Why You Should be Glad CMS Now Covers More Ambulatory Blood Pressure Monitoring

CMS covers more ambulatory blood pressure measurements now. Wait! Before you fall asleep–this is a bigger deal than you think.

Of all medical interventions available to physicians taking care of adults, blood pressure control may have the largest potential impact on lives saved. Since more than a third of Americans have hypertension, every 10 percent increase in controlled blood pressures nationwide would save something like 14,000 lives per year. And right now, less than half of people with hypertension have a well-controlled blood pressure. Going from 50% control to 90% control could be expected to save almost 60,000 lives per year. Part of the problem with getting there, though, is that measuring a blood pressure accurately is astonishingly hard. Some of this is due to obvious errors by the measurer: using the wrong size cuff, taking the measurement over clothes, and talking to you while they inflate the cuff, for example.

But some of the error is less predictable. A clever recent study (paywall) found that when participants in the SPRINT study, a large trial of very intensive blood pressure control, were seen by their own doctors during the study but outside the study protocol, their blood pressures differed markedly from the blood pressures obtained by the fastidious measurement techniques of the protocol. People in the “intensive” control group, in whom investigators were aiming for a blood pressure <120 mmHg, had a routine blood pressure at their own doctors’ offices that was 7.3 mmHg higher. People in the standard control group who were aiming for a blood pressure <140 mmHg had an average difference of 4.6 mmHg between their study blood pressure and their routine blood pressure.

Unfortunately, your own doctor may not be able to put in the time or workflow that it takes to get a study-quality blood pressure. She may not be able to let you rest for 5 minutes before a reading, or she may not invest in automated blood pressure cuffs. She may not have the time to average the results of three separate readings. But what your doctor could do is prescribe “ambulatory blood pressure monitoring,” or ABPM. ABPM is a technique by which you wear a device at home that periodically monitors your blood pressure, even at night, without any input from you. Then it sends the results to your doctor. Because the device is unaffected by the technique and timing issues above, it is considered the gold standard for the diagnosis of hypertension. But it has been historically very hard to get insurance companies to pay for. Getting payment required documenting a high likelihood of “white coat hypertension,” that is, a blood pressure in the doctor’s office that was consistently higher than blood pressures obtained outside the office on more than one occasion. People with “masked hypertension,” whose blood pressures outside the office may have been substantially higher than those measured at the doctor, were excluded.

A recent rule change by Centers for Medicare and Medicaid Services (CMS), though, allows expanded use of ABPM not only for suspected white coat hypertension, but also for masked hypertension. Since CMS is the bellwether for other insurers’ behavior, we can surely expect private insurers to follow.

So check your blood pressures at home. Or go to your local fire station or EMS. They can check your blood pressure 24/7/365 for free, and they know what they’re doing. See the image below to locate all the EMS and Fired Department stations in Sedgwick County, or download your own copy here. There is also an area where you can track your out-of-clinic blood pressures to report back to your physician.

If your home readings don’t match what you’re getting from your doctor’s office, ask your doctor about doing ambulatory blood pressure monitoring. Better yet, encourage your employees to ask about it.

Note: the Kansas Business Group on Health receives CDC funding to improve the detection and care of high blood pressures. But we believe in it either way.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Docs, you can get paid for ambulatory blood pressure monitoring

But it's not easy:

Pssst...wanna hear about quality improvement strategies in team-based hypertension care?

Then click here.

Should young, healthy people with type 1 diabetes take statins?

I encountered this question a couple months ago in a consult and intended to blog about it then, but relatively little trial data was available. I would have essentially been giving my own off-the-cuff opinion. That's very unsatisfying to me, and probably to the reader.

As background: we tend to think of type 1 diabetes as more a need for hormone replacement (insulin) than as a disease state requiring the complex management that type 2 diabetes requires. That is to say that type 1 diabetes, for all the unpleasantness it causes for people, is easier on the blood vessels as a general rule than type 2 diabetes. The ADA has a statement in its guideline that "For patients with diabetes aged <40 years with additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity or high-intensity statin and lifestyle therapy." It's a category C recommendation, meaning it's mostly opinion and has a less-than-spectacular evidence base. It also doesn't differentiate between type 1 and type 2 diabetes. Similarly, a joint statement by the ADA and the AHA states that "Adults with T1DM who have abnormal lipids and additional risk factors for CVD (eg, hypertension, obesity, or smoking) who have not developed CVD should be treated with statins." Both statements argue against the routine use of statins in young healthy type 1 diabetics.

But a recent study from the New England Journal helps us with the question of statins in kids, and throws in ACE inhibitors for good measure. Investigators led by M. Loredana Marcovecchio and Scott T. Chiesa randomized 443 kids between 10 and 16 years with type 1 diabetes and urine albumin-to-creatinine ratios in the upper third of "normal" to some combination of ACE inhibitor, statin, and placebo. Creatinine is a consistently excreted product of muscle metabolism that serves as a nice comparator for other things the kidney excretes. So even if you drink a lot of water and dilute the amount of albumin in your urine, we can look at it compared to the similarly diluted creatinine and see if you're excreting too much.

