News and Updates for Healthcare Professionals

Results from an international clinical trial of more than 4880 participants, published in the New England Journal of Medicine, show that combining clopidogrel and aspirin following a small stroke or experiencing minor stroke symptoms decreases risk of a new stroke, heart attack or other ischemic event within 90 days. The combination therapy was also associated with an increase in major bleeding, although many of those episodes were non-fatal and did not occur in the brain. The results were presented at the 4th European Stroke Organization Conference in Gothenburg, Sweden. The study was supported by the NIH’s National Institute of Neurological Disorders and Stroke (NINDS).

A new AHRQ report found that, although consumers have access to hundreds of smart phone apps for diabetes management, only 11 had been researched, and only five were associated with clinically significant improvements in levels of blood sugar control as measured by hemoglobin A1c (HbA1c) tests. Researchers sought to understand apps’ effectiveness to support self-management of type 1 and type 2 diabetes. A small number of apps were shown to provide benefits beyond A1c control, such as reducing episodes in which blood sugar levels register too high or too low. An article based on the evidence review was published in the Journal of General Internal Medicine.

AHRQ’s updated Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families features strategies for patients and families, clinicians and primary care clinical staff to improve communication.

Evidence suggests that enhanced communication leads to significant improvements in patient safety, the quality of care and patient experiences. The guide also features advice from practices from across the country that implemented the interventions.

Today, the Centers for Medicare & Medicaid Services (CMS) announced that it has released the comments submitted by patients, clinicians, innovators, and others in response to the CMS Innovation Center’s New Direction Request for Information (RFI). Last fall, CMS released the RFI to collect ideas on a new direction for the agency’s Innovation Center to promote patient-centered care and test market driven reforms that: empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes. The Innovation Center is a central focus of the Administration’s efforts to accelerate the move from a healthcare system that pays for volume to one that pays for value and encourages provider innovation.

CMS received over 1,000 responses to the RFI from a wide variety of individuals and organizations located across the country, including medical societies and associations, health systems, physician groups, and private businesses. Since the RFI comment period closed last November, CMS has been reviewing the responses, which provided valuable insight on the potential to improve existing models as well as ideas for transformative new models that aim to empower patients with more choices and better health outcomes.

“HHS has made shifting our healthcare system to one that pays for value one of our top four department priorities,” said HHS Secretary Alex Azar. “Using bold, innovative models in Medicare and Medicaid is a key piece of this effort. We value stakeholder input on the new direction for the Innovation Center, and look forward to engaging on especially promising, groundbreaking ideas such as direct provider contracting.”

“We recognize that the best ideas don’t come from Washington, so it’s important that we hear from the front lines of our healthcare system about how we can improve care” said CMS Administrator Seema Verma. “The responses from this RFI will help inform and drive our initiatives to transform the health care delivery system with the goal of improving quality of care while reducing unnecessary cost.”

The responses focused on a number of areas that are critical to enhancing quality of care for beneficiaries and decreasing unnecessary cost, such as increased physician accountability for patient outcomes, improved patient choice and transparency, realigned incentives for the benefit of the patient, and a focus on chronically ill patients. In addition to the themes that emerged around the RFI’s guiding principles and eight model focus areas, the comments received in response to the RFI also reflected broad support for reducing burdensome requirements and unnecessary regulations.

CMS is sharing the feedback received to promote transparency and facilitate further discussion of how to move the Innovation Center in a new direction. The RFI was a critical step in the model design process to ensure public input was available to help shape new models. Over the coming year, CMS will use the feedback as it works to develop new models, focusing on the eight focus areas outlined in the RFI.

Today, CMS is also taking a next step to develop a potential model in the area of direct provider contracting, informed in part by the RFI. A direct provider contract model would allow providers to take further accountability for the cost and quality of a designated population in order to drive better beneficiary outcomes. Such a model would have the potential to enhance the doctor-patient relationship by eliminating administrative burden for clinicians and providing increased flexibility to provide the high-quality care that is most appropriate for their patients, thus improving quality while reducing expenditures.

As part of its process to gain further insight from the public in this area and ask more focused questions, CMS is issuing a follow up RFI. The information being requested is detailed in nature and is intended to provide CMS the data needed to potentially design and release a model in this area. CMS is excited to continue to evaluate the concept of direct provider contracting and is also focusing its attention on other areas guided by input and feedback from the New Direction RFI as well as the public.

