Blood Pressure Control - People or Technology for Better Outcome?

Countries may vary widely in their capacity for management of hypertension, but in all cases the majority of hypertensive patients are inadequately controlled to a blood pressure (BP) goal of less than 140/90 mmHg.

In the U.S. only 35 percent of hypertensives are treated to goal. Although this is an improvement from a previous rate of 23% 10 years ago, it is still suboptimal. The goal for the Healthy People 2010 objective is 50%. Other countries are not doing much better. Europe has slightly higher rates of control but they also have a higher prevalence of high blood pressure (especially the Germans when compared to five other European Countries). China by last report had 8%, Taiwan 5%, and South Africa 14% of their hypertensives under optimal control. (uptodate)

The reasons for this level of poor control are multifactorial. There certainly is no shortage of pharmacological treatments nor is there a lack of published guidelines. However, the distribution of data alone does not lead to different outcomes. Hypertension is a chronic disease that does not have symptoms. It often requires significant lifestyle changes in addition to medications. Lifestyle changes are difficult to make and they are not a priority for many people. When lifestyle changes are made, then there may be non-compliance to medications. The physicians may not be aggressive enough or simply may not have enough time in their busy offices to advise or motivate patients regularly.

The burden of high blood pressure worldwide is high. "In 2004 the death rates per 100,000 population in U.S. from high blood pressure were 15.7 for white males, 51.0 for black males, 14.5 for white females and 40.9 for black females. From 1994 to 2004 the death rate from high blood pressure increased 26.6 percent, and the actual number of deaths rose 56.1 percent" according to the American Heart Association. It is estimated that the prevalence will increase with an aging population in the west and the adaptation of lifestyle choices such as fast food and increasing obesity in the developing countries.

Different strategies for improved management of hypertension are being evaluated. It is not surprising that a multidisciplinary intervention is most effective. In a recent study presented in JAMA , 778 participants with uncontrolled high blood were randomly assigned to three groups - usual care in clinic, home BP monitoring (with Omron Hem-705-CP bp cuff) and secure patient Web site training, or home BP monitoring, Web site training, and pharmacist care management through Web communications. These groups were studied from June 2005 to December 2007.

The patients in the latter 2 groups received training on how to use the web site (secure e-mail, refilling medications, viewing portions of their health records, use of the health library, and links to resources for lifestyle changes). The pharmacist group received a secure welcome message from the pharmacist which was also communicated to the patient's physician. The pharmacist had a telephone visit ( 1 hour) with the patient to review medications and risk factors. An action plan template designed for Web communication was then given to the patient. All feedback on the action plan was then done over the Web every 2 weeks. The pharmacist with the assistance of the physician would make specific recommendations.

Based on patient results, the data showed that compared to the usual clinic care group, the home BP monitoring plus the Web based service only group did not show a significant improvement in blood pressure control. However, the group with the Web-based pharmacist had a significant improvement over the other 2 groups with 25% more patients with optimal control. So neither people or technology but rather the intervention of both seemed to work best for this group of patients. It will be interesting to use this model in other chronic illnesses to assess the effectiveness of the model.

Finally it is important for the physicians to note that " the most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with and trust in the clinician. Empathy builds trust and is a potent motivator."

References: please see above links.

What did you learn?

1. What percentage of patients with high blood pressure who are under medical care in the U.S. are treated to a goal bp of less than 140/90 mmHg?

a. 23%
b. 35%
c. 50%
d. 8%

2. Web based services have been shown to be most effective for treatment of blood pressure when used in which of the following strategies?

a. Web services alone
b. Web services + home bp monitoring + ancillary health care provider
c. Web services + home blood pressure monitoring

Correct answers:
1. B
2. B.