There are 245 million hypertension patients in China, but the overall treatment rate is less than 50%, and the control rate is only 36%.
Recently, BMJ published a practical, multicenter randomized controlled trial conducted by Zheng Xin's team at Fuwai Hospital of the Chinese Academy of Medical Sciences in primary care institutions, which found that the application of the guideline-based Hypertension Assisted Decision System (CDSS) can improve the management of hypertension and reduce blood pressure levels.
The authors point out that the hypertension decision-making system is a simple, efficient, low-cost, and generalizable intelligent means to improve the accessibility and fairness of hypertension management, and is of great significance for the primary care system in China and other countries or regions with limited resources but a heavy burden of cardiovascular disease.
Contemporaneous reviews noted that improving hypertension management should be a priority for low- and middle-income countries, where the prevalence of hypertension is increasing. Many of these countries are still in the early stages of implementing electronic health records and may not be ready to fully benefit from assisted decision-making systems. In contrast, high-income countries have well-established electronic health records and are recognized for the use of assisted decision-making systems at the national level.
According to the article, the hypertension auxiliary decision-making system was developed according to the Chinese guidelines for primary hypertension, and provided doctors with individualized recommendations for the types and dosages of antihypertensive drugs by collecting basic data in the clinical diagnosis and treatment process such as patients' demographic characteristics, comorbidities, blood pressure, heart rate, medication, drug intolerance or contraindications.
The study compared the effects of hypertension management recommended by a decision-making system embedded in electronic medical records (i.e., the intervention group) with hypertension management based on physicians' knowledge and experience (control group).
The study showed that the proportion of standard treatment for hypertension in the control group was 62.2%, while the proportion of standard treatment in the intervention group was 77.8%, an increase of 15.2%. There were significant improvements in different regions, in the preset subgroups such as the baseline standard treatment level of primary medical institutions and the education level of primary doctors.
Systolic blood pressure was reduced by 1.5 mmHg in hypertensive patients in the intervention group and increased by 0.3 mmHg in the control group.
The rate of blood pressure control increased by 4.4%, but was not statistically significant ((69.0% vs. 64.6%).
However, the authors believe that while the rate of blood pressure control was only 4.4%, it could translate into a significant reduction in cardiovascular mortality and morbidity in a larger population.
Self-reported adverse events related to antihypertensive therapy were rare in both groups, and there was no statistical difference between groups.
According to the authors, the assisted decision-making system is embedded in the electronic medical record to collect relevant information about the diagnosis and treatment of hypertension, thus integrating it into the clinical workflow, and the simple data collection minimizes the burden on physicians to use the assisted decision-making system.
Second, the large sample size enables researchers to evaluate the effectiveness of the decision-making support system in different regions and subgroups. The effect of this system was observed to vary from region to region, in part due to differences in baseline appropriate treatment and blood pressure control rates from region to region. Nonetheless, after taking into account the heterogeneity of different locations across the four regions, a significant improvement in appropriate treatment was found in the overall population, suggesting that the decision-making system has been well implemented and accepted in different clinical settings.
Finally, the physician is not forced to follow the recommendations of the decision aids, and the final prescription is based on a shared decision between the physician and the patient. The reasons for not following the recommendations of the decision aids were collected, which may provide valuable information for improving the recommendations for the diagnosis and treatment of hypertension in the future
At the same time, the investigators also noted that the main objective of the study was to improve physicians' prescribing behavior through a hypertension-assisted decision-making system, and did not use a multifaceted intervention, so the effect on blood pressure was limited.
In future studies, combining patient-level interventions with the use of hypertension decision-making systems to improve the shared decision-making process between doctors and patients will help improve patients' compliance with treatment, thereby further improving the long-term control rate of blood pressure.
The study was conducted in 94 primary care facilities in three regions of China, including a total of 12,137 patients with hypertension.
Primary care facilities were randomly assigned 1:1 to the intervention group (46 institutions) and the control group (48 institutions).
Patients with hypertension whose blood pressure did not exceed 180/110 mmHg in the selected clinics were followed every 3 months for 9 months. Both groups were managed with hypertensive patients using a study-customized electronic medical record system.
About the Author
Jiali Song, Xiuling Wang, and Bin Wang from Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, are the co-first authors, and researcher Xin Zheng is the corresponding author.
New Milestone Health Group and Shenzhen Chronic Disease Prevention and Control Center are the regional coordination centers of the study, and the cooperative units include 18 primary medical institutions affiliated to Luoyang East Hospital, Luoyang Sixth People's Hospital and CITIC Central Hospital, 9 primary medical institutions affiliated to Yankuang New Milestone General Hospital, and 67 primary medical institutions affiliated to Nanshan District, Bao'an District, Futian District, Longgang District and Luohu District Chronic Disease Prevention and Treatment Hospital in Shenzhen. Cooperative research institutions include Oxford University, Yale University, Harvard University, Shanghai Institute of Hypertension, etc.
Zheng Xin, PI, PI, Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Deputy Chief Physician, Doctoral Supervisor of Peking Union Medical College; Deputy Director of the Coronary Heart Disease Center of Fuwai Hospital Shenzhen Hospital, Chinese Academy of Medical Sciences, and Deputy Director of the Clinical Trial Institute of Pharmaceutical and Medical Devices. His main research interests are the pathogenesis and prevention and control strategies of hypertension and coronary heart disease.
Source:
[1] Jiali Song, Xiuling Wang, Bin Wang, et al. Learning implementation of a guideline based decision support to improve hypertension treatment in primary care in China: pragmatic cluster randomised controlled trial. BMJ, 2024, 386: e079143.
[2] Amy Pui Pui Ng, Qingqi Chen, Diana Dan Wu, Suk Chiu Leung.Improving hypertension management in primary care Clinical decision support increases guideline concordant care. BMJ. 2024; 386:q1466.
[3] National Center for Cardiovascular Diseases, National Basic Public Health Service Program Primary Hypertension Management Office, National Primary Hypertension Management Expert Committee. National Guidelines for the Prevention and Management of Hypertension at the Primary Level 2020 Edition. Chinese Journal of Circulation, 2021, 36(3): 209-220. DOI:10.3969/j.issn.1000-3614.2021.03.001.
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