Summary: U.S. Surgeon General Jerome M. Adams and Commissioned Corps officers visit the opioids memorial on the Ellipse and discuss how they can fight the opioid crisis.

Officers of the U.S. Public Health Service Commissioned Corps take on many different jobs across the federal government, including foreign deployments that deal with life-threatening conditions. But at the end of the day, many of them continue to serve on their own time. Increasingly, they are finding a role to play in fighting the opioid crisis in the communities where they live.

Cmdr. Leo Angelo Gumapas, an engineer working on water systems, and Lt. Cmdr. John Pesce, managing a portfolio of research grants at NIH related to parasite infection, have been spending their off duty hours educating the public about the dangers of opioids and connecting individuals with resources to help prevent addiction.

Research from AHRQ’s EvidenceNOW Initiative Sets the Stage for Advances in Primary Care.

Nearly 600 members of the public joined NQF’s National Quality Partners™ (NQP™) Opioid Stewardship Action Team for a March 29 national discussion about how healthcare organizations, clinicians, pharmacists, and patients can support safe and effective pain management strategies, including appropriate prescribing of opioids.

At the heart of the discussion was the recently launched NQP Playbook™: Opioid Stewardship, which offers practical strategies, identifies barriers and solutions, and provides tools and resources for implementing or strengthening existing opioid stewardship programs across the country. Here are some of the discussion highlights:

“We’re quite excited about the NQP Playbook and the applicability to many different organizations at different stages of development in their own work on opioid stewardship,” said Paul Conlon, PharmD, JD, senior vice president, chief quality and patient safety, Trinity Health, and co-chair of the NQP Opioid Stewardship Action Team.

“Nine surgeries, nine times I was prescribed opioids for pain medicine, and nine times I wasn’t really given an option of other pain management suggestions,” said Joan Maxwell, patient partner and NQP Opioid Stewardship Action Team member representing Patient and Family Centered Care Partners, Inc.

“We got here as a nation in an attempt to solve a problem, which was our failure…to effectively manage pain,” said Alice Bell, PT, DPT, senior payment specialist, American Physical Therapy Association and NQP Opioid Stewardship Action Team member. She later added, “There is a role for opioids in pain management. This is not an all-or-nothing phenomenon.”

Join NQF’s national discussion to improve pain management for patients! Download your copy of the NQP Playbook from the NQF Store. Register today for NQF’s May 1 fully-accredited workshop, “Driving Patient Safety and Quality through Opioid Stewardship” to gain the frontline resources and strategies you need to improve opioid stewardship, pain management practices, and patient outcomes at your organization.

On Thursday, HHS Secretary Alex Azar announced the appointment of two individuals to lead initiatives in areas he has identified as priorities for the Department. Secretary Azar has previously identified four initiatives for his transformation agenda: combating the opioid crisis; bringing down the high cost of prescription drugs; addressing the cost and availability of health insurance; and transforming our healthcare system to a value-based system. The individuals who will be taking key roles on opioids and prescription drug pricing are:

• Daniel M. Best will be Senior Advisor to the Secretary for Drug Pricing Reform. Mr. Best will lead the initiative to lower the high price of prescription drugs.
• Brett Giroir, M.D., will, in addition to his duties as Assistant Secretary for Health, serve as Senior Advisor to the Secretary for Mental Health and Opioid Policy. Dr. Giroir will be responsible for coordinating HHS’s efforts across the Administration to fight America’s opioid crisis.

“Under President Trump, HHS has an historic opportunity to confront a number of America’s pressing health challenges, including the high price of prescription drugs and our country’s opioid crisis,” said Secretary Azar. “These leaders will play a unique role at HHS in driving coordination and results on these vital issues.”

“Daniel Best recognizes what President Trump and I, and every American know: prescription drug prices are too high. He has the deep experience necessary to design and enact reforms to lower the price of medicines that help Americans live healthier and longer lives.

“Brett Giroir, our Assistant Secretary for Health, will use his exceptional talents to tackle our country’s crisis of opioid addiction and overdose. His experience coordinating major projects within the federal government will bring new focus to our efforts on this issue.

“These two leaders will be invaluable to HHS and will advance the good work already being done at the Department serve the American people.”

Leaders for healthcare payment reform and value-based transformation of the healthcare system, will be announced in the coming weeks.

