A remote hypertension management program clinical algorithm

Abstract

Introduction: Hypertension is the leading risk factor for death, affecting over one billion people worldwide, yet control rates are poor and stagnant. We developed a remote hypertension management program that leverages digitally transmitted home blood pressure (BP) measurements, algorithmic care pathways, and patient-navigator communications to aid patients in achieving guideline-directed BP goals.

Methods: Patients with uncontrolled hypertension are identified through provider referrals and electronic health record screening aided by population health managers within the Mass General Brigham (MGB) health system. Non-licensed patient navigators supervised by pharmacists, nurse practitioners, and physicians engage and educate patients. Patients receive cellular or Bluetooth-enabled BP devices with which they monitor and transmit scheduled home BP readings. Evidence-based medication changes are made according to a custom hypertension algorithm approved within a collaborative drug therapy management (CDTM) agreement with MGB and implemented by pharmacists. Using patient-specific characteristics, we developed different pathways to optimize medication regimens. The renin-angiotensin-aldosterone system-blocker pathway prescribed ARBs/ACE inhibitors first for patients with diabetes, impaired renal function, and microalbuminuria; the standard pathway started patients on calcium channel blockers. Regimens were escalated frequently, adding thiazide-type diuretics, and including beta blockers and mineralocorticoid receptor antagonists if needed.

Discussion: We have developed an algorithmic approach for the remote management of hypertension with demonstrated success. A focus on algorithmic decision-making streamlines tasks and responsibilities, easing the potential for scalability of this model. As the backbone of our remote management program, this clinical algorithm can improve BP control and innovate the management of hypertension in large populations.

Keywords: Angiotensin II receptor blockers (ARBs) and Angiotensin-converting enzyme (ACE) inhibitors; CDTM; algorithmic management; beta blockers; calcium channel blockers (CCBs); collaborative drug therapy management; hypertension; mineralocorticoid receptor antagonists; pharmacy; thiazide diuretics.