{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T18:29:05Z","timestamp":1770748145443,"version":"3.49.0"},"reference-count":37,"publisher":"Oxford University Press (OUP)","issue":"1-2","funder":[{"DOI":"10.13039\/100006965","name":"Telemedicine and Advanced Technology Research Center","doi-asserted-by":"crossref","id":[{"id":"10.13039\/100006965","id-type":"DOI","asserted-by":"crossref"}]},{"name":"AMEDD Advanced Medical Technology Initiative"},{"name":"Analytics4Medicine Seattle Washington"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2021,1,30]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n               <jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>Based on defining criteria, hypertension (HTN) affects 31% to 46% of the adult U.S. population and almost 20% of service members. Resistant HTN (rHTN) consumes significant resources, carries substantial morbidity and mortality risk and costs over $350 billion dollars annually. For multiple reasons, only 48.3% of people with HTN are controlled, e.g., undiagnosed secondary HTN, therapeutic or diagnostic inertia, and patient adherence. Our purpose was to determine the feasibility of a web-based clinical decision support tool (CDST) using a renin-aldosterone system (RAS) classification matrix and drug sequencing algorithm to assist providers with the diagnosis and management of uncontrolled HTN (rHTN). Outcomes were blood pressure (BP) rates of control, provider management time, and end-user satisfaction.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>This two-phase, prospective, non-randomized, single-arm, six-month pilot study was conducted in primary care clinics at a tertiary military medical center. Patients with uncontrolled HTN and primary care providers were recruited. Phase 1 patients checked their BP twice daily (AM and PM), three times weekly using a standardized arm cuff. Patients with rHTN were enrolled in phase 2. Phase 2 patients were managed virtually by providers using the CDST, the RAS classification matrix, and the drug sequencing algorithm which incorporated age, ethnicity, comorbidities, and renin\/aldosterone levels. Medications were adjusted every 10 days until BP was at target, using virtual visits.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>In total, 54 patients and 16 providers were consented. One transplant patient was disqualified, 29 met phase 2 criteria for rHTN, and 6 providers completed the study. In phase 1, 45% (n\u2009=\u200924) of patients were identified as having apparent uncontrolled HTN using peak diurnal blood pressure (pdBP) home readings. In phase 2 (n\u2009=\u200929), previously undetected RAS abnormalities were identified in 69% (n\u2009=\u200920) of patients. Blood pressure control rates improved from 0% to 23%, 47%, and 58% at 2, 4, and 6 months, respectively. Provider management time was reduced by 17%. Using home pdBP readings identified masked HTN in almost 20% of patients that would have been missed by a single daily AM or PM home BP measurement. Feasibility and satisfaction trends were favorable.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Despite significant morbidity, mortality, and existing guidelines, over half of hypertensive patients are uncontrolled. Our results suggest that this CDST used with pdBP monitoring is a feasible option to facilitate improved rates of control in rHTN, aid in overcoming therapeutic\/diagnostic inertia, improve identification of secondary HTN, and potentially, access. Further research with this tool in a larger population is recommended.