Biographical Background

Daniel M. Best, Senior Advisor to the Secretary for Drug Pricing Reform

A highly accomplished, top-performing healthcare industry executive, Daniel Best is an expert on both the pharmaceutical landscape and the largest single payer for prescription drugs, the Medicare Part D program. Best recently served as the Corporate Vice President of Industry Relations for CVSHealth’s Medicare Part D business. This included the company’s prescription drug plans, Medicare Part D plans, and other clients, which together provide prescription drug coverage for millions of Americans. Prior to working at CVS, Best spent 12 years at Pfizer Pharmaceuticals.

Assistant Secretary for Health Brett Giroir, M.D., Senior Advisor to the Secretary for Mental Health and Opioid Policy

Dr. Brett Giroir is HHS’s Assistant Secretary for Health, a role he will continue. He is a four-star admiral in the U.S. Public Health Service Commissioned Corps. Dr. Giroir is the former Director of the Defense Science Office at the Defense Advanced Research Projects Agency (DARPA), and has spent his career leading major projects for academic institutions and the U.S. Departments of Defense, Health and Human Services, and Veterans Affairs. He has been recognized for his novel approach to using biomedical advancements that have accelerated the development and manufacturing of vaccines and other treatments for pandemic influenza and emerging infectious diseases.

Kamil E. Barbour, PhD1; Susan Moss, MS2; Janet B. Croft, PhD1; Charles G. Helmick, MD1; Kristina A. Theis, PhD1; Teresa J. Brady, PhD1; Louise B. Murphy, PhD1; Jennifer M. Hootman, PhD1; Kurt J. Greenlund, PhD1; Hua Lu, MS1; Yan Wang, PhD1

Abstract

Problem/Condition: Doctor-diagnosed arthritis is a common chronic condition affecting an estimated 23% (54 million) of adults in the United States, greatly influencing quality of life and costing approximately $300 billion annually. The geographic variations in arthritis prevalence, health-related characteristics, and management among states and territories are unknown. Therefore, public health professionals need to understand arthritis in their areas to target dissemination of evidence-based interventions that reduce arthritis morbidity.

Reporting Period: 2015.

Description of System: The Behavioral Risk Factor Surveillance System is an annual, random-digit–dialed landline and cellular telephone survey of noninstitutionalized adults aged ?18 years residing in the United States. Self-reported data are collected from the 50 states, the District of Columbia, Guam, and Puerto Rico. Unadjusted and age-standardized prevalences of arthritis, arthritis health-related characteristics, and arthritis management were calculated. County-level estimates were calculated using a validated statistical modeling method.

Results: In 2015, in the 50 states and the District of Columbia, median age-standardized prevalence of arthritis was 23.0% (range: 17.2%–33.6%). Modeled prevalence of arthritis varied considerably by county (range: 11.2%–42.7%). In 13 states that administered the arthritis management module, among adults with arthritis, the age-standardized median percentage of participation in a self-management education course was 14.5% (range: 9.1%–19.0%), being told by a health care provider to engage in physical activity or exercise was 58.5% (range: 52.3%–61.9%), and being told to lose weight to manage arthritis symptoms (if overweight or obese) was 44.5% (range: 35.1%–53.2%). Respondents with arthritis who lived in the quartile of states with the highest prevalences of arthritis had the highest percentages of negative health-related characteristics (i.e., arthritis-attributable activity limitations, arthritis-attributable severe joint pain, and arthritis-attributable social participation restriction; ?14 physically unhealthy days during the past 30 days; ?14 mentally unhealthy days during the past 30 days; obesity; and leisure-time physical inactivity) and the lowest percentage of leisure-time walking.

Interpretation: The prevalence, health-related characteristics, and management of arthritis varied substantially across states. The modeled prevalence of arthritis varied considerably by county.

Public Health Action: The findings highlight notable geographic variability in prevalence, health-related characteristics, and management of arthritis. Targeted use of evidence-based interventions that focus on physical activity and self-management education can reduce pain and improve function and quality of life for adults with arthritis and thus might reduce these geographic disparities.

Dear Presley Pride,
You recently read about the All of Us Research Program, an ambitious initiative by the National Institutes of Health (NIH) that is exploring individual biological, environmental, and behavioral factors affecting health and disease. This email highlights why it is important for you and your practice to be a part of this historic research program.

