MEDICINE
Home blood pressure monitoring saves lives, cuts costs, and reduces healthcare disparities
New research in the American Journal of Preventive Medicine confirms that regular self-testing better controls hypertension, especially among underserved patients
Peer-Reviewed PublicationAnn Arbor, July 13, 2023 – Expanding home blood pressure monitoring among US adults with hypertension could substantially reduce the burden of cardiovascular disease and save healthcare costs in the long term, according to a new study in the American Journal of Preventive Medicine, published by Elsevier. The results of the study show that expanding home monitoring has the potential to address pervasive health disparities facing racial and ethnic minorities and rural residents because it would reduce cardiovascular events among US adults.
Co-lead investigator Yan Li, PhD, Professor, School of Public Health, Shanghai Jiao Tong University School of Medicine, explained, “Our study is among the first to assess the potential health and economic impact of adopting home blood pressure monitoring among American adults with hypertension. We found that it facilitates early detection, timely intervention, and prevention of complications, leading to improved control and better health outcomes.”
Analyzing data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS), investigators projected that implementing home blood pressure monitoring, as opposed to traditional clinic-based care, could result in a reduction of myocardial infarction (MI) cases by 4.9% and stroke cases by 3.8% over 20 years.
Non-Hispanic Blacks, women, and rural residents had more averted cardiovascular events and greater cost savings related to adopting home blood pressure monitoring compared to non-Hispanic Whites, men, and urban residents. Adopting home blood pressure monitoring in rural areas would lead to a potential reduction of 21,278 MI cases per one million people compared to 11,012 MI cases per one million people in urban areas. Rural residents tend to have a higher prevalence of hypertension and uncontrolled hypertension than urban residents and often face additional barriers in accessing primary care services.
Estimating healthcare cost parameters based on actual healthcare payment data from the Medical Expenditure Panel Survey (MEPS), researchers projected an average of 4.4% per person annual savings and an average of $7,794 in healthcare costs per person over a span of 20 years in this population due to home blood pressure monitoring adoption and the subsequent reduced cardiovascular disease cases. Previous economic evaluations of home blood pressure monitoring have primarily focused on local health systems or conducted short-term, small-scale randomized controlled trials.
Hypertension -- systolic blood pressure (BP) greater than 130 mmHg or a diastolic BP greater than 80 mmHg or being on medication for it -- is a pressing public health challenge in the US, with significant implications for the development of heart disease and stroke and leads to substantial healthcare costs. Traditional clinic monitoring, the common method for BP measurement and hypertension diagnosis, has a number of drawbacks: Patients may not visit clinics often enough to pick up the problem, and when they do, accuracy may be compromised by the “white coat” (high office BP but normal BP on home measurements) or “masked” (normal/high normal BP in the office but elevated at home) effects.
Home blood pressure monitoring eliminates these impediments and provides more comprehensive and accurate data compared to sporadic measurements obtained during clinic visits. Yet, the highly effective practice has not been widely adopted in the US because of inadequate health insurance coverage, lack of investment in preventive services, and limited health promotion efforts provided by primary care physicians. However, the landscape has changed between 2020 and 2022 when home blood pressure monitoring attracted increasing attention due to healthcare disruptions caused by the COVID-19 pandemic.
Co-lead investigator Donglan Zhang, PhD, Associate Professor, Center for Population Health and Health Services Research, New York University Long Island School of Medicine, commented, “Given that almost half of all adults in the US (47%) are affected by high blood pressure, and considering the persistent health disparities in cardiovascular health, it is very important to advocate for the widespread adoption of effective and cost-saving strategies. Home blood pressure monitoring empowers patients to take a more active role in managing their chronic conditions. Our findings provide compelling evidence for healthcare systems and payers supporting the broader implementation of this intervention.”