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/milmed\/usaa255","type":"journal-article","created":{"date-parts":[[2020,10,2]],"date-time":"2020-10-02T19:33:29Z","timestamp":1601667209000},"page":"e225-e233","source":"Crossref","is-referenced-by-count":3,"title":["Feasibility of a Clinical Decision Support Tool to Manage Resistant Hypertension: Team-HTN, a Single-arm Pilot Study"],"prefix":"10.1093","volume":"186","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0528-1695","authenticated-orcid":false,"given":"Leilani A","family":"Siaki","sequence":"first","affiliation":[{"name":"Madigan Army Medical Center, 9040 Jackson Ave. Tacoma, WA 98431, USA \u00a0leilani.a.siaki.mil@mail.mil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Victor","family":"LIN","sequence":"additional","affiliation":[{"name":"Naval Medical Forces Pacific, 4170 Norman Scott Rd Suite 5, San Diego, CA 92136, USA \u00a0victor.s.lin.mil@mail.mil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert","family":"Marshall","sequence":"additional","affiliation":[{"name":"Madigan Army Medical Center, 9040 Jackson Ave. Tacoma, WA 98431, USA \u00a0robert.c.marshall24.civ@mail.mil"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert","family":"Highley","sequence":"additional","affiliation":[{"name":"Analytics4Medicine (A4M), 11827 26 Ave SW, Burien, WA 98146, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2021,1,30]]},"reference":[{"issue":"10","key":"2021013015071157600_R1","doi-asserted-by":"publisher","first-page":"e56","DOI":"10.1161\/CIR.0000000000000659","article-title":"Heart disease and stroke statistics-2019 update: a report from the American Heart Association [published correction appears in Circulation. 2020 Jan 14;141(2):e33].","volume":"139","author":"Benjamin","year":"2019","journal-title":"Circulation"},{"issue":"17","key":"2021013015071157600_R2","first-page":"e426","article-title":"2017 ACC\/AHA\/AAPA\/ABC\/ACPM\/AGS\/APhA\/ ASH\/ASPC\/NMA\/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology\/American Heart Association Task Force on clinical practice guidelines.","volume":"138","author":"Whelton","year":"2018","journal-title":"Circulation"},{"key":"2021013015071157600_R3","volume-title":"Hypertension prevalence among adults aged 18 and over: United States, 2017\u20132018. NCHS Data Brief No. 364","author":"Ostchega","year":"2020"},{"key":"2021013015071157600_R4","article-title":"Preventing and controlling hypertension for improved population health: healthy people 2020 heart disease and stroke objectives","author":"Healthy People 2020 Heart Disease and Stroke Federal Partnership","year":"2019"},{"issue":"2","key":"2021013015071157600_R5","doi-asserted-by":"publisher","DOI":"10.1136\/svn-2017-00013","article-title":"Controlling resistant hypertension","volume":"3","author":"Spence","year":"2018","journal-title":"Stroke Vasc Neurol"},{"key":"2021013015071157600_R6","doi-asserted-by":"crossref","DOI":"10.7249\/RR1695","article-title":"2015 Department of Defense Health Related Behaviors Survey (HRBS)","author":"Meadows","year":"2018"},{"key":"2021013015071157600_R7","doi-asserted-by":"publisher","first-page":"824","DOI":"10.1161\/HYPERTENSIONAHA.117.10496","article-title":"Associations of initial injury severity and posttraumatic stress disorder diagnoses with long-term hypertension risk after combat injury","volume":"71","author":"Howard","year":"2018","journal-title":"Hypertension"},{"issue":"12","key":"2021013015071157600_R8","article-title":"Comparison of cardiovascular health between US army and civilians","volume":"8","author":"Shrestha","year":"2019","journal-title":"J Am Heart Assoc"},{"key":"2021013015071157600_R9","author":"Department of Defense. USCENTCOM Modification Policy 14 Tab A 2019."},{"issue":"3","key":"2021013015071157600_R10","doi-asserted-by":"publisher","first-page":"e1704","DOI":"10.7205\/MILMED-D-16-00182","article-title":"Medical redeployment in soldiers with and without medical deployment waivers","volume":"182","author":"Cronrath","year":"2017","journal-title":"Mil Med"},{"issue":"5","key":"2021013015071157600_R11","doi-asserted-by":"publisher","first-page":"e53","DOI":"10.1161\/HYP.0000000000000084","article-title":"Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association","volume":"72","author":"Carey","year":"2018","journal-title":"Hypertension"},{"issue":"(Oct)","key":"2021013015071157600_R12","doi-asserted-by":"publisher","first-page":"116","DOI":"10.1016\/j.phrs.2017.07.026","article-title":"Antihypertensive drugs","volume":"124","author":"Laurrent","year":"2017","journal-title":"Pharmacol