Pletcher, Mark J.

Background Reductions in blood pressure (BP) control among patients with hypertension were observed early in the COVID‐19 pandemic. The degree to which BP control may have returned to prepandemic levels is unknown. Methods Individuals aged 18 to 85 years with hypertension from 17 health systems participating in the National Patient‐Centered Clinical Research Network were identified using electronic health record data collected as part of routine care. BP control (percentage of patients whose most recent BP measurement was <140/<90 mm Hg) was estimated in a series of 12‐month rolling measurement periods from 2017 through 2022 (January 1, 2017 through December 31, 2017; April 1, 2017 through March 31, 2018; … January 1, 2022 through December 31, 2022). Differences in average BP control between 2022 (January 1, 2022 through December 31, 2022) and 2019 (January 1, 2019 through December 31, 2019) were estimated overall (adjusted for age, sex, and race and ethnicity) and by race and ethnicity (adjusted for age and sex). Results Our sample included 1 193 314 persons with hypertension in 2019 (48.9% aged 65–85 years, 52.9% men, 66.2% non‐Hispanic White) and 1 499 418 individuals in 2022 (50.6% aged 65–85 years, 47.1% men, 62.7% non‐Hispanic White). The weighted average BP control dropped from 65.3% in 2019 to 61.8% in 2020 and then partially recovered to 62.6% in 2022 (adjusted mean difference, −2.6 percentage points [95% CI, −5.0 to −0.2]). Non‐Hispanic Asian individuals experienced the largest temporal drop in BP control, declining from 68.4% in 2019 to 63.9% in 2022. Conclusions BP control was disrupted during the COVID‐19 pandemic and had not fully rebounded to prepandemic levels by the end of 2022. Continued surveillance is needed to determine whether the decline in BP control will persist and will result in future adverse cardiovascular events.

Background: The COVID-19 pandemic resulted in reduced in-person clinic visits and declines in blood pressure (BP) control among patients with hypertension. The purpose of this study was to report on pre- to post-pandemic trends in BP control and related BP metrics through 2022. Methods: We utilized data from 17 US health systems with electronic health record data standardized to the PCORnet ® Common Data Model. Multiple BP control metrics were calculated as a series of quarterly, 12-month rolling measurement periods from 2017 to 2022 (i.e., 1/1/2017-12/31/2017, 4/1/2017-3/31/2018, …, 1/1/2022-12/31/2022). BP control was defined as the percentage of patients with hypertension whose most recent BP measurement at an ambulatory visit was <140/<90 mmHg. Improvement in BP was defined as the percentage of patients with a reduction of 10 mmHg in systolic BP or achievement of systolic BP <140 mmHg during the last 3 months of the measurement period in patients with previously uncontrolled hypertension. Results: In 2022, 1,499,418 persons with hypertension were included (50% 65-85 years old; 47% men; 11% Hispanic, 3% non-Hispanic Asian, 20% non-Hispanic Black, 63% non-Hispanic White). BP control was relatively stable within health systems prior to the COVID-19 pandemic. Worsening of BP control was seen for most health systems in the second quarter of 2020 coinciding with onset of the COVID-19 pandemic (Figure, left panel). The weighted average BP control was 65.3% in 2019, dropped to 61.8% in 2020, and increased to 62.9% in 2021 and 62.6% in 2022. Similar patterns were observed for the improvement in BP metric (Figure, right panel): weighted average 31.4% in 2019, 25.7% in 2020, 29.1% in 2021 and 28.6% in 2022. Conclusion: BP control and improvement in BP decreased substantially during the COVID-19 pandemic. While both metrics improved after 2020, they were still below pre-pandemic levels through 2022. These findings underscore the importance of continued surveillance of BP control and other health impacts of the COVID-19 pandemic.