JOURNAL
American Journal of Preventive Medicine
METHOD OF RESEARCH
Data/statistical analysis
SUBJECT OF RESEARCH
People
ARTICLE TITLE
The Health and Economic Impact of Expanding Home Blood Pressure Monitoring
New guidance: Bridging the gap between what we know and what we do
Medical organizations publish approaches for implementing infection prevention
Peer-Reviewed PublicationARLINGTON, Va. (July 11, 2023) — Five medical societies have published a set of recommendations for operationalizing strategies for infection prevention in acute care settings that account for conditions within the facility, including the culture and communications style of teams, hospital policies, resources available, leadership support and staff buy-in.
“There is no best way to implement a practice, but implementation need not be overly complex,” said Joshua Schaffzin, MD, a pediatric infectious disease physician and a senior author of Implementing Strategies to Prevent Infections in Acute Care Settings published as a new section of the Compendium, a set of guidelines for infection prevention. “This new section is a compilation of a number of options and practical tools you can use to find your best way to implement successfully. It’s a way to take the Compendium from paper to bedside to improve practices for patient safety.”
The new chapter summarizes seven models for implementing other Compendium recommendations for preventing common healthcare-associated infections. It is meant to help bridge the “knowing-doing” gap, a term that describes why healthcare practices often diverge from published evidence to prevent infections that harm patients.
The complexity of healthcare systems makes it difficult for healthcare teams to implement best practices in infection prevention. Understanding factors that promote and hinder adoption within a given setting is an important step to identifying the best framework to deploy in that setting.
“Spending time listening and exploring your context, including local factors such as operational support, informatics resources, familiarity and experience, willingness to change, and safety, is of tremendous value and will guide you to success,” Schaffzin said. “People are rarely eager to change. It’s ok to be discouraged, but don’t give up.”
Schaffzin compared establishing new infection prevention strategies to convincing a young child to try a new food. Sometimes it’s easy, and other times you have to try different tactics, but you can’t force new behaviors.
“Studies in implementation science make it clear that identifying effective interventions is a necessary first step before transferring them into real-world settings in an intentional process,” said Kavita Trivedi, M.D., Director of Clinical Guidance and Communicable Disease Controller at the Alameda County Public Health Department in California and the lead author of the chapter. “Here we provide the reader with the resources to think about implementation and evaluate the contextual determinants of behavior in order to design more successful, customized interventions.”
Implementing Strategies to Prevent Infections in Acute Care Settings is a new section to the Compendium, first published in 2008. The Compendium is sponsored by the Society for Healthcare Epidemiology (SHEA) and is the product of a collaborative effort led by SHEA, with the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association, and The Joint Commission, with major contributions from representatives of several organizations and societies with content expertise. It is a multiyear, highly collaborative guidance-writing effort by over 100 experts from around the world.
An update of strategies to prevent catheter-associated urinary tract infections will be published in coming weeks. The societies also recently updated strategies for preventing methicillin-resistant Staphylococcus aureus infections, Clostridioides difficile infections, surgical site infections, central line-associated bloodstream infections, ventilator and non-ventilator associated pneumonia and events, and strategies to prevent healthcare-associated infections through hand hygiene.
Each Compendium article contains infection prevention strategies, performance measures, and approaches to implementation. Compendium recommendations are derived from a synthesis of systematic literature review, evaluation of the evidence, practical and implementation-based considerations, and expert consensus.
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About Infection Control & Hospital Epidemiology
Published through a partnership between the Society for Healthcare Epidemiology of America and Cambridge University Press, Infection Control & Hospital Epidemiology provides original, peer-reviewed scientific articles for anyone involved with an infection control or epidemiology program in a hospital or healthcare facility. ICHE is ranked 24th out of 94 Infectious Disease Journals in the latest Web of Knowledge Journal Citation Reports from Thomson Reuters.
About the Society for Healthcare Epidemiology of America (SHEA)
The Society for Healthcare Epidemiology of America (SHEA) is a professional society representing more than 2,000 physicians and other healthcare professionals around the world who possess expertise and passion for healthcare epidemiology, infection prevention, and antimicrobial stewardship. The society’s work improves public health by establishing infection-prevention measures and supporting antibiotic stewardship among healthcare providers, hospitals, and health systems. This is accomplished by leading research studies, translating research into clinical practice, developing evidence-based policies, optimizing antibiotic stewardship, and advancing the field of healthcare epidemiology. SHEA and its members strive to improve patient outcomes and create a safer, healthier future for all. Visit SHEA online at shea-online.org, facebook.com/SHEApreventingHAIs and twitter.com/SHEA_Epi.