Anyway: the investigators used a 2 x 2 trial design, meaning that there were ultimately four groups: placebo-placebo, placebo-ACEi, placebo-statin, and ACEi-statin. The statin was atorvastatin 10 mg daily, and the ACEi was quinapril 10 mg daily (after titration). They were most interested in the change in albumin excretion (that is, how much protein spilled through the kidneys into the urine). They assessed this according to that same measure, the albumin-to-creatinine ratio in the urine, from three early-morning urine samples obtained every 6 months over about two and a half years. They also looked at secondary outcomes like the new development of microalbuminuria (that is, the new appearance of protein in the urine), worsening of eye disease, changes in kidney function, blood lipid levels, and measures of cardiovascular risk. For the cardiovascular risk, they did ultrasounds of the carotids to measure the thickness of the vessels (carotid intima–media thickness) and measured levels of high-sensitivity C-reactive protein and asymmetric dimethylarginine in the blood. Both of these are generic markers of vascular risk.

After an average of 2.6 years, no benefits were found within the ACEi group, the statin group, or the ACEi+statin group compared to placebo. Unsurprisingly, the ACEi group had a much lower incidence of new microalbuminuria, but "in the context of negative findings for the primary outcome and statistical analysis plan, this lower incidence was not considered significant (hazard ratio, 0.57; 95% confidence interval, 0.35 to 0.94)." Also unsurprisingly, the use of statins resulted in lower cholesterol levels (including, unfortunately, HDL). But neither drug had significant effects on carotid intima–media thickness, C-reactive protein, kidney function, or progression of eye disease.

So we can take away from this small-ish study that, at least in a short amount of time in pretty healthy twelve-year-olds (the subjects were excluded if they had genetically bad lipid levels; the participants' average A1c was ~8.3% and their average blood pressure was 116/65 mmHg), there was no benefit to statins or ace inhibitors. This study will influence my recommendations to patients and other docs in the future. The kicker, naturally, is that many young people with type 1 diabetes have imperfect blood sugar control. What about those who can't get their diabetes controlled? It's a tougher call in that case, and this study didn't address it. 

Links for July 27, 2017: lead levels and crime, CTE, happiness in bariatric surgery, and the Fda's cheese problem

Are high lead levels associated with high crime rates?

In a sample fraught with selection bias, 99.9% of autopsied NFL brains had chronic traumatic encephalopathy.

This bothers me less than I might have thought it would. NFL players are small in number, they have a job that they know is risky, and they're pretty well paid for the work. The fact that they have a now well-documented complication of their employment is only mildly interesting. Where this research needs to go now is into lower levels of play. If evidence begins to accumulate that college, high school, or younger players are at risk for CTE, then wholesale changes are going to be needed in football or the sport is in real danger. 

People with a BMI under 40 are happier and healthier after their surgeries.

I'm a big, big fan of bariatric surgery for people with morbid obesity. We simply have access to no other treatment that improves quality of life and prolongs life to the extent that surgery can. But now there's some evidence (albeit weak) that people should have surgery earlier, not later. In a study published in JAMA Surgery, investigators found that people who had surgery before their body mass index, or BMI, hit 40 were about 12 times as likely as people with higher BMIs to get to a non-obese BMI (that is, less than 30) after surgery. A couple things to consider here: first, surgeons want to operate, so we should acknowledge their bias in this study; of course they want people with lower BMIs to qualify for surgery. It opens up more patients for them and they get to operate on a less sick, less complicated population of patients. But second, weight isn't the only thing we worry about post-surgery, so why does this matter? Because people who got to a BMI of less than 30 were much more likely to be able to stop medications for cholesterol, diabetes (especially insulin), and blood pressure. They were also much more likely to see a remission in their sleep apnea. Finally, the people who got to a lower BMI were just happier, with a satisfaction rate of 92.8% vs 78.0% for folks who didn't get to a non-obese BMI. The study can be tossed into the growing pile of studies showing that gastric banding sucks. Patients who had any other surgery--sleeve gastrectomy, gastric bypass, or duodenal switch--were 8 times, 21 times, and 82 times more likely, respectively, to get to a BMI less than 30 compared with those who got gastric banding. And that doesn't even take into account the disturbingly high complication rate of gastric banding. Take-home points? If you're considering bariatric surgery, get it sooner rather than later, and don't get a gastric band. 

The USDA is all about cheese right now.

I have mixed feelings on this. On the one hand, it seems a little absurd that we so misallocate food subsidies that dairy farmers are literally pouring milk into holes in the ground:

Farmers poured out almost 50 million gallons of unsold milk last year—actually poured it out, into holes in the ground—according to U.S. Department of Agriculture data. In an August 2016 letter, the National Milk Producers Federation begged the USDA for a $150 million bailout.