Contributing to individualized disease prevention, treatment, and care

The All of Us Research Program, a key component of the federal government’s Precision Medicine Initiative, has begun enrolling a diverse population of participants and is rapidly building a large network of partner organizations.

Precision medicine gives clinicians tools to better understand the complex mechanisms underlying a person’s health, disease, or condition, and to better predict which treatments and prevention strategies will be most effective. Data and information from participants in All of Us are expected to help accelerate health research and medical breakthroughs, and thus facilitate individualized disease prevention, treatment, and care for everyone.

Advancing health care in a variety of ways

The All of Us Research Program is expected to contribute to advances in health care in a variety of ways, such as identification of the causes of individual variation in response to commonly used therapeutics, and discovery of biological markers that signal increased or decreased risk of developing common diseases.

The program is currently collecting a limited set of standardized patient data from different sources. However, the types of data collected by All of Us will grow and evolve over time.

Sources of data currently being collected by All of Us

• Participant questionnaires
• Electronic health records
• Physical measurements
• Biosamples (blood and urine samples)
• Mobile/wearable technologies
• Geospatial/environmental data

‘Arming’ patients with wearable devices

One particularly exciting aspect of All of Us is the generation of data from wearable devices that will make it possible to explore the relationship between everyday activities and health outcomes.

Scripps Translational Science Institute (STSI), a part of the Scripps Research Institute in San Diego, is responsible for designing and implementing strategies to keep diverse populations of participants engaged over the long term. Commenting on the importance of gathering individual data from wearable devices, Steven Steinhubl, MD, Director of Digital Medicine at STSI, said that the program will provide “access to comprehensive activity, heart rate, and sleep data that may help us better understand the relationship between lifestyle behaviors and health outcomes and what that means for patients on an individualized basis.”

AHRQ’s Academy for Integrating Behavioral Health and Primary Care now offers an updated online list of resources and tools to promote integrating behavioral health with primary care. Medication-assisted treatment (MAT) for opioid use disorder (OUD) tools and resources are available to help patients, providers and community organizations battle the opioid epidemic. The Opioid & Substance Use Resources page includes information and tools from Federal sources, health professional societies, academic institutions and researchers. Another feature, the Literature Collection, provides access to the growing inventory evidence on the integration of behavioral health and primary care. The online Academy Community allows individuals and practices working to implement MAT to collaborate and share insights with peers.

Collaborative effort provides important clues about potential research targets.

Dr. David Meyers, M.D., AHRQ’s chief medical officer, recognizes the importance of February as Heart Health Month while highlighting important contributions made by AHRQ’s EvidenceNow initiative. AHRQ is working with more than 1,500 primary small- and medium-size care practices to help improve the delivery of services proven to prevent heart attacks and strokes. These include the “ABCS” of heart health – Aspirin use by high-risk individuals,Blood pressure control, Cholesterol management, and Smoking cessation. Dr. Meyers’ blog post describes examples of project successes, including expanded use of medications to prevent heart disease, more effective use of blood pressure measurement among patients at risk for heart attack or stroke, and increased use of smoking cessation counseling. AHRQ’s contributions to heart health are in alignment with the Million Hearts® initiative, a national effort to control risk factors for heart disease, the nation’s number one killer.

Azar: Plans to reduce high drug costs reflect President’s deep commitment to issue

Health and Human Services Secretary Alex Azar issued the following statement today on President Trump’s Fiscal Year 2019 Budget:

“The President’s budget makes investments and reforms that are vital to making our health and human services programs work for Americans and to sustaining them for future generations. In particular, it supports our four priorities here at HHS: addressing the opioid crisis, bringing down the high price of prescription drugs, increasing the affordability and accessibility of health insurance, and improving Medicare in ways that push our health system toward paying for value rather than volume.

“This budget supports the hard work the men and women of HHS are already doing toward these goals. In particular, the budget’s efforts to reduce the high cost of prescription drugs, especially for America’s seniors, are a reflection of President Trump’s deep commitment to addressing this important issue.”

National Institutes of Health scientists developing a rapid, practical test for the early diagnosis of prion diseases have modified the assay to offer the possibility of improving early diagnosis of Parkinson’s disease and dementia with Lewy bodies. The group, led by NIH’s National Institute of Allergy and Infectious Diseases (NIAID), tested 60 cerebral spinal fluid samples, including 12 from people with Parkinson’s disease, 17 from people with dementia with Lewy bodies, and 31 controls, including 16 of whom had Alzheimer’s disease. The test correctly excluded all the 31 controls and diagnosed both Parkinson’s disease and dementia with Lewy bodies with 93 percent accuracy.

