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A look at how three groups have kept their patients' hypertension in check

From the July-August ACP Observer, copyright 2003 by the American College of Physicians.

By Tim Gray

When public health officials this spring called on physicians to be more vigilant in treating and preventing hypertension, they left more than a few internists perplexed. Many doctors feel they are already doing just about everything they can to screen and treat patients for high blood pressure in packed patient visits.

The truth, however, is that those efforts have fallen short. According to new guidelines for treating hypertension, 50 million Americans—nearly one-fifth of the population—suffer from high blood pressure. And while the basic treatments for hypertension have not changed much in the last decade or so, control levels have remained stubbornly low.


While basic treatments for hypertention have not changed much in the past 10 years, control levels remain low.


"Hypertension awareness has not changed in the past decade, and treatment rates have increased by less than 10%," concluded an editorial accompanying the guidelines, which appeared in the May 21 Journal of the American Medical Association. "Control rates are stagnant at 34%."

To draw attention to the issue, the new guidelines, which were part of the seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7), created a new category of the disease: prehypertension. By identifying patients who are at risk for developing hypertension, the thinking goes, physicians can get an early jump on prevention and treatment.

If you are wondering exactly how you can screen and treat even more patients for hypertension, there is some good news. As the editorial accompanying the new guidelines pointed out, a handful of clinics and hospitals around the country have found ways to better control their patients' hypertension.

Even better, most of the strategies did not involve significant cost or fancy new systems. By following treatment guidelines and implementing low-tech reminder systems to flag hypertensive patients, these groups were able to ensure that, no matter how urgent patients' other complaints were, their hypertension wasn't overlooked.

Here is a look at several programs that have been able to bring patients' high blood pressure under control.

Mayo Clinic

The community internal medicine group at the Mayo Clinic in Rochester, Minn., dramatically improved its blood pressure control rate largely by using a system of sticky notes and follow-up visits.

The group, which consists of 30 physicians, focused on treating patients in Olmsted County, where Mayo is located. The physicians started by reviewing their patients' records to establish a baseline rate, thinking that you can't improve something unless you can measure it.

They were surprised by what they found. "We'd all assumed our control rate was 80% or 90%," said Robert J. Stroebel, ACP Member, an internist in the group and one of the authors of the JAMA editorial. Instead, the physicians learned that their control rate hovered around 30%.

To improve that dismal finding, the Mayo physicians first implemented the hypertension care guidelines published by the Institute for Clinical Systems Improvement, a Minnesota nonprofit that studies and promotes best practices. (The group's guidelines are similar to those released this spring.) In December 1997, a group of five physicians and physician assistants (PAs) began using new procedures to manage patients with hypertension.

From talking to colleagues elsewhere, the Mayo doctors knew that some physicians were using sticky notes to flag the charts of hypertensive patients. The person who took a patient's pressure—a nurse or PA—would put the sticky note in the patient's chart. The goal was to make sure the physician wouldn't overlook the patient's hypertension during the exam.

The Mayo physicians decided to take that idea one step further. When the practice found a reading greater than 140/90, the nurse or PA would wait five minutes and take another measurement. If it remained high, the nurse would scheduled a follow-up visit, noting that appointment on the patient's chart.

When physicians saw the patient a few minutes later, they could cancel the appointment. But if they agreed with the assessment—or if they didn't notice the note at all—the patient would return for the appointment with a nurse.

A nurse would then check what, if any, medications the patient was taking for hypertension. The nurse would also discuss lifestyle modifications such as exercising and consuming fewer calories, salt and alcohol. Nurses would also review any new information with the patient's doctor and ask about additional treatments.

The nurses kept bringing patients back for follow-up visits until their blood pressure was in check. Because of those procedures, the group was able to boost its control rate from 30% to 50%.

In October of 1998, 10 more Mayo physicians started applying the new methods. They also saw their control rates jump from about 30% to 50%.


Having nurses take more responsibility for identifying and education hypertensive patients gives them a greater sense of ownership of their patients' treatment.


"We made it easier for the right thing to happen," Dr. Stroebel said. "If you're creating more work for the physician, that doesn't work."

While he acknowledged that the nurses had to do more work, he added that they also received a greater sense of ownership of their patients' treatment.

Mayo's entire community internal medicine group has since adopted the new method, and its control rates are now hitting more than 55%. "There was no particular magic to it," Dr. Stroebel added. "We just had to decide to be more clever and to apply some common sense."

HealthPartners

Mayo got many of its ideas on blood pressure control from nearby HealthPartners in Minneapolis, Minn. The nonprofit managed care company had undertaken a blood-pressure-lowering push of its own with two physician practices only a few months before the Mayo group.

Like Mayo, the practices used the Institute for Clinical Systems Improvement's guidelines as their jumping-off point, said Patrick O'Connor, MD, a primary care physician with HealthPartners and a researcher with the HMO's foundation. Like Mayo, nurses took the initial responsibility for flagging and educating hypertensive patients.

From there, however, HealthPartners' system of targeting blood pressure took a different tack. Nurses put notes in patients' charts to remind physicians to speak with them about their hypertension. Nurses also followed up with patients directly, making sure they were getting the care they needed.

