• 6
    Feb
  • TREATMENT OF DIFFICULT-TO-CONTROL BLOOD PRESSURE: DISCUSSION

patient care team

We demonstrated that a multidisciplinary clinic for difficult-to-control blood pressure can be successful in a public health setting serving a disadvantaged minority population. Our success rate over 6 months of 58% compares favorably to the success rate (64%) in a private setting that serves primarily well-educated, Caucasian patients. The fact that eleven subjects of fifty were lost to follow-up highlights why blood pressure can be so difficult to control in a population in which intense personal and socioeconomic pressures supersede health care priorities. If these eleven subjects had been excluded, the success rate would have been 74%.

It is instructive to compare our success with the results of the African-American Study of Kidney Disease and Hypertension (AASK); in African-American patients with hypertension and renal disease, the percentage of patients at target blood pressure increased from 20.0% to 78.9% over 14 months. Clearly, it is possible to meet national health goals even in extremely challenging patient populations.
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Previous studies found that nonadher-ence and volume overload are the most common reasons for poor blood pressure control, and we confirmed these findings in a predominantly African-American, inner-city population. Although secondary hypertension has been reported among patients evaluated for difficult-to-control hypertension at a rate of 5 to 15 percent, we found no cases of secondary causes despite actively considering the diagnosis and performing tests in 68% of all patients referred to the clinic. Since our finding of no cases of secondary hypertension among 50 patients has a 95% confidence interval that includes a 7% underlying risk, it is possible that our population is not dissimilar from others described in the literature. It is uncertain whether our low rate of secondary hypertension is because primary care physicians had previously identified those patients and referred them to another subspecialty clinic or because African-Americans have lower rates of secondary hypertension. This controversy will be investigated further as we enroll more patients.

We were most successful at controlling the blood pressures of patients with consensus initial diagnoses of nonadherence (twelve of twenty patients) or drug interactions (five of five patients). An additional 30% of the patients with nonadherence showed improvement in blood pressure after six months but did not meet goal. Similar success has been reported in other studies of clinics that provide intensive education about medication and dietary adherence with frequent follow-up visits. cialis canadian pharmacycialis

The most successful medication intervention was better diuretic therapy—either by increasing the dose within a class or by switching from a thiazide to a loop diuretic (Table 3). Diuretics are frequently effective even when patients have no clinical evidence of volume expansion.

We believe that our clinic, when used as an adjunct to the care provided by the patient’s primary care physician, was effective in controlling blood pressure. Moreover, this reorganization of existing resources, with little additional expense incurred for training or materials, seems to be a fairly low-cost option for improving rates of blood pressure control.

This study has several limitations. First, there is no concurrent control group and regression to the mean might explain improvement in blood pressure. However, since all patients were referred from primary care providers who had tried and failed to control hypertension with at least three medications for at least three months, we are confident that all patients truly had poorly controlled at entry. Furthermore, every patient’s blood pressure was checked twice at each clinic visit using accurate and reproducible methods.

A second limitation is that we were unable to identify the specific interventions responsible for successfully lowering blood pressure, since several interventions were implemented simultaneously at each visit. Enrollment in the clinic and increased time and attention to a single medical problem may have been as important to the patients as modifying their medication regimens. Further research is necessary to discern which elements of the clinic are most effective and useful to the patients.

Finally, this evaluation involved a small number of patients and a short duration of follow-up. It will be important to follow more patients for a longer time to verify persistent blood pressure control after discharge from the clinic. Our initial evaluation, however, suggests a model for successfully treating difficult-to-control hypertension that might be generalizable to a variety of settings, even among culturally diverse and disadvantaged populations.

Since most patients had poorly controlled blood pressure for over 10 years, our 58% success rate was gratifying. But the reasons for success—after 10 years of effort by primary care physicians had failed—are still nebulous. All patients listed multiple factors as important contributors in achieving control, but no single factor was described as being the most important by a majority of the patients. This supports the development of a multifactorial causal model and the use of a multifaceted, multidisciplinary treatment approach. But these results suggest another intriguing possibility, that the process of the clinic experience may be as important as its content. In other words, the systematic exploration of the psychosocial determinants of health and disease and emphasis on the patient’s own strategic role may be equally as important as the educational programs and medication changes that we implement. By respectfully validating the complexity, difficulty, and uniqueness of each patient’s life, this experience may have empowered patients to participate more fully in the treatment plan, which ultimately may be much more beneficial than merely “throwing another prescription at the problem.”
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