The Human Genome Project has been awarded the 2017 Prince Mahidol Award for ground-breaking advances in the field of medicine. The award will be received on behalf of the project by Eric Green, M.D., Ph.D., director of the National Human Genome Research Institute (NHGRI), part of the National Institutes of Health, and the institute responsible for leading NIH’s effort in the project.

COPD, a progressive disease that makes it hard to breathe, is the fourth leading cause of death in the United States.

Diet helps people prevent and treat high blood pressure, lower blood cholesterol.

NIH-supported study could lead to better approaches for treating insomnia, other sleep disorders.

Today, the Centers for Medicare & Medicaid Services (CMS) finalized the cancellation of the mandatory hip fracture and cardiac bundled payment models that were to be operated by the CMS Innovation Center and implemented changes to the Comprehensive Care for Joint Replacement (CJR) Model. These changes will offer greater flexibility and choice for hospitals in providing care to Medicare patients.

“While CMS continues to believe that bundled payment models offer opportunities to improve quality and care coordination while lowering spending, we believe that focusing on developing different bundled payment models and engaging more providers is the best way to drive health system change while minimizing burden and maintaining access to care. We anticipate announcing new voluntary payment bundles soon,” said CMS Administrator Seema Verma.

In the final rule, CMS is reducing the number of mandatory geographic areas participating in CJR from 67 areas to 34 areas. As part of the agency’s ongoing commitment to addressing the unique needs of rural providers, CMS is also making participation voluntary for all low volume and rural hospitals participating in the model in all 67 geographic areas. This regulation also includes an Interim Final Rule with Comment Period, in which CMS is establishing and seeking comment on a final policy to provide flexibility in determining episode costs for participant hospitals located in areas impacted by extreme and uncontrollable circumstances, such as the major hurricanes of 2017.

CMS is also finalizing the cancelation of the hip fracture and cardiac bundled payment and incentive payment models – the Episode Payment Models and the Cardiac Rehabilitation Incentive Payment Model – that were scheduled to begin on January 1, 2018. Not pursuing these models gives CMS greater flexibility to design and test innovations that will improve quality and care coordination across the in-patient and post-acute care spectrum.

Moving forward, CMS expects to increase opportunities for providers to participate in voluntary initiatives rather than large mandatory bundled payment models. The changes in the final rule will help position the agency to engage in future voluntary efforts.

For a technical fact sheet on the changes in this final rule and interim final rule with comment period, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-30.html.

For more information on the Comprehensive Care for Joint Replacement Model, please visit: https://innovation.cms.gov/initiatives/cjr.

The final rule and interim final rule with comment (CMS-5524-F and IFC) can be downloaded from the Federal Register at https://www.federalregister.gov/public-inspection.

To determine optimal doses, routes of administration, and dosing strategies of naloxone for suspected opioid overdose in out-of-hospital settings, and whether transport to a hospital following successful opioid overdose reversal with naloxone is necessary.

The new high blood pressure guidelines illustrate the utility and impact of NHLBI scientific studies.

Five primary care practices participating in AHRQ’s EvidenceNOW project have been named as 2017 Million Hearts® Hypertension Control Champions. The award winners – three in New York, one each in Oklahoma and Wisconsin – are among 24 honorees that include primary care practices, individual clinicians and health systems. The honorees were recognized for achieving blood pressure control for at least 70 percent of their patients through innovations in health information technology and electronic health records, patient communication, and teamwork. EvidenceNOW, launched in May 2015, provides support services to 1,500 small and medium primary care practices with the objective of improving patients’ blood pressure and addressing other risk factors to improve heart health.

By: Christopher M. Jones, PharmD, MPH and Vanila M. Singh, MD, MACM

Over the past 15 years, communities across America have been devastated by increasing prescription and illicit opioid abuse, addiction, and overdose.

In 2016, 11 million Americans misused prescription opioids, nearly 1 million used heroin, and 2.1 million had an opioid use disorder due to prescription opioids or heroin. And every day, an estimated 90 Americans die from an opioid overdose—resulting in more than 300,000 deaths since 2000. Meanwhile, an estimated 25 million Americans experience pain every day. For many of these individuals, this pain interferes with their physical and mental health, work productivity, and ability to engage in social activities.

