in the number of hospital admissions did not result in dramatic increases in morbidity, which would have been expected, the increase was most likely related to a change in coding practices that was implemented in 2007 and not actual changes in disease incidence.

Commentary

Hypertension is a major public health problem associated with significant morbidity and mortality [2]. In general, hypertension is asymptomatic; however, life-threatening manifestations of hypertension can develop. A hypertensive emergency is a situation in which uncontrolled hypertension is associated with acute end-organ damage.  Most patients presenting with hypertensive emergency have chronic hypertension, although the disorder can present in previously normotensive individuals [3]. The 2 major emergency syndromes are malignant hypertension and hypertensive encephalopathy. They usually require hospitalization, and therefore monitoring trends in admissions for these conditions is a reasonable population-based indicator for failures related to hypertension management.

In this epidemiologic study by Polgreen et al, the authors found a increasing trend in admissions for malig-nant hypertension and hypertensive emergencies, with a substantial increase after 2007. Although the authors considered the possibility that their findings represented a true change in the epidemiology of hypertensive emergencies, they concluded that this appears unlikely, as the diagnoses of essential hypertension fell, and in addition, an expected associated increase in morbidity was not seen. They attribute the shift to a change in assignment of administrative billing codes. In 2007, DRG codes were changed to medical severity DRG codes [4]. The authors acknowledge that there was a recession from 2007 to 2009 that led to an increase in the number of uninsured Americans [5]. However, they noted that the uninsured were no more likely to be diagnosed with malignant hypertension or hypertensive encephalopathy than essential hypertension and there is no reason to think that a change provider’s management of hypertension could have been responsible.

Limitations to this study were the use of administrative data only and the lack of data on outpatient medication use.

Applications for Clinical Practice

As the authors suggest, the study raised questions regarding the use of administrative data for monitoring hypertension outcomes. Future studies are needed to examine whether the rise in diagnoses for malignant hypertension and hypertensive encephalopathy are related to coding practices or other variables.

—Paloma Cesar de Sales, BN, RN, MS

Study Overview

Objective. To investigate national trends in hospital admissions for malignant hypertension and hypertensive encephalopathy.

Study design. Retrospective cohort study. The Nation-wide Inpatient Sample [1] was used to identify all hospitalizations between January 2000 and December 2011 during which a primary diagnosis of malignant hypertension, hypertensive encephalopathy, or essential hypertension occurred. Time series models were estimated for these diagnoses and also for the combined series. A piecewise linear regression analysis was done to investigate whether there were changes in the trends of these series. In addition, the researchers compared patient characteristics.

Results. There was a gradual increase in the number of hypertension-related hospitalizations from 2000 to 2011. However, after 2007, the number of admissions for malignant hypertension and hypertensive encephalopathy increased dramatically, whereas diagnoses for essential hypertension fell (P < 0.001). Mortality for malignant hypertension significantly fell after the change point of 2007 (–36%, P = 0.02) but there was no significant difference in mortality for hypertensive encephalopathy or essential hypertension. The number of diagnoses and the adjusted average charges significantly increased after the change point for all hypertension series, although the increase in malignant hypertension and hypertensive encephalopathy was higher than in essential hypertension. Length of stay significantly decreased after 2007 for all series. Mean patient age and number of procedures for all series were similar before and after the change point.

Conclusion. Since the dramatic increase in the number of hospital admissions did not result in dramatic increases in morbidity, which would have been expected, the increase was most likely related to a change in coding practices that was implemented in 2007 and not actual changes in disease incidence.

Commentary

Hypertension is a major public health problem associated with significant morbidity and mortality [2]. In general, hypertension is asymptomatic; however, life-threatening manifestations of hypertension can develop. A hypertensive emergency is a situation in which uncontrolled hypertension is associated with acute end-organ damage.  Most patients presenting with hypertensive emergency have chronic hypertension, although the disorder can present in previously normotensive individuals [3]. The 2 major emergency syndromes are malignant hypertension and hypertensive encephalopathy. They usually require hospitalization, and therefore monitoring trends in admissions for these conditions is a reasonable population-based indicator for failures related to hypertension management.

In this epidemiologic study by Polgreen et al, the authors found a increasing trend in admissions for malig-nant hypertension and hypertensive emergencies, with a substantial increase after 2007. Although the authors considered the possibility that their findings represented a true change in the epidemiology of hypertensive emergencies, they concluded that this appears unlikely, as the diagnoses of essential hypertension fell, and in addition, an expected associated increase in morbidity was not seen. They attribute the shift to a change in assignment of administrative billing codes. In 2007, DRG codes were changed to medical severity DRG codes [4]. The authors acknowledge that there was a recession from 2007 to 2009 that led to an increase in the number of uninsured Americans [5]. However, they noted that the uninsured were no more likely to be diagnosed with malignant hypertension or hypertensive encephalopathy than essential hypertension and there is no reason to think that a change provider’s management of hypertension could have been responsible.

Limitations to this study were the use of administrative data only and the lack of data on outpatient medication use.

Applications for Clinical Practice

As the authors suggest, the study raised questions regarding the use of administrative data for monitoring hypertension outcomes. Future studies are needed to examine whether the rise in diagnoses for malignant hypertension and hypertensive encephalopathy are related to coding practices or other variables.

—Paloma Cesar de Sales, BN, RN, MS