JOURNAL
Infection Control and Hospital Epidemiology
METHOD OF RESEARCH
Literature review
SUBJECT OF RESEARCH
Not applicable
ARTICLE TITLE
Implementing Strategies to Prevent Infections in Acute Care Settings
ARTICLE PUBLICATION DATE
11-Jul-2023
Caesarean birth injury rates have risen for mums and babies but training and a new device could change that
IMAGE: FETAL PILLOW. IMAGE REPRODUCED COURTESY OF COOPER SURGICAL, INC. view more
CREDIT: BJOG: AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY
Over 34% of women in Australia have a caesarean birth, and a significant proportion of these happen in late labour when the fetal head is deep in the mother’s pelvis and can be impacted which makes delivering a baby challenging and poses serious risks to both the mother and the baby.
It’s estimated the baby’s head is wedged, known as impacted fetal head (IFH) in around 10% of all emergency caesarean births (CB). This makes it difficult for the doctor to get their hand below the baby’s head to deliver it, which leads to longer delivery times.
Recent statistics show that while the majority of babies born following IFH sustain minor damage, 2% of these infants die or suffer serious injuries with lifelong consequences.The NHS Resolution report in the UK states that 9% of avoidable brain injuries at birth are caused by impacted fetal head (IFH).
Complications for the mother include increased blood loss, an increased risk of infection, bladder and urinary tract damage, uterine tears that require repair and may cause issues in subsequent pregnancies, or even a hysterectomy. While complications for the baby include lacerations and bruising to the head and face, skull fractures, and haemorrhages, there have also been reports of eye injuries.
A Scientific Impact Paper published in BJOG: an International Journal of Obstetrics & Gynaecology by the Royal College of Obtsetricians & Gynaecologists in the UK and Professor Annette Briley at Flinders University has reported a significant rise in cases of IFH injuries in recent years, with maternity staff implementing varied approaches and no consensus regarding the definition or training regarding management to help deliver the baby during CB.
Approaches to managing this obstetric emergency include having an assistant push the baby's head up during birth, delivering the baby feet first, using an inflatable balloon device (Fetal Pillow) designed to elevate the baby’s head, and administering medication to relax the mother’s womb.
However, this scientific impact paper reviewed the available evidence, concluding there is currently no consensus on the best approach for these risky cases.
Various manoeuvres and some devices have been introduced to help with the delivery of the baby in this situation, but to date there is no consensus on which is best for mothers and babies or the training required for staff managing this emergency situation.
Most commonly, an assistant is asked to push up from below, although some evidence suggests reverse breech extraction may be associated with better outcomes. A UK-wide survey reported that more than half of obstetric registrars did not feel confident performing reverse breech extraction, and fewer than one in 10 are familiar with the Patwardhan technique.
"The aim of this scientific impact paper was to examine all the current available evidence regarding different manoeuvres and devices currently in use to manage IFH, with the results integrated into the findings of a systematic review commissioned by the National Guideline Alliance (UK)," says research co-author and midwife at Flinders University, Dr. Annette Briley.
The researchers say key steps need to be taken to improve standards:
• High-quality adequately powered RCTs comparing techniques to manage and prevent IFH are required. (Those currently available have significant weaknesses.)
• A universally accepted definition of IFH would facilitate future research and education.
• Women and their partners need to inform research around the language and management of IFH.
• The development and implementation of an evidence-based multi-professional educational package would lead to consistent management of this obstetric emergency.
• More research is required around the efficacy and cost-effectiveness of the Fetal Pillow
Dr Briley says the data clearly shows that there has been a significant rise in caesarean sections in late labour and associated cases of IFH-related injuries in recent years, and further education is needed to develop consistent management of this obstetric emergency.