Objective: We aimed to characterize seasonal variation in US population-based blood pressure (BP) control and BP-related metrics and evaluate the association between outdoor temperature and BP control variation. Methods: We queried electronic health records (EHRs) from 26 health systems, representing 21 states, to summarize BP metrics by quarters of 12-month periods from January 2017 to March 2020. Patients with at least one ambulatory visit during the measurement period and a hypertension diagnosis during the first 6 months or prior to the measurement period were included. Changes in BP control, BP improvement, medication intensification, average SBP reduction after medication intensification across quarters and association with outdoor temperature were analyzed using weighted generalized linear models with repeated measures. Results: Among 1 818 041 people with hypertension, the majority were more than 65 years of age (52.2%), female (52.1%), white non-Hispanic (69.8%) and had stage 1/2 hypertension (64.8%). Overall, BP control and process metrics were highest in quarters 2 and 3, and lowest in quarters 1 and 4. Quarter 2 had the highest percentage of improved BP (31.95 ± 0.90%) and average SBP reduction after medication intensification (16 ± 0.23 mmHg). Quarter 3 had the highest percentage of BP controlled (62.25 ± 2.55%) and lowest with medication intensification (9.73 ± 0.60%). Results were largely consistent in adjusted models. Average temperature was associated with BP control metrics in unadjusted models, but associations were attenuated following adjustment. Conclusion: In this large, national, EHR-based study, BP control and BP-related process metrics improved during spring/summer months, but outdoor temperature was not associated with performance following adjustment for potential confounders.

Background Uncontrolled blood pressure (BP) remains a leading cause of death in the United States. The American Medical Association developed a quality improvement program to improve BP control, but it is unclear how to efficiently implement this program at scale across multiple health systems. Methods and Results We conducted BP MAP (Blood Pressure Measure Accurately, Act Rapidly, and Partner With Patients), a comparative effectiveness trial with clinic‐level randomization to compare 2 scalable versions of the quality improvement program: Full Support (with support from quality improvement expert) and Self‐Guided (using only online materials). Outcomes were clinic‐level BP control (<140/90 mm Hg) and other BP‐related process metrics calculated using electronic health record data. Difference‐in‐differences were used to compare changes in outcomes from baseline to 6 months, between intervention arms, and to a nonrandomized Usual Care arm composed of 18 health systems. A total of 24 safety‐net clinics in 9 different health systems underwent randomization and then simultaneous implementation. BP control increased from 56.7% to 59.1% in the Full Support arm, and 62.0% to 63.1% in the Self‐Guided arm, whereas BP control dropped slightly from 61.3% to 60.9% in the Usual Care arm. The between‐group differences‐in‐differences were not statistically significant (Full Support versus Self‐Guided=+1.2% [95% CI, −3.2% to 5.6%], P =0.59; Full Support versus Usual Care=+3.2% [−0.5% to 6.9%], P =0.09; Self‐Guided versus Usual Care=+2.0% [−0.4% to 4.5%], P =0.10). Conclusions In this randomized trial, 2 methods of implementing a quality improvement intervention in 24 safety net clinics led to modest improvements in BP control that were not statistically significant. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03818659.

ImportanceSelf-measured blood pressure (SMBP) with commercially available connected smartphone applications may help patients effectively use SMBP measurements.ObjectiveTo determine if enhanced SMBP paired with a connected smartphone application was superior to standard SMBP for blood pressure (BP) reduction or patient satisfaction.Design, Setting, and ParticipantsThis randomized clinical trial was conducted among 23 health systems participating in PCORnet, the National Patient-Centered Clinical Research Network, and included patients who reported having uncontrolled BP at their last clinic visit, a desire to lower their BP, and a smartphone. Enrollment and randomization occurred from August 3, 2019, to December 31, 2020, which was followed by 6 months of follow-up for each patient. Analysis commenced shortly thereafter.InterventionsEligible participants were randomly assigned to enhanced SMBP using a device that paired with a connected smartphone application (enhanced) or a standard device (standard). Participants received their device in the mail, along with web-based educational materials and phone-based support as needed. No clinician engagement was undertaken, and the study provided no special mechanisms for delivering measurements to clinicians for use in BP management.Main Outcomes and MeasuresReduction in systolic BP, defined as the difference between clinic BP at baseline and the most recent clinic BP extracted from electronic health records at 6 months.ResultsEnrolled participants (1051 enhanced [50.0%] vs 1050 standard [50.0%]; 1191 women [56.7%]) were mostly middle-aged or older (mean [SD] age, 58 [13] years), nearly a third were Black or Hispanic (645 [31%]), and most were relatively comfortable using technology (mean [SD], 4.1 [1.1] of 5). The mean (SD) change in systolic BP from baseline to 6 months was −10.8 (18) mm Hg vs −10.6 (18) mm Hg (enhanced vs standard: adjusted difference, −0.19 mm Hg; 95% CI, −1.83 to 1.44;P = .81). Secondary outcomes were mostly null, except for documented attainment of BP control to lower than 140/&amp;lt;90 mm Hg, which occurred in 32% enhanced vs 29% standard groups (odds ratio, 1.15; 95% CI, 1.01-1.34). Most participants were very likely to recommend their SMBP device to a friend (70% vs 69%).Conclusions and RelevanceThis randomized clinical trial found that enhanced SMBP paired with a smartphone application is not superior to standard SMBP for BP reduction or patient satisfaction.Trial RegistrationClinicalTrials.gov Identifier:NCT03796689