Res"},{"issue":"9","key":"2021013015071157600_R13","doi-asserted-by":"crossref","first-page":"929","DOI":"10.1038\/ajh.2010.135","article-title":"Renin-guided treatment of hypertension: time for action","volume":"23","author":"Furberg","year":"2010","journal-title":"Am J Hypertens"},{"issue":"7","key":"2021013015071157600_R14","doi-asserted-by":"publisher","first-page":"792","DOI":"10.1038\/ajh.2009.63","article-title":"Plasma Renin test-guided drug treatment algorithm for correcting patients with treated but uncontrolled hypertension: a randomized controlled trial","volume":"22","author":"Egan","journal-title":"Am J Hypertension"},{"issue":"3","key":"2021013015071157600_R15","doi-asserted-by":"publisher","first-page":"324","DOI":"10.1111\/j.1365-2265.2007.02898.x","article-title":"Diagnosis and treatment of low-renin hypertension","volume":"67","author":"Mulatero","year":"2007","journal-title":"Clin Endocrinol (Oxf)"},{"issue":"5","key":"2021013015071157600_R16","doi-asserted-by":"publisher","first-page":"720","DOI":"10.1016\/j.ihj.2016.08.013","article-title":"Diuretics in primary hypertension \u2013 reloaded","volume":"68","author":"Mishra","year":"2016","journal-title":"Indian Heart J"},{"issue":"2","key":"2021013015071157600_R17","doi-asserted-by":"publisher","DOI":"10.3390\/ijms190205466","article-title":"The low-renin hypertension phenotype: genetics and the role of the mineralocorticoid receptor","volume":"19","author":"Baudrand","year":"2018","journal-title":"Int J Mol Sci"},{"issue":"2","key":"2021013015071157600_R18","doi-asserted-by":"publisher","first-page":"263","DOI":"10.1161\/HYPERTENSIONAHA.118.11064","article-title":"Hypertension in blacks individualized therapy based on renin\/aldosterone phenotyping.","volume":"72","author":"Spence","year":"2018","journal-title":"Hypertension"},{"key":"2021013015071157600_R19","doi-asserted-by":"publisher","DOI":"10.3389\/fcvm.2016.00003","article-title":"Timeline of history of hypertension treatment.","volume":"3","author":"Saklayen","year":"2016","journal-title":"Front Cardiovasc Med"},{"issue":"(9590)","key":"2021013015071157600_R20","doi-asserted-by":"publisher","first-page":"829","DOI":"10.1016\/S0140-6736(07)61303-8","article-title":"Effect of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomized controlled trial","volume":"370","author":"Patel","year":"2007","journal-title":"Lancet"},{"issue":"Suppl 1","key":"2021013015071157600_R21","doi-asserted-by":"publisher","first-page":"S103","DOI":"10.15265\/IYS-2016-s034","article-title":"Clinical decision support: a 25 year retrospective and a 25 year vision.","author":"Middleton","year":"2016","journal-title":"Yearb Med Inform"},{"issue":"1","key":"2021013015071157600_R22","doi-asserted-by":"crossref","DOI":"10.2196\/16912","article-title":"Accuracy and effects of clinical decision support systems integrated with BMJ best practice\u2013aided diagnosis: interrupted time series study","volume":"8","author":"Tao","year":"2020","journal-title":"JMIR Med Informat"},{"key":"2021013015071157600_R23","first-page":"633","article-title":"angiotensin and aldosterone system in pathogenesis and management of hypertensive vascular disease. Am J Med","volume":"52","author":"Laragh","year":"1972"},{"issue":"(9)","key":"2021013015071157600_R24","doi-asserted-by":"publisher","first-page":"1731","DOI":"10.1097\/HJH.0b013e328363e964","article-title":"European Society of Hypertension position paper on ambulatory blood pressure monitoring [published correction appears in J Hypertens. 2013 Dec;31(12):2467]","volume":"31","author":"O\u2019Brien","year":"2013","journal-title":"J Hypertens"},{"issue":"5","key":"2021013015071157600_R25","doi-asserted-by":"publisher","first-page":"507","DOI":"10.1001\/jama.2013.284427","article-title":"2014 Evidence-based guideline for the management of high blood pressure in adults\u2014report from the panel members appointed to the eighth Joint National Committee (JNC 8)","volume":"311","author":"James","year":"2014","journal-title":"JAMA"},{"issue":"22","key":"2021013015071157600_R26","doi-asserted-by":"publisher","first-page":"E773","DOI":"10.1503\/cmaj.161486","article-title":"Primary aldosteronism: a common cause of resistant