"If somebody hadn't been in for six months, the nurses would call them and get them in," Dr. O'Connor said. The nurses also tracked when patients' prescriptions would run out. They would call patients to remind them to come in for a visit to get a new prescription.

The results were impressive. Over 18 months, the practices' control rates doubled from about 30% to 60%. The number of average annual visits per patient with hypertension also rose from five to six.

"That puts money in doctors' pockets," Dr. O'Connor pointed out. The additional visits also helped pay for the extra time nurses devoted to hypertensive patients.

Interestingly, the types of medications used to treat hypertension did not change much. About 30% of hypertensive patients were taking diuretics and beta-blockers before the practices implemented the new tracking methods. Afterwards, that number rose to about 35%.

"The practices' educational efforts may have made the doctors increase the doses and make an extra push for patient behavioral changes," Dr. O'Connor said.

To those who say insurers won't pay for extra visits, Dr. O'Connor has a ready response. "For people with many chronic diseases," he said, "the most efficient thing you can do clinically is to treat the hypertension. The patients' blood-pressure drop probably decreased their rates of heart attack and stroke by 20% to 30%."

Cleveland VA

A push to save money motivated the Louis Stokes Cleveland Veterans Administration Medical Center in Ohio to change hypertension treatment. In the early 1990s, the hospital's pharmacy considered dropping the calcium channel blocker nifedipine because of its cost.

"It was the most expensive hypertension drug at the time and was being widely prescribed," said Eleni Pelecanos, MD, a physician at the hospital who co-wrote a paper on treatment changes there. While a month's worth of the diuretic hydrochlorothiazide cost about 25 cents per patient, she recalled, a similar amount of nifedipine cost $30 to $45.

When administrators proposed changing medications, however, physicians asked for evidence to back up the move. The Cleveland VA responded with a study comparing the effectiveness of various drugs for hypertension, including calcium channel blockers, diuretics and beta-blockers.

The hospital worked with local experts to create three algorithms to treat hypertension: one for patients with just hypertension, one for patients with coronary artery disease and one for patients with congestive heart failure. In 1992, the hospital disseminated its care guidelines to attending physicians who, in turn, educated their residents.

One group of the VA's physicians took some additional steps. An attending physician became the "clinical champion" for the antihypertension push and took the lead on implementing the new guidelines.

Physicians attended educational meetings on hypertension. A pharmacologist acted as a hypertension consultant and came to clinic five half-days a week. At the same time, the doctors held regular feedback meetings.

After two years, "there was a significant increase in the use of the diuretic and the beta-blocker among the intervention group's patients, and there was no difference in the number of medications used per patient," Dr. Pelecanos said.

In the intervention group, 25% of the patients were prescribed a diuretic or beta-blocker, and 51% were taken off the calcium channel blocker. In the control group, 17% of patients were prescribed one of the less expensive medications, while 39% were taken off the calcium channel blocker.

Patients in the intervention group also showed a slight improvement in their blood pressures, with the average diastolic pressure dropping from 89 to 76. Their average systolic pressure didn't change.

The control group's average diastolic pressure fell from 86 to 80, while its average systolic pressure rose from 151 to 166.

The VA was able to achieve its goal of moving patients to less expensive medications without compromising care. But the results also underscored another lesson: While national guidelines are helpful, most practitioners also need local guidance.

In a 1996 paper in the Journal of General Internal Medicine, Dr. Pelecanos and her colleagues concluded that local guidelines have a much better chance of being accepted and implemented when practicing physicians are involved in their development. "In fact, the actual process of local development and adaptation," the paper concluded, "may be both an important and necessary first step in successful implementation."

Dr. Pelecanos identified two other keys to the success of the VA study: selling the opinion leaders—attending physicians—on the idea, and including a pharmacologist well-versed in the latest research on hypertension drugs.

The Finnish model

Despite the advances made by the Cleveland VA, HealthPartners and Mayo, following clinical guidelines and closely tracking patients can go only so far. Patients have to shoulder part of the work themselves by exercising, eating better, drinking less and stopping smoking.

Helping them do that is the goal of another project at the Mayo Clinic. Called CardioVision 2020, it's a public health campaign intended to motivate people in Olmsted County, Minn., to adopt healthier lifestyles.

The program is modeled after a renowned public health project undertaken in Finland's North Karelia province in the early 1970s. The agricultural region confronted near-epidemic levels of cardiovascular disease.

"More than 50% of the people were hypertensive," said Thomas E. Kottke, MD, a Mayo cardiologist leading CardioVision who studied the province's efforts. "And 90% of them had high cholesterol."

The Finns educated the public by preaching the benefits of exercise and the dangers of smoking. They even persuaded local dairy farmers to grow berries and apples. Over 30 years, Dr. Kottke said, "they've lengthened life expectancy in men by six years and by eight years in women."

Mayo aims to achieve the same results. To that end, CardioVision has sponsored contests to encourage people to stop smoking and lose weight. Volunteers have persuaded local restaurants to flag their heart-healthy offerings. And the program has given away pedometers so people can track their walking mileage.

"The news here is that there's nothing new," Dr. Kottke said. "For survival, we all need to be physically active and have the discipline to eat right and not smoke."

Tim Gray is a freelance writer in Philadelphia.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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