Quantifying effects of blood pressure control on neuroimaging utilization in a large multi-institutional healthcare population

Theodore R. Welch,  Aliza Yaqub,  Danny Aiti,  Luciano M. Prevedello,  Zarar A. Ajam,  Xuan V. Nguyen


Essential hypertension is a common chronic condition that can exacerbate or complicate various neurological diseases that may necessitate neuroimaging. Given growing medical imaging costs and the need to understand relationships between population blood pressure control and neuroimaging utilization.


Hypertension is a common chronic disease with high morbidity and mortality. According to CDC statistics, the prevalence of hypertension in adults over 20 years of age in the United States is 50% [1]. Moreover, optimal blood pressure control in the hypertensive population is difficult to achieve, with a third of patients in the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial failing to achieve the goal of blood pressure of <140/90 mmHg at 5-year follow-up [2]. Hypertension is a major cardiovascular risk factor due to the relationship between high blood pressure, stroke and cardiovascular mortality [3]. Since the brain is susceptible to early effects of hypertension-induced organ damage [4], numerous neurological disease process are potentiated or exacerbated by poorly controlled hypertension [5].

Materials and Methods: 

This retrospective cohort study was determined to be exempt from human subjects research review by the Office of Responsible Research Practices at the Ohio State University, and patient consent was not obtained, as the authors do not have access to information that could identify individual participants during or after data collection. Data were obtained using Cosmos (Epic Systems, Verona, WI), an informatics-based application that provides a data-mining framework to aggregate electronic health data for research [12].


The Cosmos analysis included over 38 million patients. The number of patients included, along with the subsets undergoing CT or MR utilization are shown in Table 1. Multi-institutional Cosmos data encompassing a broad mix of institutions had overall utilization for CT neuroimaging of 3.8–5.1% and MR neuroimaging of 1.5–2.0%. Mild increases in utilization over time were observed, with an absolute change of 0.5% for MR and 1.4% for CT over the calendar years analyzed, corresponding to a relative increase of 33% for MR and 37% for CT.


The current study demonstrates a strong quantitative relationship between annual maximum recorded blood pressure and the probability of undergoing at least one CT or MR neuroimaging study in the same year, with the effect more apparent among older individuals. The broad multi-institutional, national patient population used in this study shows a nonlinear dependence of utilization across the examined blood pressure ranges, with markedly higher rates of utilization among patients with higher blood pressures.


Higher annual maximum recorded blood pressure is associated with higher same-year neuroimaging CT and MR utilization rates. These observations are relevant to public health efforts on hypertension management to mitigate costs associated with growing imaging utilization.

Citation: Welch TR, Yaqub A, Aiti D, Prevedello LM, Ajam ZA, Nguyen XV (2024) Quantifying effects of blood pressure control on neuroimaging utilization in a large multi-institutional healthcare population. PLoS ONE 19(4): e0298685.

Editor: Mabel Aoun, Faculty of Medicine, Saint-Joseph University, LEBANON

Received: August 11, 2023; Accepted: January 30, 2024; Published: April 30, 2024

Copyright: © 2024 Welch et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Source data for this study are owned by a third party (Epic Systems, Verona, WI) and consist of patient data that are accessible to researchers only as aggregate results of structured data queries. All aggregate data relevant to this manuscript that were obtained by the authors are available without restriction in the form of a supplemental data file. Interested researchers would be able to replicate the results based on data contained within the supplemental data file. The Cosmos platform accessed by the authors is supported by Epic Systems Corporation, and the dataset is available through a license and under a HIPAA-required data use agreement. Access to the platform is via The Cosmos data and related assets are available at any time to a user with appropriate access. Access to the data for research is limited to those with an approved use that are members of a participating organization. Aside from membership in a participating organization, the authors have no additional special access privileges. Interested researchers with user access to the system may be able to attempt replication of the queries, but results may differ when accessed on a different date, since the dataset may evolve over time as new participating institutions are added.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.





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