Missed Opportunities in Chronic Disease Management - especially Hypertension and Heart Failure Programs

Our health system is missing the opportunity to improve the quality of life and longevity for millions of patients with hypertension and heart failure. Since hypertension leads to so many other diseases, early identification and intervention is crucial.

Yet, millions of patients with hypertension will progress into more serious disease states, like heart failure, kidney failure, and stroke - unless they receive care for which they are eligible - care based on established, clinically directed medical guidelines.

Hypertension is the leading cardiovascular risk factor globally, accounting for approximately half of the burden of coronary heart disease and nearly two-thirds of cerebrovascular disease.

Primary care physicians and specialists in cardiology, nephrology, endocrinology, oncology, and neurology (with neuropathology often focusing more on brain pathology rather than clinical care) consider hypertension to be a major indicator of disease development and progression across a wide range of conditions.

In these specialties, hypertension is viewed somewhat differently but is still a leading indicator:

1. Primary Care Physicians: Hypertension is one of the most common chronic conditions they manage. It is often considered a "silent" risk factor because it can lead to serious complications like heart disease, stroke, kidney failure, and other issues without causing noticeable symptoms early on.
2. Cardiology: Hypertension is a critical factor in the development of heart disease, including coronary artery disease, heart failure, and arrhythmias. It contributes to the thickening of the heart muscle (left ventricular hypertrophy), leading to heart failure with preserved ejection fraction (HFpEF) and other complications.
3. Nephrology: Hypertension is a leading cause and consequence of chronic kidney disease (CKD). High blood pressure damages the delicate blood vessels in the kidneys, reducing their ability to filter waste, which in turn exacerbates hypertension in a vicious cycle.
4. Endocrinology: Hypertension is often associated with metabolic and hormonal disorders, such as diabetes, and conditions like Cushing's syndrome or hyperaldosteronism, which directly affect blood pressure regulation. It is a significant concern in managing these diseases.
5. Oncology: Hypertension may emerge as a side effect of cancer treatments, mainly with certain chemotherapy drugs or targeted therapies that affect blood vessels. It can also serve as an indicator of underlying cancer in some cases, especially in rare conditions like paraneoplastic syndromes.
6. Neurology/Neuropathology: In the context of neurology, hypertension is a leading risk factor for stroke, dementia, and other cerebrovascular diseases. Chronic hypertension can lead to small vessel disease in the brain, contributing to cognitive decline and increasing the risk of vascular dementia.

The need for education, identification, GDMTs, and CCM enrollment

Only 4,500 providers out of over a million Medicare providers who treat patients implemented and billed CCM services last year.

It's true.

The need for education, identification, enrollment, monitoring, and adherence to guideline-directed therapies (including physician-designed patient care plans) to better manage chronic disease is wildly underutilized—even though the services can be performed in collaboration with a CCM vendor (in a proven model) and have valid, billable CPT codes.

Why?

And 50 million patients who should be receiving and who are eligible for guideline-directed medical therapies to help treat hypertension, congestive heart failure, and other cardiovascular diseases do not receive the therapy.

It's true.

A recent UCLA-led study highlights some fascinating insights about the significant impact that guideline-directed medical therapy (GDMT) can have in lowering mortality rates among patients with heart failure with reduced ejection fraction (HFrEF).

This particular form of heart failure affects approximately 29 million people globally, an astounding number - and imparts a significant insight into the widespread relevance of effective treatment strategies, along with, unsurprisingly, chronic disease management programs.

The UCLA analysis, published in?JAMA Cardiology, found that many patients eligible to be given life-saving?medical therapy do not receive it," demonstrating a major challenge in implementing global (care management) guidelines."

This represents a major challenge in adhering to global care management guidelines.

Amber Tang, MD, lead author of the study and a medical resident at UCLA, said, "The guidelines are being significantly underutilized by providers within clinical settings, especially in programs like chronic disease management. And make no mistake, there are barriers that contribute to this, including poor health literacy, limited access to care and medication costs."

GDMTs

Guideline-directed medical therapy is essentially the use of care plans developed by physicians that care for patients, largely in acute care settings or in post-discharge care plans. Naturally, those care plans may be embedded in chronic disease management programs, those care plans are included as well, although in a different setting (chronic deasemanagement).

GDMTs include medications and treatment strategies recommended by major clinical guidelines, such as those from the American College of Cardiology (ACC), American Heart Association (AHA), and the Heart Failure Society of America (HFSA). These guidelines are based on evidence from clinical trials and expert consensus, and they aim to improve patient outcomes, including survival, symptom management, and quality of life.

The UCLA study identified 8.2 million patients who qualify but do not receive beta-blocker treatment. Large numbers of patients were identified who would benefit from angiotensin receptor neprilysin inhibitors (20.4 million), mineralocorticoid receptor antagonists (12.2 million), and SGLT2 inhibitors (21.2 million).

These therapies include:

1. Beta-blockers help slow heart rate and reduce the workload, improving cardiac function over time.
2. Specific "receptor antagonists," that reduce fluid retention associated with heart failure and lower blood pressure.
3. A new class of Angiotensin receptor-neprilysin inhibitors (ARNIs) – medications that combine angiotensin receptor benefits with neprilysin inhibition to enhance cardiovascular outcomes.
4. Sodium-glucose cotransporter 2 (SGLT2) inhibitors – drugs that were originally used for diabetes but found to improve heart failure outcomes by reducing hospitalizations and mortality.

CCM and RPM programs that incorporate CGMTs and monitoring

While social determinants of health, including nutrition, smoking, pollution, and education may be factors that are difficult to influence, we CAN identify, educate, and provide therapies for millions of people who deserve the opportunity to live longer better lives - and to halt or slow the progression of disease today.

CCM and RPM programs are intended to identify, enroll, engage, apply GDMTs, and slow the disease process. They are billable services with peer-reviewed proven results - especially with hypertension management.

And, through collaboration between providers and CCM vendors, it doesn't overburden staff or physicians.

We need to advance the management and treatment of hypertension. Too many of us have watched parents, siblings, and others suffer from the disease caused by hypertension.

We can make a difference with RPM and CCM. Before it's too late.

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