Background The National Patient‐Centered Clinical Research Network Blood Pressure Control Laboratory Surveillance System was established to identify opportunities for blood pressure (BP) control improvement and to provide a mechanism for tracking improvement longitudinally. Methods and Results We conducted a serial cross‐sectional study with queries against standardized electronic health record data in the National Patient‐Centered Clinical Research Network (PCORnet) common data model returned by 25 participating US health systems. Queries produced BP control metrics for adults with well‐documented hypertension and a recent encounter at the health system for a series of 1‐year measurement periods for each quarter of available data from January 2017 to March 2020. Aggregate weighted results are presented overall and by race and ethnicity. The most recent measurement period includes data from 1 737 995 patients, and 11 956 509 patient‐years were included in the trend analysis. Overall, 15% were Black, 52% women, and 28% had diabetes. BP control (<140/90 mm Hg) was observed in 62% (range, 44%–74%) but varied by race and ethnicity, with the lowest BP control among Black patients at 57% (odds ratio, 0.79; 95% CI, 0.66–0.94). A new class of antihypertensive medication (medication intensification) was prescribed in just 12% (range, 0.6%–25%) of patient visits where BP was uncontrolled. However, when medication intensification occurred, there was a large decrease in systolic BP (≈15 mm Hg; range, 5–18 mm Hg). Conclusions Major opportunities exist for improving BP control and reducing disparities, especially through consistent medication intensification when BP is uncontrolled. These data demonstrate substantial room for improvement and opportunities to close health equity gaps.

Background: Uncontrolled blood pressure (BP) is a leading preventable cause of death that remains common in the US population despite the availability of effective medications. New technology and program innovation has high potential to improve BP but may be expensive and burdensome for patients, clinicians, health systems, and payers and may not produce desired results or reduce existing disparities in BP control. Methods and Results: The PCORnet Blood Pressure Control Laboratory is a platform designed to enable national surveillance and facilitate quality improvement and comparative effectiveness research. The platform uses PCORnet, the National Patient-Centered Clinical Research Network, for engagement of health systems and collection of electronic health record data, and the Eureka Research Platform for eConsent and collection of patient-reported outcomes and mHealth data from wearable devices and smartphones. Three demonstration projects are underway: BP track will conduct national surveillance of BP control and related clinical processes by measuring theory-derived pragmatic BP control metrics using electronic health record data, with a focus on tracking disparities over time; BP MAP will conduct a cluster-randomized trial comparing effectiveness of 2 versions of a BP control quality improvement program; BP Home will conduct an individual patient-level randomized trial comparing effectiveness of smartphone-linked versus standard home BP monitoring. Thus far, BP Track has collected electronic health record data from over 826 000 eligible patients with hypertension who completed ≈3.1 million ambulatory visits. Preliminary results demonstrate substantial room for improvement in BP control (<140/90 mm Hg), which was 58% overall, and in the clinical processes relevant for BP control. For example, only 12% of patients with hypertension with a high BP measurement during an ambulatory visit received an order for a new antihypertensive medication. Conclusions: The PCORnet Blood Pressure Control Laboratory is designed to be a reusable platform for efficient surveillance and comparative effectiveness research; results from demonstration projects are forthcoming.

