Patients often get the blame for uncontrolled hypertension.
Medication noncompliance is high among patients with hypertension, and for most of the 120 million adults in the US living with high blood pressure, the condition is uncontrolled.
The larger problem, however, is not patients forgoing their medications but physicians failing to prescribe the right therapy, says Robert E. Matthews, vice president of quality and care design for PriMed Physicians, a medical group with 14 practices in and around Dayton, Ohio.
The magnitude of the many drug and patient variables, combinations and classes of medications, and causes of hypertension make choosing the correct regimen “a complexity problem that is beyond the capabilities of human cognition,” he said.
“We’re asking primary care doctors to go into a room and sort through 80, 90 variables in their heads in a 15-minute visit. That’s not going to work,” said Matthews, who is president and CEO of MediSync, a company that provides performance improvement solutions and management tools to medical practices. “We have to make it easier and better for doctors to, first, pick the right medicine, and second, to communicate with patients so that patients take that medicine.”
Enter MedsEngine. The technology, developed by MediSync through years of refinement, is dramatically improving hypertension control through the use of artificial intelligence (AI). MedsEngine works with the patient’s electronic health record (EHR) to analyze the relevant variables, combinations, and permutations before spitting out a personalized list of recommended medications for each patient in the order they’re recommended — often down to the milligram.
The AI tool has led to rates of hypertension control between 93% and 95% for patients of PriMed Physicians, possibly tops in the nation.
By comparison, the rate of controlled hypertension among US adults fell from 53% in 2009-2012 to 48% in 2017-2020, according to a 2022 study published in Hypertension. Among those taking antihypertensive medication, blood pressure control dropped from 69.9% during the same time frame to 67.7% in 2017-2020, the investigators found.
PriMed Physicians’ success has mostly flown under the radar, although they have been recognized in the past for their hypertension improvement work by the Centers for Medicare & Medicaid Services and the American Medical Group Association.
“More than once, people have assumed that we must be lying about our control rate,” Matthews, who speaks regularly about his group’s progress, said. “That it’s ‘impossible’ to be this good, so we are just ‘making this up.’ “
On the contrary, Matthews and his team are more than willing to share their data and the steps behind their success. Their goal? To drive more primary care practices to adopt the model.
How Does It Work?
MediSync’s novel hypertension approach starts with a decades-old test.
Patients with hypertension first take an impedance cardiography (ICG) test, an in-office process that takes about 5 minutes and points to what’s triggering the patient’s hypertension. ICG measures hemodynamic parameters, including stroke volume, cardiac output, heart rate, and total peripheral resistance.
To Matthews’ knowledge, PriMed Physicians is one of only a few clinics in the country that use ICG for blood pressure patients. The technique is more frequently used for heart failure, he said.
“To me, if you’re going to pick a drug and you don’t know where the problem is coming from that’s making the blood pressure high, then you’re just guessing,” he said.
After learning the results, clinicians turn on a screen to launch MedsEngine. The program connects to the patient’s EHR, analyzes the data, and recommends a list of appropriate medications in seconds.
MediSync has been working for two decades to improve the control of hypertension and other chronic diseases, such as diabetes and heart failure, Matthews said. The program evolved from a paper system to computer technology. In 2017, the company released a beta version of MedsEngine for hypertension, which is now used by all PriMed Physicians facilities. PriMed Physicians treat about 55,000 patients across their 14 Ohio locations.
A key piece of the process is how the group communicates test results and recommendations to patients, Matthews said. When clinicians use MedsEngine, they turn their screens so patients can view the elements and complications associated with their case. Red and green bars show the tightness of their arteries, cardiac power, and fluid level, among other specifics.
Enabling patients to visualize the problem causing their hypertension and discussing why the suggested medications will help fuels deeper comprehension and stronger medication adherence, said Jan Froehlich, MD, president of PriMed Physicians and a family physician at the group’s Beavercreek location.