Primary care clinicians are often the first to see older adults with memory loss or other signs of cognitive impairment. Three brief, online guides from NIA can help healthcare providers assess, manage, and support their patients with memory complaints or impairment:

• Assessing Cognitive Impairment in Older Patients: A Quick Guide for Primary Care Physicians — read about the benefits of early screening and learn how to screen quickly and accurately.
• Managing Older Patients with Cognitive Impairment: A Quick Guide for Primary Care Physicians — get practical advice on planning and care strategies for patients with mild cognitive impairment, Alzheimer’s, or a related dementia.
• Now What? Next Steps After a Diagnosis of Alzheimer’s Disease — give this checklist of resources and referrals to newly diagnosed patients. Available in English and Spanish.

The Effective Health Care Program has posted the following on its Web site:

Draft Report
This draft report is available for comment until November 15, 2017.

Final Report
Understanding Health-Systems’ Use of and Need for Evidence To Inform Decisionmaking

Twelve specialized research centers designed to conduct multidisciplinary research, research training, and community engagement activities focused on improving minority health and reducing health disparities will launch. The centers, to be funded by the National Institute on Minority Health and Health Disparities (NIMHD), part of the National Institutes of Health, will share approximately $82 million over five years, pending the availability of funds.

Joint HHS-DoD-VA initiative will award multiple grants totaling $81 million.

The American Diabetes Association (ADA) has released a position statement to update the assessment and treatment of hypertension among patients with diabetes.

The position statement, published in Diabetes Care, includes advances in care since the ADA last published a statement on this topic in 2003. The ADA notes that antihypertensive therapy is shown to reduce atherosclerotic cardiovascular disease (ASCVD) events, heart failure, and microvascular complications in patients with diabetes. There have also been reductions in ASCVD morbidity and mortality in patients with diabetes since 1990, which are likely due to improvements in blood pressure control.

“Treatment should be individualized to the specific patient based on their comorbidities; their anticipated benefit for reduction in ASCVD, heart failure, progressive diabetic kidney disease, and retinopathy events; and their risk of adverse events,” according to the ADA. “This conversation should be part of a shared decision-making process between the clinician and the individual patient.”

The ADA has made the following recommendations:

Screening and diagnosis

• Clinicians should measure blood pressure at every routine clinical care visit. Patients with elevated blood pressure ?140/90 mmHg should have blood pressure confirmed with multiple readings to diagnose hypertension (Grade B recommendation).
• Hypertensive patients with diabetes should have home blood pressure monitoring to identify white-coat hypertension (Grade B recommendation).
• Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed (Grade E recommendation).

Blood pressure targets

• The systolic blood pressure goal should be <140 mmHg, and the diastolic blood pressure goal should be <90 mmHg for most individuals with diabetes and hypertension (Grade A recommendation).
  Lower systolic and diastolic blood pressure targets may be appropriate for those with high risk of cardiovascular disease if they can be achieved without excessive treatment burden (Grade B recommendation).

Lifestyle management

• Lifestyle intervention for those with systolic blood pressure >120 mmHg or diastolic blood pressure >80 mmHg consists of weight loss if overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern; increased fruit and vegetable consumption; moderation of alcohol intake; and increased physical activity (Grade B recommendation).

Pharmacologic antihypertensive treatment

• Patients with confirmed blood pressure ?140/90 mmHg should have timely titration of pharmacologic therapy to achieve blood pressure goals, in addition to lifestyle therapy (Grade A recommendation).
• Patients with confirmed blood pressure ?160/100 mmHg should have prompt initiation and timely titration of 2 drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes, in addition to lifestyle therapy (Grade A recommendation).
• Treatment should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes. These include ACE inhibitors, angiotensin receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium channel blockers. Multiple-drug therapy is generally required to achieve blood pressure targets (Grade A recommendation).
• An ACE inhibitor or ARB is the recommended first-line treatment for hypertension in patients with diabetes and urine albumin-to creatinine ratio ? 300 mg/g creatinine (Grade A recommendation) or 30–299 mg/g creatinine (Grade B recommendation). If one class is not tolerated, the other should be substituted. (Grade B recommendation).
• Serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored in patients treated with an ACE inhibitor, ARB, or diuretic (Grade B recommendation).