Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model
Simulating Strategies for Improving Control of Hypertension Among Patients with Usual Source of Care in the United States: The Blood Pressure Control Model
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DOI：
10.1007/s11606-015-3231-8
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发表时间：
2015-08-01
影响因子：
5.7
通讯作者：
Pletcher, Mark J.
中科院分区：
文献类型：
--
作者：
Fontil, Valy;Bibbins-Domingo, Kirsten;Pletcher, Mark J.
在美国，只有一半的高血压成年人实现了血压（BP）控制，目前还不清楚如何在人群水平上最有效地提高血压控制率。我们试图比较全系统范围内单独改善药物依从性、就诊频率、和较高的医生处方率在52周时实现血压控制。我们开发了一个马尔可夫微观模拟模型，以及药物控制高血压的系统级过程。该模型由国家调查，队列研究和试验的数据提供信息，并通过两项多中心临床试验进行验证（ALLHAT和VALUE）。我们研究了一个模拟的、具有全国代表性的队列，这些患者被诊断为高血压，但不受控制，接受常规治疗。我们模拟了一个基础病例和10%和50%的改善，以及三个可修改参数的理想场景：访视频率、治疗强化和药物依从性。理想情况定义为100%的治疗强化和依从性，并且在诊室收缩压升高的4周内进行回访。在52周的随访中检查血压控制情况。在25，000例假设的高血压不受控制的成年患者中，（收缩压a千分之一日元140 mmHg），使用基本情况假设，52周后只有18%的人实现了血压控制。在每个孤立参数的10/50%/理想化增强情况下，与增强访视频率（19/21/35%）和药物依从性（19/23/26%）相比，增强治疗强化实现了最大的BP控制（19/23/71%）。当所有三个过程都理想化时，该模型预测52周时血压控制率为95%。血压控制的实质性改善只能通过护理过程的重大改善来实现。医疗保健系统可以通过增加临床就诊的频率和改善医生的处方行为而不是试图改善患者对药物的依从性来取得更大的成功。
Only half of hypertensive adults achieve blood pressure (BP) control in the United States, and it is unclear how BP control rates may be improved most effectively and efficiently at the population level.We sought to compare the potential effects of system-wide isolated improvements in medication adherence, visit frequency, and higher physician prescription rate on achieving BP control at 52 weeks.We developed a Markov microsimulation model of patient-level, physician-level, and system-level processes involved in controlling hypertension with medications. The model is informed by data from national surveys, cohort studies and trials, and was validated against two multicenter clinical trials (ALLHAT and VALUE).We studied a simulated, nationally representative cohort of patients with diagnosed but uncontrolled hypertension with a usual source of care.We simulated a base case and improvements of 10 and 50 %, and an ideal scenario for three modifiable parameters: visit frequency, treatment intensification, and medication adherence. Ideal scenarios were defined as 100 % for treatment intensification and adherence, and return visits occurring within 4 weeks of an elevated office systolic BP.BP control at 52 weeks of follow-up was examined.Among 25,000 hypothetical adult patients with uncontrolled hypertension (systolic BP a parts per thousand yen 140 mmHg), only 18 % achieved BP control after 52 weeks using base-case assumptions. With 10/50 %/idealized enhancements in each isolated parameter, enhanced treatment intensification achieved the greatest BP control (19/23/71 %), compared with enhanced visit frequency (19/21/35 %) and medication adherence (19/23/26 %). When all three processes were idealized, the model predicted a BP control rate of 95 % at 52 weeks.Substantial improvements in BP control can only be achieved through major improvements in processes of care. Healthcare systems may achieve greater success by increasing the frequency of clinical encounters and improving physicians' prescribing behavior than by attempting to improve patient adherence to medications.