hypertension.","volume":"189","author":"Kline","year":"2017","journal-title":"CMAJ"},{"issue":"5","key":"2021013015071157600_R27","doi-asserted-by":"crossref","first-page":"1889","DOI":"10.1210\/jc.2015-4061","article-title":"The management of primary aldosteronism: case detection, diagnosis, and treatment: an endocrine society clinical practice guideline","volume":"101","author":"Funder","year":"2016","journal-title":"J Clin Endocrinol Metab"},{"issue":"12","key":"2021013015071157600_R28","doi-asserted-by":"publisher","DOI":"10.1007\/s11906-017-0792-4","article-title":"An update on masked hypertension","volume":"19","author":"Anstey","year":"2017","journal-title":"Curr Hypertens Rep"},{"issue":"15","key":"2021013015071157600_R29","doi-asserted-by":"publisher","first-page":"1112","DOI":"10.1093\/eurheartj\/ehw5022","article-title":"Masked hypertension: understanding its complexity","volume":"38","author":"Franklin","year":"2017","journal-title":"Eur Heart J"},{"issue":"5","key":"2021013015071157600_R30","doi-asserted-by":"publisher","first-page":"453","DOI":"10.1093\/ajh\/hpw148","article-title":"Blood pressure measurement Anno 2016 American","volume":"30","author":"Staessen","year":"2017","journal-title":"J Hypertens"},{"issue":"(9)","key":"2021013015071157600_R31","doi-asserted-by":"publisher","first-page":"1026","DOI":"10.1136\/hrt.2006.107706","article-title":"Renin. friend or foe?","volume":"93","author":"Brown","year":"2007","journal-title":"Heart"},{"issue":"1","key":"2021013015071157600_R32","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1016\/S2213-8587(17)30367-4","article-title":"Cardiometabolic outcomes and mortality in medically treated primary aldosteronism: a Retrospective Cohort Study","volume":"6","author":"Hundemer","year":"2018","journal-title":"Lancet Diabetes Endocrinol"},{"issue":"(22)","key":"2021013015071157600_R33","doi-asserted-by":"publisher","first-page":"2103","DOI":"10.1056\/NEJMoa1511939","article-title":"A randomized trial of intensive versus standard blood-pressure control [published correction appears in N Engl J Med. 2017 Dec 21; 377(25):2506]. N Engl J Med.","volume":"373","author":"SPRINT Research Group,","year":"2015"},{"issue":"(9118)","key":"2021013015071157600_R34","doi-asserted-by":"publisher","first-page":"1755","DOI":"10.1016\/s0140-6736(98)04311-6","article-title":"Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial","volume":"351","author":"Hansson","year":"1998","journal-title":"HOT Study Group. Lancet"},{"issue":"(3)","key":"2021013015071157600_R35","doi-asserted-by":"publisher","first-page":"243","DOI":"10.1056\/NEJMoa1803180","article-title":"Effect of systolic and diastolic blood pressure on cardiovascular outcomes","volume":"381","author":"Flint","year":"2019","journal-title":"N Engl J Med"},{"key":"2021013015071157600_R36","article-title":"Health effectiveness data and information set 2019: controlling high blood pressure."},{"issue":"1","key":"2021013015071157600_R37","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1097\/HJH.0000000000000065","article-title":"Clinical practice guidelines for the management of hypertension in the community- a statement by the American Society of Hypertension and the International Society of Hypertension.","volume":"32","author":"Weber","year":"2014","journal-title":"J Hypertens"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/milmed\/article-pdf\/186\/1-2\/e225\/36155124\/usaa255.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/milmed\/article-pdf\/186\/1-2\/e225\/36155124\/usaa255.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,1,30]],"date-time":"2021-01-30T15:07:50Z","timestamp":1612019270000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/article\/186\/1-2\/e225\/5917407"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,1,1]]},"references-count":37,"journal-issue":{"issue":"1-2","published-online":{"date-parts":[[2021,1,30]]},"published-print":{"date-parts":[[2021,1,30]]}},"URL":"https:\/\/doi.org\/10.1093\/milmed\/usaa255","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2021,1,1]]},"published":{"date-parts":[[2021,1,1]]}}}