Publications

Conventional cuff-based blood pressure (BP) monitoring has several limitations, including patient discomfort with arm cuff inflation, inconvenience, and limited frequency of readings. Cuffless BP devices, which are increasingly available for purchase on the international market, have the potential to remove barriers to BP measurement in both research and clinical care. However, there are unanswered questions on whether, how, and in what settings these devices may be appropriate for use. Gaps include the need to understand whether the somewhat distinctive and often enormous volume of readings obtained by these devices have meaningful relationships with clinical outcomes and are appropriate for determining actionable interventions. Furthermore, international standards for determining the accuracy of some, but not yet all, of these devices only recently became available and do not provide a full assessment of the typical use of the devices. Thus, the devices on the market have not yet been adequately vetted for accuracy and efficacy. Several of these devices, however, have been cleared by the US Food and Drug Administration and are being used clinically. Moreover, many patients use cuffless devices for BP self-monitoring, often without disclosing this information to health care professionals. This scientific statement provides an overview of the existing literature on cuffless BP monitoring technologies and their potential future applications, and stresses the importance of understanding the gaps that need to be filled before these devices can be used clinically, recognizing that currently available devices may be inappropriate for clinical use.

OBJECTIVE: Complicated mild traumatic brain injury (cmTBI) is a common emergency consultation in trauma care at community and tertiary hospitals. While neurosurgical evaluation is typically required, actual neurosurgical intervention is rare. The aim of this study was to evaluate the adoption, safety, and effectiveness of a telemedicine-based neurosurgery consultation program (tele-TBI) in reducing unnecessary interhospital transfers of patients with cmTBI.

METHODS: A multidisciplinary team implemented the tele-TBI program at 4 community hospitals. Patients with cmTBI who were eligible to receive telehealth consultations over the first 2 years of the program were retrospectively analyzed. The program's impact on reducing interhospital transfers, disposition outcomes, and safety were assessed.

RESULTS: Of 179 eligible patients (94 female, mean age 75 years) reviewed, 117 underwent tele-TBI consultation and 62 did not. Among the patients with tele-TBI consultations, 15 (13%) were transferred to tertiary centers, with 2 (1.7%) admitted to the ICU, 10 (8.5%) admitted to the floor, and 3 (2.6%) managed in the emergency department. Most patients (87%) who underwent tele-TBI consultation were effectively managed at community hospitals; 90 (77%) were observed in the emergency department then discharged and 12 (10%) were admitted. In contrast, all 62 patients without tele-TBI consultation were transferred to tertiary hospitals, of whom 10 (16%) were admitted and 52 (84%) were observed in the emergency department and then discharged. Multivariate analysis revealed that subdural hematoma (OR 2.90, 95% CI 1.53-5.51) and age < 80 years (OR 0.25, 95% CI 0.11-0.56) significantly influenced the likelihood of transfer.

CONCLUSIONS: The tele-TBI program reduced unnecessary interhospital transfers. Notably, most patients with tele-TBI consultation were successfully managed in their community hospital. Moreover, nearly 4 of 5 patients without tele-TBI consultation were transferred, only to be discharged directly from the tertiary referral center's emergency department.

BACKGROUND: The Dietary Approaches to Stop Hypertension (DASH) Eating Plan is proven to lower blood pressure; however, the original DASH diet involved a set menu of meals prepared in a metabolic kitchen. There is little evidence mapping this dietary pattern to real-world groceries, tailored to a range of personal preferences and dietary practices.

METHODS: The GoFresh Trials, two parallel-arm randomized, controlled trials, are studying the impact of DASH-patterned, home-delivered groceries on the blood pressure of Black adults living in communities with reduced access to grocery stores. Participants were able to choose the groceries according to their preferences for themselves and up to five family members from local supermarkets. A dietitian assisted participants with selection to ensure that groceries followed a DASH pattern and met a potassium/sodium ratio of > 2.0 with kilocalories from saturated fat ≤ 7%. Dietitians also provided weekly educational modules on sustainably adopting DASH. To support meal preparation, a recipe book and 24 demonstration videos were created in collaboration with Boston Chefs. A community advisory board participated in the conception of intervention materials to ensure the program was feasible and grounded in community priorities.

RESULTS: Compliance assessments include 24-h urine paired with 24-h nutrition recalls, seated blood pressure, and surveys on food preparation and shopping habits. A knowledge assessment and palatability form were used to assess changes in DASH knowledge and acceptability before and after the intervention.