On the other hand, given the growing evidence that excess meat intake is shortening American lives, diverting some of that desire for meat toward cheese, yogurt, and other dairy products isn't the worst thing in the world. 

Tyler Cowen and Atul Gawande for your listening pleasure

I'm a big Tyler Cown fan, and an even bigger Atul Gawande fan. That doesn't make me special. Everyone who's ever read or listened to any of their work has the same opinion. So take advantage of this rare opportunity to hear them together:

If you're not the listening type, you can read the transcript here. 

June 15, 2017 laser links: drones for cardiac arrest, aircraft noise and blood pressure, and BMI's effect on fetal malformations

Drones can deliver automatic external defibrillators (AEDs) to cardiac arrests 3 km away in 5 minutes. Drones!

We better hope those drones aren't noisy, though: a couple months ago I stayed in an AirBnB east of downtown San Diego for a few days. We were directly under the final approach for SAN, and except late at night, a plane would roar overhead every few minutes. Bad news for the people in that otherwise charming neighborhood: all that aircraft noise may increase their blood pressure.

In case you woke up in too good of a mood, here's evidence that women with a higher BMI have a higher risk of giving birth to a baby with malformations.

The effect size is small (adjusted risk ratios for any birth defect were 1.05 for BMIs 25–29.9, 1.12 for BMIs 30–34.9, 1.23 for BMIs 35–39.9, and 1.37 for BMIs over 40.

Freedom from the vortex

Maybe you’re sick. Not throwing up or coughing up blood or having a fever, at least not most of the time, but you’re on a few medications, probably for diabetes or blood pressure issues or cholesterol, and your doctor picks on you to change your diet or be more active whenever you see her. Your medications cost a couple hundred dollars per month, and every second or third time you visit the doctor she adds another one, or replaces an old, cheap medication with a newer, more expensive one.

And maybe you weigh a few pounds (or many pounds) more than you want to. You’ve tried a few diets, mostly Atkins-type stuff, or low-fat, or calorie counting, and you’ve lost weight a few times, but each time the weight eventually came back.

Maybe you’re tired all the time. You feel bad when you get up in the morning, you are fatigued and achy all day, and you don’t sleep well at night. Your doctor thinks you might be depressed, and you’ve tried a couple medications for it, but they don’t seem to help.

And maybe you worry about money. You spend a lot of it on medications, and you go through the drive-through a few times a month even though you promise yourself that you won’t, and you end up working longer hours than you want to because you need to make sure the bills get paid.

Maybe you worry about the environment. You worry that our habits are putting your kids’ futures at risk, and you worry about it, but you aren’t sure what to do. A couple of times you’ve clicked the button to buy carbon offsets when you flew somewhere, but mostly you just try to ignore the problem.

And maybe it hasn’t occurred to you that these are all different manifestations of the same problem. You read that right. There is a very good chance that your diabetes is just another manifestation of the same set of problems as your weight and your fatigue and your money issues and even climate change.

We’re gonna talk about how. This blog is about your health, but not in the way that you’re used to talking about it with your doctor. It's not about the “blood pressure, blood sugar, cholesterol,” kind of health that makes you feel like a gadget someone is tinkering with. It’s more about the “What do I look forward to when I get out of bed in the morning?” kind of health. Or the “What can I do today to make sure I’m happier tomorrow than I was yesterday?” kind of health. Health as freedom: freedom from false choices, freedom from medications (not all of them, but some of them), freedom from the, *ahem*, Bravo Sierra that passes for medical advice from celebrities and celebrity doctors. I’m talking to you, Dr. Oz.

You’re not going to see click-baity posts on this blog about some new supplement or cellulite-destroying cream. You’re going to see posts on how you can take control of your life back. I’m not talking about a life jacket to protect you from the evil, swirling vortex of drug companies, subsidized faux-food, and carbon-spewing cars and factories. I’m talking about the freedom of learning how to swim your way out of that vortex altogether, put your feet on dry land, and walk away. All those people wrapped in spandex and padding away on a commercial gym’s treadmill under creepy fluorescent lights: do you think they’re free? They sure don’t look like it to me. You, with dry feet, having sprung once and for all from the vortex and now walking one foot in front of the other toward a happier, healthier life: that’s what freedom looks like.

I intend to be your guide along this path to medical freedom. I want to teach you a new way to think about your health; a way that allows you to make decisions that are your own and that will get you out of the vortex. You know the last time you had a bad cold, and you felt guilty for taking all the healthy days you had before that for granted, and you wondered when you would finally feel normal again? Remember how you said to yourself that you’d never take a healthy day for granted again? Once you claw your way out of the vortex, you won’t. And it will be because you MADE that next healthy day. You will have made it yourself, with your own hands and feet and decisions. If you believe me, I’ll see you at the next post.