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What can be learned from what works!

Michael H. Alderman, MD
Department of Epidemiology & Social Medicine
Albert Einstein College of Medicine
Bronx, New York 10461

For nearly three decades, since hypotensive therapy was first shown to save lives, a huge therapeutic chasm has separated the potential of antihypertensive therapy from its realization. Despite vast public and professional investment, supported by increasingly tolerable and effective drugs nearly 3/4’s of all hypertensive persons do not achieve blood pressure control 1.

The reasons for this shortfall are multiple. A third of hypertensive persons are not even aware of their condition, and many who know, are not being treated. Nevertheless, the ultimate bottleneck is that only about half of those treated achieve control. Disappointingly, this 50% success rate for treated hypertensive patients has not changed very much since such data was first reported 25 years ago!2 Thus, even in the exceedingly unlikely event that case finding and referral become 100% effective, using current methods of care, most American hypertensive would remain uncontrolled.

Why is it so difficult for treated patients to achieve blood pressure control? Most analysts have focused upon identification of barriers to success? The frequently taped culprits include cost, social and cultural gaps, and behavioral lapses on the part of physicians and/or patients.
Thus, recently, in an analysis of patient experience in the Veterans Administration system, where all care is free and access is unimpeded, it was found that failure to increase the dose of medication was associated with poor blood pressure results
2.

Not surprisingly, the authors exhorted reading physicians to increase medication until goal pressure was reached. Presumably, the gap was felt to be informational. It is hard for me, however, to imagine, in a world where treatment of hypertension is the most common reason for a patient to visit a physician, that lack of motivation or knowledge could be the problem. Maybe so, but it still needs to be tested.

Perhaps this kind of detailed tinkering with the conventional process of care will ultimately improve outcomes, but the record of the past 25 years is not encouraging. Perhaps its time to take a new tact. It may be that the problem does not reside in patient and physician behaviors, but in the system through which antihypertensive care is provided.

Medical care in the United States is provided through an organizational structure developed more than a century ago. Its purpose was to respond to the needs of the sick. The evolving personal encounter, "sick care" system, in many ways, has become marvelous vehicle through which to deliver increasing powerful medical care.

The problem may be that treatment of hypertension (and hyperlipidemia, and, perhaps, diabetes) differs fundamentally from usual dimensions of sick care. Here the goal is neither relief of symptoms, nor cure, but prevention. The patients are not sick, but generally fit. The course of treatments are not measured in hours, days, or weeks, but rather in decades. And, since the patients feel well, the best that can be hoped is that the interventions will not cause harm, or be intolerable. These two types of care - sick and preventive - inevitably conflict in the physicians office, and, not surprisingly, urgent trumps routine.

The point is that the skills generally ascribed to physicians - ability to diagnose, prognosticate, and plan therapy - are not the skills required to accomplish long term blood pressure control. In short, it is entirely possible that our problem is the inability to force a new kind of health care (long term prevention) through a system designed for another purpose. It may not be weaknesses in patients or physicians that explains are enduring dilemma, but rather a structural misfit.

It is not surprising that this misfit between preventive and sick care has evolved. The sick care system is what we have. Prevention, as an enterprise, has emerged in this generation. The notion that our medical care system, unmodified, was a suitable vehicle through which to deliver each new therapeutic modality was probably always rather naive. In view of the different needs and goals of preventive interventions, perhaps a new or at least substantially modified delivery system must be invented.

In fact, it is possible to overcome the seeming intractability of uncontrolled blood pressure. There is solid evidence, in a variety of unconventional settings, that long term blood pressure control can be achieved and maintained for most patients.3,4,5 An examination of the characteristics of these successful programs might offer clues as to how more widespread blood pressure control can be achieved. In short, perhaps it is time to focus on what works!.

What, then, are the important and common elements of successful programs? (Table 1). They all seem to be carefully structured. They follow a defined protocol which guides therapists who usually limit their care to this preventive intervention. Most programs depend upon a team strategy for providing care. The team is specially prepared in the problem of hypertension and trained in application of the protocol. In most cases, a Nurse is the primary provider of direct patient care and the Physician plays a more supervisory and consultative role. A rigorous data management system is invariably present. This facilitates another common feature - regular oversight of patient progress and medical behavior. Every patient's course is important, not only to the therapist directly responsible for treatment, but up through a chain of concern. This identifies individuals who fail to achieve protocol goals to assure that all the available resources are brought to bear to meet each patient’s needs.

 

Characteristics of Conventional & Structured Antihypertensive Care Systems

Conventional Clinical Trial Worksite
Protocol

No

Yes

Yes

State Goals

Yes/No

Yes

Yes

Primary Care Nurse

No

Yes

Yes

Standard Data

No

Yes

Yes

Clinical Oversight

No

Yes

Yes

Categorical

No

Yes

Yes

Free Care

No

Yes

Yes

Cohesive Context

No

No

Yes

3, 5

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The central fact is that these programs work. For example, in clinical trials, more than 75% of subjects usually reach goal, with drop out rates of less than 10% per year - for all causes that include moving from the treatment center. In one worksite based program, where more than 20 years of carefully documented experience has been accumulated, annual drop out rates are 6 - 10%, and blood pressure control is achieved in 70% of participants.5 The Worksite program, in contrast to clinical trials, does not limit participation to carefully selected patients, but enrolls all comers. Thus, the results achieved in clinical trials cannot be ascribed to the characteristics of the participants.

The physicians and nurses in these programs may be no smarter or more committed or more diligent than those in conventional settings. They may get dramatically better results because they have protocols, are well focused, use data management, are subject to oversight, and include nurses as the front-line therapists. It is neither feasible, nor necessarily desirable to expect that the millions of hypertensive patients in America or elsewhere can or should be treated in special programs like those identified here. Instead, the successful programs that exist might be viewed as hot house pilot projects. Thus, to improve antihypertensive treatment, it might be useful to identify components of these successful systems and integrate these into the conventional care system, and then determine whether their functional effectiveness will survive transplantation.

Perhaps a protocol, implemented by a nurse, given wide latitude by the supervising physician, whose primary role for uncomplicated hypertensive patients will be nurse education, protocol oversight, and consultation, could be imposed in a group practice setting containing sufficient patients to support a dedicated "special" treatment tract. This approach, after a demonstration project, could then be assessed by comparison with conventional care.

Breaking out of the conventional personal encounter therapeutic model will not be easy, but in the face of widespread failure to deliver on the promise of antihypertensive care, perhaps it is time to try something new. In any event, there is plenty of reason to believe that more of the same is a strategy not likely to yield much progress.

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References

  1. Burt VL, Cutler JA, Higgins M, et al. Trends in the prevalence, awareness, treatment and control of hypertension in the adult US population: data from the Health Examination Surveys, 1960 to 1991. Hypertension 1995;26:60-69.
  2. Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med., 1998;339:1957-1963.
  3. Hanson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, Menard J, Rahn KH, Wedel H, Westerling S. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998;351:1755-62.
  4. Foote A, Erfurt JC. Hypertension control at the work site: comparison of screening and referral alone, referral and follow-up, and on-site treatment. N Engl J Med., 1983;308:809-813.
  5. Alderman MH, Cohen H, Madhavan S. Distribution and determinants of cardiovascular events during 20 years of successful antihypertensive treatment. Journal of Hypertension 1998;16:761-769.

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Update
10/21/99