Using Evidence-Based Resources to Engage Patients in High Blood Pressure Management

1. Using Evidence-Based Resources to Engage Patients in High Blood Pressure Management Sandy Robinson Senior Research Analyst , American Institutes for Research skrobinson@air.org Speaking on behalf of the Agency for Healthcare Research and Quality (AHRQ)

2. Overview • Overview of Comparative Effectiveness Research (CER) • AHRQ’s Effective Health Care products • CERs on hypertension medication and blood pressure self monitoring • Using AHRQ’s research summaries to engage patients in care of hypertension

3. Agency for Healthcare Research and Quality (AHRQ) • As an HHS agency, AHRQ’s mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans • AHRQ supports research that helps people make more informed decisions and improves the quality of health care services AHRQ Director Carolyn Clancy, MD

4. AHRQ’s Comparative Effectiveness Research • Compares the benefits and harms of different interventions and strategies to prevent, diagnose, treat, and monitor health conditions • Compares drugs, medical devices, tests, surgeries, or health care delivery methods • Provides the best available evidence for patients and their clinicians to work together to choose the best possible treatment for an illness or condition

5. Examples of Effectiveness Research Types • Systematic review compared existing research on diabetes pills and found that metformin works just as well as newer diabetes drugs • Clinical trial (COURAGE) by the Veterans Affairs (VA) demonstrated that patients treated with optimal medical therapy alone did just as well as patients who received percutaneous coronary intervention (PCI) plus medical therapy in preventing heart attack and death.(FCCCER, 2009) • Observational study is planned to evaluate the effectiveness of different treatment pathways in achieving relief from symptoms of uterine fibroids and improving overall quality of life

6. Process to Develop CER Reviews • Topics are nominated through a public process • Systematic review of all relevant clinical studies is conducted by independent researchers • Draft reports reviewed by public, expert panels • Results of these reviews are summarizedfor clinicians and consumers to use in decision-making and in discussions with patients • Summaries and the full report, with references for included and excluded studies, are available at www.effectivehealthcare.ahrq.gov

7. Rating the Strength of Evidence from the CER Uhlig K, Balk EM, Patel K, et al. AHRQ Comparative Effectiveness Review No. 45. January 2012. Available at: http://www.effectivehealthcare.ahrq.gov/selfmeasuredbp.cfm.

8. Effective Health Care Program Resources

9. Consumers and Clinicians Test the Research Summaries • CONSUMERS • Have experience with condition/topic • Patient or adult caregiver • Education level: High School or Some College • CLINICIANS • Primary Care Physicians (Family, GP, Internists) • Specialists (representative by topic) • PAs or NPs when appropriate to topic • Pharmacists

10. What the “Testers” Told Us Patients need info Clinicians need info Source of the evidence Quality of the evidence How it applies to their patients How it can help them help patients to self manage And how it fits into the point of care • Health condition • Treatment options • Potential side effects • Effect on lifestyle choices such as exercise, diet, stress reduction • What they can do for themselves • Associated costs And optimism and hope

11. Effective Health Care Program Resources

12. Keeping the Patient at the Center • Patients are more involved in their health care decisions • Each patient is different • Patients need reliable, relevant, and understandable information

13. Companion Resources

14. Clinician Research Summary RESEARCH FOCUS Support patient counseling CLINICAL BOTTOM LINE BACKGROUND CONCLUSIONS STRENGTH OF EVIDENCE SCALE

15. Key Features of Clinician Summaries • Can help answer questions from patients • Synthesizes key findings and latest data in concise, easy-to-scan format • Can serve as reminder of best practices

16. HBP Meds: Clinical Bottom Line

17. HBP Meds: Conclusions • ACEIs and ARBs control blood pressure to a similar extent. • Data are limited for comparisons involving the DRI aliskiren. • ACEIs and ARBs have similar effects on mortality, major cardiovascular events, quality of life, lipid levels, markers of carbohydrate metabolism/diabetes control, and other adverse events excluding cough. • Cough is significantly higher with ACEIs when compared with an ARB. • For many outcomes, comparisons of ACEIs or ARBs with the DRI aliskiren were not evaluated, precluding meaningful conclusions about aliskiren.

18. Blood Pressure Self Monitoring: Clinical Bottom Line

19. Blood Pressure Self Monitoring Conclusions • Blood pressure self monitoring alone versus usual care yielded a modest reduction in clinic systolic BP (SBP) and diastolic BP (DBP) at 6 months (SBP/DBP -3.1/ -2.0 mmHg) and 12 months (SBP/DBP -1.2/-0.8 mmHg). • Net reduction in SBP and DBP was statistically significant at 6 months but not at 12 months. • Combining additional support with BP self-monitoring led to greater BP reduction when compared to usual care at up to 12 months of followup based on consistent findings in six high quality studies. • However, the evidence was too limited to determine the superiority of any one form of clinical support, as modalities varied widely across studies. The evidence is weak or insufficient to determine if SMBP with or without additional support has an impact on other outcomes.

20. Summaries Give Tips on What to Discuss with Your Patients and Their Caregivers • The importance of effectively controlling high BP • The link between measuring BP and controlling high BP • The importance of adherence to strategies aimed at managing hypertension such as lifestyle and dietary modifications and medication • How self monitoring of blood pressure helps patients to actively manage their BP • The types of SMBP devices available and how to operate the device selected for the patient

21. Consumer Summary • Each clinician guide has a companion patient research summary • Supports conversations between patients and healthcare providers • Helps lead to shared decisions about the best treatment • Available in English and Spanish

22. Key Features • Overview of condition • How to use the information • Understanding side effects • What to ask and tell a health care provider

23. Choosing High Blood Pressure Medicines

24. Measuring Blood Pressure at Home

25. Choosing a Blood Pressure Monitor

26. Comparing Side Effects

27. Helps Patients Get Involved • Gives some questions to ask and consider • One page “at-a-glance” format • Space to jot down notes

28. How Summaries Can Help You Support Blood Pressure Management • Discuss importance of tracking key health tests, such as HbA1c, cholesterol, blood pressure. • Descriptions of condition – reinforces knowledge • Helps patient involve friend or family member • Identifying issues to discuss with patients • Talking about side effects • Analyzing treatments • Assessing benefits and harms for patient outcomes

29. Tips on Partnering with Patients • Keep information simple and to the point • Put information in a context that is meaningful to people • Recognize the emotional aspects of the information and decisions • Help patients organize the decision • Talk about what is known and not known • Don’t be afraid of numbers

30. How can clinicians use these evidence summaries at the point of care? • Ideas from Michael Pontious, MD • Ideas from the audience

31. Accessing the Summaries www.effectivehealthcare.ahrq.gov Summaries for Consumers and Clinicians Search for Summaries on specific topics

32. Accessing the Summaries Order FREE printed copies of the guides from the AHRQ Publications Clearinghouse. Call: 1-800-358-9295 or E-mail: ahrqpubs@ahrq.hhs.gov Please reference code: C-02

33. Partner with AHRQ • AHRQ is building a National Partnership Network of organizations interested in using PCOR/CER • AHRQ supports partners in using the resources and communicating with clinicians and patients • Partners also can receive a larger quantity of free resources • Interested? Contact: • Jake Yarbrough • AHRQ Dallas Regional Office • 817-920-1834 • jake.yarbrough@ahrq.hhs.gov