“Over time, [the system] has become not just information for the provider but a tool to drive understanding for our patients, to really engage them in shared decision-making,” she said. “That’s the secret sauce to everything quality. We know if we want to achieve [optimal] outcomes, you’ve got to bring the patients along in the journey.”
Patients often show marked changes at their next visit, said Marlon Twyman, MD, a family physician at the group’s Wright Dunbar location in Dayton.
Twyman cited the case of a 50-year-old man he saw during a visit last January. The man weighed 347 pounds, and his blood pressure was 172/120. An ICG test determined he had increased total peripheral resistance. His data were then run through MedsEngine. After taking a new medication recommended by the AI program, the patient returned in February with a BP of 138/88, Twyman said ― a solid improvement, but not sufficient. Twyman is working with the patient to further lower his rate, he said.
In another case, a 60-year-old woman being treated at Allegheny Health Network in Pittsburgh had a blood pressure of 154/85. Allegheny is the first and only non-PriMed practice to launch MedsEngine. After an ICG test, Francis Colangelo, MD, told the patient her blood vessels were “clamped down” and that her heart function was struggling because of it. After running the patient’s data through MedsEngine, Colangelo changed her medication on the basis of the recommendations. At the next visit, her blood pressure was 120/75.
“She asked me, ‘Could you please run that test again that showed my heart was struggling? I’ve been worried about it ever since my last visit.’ ” Colangelo said. “We ran the test again, and when we showed her that her blood vessels were no longer clamped down and her heart function was now normal, she burst into tears because she was so happy. It was an amazing reaction.”
Twyman’s clinic is in a socioeconomically challenged working class area of Dayton, where a large proportion of patients are uninsured or on public insurance, he said. About 85% of Twyman’s patients are Black Americans, a demographic group that has the highest prevalence of hypertension of any racial or ethnic group (45.3%). Compared with White Americans, Black Americans also have significantly lower rates of blood pressure control (39.2% vs 49.1%, respectively).
Despite the challenges, the practice has achieved a blood pressure control rate in the 90% range, he said. By comparison, in 2022, nearby Cleveland Clinic reported a control rate of 70% for patients with hypertensin who were aged 18 to 85.
“It’s definitely an accomplishment,” Twyman said. “It makes us feel good because the Cleveland Clinic is renown, and they definitely have more resources. If a small practice like us can do this, larger groups with better funding and backing should be able to do this, too.”
“Love It or Hate It”
While the technology may sound like a clear-cut solution for providers, patients, and the healthcare system, the approach is not without barriers. A top challenge to the technology? Physicians.
When Colangelo’s practice started using MedsEngine, most doctors were on board, but a third of physicians were not pleased, said Colangelo.
“They either loved it or hated it,” Colangelo said. “Some did not want to admit to a patient that they had them on the wrong medicine.”
At Twyman’s practice, some physicians left after they launched the tool, he said, calling the tool “cookbook medicine.”
“For some, it feels like a loss of control, that they don’t have autonomy in how they’re treating patients,” he said.
Not surprisingly, a largely fee-for-service medical system is another obstacle. Insurers are slow to grasp the value and cost savings of solutions such as MedsEngine, Froehlich said. Using MedsEnging also can mean extra work for clinicians, she said.
“It’s a lot easier to say, ‘I wrote a prescription, it’s at the pharmacy. See you in 3 months,’ ” she said. “But that’s not what moves the dial. We know in order to see reduced kidney disease, reduced stroke and heart attack, that it’s probably going to take 10 or 15 years to see it, but we know it’s the right thing to be doing right now.”
Colangelo calls using MedsEngine, a “no brainer” for practices involved in value-based contracts with insurers. Data have long shown that better hypertension control means fewer emergency department visits, fewer hospitalizations for major cardiovascular events, and an overall reduction in the cost of care.
“We have a lot of work to do in the United States on improving hypertension control,” he said. “Using this tool is one way to better serve our patients and improve patient outcomes.”
Alicia Gallegos is a freelance healthcare reporter based in the Midwest.
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