CONCLUSION: By describing the unique features and development process of GoFresh, this paper offers practical guidance for adapting and scaling similar nutrition interventions in other communities.

TRIAL REGISTRATION: ClinicalTrials.gov NCT05121337. Registered on November 16, 2021. https://clinicaltrials.gov/ct2/show/NCT05121337 .

Achieving digital health equity and proper use of identity credentials is crucial as reliance on electronic modalities increases. Proxy access-now increasingly referred to as shared access-is a widely available functionality that offers identity credentials to care partners who assist loved ones in navigating the electronic care delivery demands of patients with complex care needs. However, adoption of these tools has been hindered by complicated user interfaces and low awareness.Drawing on frameworks and principles rooted in human-centered design (HCD), we conducted an evaluation of a multisite quality improvement study designed to increase the awareness and adoption of shared access to patient portals for older adults and their care partners. Through feedback gathered from key informants, we identified barriers to the adoption of materials created for the parent quality improvement project, and synthesize additional implementation strategies from informant feedback to improve shared access.We employed the Double Diamond Model (DDM) of HCD to guide our research. The DDM includes engaging a diverse group of community partners-older adults, care partners, health care system leaders, communications professionals-through focus groups and individual interviews. Our process involved identifying pain points related to registration for shared access, then synthesizing these insights through inductive coding and affinity mapping to generate solutions.An analysis of our community partner feedback revealed several themes, including the necessity for simplified patient portal registration, standardized terminology about shared access, and clear messaging strategies. A step-by-step video tutorial was developed as a prototype. The prototype was then implemented at a partner health system and received positive feedback, suggesting its potential for broader use.These findings emphasize the importance of involving "end users" (patients, care partners, health care system leaders, communications professionals) in the evaluation and implementation of digital health tools. Approaching challenges with an HCD mindset helped our team identify barriers to shared access adoption and led to the development of a tangible resource (prototype and video). This project highlights the potential for HCD to drive improvements in digital health equity.This research demonstrates a practical application of HCD methods in developing effective solutions for enhancing shared access for older adults, and all people using patient portals.

BACKGROUND: Hypertension-related deaths in the United States have sharply increased over the past decade. Understanding factors behind this concerning trend is crucial to guide public health strategies.

OBJECTIVES: This study sought to examine changes in prevalence, treatment, and control of cardiometabolic risk factors among U.S. adults with hypertension.

METHODS: Using National Health and Nutrition Examination Survey, we identified 21,822 adults with hypertension from 1999 to 2023. Trends in age-adjusted prevalence of diabetes, hyperlipidemia, obesity, smoking, and high-risk drinking, as well as in age-adjusted treatment and control rates for hypertension, diabetes, and hyperlipidemia, were assessed.

RESULTS: In adults with hypertension, prevalence of diabetes increased from 17.2% (95% CI: 14.6%-20.2%) in 1999-2000 to 27.8% (95% CI: 25.2%-30.7%) in 2021-2023. Among patients with hypertension and diabetes, the proportion receiving treatment for both conditions rose until 2009-2010 but subsequently plateaued (71.6% in 2021-2023; 95% CI: 67.5%-75.4%). A similar trend was observed for the proportion achieving control of both conditions, which remained at 31.2% in 2021-2023 (95% CI: 26.5%-36.3%). Prevalence of hyperlipidemia decreased in adults with hypertension but was still high at 73.1% (95% CI: 70.6%-75.4%) in 2021-2023. Among patients with hypertension and hyperlipidemia, treatment and control rates for both conditions increased only until around 2007; the respective rates were 50.4% (95% CI: 47.2%-53.6%) and 32.3% (95% CI: 29.5%-35.2%) in 2021-2023. Prevalence of concurrent diabetes and hyperlipidemia in adults with hypertension nearly doubled from 12.5% (95% CI: 10.6%-14.7%) in 1999-2000 to 21.3% (95% CI: 19.0%-23.8%) in 2021-2023. Among patients with hypertension, diabetes, and hyperlipidemia, the treatment rate for all 3 conditions increased until 2007-2008 and plateaued afterward (62.1% in 2021-2023; 95% CI: 56.6%-67.2%). The control rate for all 3 conditions followed a similar trend but remained low at 26.3% (95% CI: 20.8%-32.6%) in 2021-2023. Prevalence of obesity and high-risk drinking increased over time, whereas prevalence of smoking held steady.

