Evidence mapPaperPMID 39494161Full record

ArticleSAGE open medicine2024

Software-driven chronic disease management: Algorithm design and implementation in a community-based blood pressure control pilot.

Rahul C Deo, Rebecca Smith, Calum A MacRae, Esha Price, Horace Sheffield, Rahul Patel

Abstract read
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Article in SAGE open medicine, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.

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field-weighted citation impact
1 · What the graph read from it

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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

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3 · Its place in the literature

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0 citing papers in PubMed.

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4 · The record

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5 · Who and what money

Authors and funding

6 authors.

Rahul C DeoAtman Health, Needham, MA, USA.ORCID https://orcid.org/0000-0002-2791-9434
Rebecca SmithAtman Health, Needham, MA, USA.
Calum A MacRaeAtman Health, Needham, MA, USA.
Esha PriceDetroit Association of Black Organizations, Detroit, MI, USA.
Horace SheffieldDetroit Association of Black Organizations, Detroit, MI, USA.
Rahul PatelAtman Health, Needham, MA, USA.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

Background: Optimal guideline-directed medical therapy is rarely attained in practice, resulting in inadequate control of diseases such as hypertension, with poorer results in under-resourced communities. Technology, including artificial intelligence-driven decision support and software-driven workflow transformation, can potentially improve disease outcomes at a reduced cost, although it must be integrated with a holistic approach. Methods: We describe the design of a software platform that enables rapid iterative remote management of >20 conditions across cardiac-kidney-metabolic disease. The platform distributes work across a care team of providers and care navigators, automates decision-making, ordering, and documentation, supports rapid incorporation of new evidence, and launches pragmatic trials. We describe software used in a 500-person community-based blood pressure control implemented as a single-arm quality improvement program. The primary endpoint was the proportion of patients meeting the Healthcare Effectiveness Data and Information Set quality measure blood pressure goal (<140/90) at 12 weeks. Results: A total of 1609 patients were screened, 945 (59%) were found to have uncontrolled hypertension, and 512 patients consented to join the program. The average age was 61 ± 11 years; 59% were female, and 99% self-identified as Black. Blood pressure distribution was: 10% Stage 1 (SBP 130-139 mmHg or DBP 80-89 mmHg), 69% Stage 2 (SBP 140-179 mmHg or DBP 90-119 mmHg), and 21% Stage 3 (SBP >180 mmHg or DBP >120 mmHg). Two hundred four patients (39%) proceeded to a provider encounter, and 160 of these (78%) completed the program. The Healthcare Effectiveness Data and Information Set blood pressure goal was achieved in <12 weeks of enrollment for 141 participants (69% of those enrolled, 88% of those who completed the program). Conclusion: Software-driven remote blood pressure is feasible, although strategies to improve patient enrollment will be needed to achieve maximum impact. Future work will be required to compare outcomes to usual care and evaluate concurrent management of multiple cardiac-kidney-metabolic conditions.

Indexed as

artificial intelligenceautomationguideline-directed medical therapyHealth equityhypertensionquality measuressoftwarevalue-based care

Identifiers

PMID39494161
PMCPMC11530998

What Socratic holds

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LicenceCC BY-NC
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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the Socratic graph.