Introduction: Alcohol use is common in the United States. Most studies describe a J-shaped relationship between alcohol consumption and cognitive function: frequent heavy consumption alters brain functions and decreases cognitive performance; regular light and moderate consumption may have protective impact. We are unaware of any reports utilizing longitudinally collected data to derive a cumulative exposure of alcohol use and assess its association with cognitive function. Hypothesis: Cumulative 30-year exposure to alcohol has a J-shaped association with mid-life cognitive function. Methods: We included 3,068 participants aged 18-30 years at the baseline examination (1985-86) and having up to 8 follow-up exams at 2- to 5-year intervals including at 30 years (2015-16). Cumulative “drink-years” exposure to alcohol was estimated at each exam by multiplying the usual number of drinks/day reported by the number of years since last exam, and then summing across exams. We used multivariable adjusted linear regression models to assess the independent associations of number of drink-years with 6 measures of cognitive function studied at Year 30: Rey Auditory Verbal Learning Test (RAVLT), Digit Symbol Substitution Test (DSST), Stroop Test, Montreal Cognitive Assessment (MoCA), Category Fluency Test, and Letter Fluency Test. We used inverse probability of censoring weighting to account for potential informative censoring. Linear regression models estimated standardized mean test scores for the cumulative alcohol use categories (drink-years: >0 and <15, 15-29.9, 30+). Too few participants were available for assessment of higher categories of use. Results: Compared with never drinking, the 3 categories of cumulative exposure were unassociated with any of the cognitive function measures. Conclusions: Cumulative 30-year alcohol use is not associated with cognitive function in middle-aged adults in the CARDIA study.

Background: The Patient-Centered Outcomes Research Institute (PCORI) funded National Blood Pressure Surveillance System (BP Track) is a new national system that generates quarterly metrics of blood pressure (BP) control and BP-related quality metrics for participating healthcare systems from electronic health record (EHR) data. Methods: Queries against standardized EHR data in the national Patient-Centered Clinical Research Network (PCORnet) Common Data Model format produce a set of quality metrics relevant to improving BP control, including Controlling High BP (NQF 0018) and Improvement in BP (CMS65v7), and eight process measures specific to clinical management and treatment practices for improving BP control ( Table ). The metrics, aggregated overall and by health system are reported back to health systems via user-friendly Tableau dashboards, and allow for observation of metric trends. Results: To date, 19 datamarts have contributed EHR data from 1,177,232 patients who met the eligibility criteria for the BP Control measure and 4,454,729 encounters that included a BP measurement during the measurement period. Average age was 62 years; 10% were young adults (<45 years), 17% were African American, 52% female, 28% had diabetes, 15% had coronary heart disease, and 14% had depression. Results demonstrate substantial opportunity for improvement in overall BP control (60% with BP<140/<90 mmHg, range: 42-72%), and many healthcare processes, including medication intensification (12%, 0.6-22%) and use of fixed dose combination medications (24%, 0-88%, Table ). Conclusion: Major opportunities exist for improving BP control, especially in improving the frequency and quality of BP medication prescribing for patients with high BP. The BP Track National BP Surveillance System will track these metrics, by demographic subgroup and over time, and will generate data that can guide and focus quality improvement initiatives aimed at effective BP management.

Background: New technology and healthcare delivery approaches may help improve blood pressure (BP) control. Randomized controlled trials (RCTs) can demonstrate effectiveness of these emerging approaches, both overall and especially within underserved populations, but RCTs are expensive. Our objective is to establish a national platform to support BP control surveillance and efficient RCTs. Methods: The PCORnet BP Control Laboratory, designed and launched in partnership with the American Heart Association (AHA) and the American Medical Association (AMA), leverages electronic health record (EHR) systems throughout the US, the National Patient-Centered Outcomes Research Network (PCORnet), and the NIH-funded Eureka Research Platform, which enables direct-to-participant research including collection of patient-reported outcomes and mHealth data from wearable devices and smartphones. We will use these resources to 1) Conduct national surveillance through quarterly EHR data queries to calculate and track institution- and clinic-level BP control metrics across 23 PCORnet institutions, overall and within key subgroups, and support participation in the AHA/AMA’s Target:BP recognition program (BP Track); 2) Compare effectiveness of a Full Support versus Self-Guided version of the AMA’s Measure Accurately, Act Rapidly, and Partner with Patients (MAP) program at improving BP control in a cluster randomized trial of 24 safety net clinics (BP MAP); and 3) Compare effectiveness of Smartphone-linked versus standard home BP monitoring at reducing systolic BP in an individual-level, direct-to-participant RCT of 2000 patients with uncontrolled BP (BP Home). Results: Preliminary BP Track queries demonstrate an overall BP control rate of 56%, lower control in Black patients (51%), substantial heterogeneity in clinic-level metrics (e.g., 33% vs. 64% BP control), and low rates of medication intensification (9% prescribed a new medication class when BP was high). BP Track will launch PCORnet-wide queries in June; BP MAP in May; and BP Home in August 2019. Conclusions: Feasibility testing is underway to determine if the PCORnet BP Control Laboratory will be useful for investigators interested in conducting efficient RCTs of BP control interventions.