CONCLUSIONS: The burden of cardiometabolic risk factors among U.S. adults with hypertension has increased overall, with concurrent diabetes and hyperlipidemia now affecting more than 1 in 5. Only one-quarter of adults with hypertension, diabetes, and hyperlipidemia have all 3 conditions controlled-a proportion that has not improved in more than a decade.

The current guideline-recommended clinic blood pressure (BP) measurement procedure takes nearly 10 minutes to complete and may not be feasible to implement in busy clinical practice settings. Additionally, evidence supporting the steps in the current guideline-recommended procedure is of uneven quality. A streamlined, evidence-based approach to clinic BP measurement that still produces accurate and precise BP measurements may facilitate improved hypertension diagnosis and management. We summarized the latest evidence from studies that have quantified the impact of streamlining certain steps in the BP measurement procedure on BP measurement accuracy and precision. We translated this evidence into a practical, streamlined protocol for office BP measurement in usual primary care and potentially other settings. Studies have demonstrated it is possible to reduce the rest period before measurements from 5 to 0 minutes, and the interval between measurements from 60 to 30 seconds, without compromising accuracy. Additionally, analyses of studies with replicate BP measurements performed according to clinical practice guideline recommendations showed that repeating the initial screening measurement only when the first one is ≥130/80 mm Hg optimized accuracy and efficiency. Meanwhile, using the proper cuff size, arm support, and patient positioning are critical for BP measurement accuracy and recommendations for these steps remain unchanged from current guidelines. Broad implementation of a streamlined approach would result in more efficient BP measurement without compromising accuracy or precision, thereby increasing capacity to screen, diagnose, and manage hypertension.

BACKGROUND: For most physicians trained in internal medicine (IM), residency represents the last opportunity to compare and contrast generalist versus subspecialty careers. Decisions about subspecialty practice impact physician supply and distribution in the United States. This study tested the association between randomly assigned intern year rotation duration and career choice and assessed the importance of resident characteristics versus residency experiences in predictive modeling.

METHODS: This retrospective observational study included all categorical residents graduating from a university-affiliated IM program between 2017 and 2023 (N = 338). The association between randomly assigned intern year rotation duration and career choice was evaluated with univariable and multivariable log-link Poisson regression models. "Career choice" was defined as the field in which residents were practicing one year after residency. Predictive models were built using random forest modeling to compare the relative importance of resident characteristics and residency experiences.

RESULTS: Pre-residency career interests and ultimate career choice were highly concordant (P < 0.001, Cramer's V 0.50 (95% CI: 0.41-0.51)), particularly among residents pursuing cardiology, gastroenterology, and hematology/oncology. Rotation duration and career choice were not consistently associated; in multivariable analyses, weeks on service in the intensive care unit were associated with a career in pulmonary/critical care (RR 1.40, 95% CI 1.23-1.56), but there was no association between rotation duration and career in hematology/oncology, cardiology, gastroenterology, or general medicine. Internally cross-validated predictive models revealed that pre-residency demographics and interests were highly discriminative of career choice (AUC 0.824). The addition of residency experiences did not improve model performance (AUC 0.829).

CONCLUSIONS: Pre-residency career interests are a key determinant of career choice and hold greater weight in predictive models than intern year clinical exposure.

No study has evaluated whether associations of plasma phosphorylated tau 217 (p-tau217) with mild cognitive impairment (MCI) or dementia vary by race or hormone therapy (HT) use. We examined 2,766 cognitively unimpaired women ≥65 years randomized to HT vs placebo with 25-year follow-up. P-tau217 was associated with incident MCI/dementia (hazard ratio [HR], 2.43; 95% CI, 2.18-2.71) and each individual outcome (MCI: HR, 1.94; 95% CI, 1.72-2.20; dementia: HR, 3.17; 95% CI, 2.79-3.61). Associations between p-tau217 and dementia were stronger for women randomized to estrogen plus progestin vs placebo (HR, 4.18; 95% CI, 3.41-5.13 vs HR, 3.07; 95% CI, 2.41-3.91, respectively; P interaction=0.044) but did not vary for estrogen alone vs placebo. The combination of p-tau217 and age performed similarly in White and Black women (AUC=72.0% and 70.4%, respectively). Findings show the value of plasma p-tau217 for prediction of MCI and dementia up to 25 years in advance in older women.