"We’ve reviewed the existing evidence on strategies to identify, prevent, and manage the IFH during births to provide guidance and recommendations that improve outcomes for mothers and babies when this potentially serious complication occurs. It’s essential that clinicians use the best evidence to inform care for women and babies, including the optimal techniques to reduce the potentially devastating complications associated with IFH."
Dr Briley is also part of a research team developing and evaluating the Tydeman tube, an innovative single-use, hollow silicone tube inserted to elevate the baby’s head. Its designed to minimise applied pressure to the head and reduce any suction effect once access has been achieved.
"A minimal number of Tydeman Tubes have been used clinically; further research in a clinical setting, compared with appropriately trained and executed manual disimpaction, is required to investigate its efficacy and safety before use."
JOURNAL
International Journal of Obstetrics and Gynaecology
METHOD OF RESEARCH
Systematic review
SUBJECT OF RESEARCH
People
ARTICLE TITLE
Management of Impacted Fetal Head at Caesarean Birth
Chagas Disease is also
underdiagnosed in Spain
A new study of nearly 3,000 Latin Americans who visited the Hospital Clinic over 17 years shows that 47% were infected with the parasite that causes the disease, and more than 10% had heart lesions
Peer-Reviewed PublicationA high percentage of people from Latin America are infected with the parasite that causes Chagas disease. This is the conclusion of an analysis of nearly 3,000 people from countries where the disease is endemic and who attended the International Health Service at Barcelona’s Hospital Clinic, over a 17-year period. The study, published in PLOS Neglected Tropical Diseases, was led by the Barcelona Institute for Global Health (ISGlobal), an institution supported by "la Caixa" Foundation.
Nearly 7 million people in the world are estimated to be infected with Trypanosoma cruzi, the parasite that causes Chagas disease. Although the vector that transmits the parasite (the kissing bug) is endemic in 21 Latin American countries, the parasite has spread globally due to migratory flows. In non-endemic countries, the parasite can be transmitted vertically, from mother to child or, less commonly, through blood or organ donations. In 30-40% of cases, the infection ends up damaging the heart and digestive system, causing Chagas disease.
"It is therefore recommended that Latin Americans arriving in the country be tested in order to treat them if they are infected and, in the case of women of childbearing age, to prevent the vertical transmission of the parasite," explains Irene Losada, coordinator of the Chagas Initiative and first co-author of the study, along with Pedro Laynez-Roldán, ISGlobal researcher and physician at the ClÃnic’s International Health Service.
This retrospective study describes one of the largest samples of people at risk of infection in a non-endemic country: 2,820 Latin Americans, the vast majority from Bolivia, who attended the International Health Service of the Hospital Clinic of Barcelona between 2002 and 2019. Of the total number of people analysed, almost half (47%) were infected with T. cruzi and 17% had heart lesions typical of the disease. Although in most cases an electrocardiogram was sufficient to detect the lesions, an echocardiogram was needed in 10% of cases. "These results reinforce the importance of echocardiograms in the initial assessment of patients with T. cruzi infection," says Laynez-Roldán.
An underdiagnosis problem
The authors note that many people arriving from highly endemic regions of Latin America, such as Bolivia, had never been tested before. "The infection is clearly under-diagnosed even in Spain, one of the European countries with the highest diagnostic coverage," warns Maria Jesús Pinazo, last author of the study, former researcher at ISGlobal and currently at DNDi.
The majority of the cases are women of working age, reflecting the migratory flows of recent years, which allows for better targeting of screening and prevention programmes.
Reference
Laynez-Roldán P, Losada-Galván I, Posada E et al. Characterization of Latin American migrants at risk for Trypanosoma cruzi infection in a non-endemic setting. Insights into initial evaluation of cardiac and digestive involvement. Plos NTD. 2023.
JOURNAL
PLoS Neglected Tropical Diseases
METHOD OF RESEARCH
Observational study
SUBJECT OF RESEARCH
People
ARTICLE TITLE
Characterization of Latin American migrants at risk for Trypanosoma cruzi infection in a non-endemic setting. Insights into initial evaluation of cardiac and digestive involvement
ARTICLE PUBLICATION DATE
13-Jul-2023
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