Fontil Valy, Gupta Reena, Moise Nathalie, Chen Ellen, Guzman David, McCulloch Charles E, Bibbins-Domingo Kirsten
Division of General Internal Medicine, Zuckerberg San Francisco General Hospital (V.F., R.G., D.G., K.B.-D.)
University of California San Francisco. UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital (V.F., D.G., K.B.-D.).
Circ Cardiovasc Qual Outcomes. 2018 Jul;11(7):e004386. doi: 10.1161/CIRCOUTCOMES.117.004386.
Nearly half of Americans with diagnosed hypertension have uncontrolled blood pressure (BP) while some integrated healthcare systems, such as Kaiser Permanente Northern California, have achieved control rates upwards 90%.
We adapted Kaiser Permanente's evidence-based treatment protocols in a racially and ethnically diverse population at 12 safety-net clinics in the San Francisco Health Network. The intervention consisted of 4 elements: a hypertension registry, a simplified treatment intensification protocol that included fixed-dose combination medications containing diuretics, standardized BP measurement protocol, and BP check visits led by registered nurse and pharmacist staff. The study population comprised patients with hypertension who made ≥1 primary care visits within the past 24 months (n=15 917) and had a recorded BP measurement within the past 12 months. We conducted a postintervention time series analysis from August 2014 to August 2016 to assess the effect of the intervention on BP control for 24 months for the pilot site and for 15 months for 11 other San Francisco Health Network clinics combined. Secondary outcomes were changes in use of guideline-recommended medication prescribing. Rates of BP control increased at the pilot site (68%-74%; <0.01) and the 11 other San Francisco Health Network clinic sites (69%-74%; <0.01). Statistically significant improvements in BP control rates (<0.01) at the 11 San Francisco Health Network clinic sites occurred in all racial and ethnic groups (blacks, 60%-66%; whites, 69%-75%; Latinos, 67%-72%; Asians, 78%-82%). Use of fixed-dose combination medications increased from 10% to 13% (<0.01), and the percentage of angiotensin-converting enzyme inhibitor prescriptions dispensed in combination with a thiazide diuretic increased from 36% to 40% (<0.01).
Evidence-based system approaches to improving BP control can be implemented in safety-net settings and could play a pivotal role in achieving improved population BP control and reducing hypertension disparities.
近一半被诊断为高血压的美国人血压未得到控制，而一些综合医疗系统，如北加利福尼亚凯撒医疗集团，已实现了90%以上的控制率。
我们在旧金山医疗网络的12家安全网诊所中，针对不同种族和民族的人群采用了凯撒医疗集团基于证据的治疗方案。干预措施包括4个要素：高血压登记册、简化的治疗强化方案（包括含利尿剂的固定剂量复方药物）、标准化血压测量方案以及由注册护士和药剂师工作人员主导的血压检查就诊。研究人群包括在过去24个月内进行过≥1次初级保健就诊（n = 15917）且在过去12个月内有血压测量记录的高血压患者。我们在2014年8月至2016年8月期间进行了干预后时间序列分析，以评估该干预措施对试点站点24个月以及旧金山医疗网络其他11家诊所联合15个月的血压控制效果。次要结局是指南推荐药物处方使用情况的变化。试点站点的血压控制率有所提高（从68%提高到74%；P<0.01），旧金山医疗网络其他11家诊所站点也如此（从69%提高到74%；P<0.01）。旧金山医疗网络11家诊所站点的所有种族和民族群体（黑人，从60%提高到66%；白人，从69%提高到75%；拉丁裔，从67%提高到72%；亚裔，从78%提高到82%）的血压控制率均有统计学显著改善（P<0.01）。固定剂量复方药物的使用从10%增加到13%（P<0.01），血管紧张素转换酶抑制剂与噻嗪类利尿剂联合配药的百分比从36%增加到40%（P<0.01）。
基于证据的改善血压控制的系统方法可在安全网环境中实施，并且在实现人群血压控制改善和减少高血压差异方面可能发挥关键作用。
