Shorter Encounter Intervals
are Associated with Improved
Blood Pressure Control
Alexander Turchin, MD, MS
1
Encounter Intervals and Outcomes
• U-shaped relationship between encounter
interval and long-term
g
outcomes in p
patients
with rheumatoid arthritis
• In a cohort of 429 patients shorter encounter
i
intervals
l were associated
i d with
i h llarger
decreases in blood pressure
• No significant relationship between encounter
interval and blood pressure detected in a
cohort of 113 patients
• Ward MM. Rheumatology visit frequency and changes in functional disability and pain in
patients with rheumatoid arthritis. J Rheum 1997; 24:35-42.
• Guthmann R et al. Visit frequency and hypertension. J Clin Hypertension 2005; 7:327
7:327-332.
332.
• Parchman ML, et al. Hypertension management: relationship between visit interval and control.
Fam Pract Res J 1993; 13:225-231.
Encounter Intervals as a
Component of Clinical Inertia
Elevated BP
Encounter Intervals as a
Component of Clinical Inertia
Rx
Elevated
Intensified
BP
Encounter Intervals as a
Component of Clinical Inertia
Rx Intensified
Encounter Intervals as a
Component of Clinical Inertia
Time, months
Blood Pressure Control in Diabetes
• 12.9% of American adults have diabetes
• Over 80% of patients with diabetes have
hypertension
• Over 60 % of hypertensive diabetics do
NOT have blood pressure under control
• JNC-VII
JNC VII recommends 1 month follow
follow-up
up
• In reality encounter intervals 2-3 months
• Cowie CC, et al. A full accounting of diabetes and pre-diabetes in the U.S. population. Diabetes
Care 2009; 32:287-294.
• Kabakov E, et al. Prevalence of Hypertension in Type 2 Diabetes Mellitus. J of Cardiometabolic
Syndrome 2007; 1:95-101
• Resnick HE et al. Achievement of ADA Clinical Practice Recommendations among U.S. Adults
with Diabetes 2006; 29:531-537
Study Questions
• Does blood pressure normalize faster if
encounter intervals are shorter?
• What encounter intervals are optimal for
blood pressure control?
• What affects encounter intervals?
Methods
9
Study Cohort
• Hypertensive adults with diabetes
• Followed at primary care practices affiliated
with Brigham and Women’s Hospital and
Massachusetts General Hospital for at least
two years between 2000 and 2005
• BP < 130/85 used as the treatment target
(recommendations in effect prior to the onset
of the study)
y)
Study Measurements
Unit of
Analysis
Study Measurements
Time to BP
normalizatio
n
Results
13
Study Cohort
• 5,042 patients in the cohort
• Average BP 133/76 mm Hg
• Treatment
ea e intensified
e s ed in 20.7%
0 %o
of e
encounters
cou e s
with elevated BP
• Average encounter interval 3
3.7
7 months
• Median length of a hypertensive period 9
months
Time to BP Normalization
P < 0.0001 in
multivariable
analysis (Cox prop.
prop
hazards)
Time to BP Normalization
P < 0.0001 in
multivariable
analysis (Cox prop.
prop
hazards)
Rate of BP Change
Rate of BP Change
Predictors of Encounter Interval
* For 10 mm Hg
** For 10 years
Discussion
20
Implications
• Encounter intervals shorter than the ones
currentlyy recommended ((e.g.
g 2 weeks)) were
associated with greatest benefits
• Encounters other than face-to-face physician
visits may be needed to accomplish this:
– Telephone
– Email
– Mid-level providers
– Self-intensification by patients
Limitations
• Localized to two academic centers in Eastern
Massachusetts
• Only encounters with physicians were
available
a
a ab e for
o a
analysis
a ys s ((very
e y few
e mid-level
d e e
providers in practices studied)
• Missing
ss g data cou
could
db
bias
as tthe
e findings
d gs (e
(e.g.
g
earlier return visit might “discover” normalized
BP sooner)
• Limited to patients with diabetes
Conclusions
• Shorter encounter intervals are associated
with:
– Earlier normalization of blood pressure
– Faster decrease in blood pressure
• Encounter intervals shorter than the ones
currently recommended (e
(e.g.
g 2 weeks) may
be optimal for treatment of hypertension
Acknowledgements
• Saveli Goldberg, PhD
• Maria Shubina, DSc
Einbinder, MD
MD, MPH
• Jonathan Einbinder
• Paul Conlin, MD
Agency for HealthCare Research & Quality
Diabetes Action Research & Education Foundation
Questions?
Alexander Turchin, MD, MS
aturchin@partners.org