Speaker
Gbenga Ogedegbe, MD, MPH, FACP
Dr. Adolph & Margaret Berger Professor of Population Health
NYU Grossman School of Medicine
Director, Institute for Excellence in Health Equity (IEHE)
NYU Langone Health
Keywords
Hypertension; Racial Disparities; Case Management; Telemonitoring
Key Points
- There are significant racial disparities when it comes to stroke outcomes in the U.S., with Black and Hispanic populations experiencing poorer outcomes than Caucasian populations. A major predictor for these disparities is hypertension (HTN); controlling HTN is key to secondary stroke prevention.
- Home Blood Pressure Telemonitoring (HBPTM) and Nurse Case Management (NCM) have proven efficacy in addressing multilevel barriers to HTN control. However, their effectiveness remains untested in stroke patients, and their implementation is sub-optimal in Black and Hispanic patients.
- The research team looked at the comparative effectiveness of HBPTM alone versus HBPTM plus telephone-based NCM when administered to Black and Hispanic stroke survivors with uncontrolled hypertension. They measured within-patient change in systolic blood pressure (SBP) from baseline to 12 months and the rate of recurrent stroke at 24 months.
- This was a multisite, practice-based, comparative effectiveness randomized clinical trial conducted at six public hospitals and three academic medical centers in New York City. About 225 patients were randomized to each of the two arms.
- The study population was defined by low-income, minoritized communities with significant comorbidity. This is a departure from much of the existing literature, Dr. Ogedegbe noted, in which patient populations tend to be more insured, more highly educated, and have higher employment rates.
- The research team found that both groups experienced significant SBP reduction at both the six-month and 12-month mark. The telehealth intervention that combined HBPTM with NCM led to greater SBP reduction than HBPTM alone. There was no significant difference in the rate of recurrent stroke between the two groups across a 24-month period.
- These findings provide strong empirical evidence for widespread implementation in low-income stroke survivors with multiple comorbidities. Policymakers can use this evidence to implement these strategies in minority patients with stroke and uncontrolled hypertension.
- Implementation challenges will include coverage of HBPM, which varies among private payers and Medicaid programs; clinical support services for use; access to the internet, to transmit data for virtual care; and integration of data into electronic medical records.
Discussion Themes
To effectively address inequities in hypertension, researchers must partner with policymakers, payers, and community-based organizations ahead of time, with a focus on team-based care.
Sustainment can be an Achilles Heel for embedded trials, as programs that have been shown to be successful aren’t always covered by insurance. Chronic disease management with team-based care is a good step that practices can invest in in the interim.
The fidelity to the NCM intervention, measured by the participation in 20 NCM calls and the compliance with HBPTM, was around 68% – a decent figure given the challenges of conducting a trial in a real-world setting, Dr. Ogedegbe noted.
Front-line doctors were instrumental in helping the research teams onboard the sites and think through recruitment.