The trusted source for
healthcare information and
Consider combination drug therapy, tailored treatment strategies
Last month in CHF Disease Management, you read the disturbing news that the dramatic improvements in hypertension management seen in the ’70s and ’80s have slowed and even decreased to the point that currently only about 25% of hypertensive patients have their blood pressure adequately controlled.
Experts largely blame hypertension for the increase in CHF in recent years and expect the problem will only worsen as improving life expectancy increases the number of elderly people in the United States.
This month, CHF Disease Management offers you some updated practical strategies for improving hypertension management, including fresh ideas for tailoring treatment to specific patient types, managing drug therapy, helping patients modify their lifestyles, and measuring the quality of care.
If these issues plague your practice, you’re not alone. In April, a national alliance was formed by leading medical, patient, and government organizations to reverse the growing trend of uncontrolled high blood pressure. The group, From Awareness to Action: The National Alliance to Reach Blood Pressure Goals, is a coalition of about 25 organizations. Members include the National Association of Mayors, the National Center for Health Statistics, and the National Consumers League as well as the American Heart Association and the American College of Cardiology.
The alliance plans to sponsor a series of high- profile intervention programs, such as blood pressure screenings and open forums, around the country to promote meaningful dialogue between providers and patients, says Martha Hill, RN, PhD, chair of the alliance’s advisory council and director of The Center for Nursing Research at Johns Hopkins University School of Nursing in Baltimore.
"A large percentage of the public does know that high blood pressure is serious, but knowledge is inadequate in terms of getting people to get their blood pressure checked, and if it’s high, getting it under control," she says.
Hill says negative experiences with the health care system — long waits for appointments, medications with side effects — keep many patients from getting their blood pressure under control. That’s why providers need to spend time learning and respecting the beliefs and attitudes of patients so they can find affordable, well-tolerated ways to lower blood pressure. Providers can take actions as simple as mailing out appointment reminders and calling people who have missed appointments to more complicated actions such as installing computer programs to track blood pressures.
One of the most important things that many physicians neglect to do for their hypertensive patients is set a blood pressure goal and inform the patient of that goal, Hill says. It’s hard to meet a goal that hasn’t been set and for which there is no feedback. "You have to be aware of the fact that it’s the patient’s daily life that will make the ultimate difference. The day-to-day work is the patient’s, so you have to involve them in the decision making."
One complicating factor in treating hypertension is that the same strategy won’t work for every patient. Researchers at the University of Maryland have identified four distinct types of hypertensive patients based on lifestyle choices and the ability to adhere to medication protocols, and they say that tailoring treatment to each group may improve your chances of success.
Matthew Weir, MD, professor of medicine in the division of nephrology at the University of Maryland in Baltimore, and his colleagues interviewed 727 hypertensive patients by telephone about their beliefs and behaviors surrounding the management of their disease. They weighted the composition of the cohort to match the age and sex distribution of hypertensive patients in the 1992 National Health Interview Survey. The researchers found four distinct groups that need different management strategies:1
• Group A. Patients use an effective mix of medication and lifestyle regimens to control blood pressure. These patients need positive reinforcement, such as monthly telephone contact by nurses and encouragement to gradually adopt more aggressive healthy lifestyle goals.
• Group B. Patients are most likely to depend on medication and have high adherence rates, but they also have high rates of smoking (29%) and alcohol use (an average of 104 times per year) and are less likely to exercise regularly. This group needs more aggressive medical management and needs to take small steps toward a more active lifestyle.
• Group C. Patients are most likely to forget to take medication, are likely to be obese, and find it most difficult to comply with lifestyle changes (except for very low rates of smoking and alcohol use). They need a simplified medication schedule with care taken to minimize side effects. They also need encouragement to incorporate easy physical activity such as taking the stairs or taking a 10-minute walk during lunch, into their daily life.
• Group D. Patients are least likely to take medication, most likely to change or stop medication without consulting their physician (20%), most likely to smoke (40%), and least likely to control diet (29%). This group needs strategies to make it easier for them to take their medications and increased frequency of patient contact through a case manager.
Weir and his colleagues are planning another trial to test the hypothesis that tailoring treatment in those ways would reduce the incidence of high blood pressure. They suggest caregivers need a hypertension lifestyle assessment instrument that would identify the subgroup into which an individual falls, as well as clinical management protocols that are tailored for members of each group.
"Congestive heart failure has increased in the last five years partly because hypertension is not well-controlled," Weir says. "Anything we can do to improve hypertension would improve heart failure as well. We need to be more aggressive to get intensified control of hypertension."
