Blood pressure control best achieved with a multilevel, multicomponent approach

1. Blood pressure control best achieved with a multilevel, multicomponent approach

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1805

Editorial: http://annals.org/aim/article/doi/10.7326/M17-3036

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Current clinical guidelines recommend lower blood pressure targets for the general population, yet control remains elusive for most. A new study suggests that patients with hypertension can best achieve blood pressure control with a multilevel, multicomponent approach that includes physician- and non-physician-led interventions. The findings from a comparative effectiveness review are published in Annals of Internal Medicine.

Hypertension is the leading risk factor for cardiovascular disease. Despite strong evidence that antihypertensive medications and lifestyle modifications reduce blood pressure and subsequent morbidity and mortality from cardiovascular disease, hypertension control rates hover between 25 and 40 percent, a rate that has remain unchanged for the past 40 years. As such, strategies are needed to increase control rates.

Researchers from Tulane University reviewed published research to assess effectiveness of eight implementation strategies for blood pressure control in adults with hypertension compared with regular care. They found that multilevel, multicomponent strategies, such as team-based care with medication titration by a nonphysician clinician, team-based care with medication titration by a physician, and multilevel strategies without team-based care, lead to reductions in systolic blood pressure of around 7, 6, and 5 mm Hg, respectively. Patient-level strategies resulted in systolic blood pressure reductions of around 4 mm Hg for health coaching and 3 mm Hg for home blood pressure monitoring. Trends were similar for diastolic blood pressure reduction.

According to the researchers, these findings provide evidence that multilevel, multicomponent implementation strategies are most useful and should be recommended in clinical practice and public health policy for hypertension control in communities.

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2. More than one third of U.S. HIV patients fail to receive vaccination for hepatitis B

Abstract: http://annals.org/aim/article/doi/10.7326/M17-1689

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Despite their high risk for infection, more than one third of U.S. HIV patients fail to get vaccinated for hepatitis B. The findings are published in Annals of Internal Medicine.

Persons with HIV are at increased risk for hepatitis B virus infection and vaccination is recommended. However, liver-related deaths among HIV patients, in which hepatitis B plays a central role, account for the largest proportion of deaths not related to AIDS. In 2016, the World Health Organization (WHO) resolved to eliminate HBV infection as a public health threat by 2030.

To estimate the prevalence of hepatitis B vaccination among HIV patients and establish a benchmark for the WHO initiatve, researchers from the Centers for Disease Control and Prevention (CDC) surveyed a nationally representative sample of 18,089 adults receiving HIV medical care who participated in the Medical Monitoring Project during 2009 to 2012. They found that more than one third of U.S HIV patients had not been vaccinated for hepatitis B. In addition, only 1 in 10 of these vaccination candidates was vaccinated in the course of 1 year of ongoing HIV care.

According to the researchers, meeting goals for hepatitis B elimination will require a multifaceted approach to increasing vaccination of HIV patients. Particular attention should be focused on increasing vaccination of patients who receive care in private practices and at facilities not funded by the Ryan White HIV/AIDS Program.

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3. Slow-release oral morphine could expand options for treating opioid abuse

Abstract: http://annals.org/aim/article/doi/10.7326/M17-2373

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Slow-release oral Morphine (SROM) has emerged as a promising candidate for oral opioid agonist therapy. However, more research is needed before it can be incorporated into U.S. treatment guidelines. A commentary from the British Columbia Centre on Substance Use is published in Annals of Internal Medicine.

With more Americans dying from accidental opioid-related overdoses than from motor vehicle accidents and homicides combined, it is clear that evidence-based solutions are urgently needed. Despite the proven benefits of opioid agonist therapy with buprenorphine or methadone, several health system and regulatory barriers to this treatment persist throughout North America. In addition, buprenorphine and methadone may not be effective for all patients. These barriers have resulted in a large unmet treatment need, leaving an estimated gap of up to one million persons with untreated opioid use disorder, who continue to be at risk for overdose death and other negative health and social outcomes.

Existing studies suggest that SROM has comparable efficacy to methadone and is well-tolerated by patients, with a lower risk for drug-drug interactions. SROM-based oral opioid agonist therapy is increasingly and successfully used in several European countries and Canada, but more research is needed before it can be determined how SROM could be used in the United States.

The authors suggest that the U.S. must also address the regulatory burdens that create barriers to treatment. The Canadian model, in which methadone is dispensed through daily witnessed ingestion in community-based pharmacies could be adapted in this country, which could help to overcome current treatment gaps.

4. Glucagon is underutilized in the out-of-hospital and outpatient setting

Abstract: http://annals.org/aim/article/doi/10.7326/M17-2222

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More widespread use of glucagon could reduce the number and severity of hypoglycemic episodes requiring emergency medical attention and hospitalization. A brief research report is published in Annals of Internal Medicine.

Researchers from Harvard Medical School reviewed data from the National Emergency Medical Services Information System (MEMSIS) Public-Release Research Datasets from 2013 to 2015 and from Medicare Part D claims from 2014 to characterize glucagon use and availability in the pre-hospital and outpatient setting. They found that glucagon is underutilized by emergency medical personnel and underprescribed to patients.

According to the researchers, prescribing glucagon to patients could effectively reduce pre-hospital hypoglycemic complications. They also suggest that all emergency personnel nationwide should have access to glucagon along with training to safely administer it. Ensuring this access could reduce morbidity, mortality, and healthcare costs.

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