Start Strong: A mixed methods study to inform initial antihypertensive prescribing and a patient-self titration intervention to improve blood pressure control, safety, and reduce cardiovascular risk

University Of Colorado Denver, Aurora CO

Investigators

Abstract

High blood pressure (BP) is the leading modifiable cause of cardiovascular disease (CVD), the number one cause of death in the US. Despite widespread availability of effective, safe, and inexpensive antihypertensive medications, BP control rates remain suboptimal, partly due to the strategies applied at treatment initiation. There are two general approaches to initiating treatment for high BP: stepped care (initiate one medication at low doses, slowly increase the dose, then add another medication, etc.) or combination therapy (initiate ≥2 medications at once). Stepped care theoretically minimizes pill burden and maximizes patient safety, but it requires significant time and resources to achieve BP control. Initial combination therapy may be more effective and safer than stepped care (especially at low doses), leading to better short-term outcomes, but has not been evaluated against stepped care for long-term outcomes (≥1 year). The unifying theme of this K01 proposal is to provide mentored career development and accelerate Dr. Derington’s transition to an independent investigator. It will establish the foundation for achieving her long-term goal of bridging gaps in CVD care through evidence-based health services research. Her K01 research objectives are to understand and evaluate antihypertensive initiation strategies and generate evidence for a future pragmatic trial testing a feasible and acceptable patient self-titration program to improve initiation of evidence-based antihypertensive medication regimens. The research aims are (1) identify barriers and facilitators initiating antihypertensive combination therapy vs. stepped care (Aim 1), (2) determine the real-world, long-term comparative effectiveness of initial antihypertensive treatment strategies on patient-centered outcomes (Aim 2), and (3) refine a pilot intervention to increase initiation of antihypertensive combination therapy (Aim 3). This work will leverage existing resources and data available in the Veterans Health Administration (VHA), for which the study team has already generated a dataset of 1,005,919 Veterans initiating antihypertensive treatment. Dr. Derington’s training and experience in clinical pharmacy, pharmacoepidemiology, and observational research will be complemented with additional training in qualitative research, causal inference, and pragmatic trials. The University of Utah, including its CTSI, and the VHA Salt Lake City Health System provide an ideal environment for achieving the proposed objectives and Dr. Derington’s long-term goals. Dr. Adam Bress, an internationally recognized expert and mentor in CVD pharmacoepidemiology and causal inference, will lead a multidisciplinary mentorship team composed of experts in qualitative research (Dr. Susan Zickmund), pragmatic trials (Dr. P. Michael Ho), biostatistics (Drs. Daniel Scharfstein and Tom Greene), health services (Dr. Jordan King), and antihypertensive medication use (Dr. Anthony Rodgers). The integrated mentored research experience and training will allow Dr. Derington to compete for R01 funding and become an independent clinician-scientist, with the ultimate goal of preventing CVD-related morbidity and mortality.