One way providers can become more aggressive is through the use of combination drug therapy, says Joel Neutel, MD, chief of clinical pharmacology and hypertension at the Veterans Affairs Medical Center in Long Beach, CA, and assistant clinical professor of medicine at the University of California, Irvine.
Because hypertension is a multifaceted disease, it is extremely difficult to get to goal blood pressure using only one drug, Neutel says. He recommends that physicians consider using low-dose combination therapy earlier in the treatment process.
Combining two drugs in one tablet is more likely to reduce blood pressure and makes compliance easier for patients. "There’s been somewhat of a reluctance to using combination therapy, but now with the new low-dose products that are available, you are much more likely to get control," he says. "Some are concerned that there might be more side effects, but when you compare studies in which patients are started on low-dose combination therapy to those on monotherapy, there are really no differences in the side-effect profile. In almost all patients, it is possible to find a treatment regimen that would not have side effects. You have to do that if you want your patients to comply."
The step-care approach has been ingrained in doctors as the right approach to treating hypertension, and that’s not necessarily a bad thing as long as blood pressure is controlled, Neutel says. "But by virtue of the fact that in 75% of patients we’re not getting to control, the system is somehow breaking down. We have to be more aggressive with combination therapy earlier on in the treatment of hypertension, which is something that is not taught at medical school. Physicians have to constantly change their approach."
Physicians should try to spend as much time as possible with patients to educate them on the importance of lifestyle modification, but it’s important not to waste too much time before beginning drug therapy. With some patients, preaching life-style change is a fruitless exercise, and damage is being done while they struggle to cut salt from their diet or lose weight, Neutel says.
"The decision needs to be made fairly early on as to whether it’s worth pursuing nonpharmacological treatment or whether it’s in the best interest of the patient to start drug treatment," he says. "The physician can always stop the drugs if some dramatic improvement happens. The longer it takes physicians to get to goal, the more likely they are to have some obstacle that results in acceptance of inadequate control."
Some physicians are turning to the Internet for ways to help patients learn to manage their blood pressure. One resource is a Web site that allows patients to assess their risk for hypertension, track their vital signs on a graph that can be sent to the physician, and access tips on lifestyle changes and the latest published research in the field. (www. lifeclinic.com)
Patients can type in their own blood pressure levels as well as pulse, weight, and cholesterol, and information pops up showing normal levels and what action should be taken if the patient falls outside the norm. The site also offers a place to keep personal and family health records, a reminder service for taking medications and making appointments, and a locator service for blood pressure kiosks around the country.
"This kind of site helps physicians because it provides basic information to patients that they may not have time to cover in an appointment," says Michael Ruddy, MD, FACP, associate professor of medicine and chief of the section of hypertension in the division of nephrology at the Robert Wood Johnson Medical School in New Brunswick, NJ. Ruddy serves on the clinical advisory board for Lifeclinic.com. "This helps patients have an active role in managing their high blood pressure, and that’s the only way it will ever get under control."
The onus for improving blood pressure doesn’t fall solely on the patient. Physicians must be more aggressive in their care, says Pablo LaPuerta, MD, clinical assistant professor at the Robert Wood Johnson Medical School and director of outcomes research at the Bristol-Myers Squibb Pharmaceuti-cal Research Institute in Princeton, NJ.
LaPuerta was one of the authors of a study published recently in the Journal of the American College of Cardiology that outlined a set of indicators for measuring process quality in hypertension.2 The indicators, based on national guidelines, include screening patients yearly for blood pressure, evaluating newly diagnosed patients for kidney function and cholesterol, getting patients started on drug therapy, and stepping up therapy to get control. When the indicators were tested on about 700 hypertensive women, deficiencies were found in every area.
"One of the most notable things we found was that when patients persisted with uncontrolled blood pressure of more than 160/90 mm Hg for six months or more, 50% of the time physicians didn’t change their treatment," LaPuerta says.
Patients in the study who had blood pressure control passed more indicators, showing that physicians who are more aggressive do achieve better results. "A lot of physicians may think that a lot of the problems with blood pressure are outside their control, such as patient noncompliance," LaPuerta says. "But this study suggests physicians can do something to improve control, like stepping up care when the blood pressure remains elevated. They may need to add another medication or go to a full dose of the existing medication."
(To learn more about From Awareness to Action: The National Alliance to Reach Blood Pressure Goals, go to: www.fromatoa.org.)
1. Weir M, et al. Implications of a health lifestyle and medication analysis for improving hypertension control. Arch Intern Med 2000; 160:481-490.
2. Law A, et al. Implementing tools to improve cardiovascular care. J Am Coll Cardiol 2000; 35(suppl A):558.