TREATMENT OF DIFFICULT-TO-CONTROL BLOOD PRESSURE: METHODS
A multidisciplinary hypertension clinic was established in the summer of 2000 to treat patients with difficult-to-control hypertension within the Cook County ambulatory health care network. The team of providers included three general internists, a nurse health educator, pharmacist, and dietician. Eligible patients with difficult-to-control hypertension were defined as having blood pressure persistently greater than 140 mm Hg systolic or 90 mm Hg diastolic despite concurrent treatment with three or more anti-hypertensive medications for at least three months. A classification of resistant hypertension usually necessitates use of a diuretic; two of our patients did not use a diuretic due to intolerable side effects, but met other criteria for the definition and were included in the study.
The Cook County ambulatory health care network serves over 800,000 patients in Chicago and the surrounding communities, offering free health care and medications to those without health insurance or who are unable to afford medical care. Thus, the network serves an ethnically diverse (70% African American, 20% Hispanic/Latino, 10% other) disadvantaged population. generic viagra online
Using standardized data collection instruments, we collected data on socio-demographic characteristics, health beliefs and attitudes, and health behaviors. Items were designed to accrue information on topics previously found by other studies to be most relevant to our population, including knowledge of target blood pressure and the current medication regimen, exercise, diet, and use of herbal or nontradi-tional medicine. We also recorded the results of a detailed clinical history and physical examination. At the conclusion of the initial evaluation, the clinic physician suggested the most likely explanation for the poorly controlled in order to guide the treatment plan for that patient. A second physician then independently reviewed the records, and if there was disagreement about the most likely causal factor, a consensus diagnosis was reached after jointly reviewing the data and further discussion. Potential causal factors included nonadherance, volume overload, drug interactions, white-coat hypertension, obesity, suboptimal dosing, and diet. Volume overload was determined clinically in patients with evidence of excess sodium intake, progressive renal disease, or fluid retention. Blood pressure was measured at each visit according to a standard protocol—twice in both arms with an appropriately sized cuff after the patient had rested in a sitting position for five minutes. The average of two readings for the arm with the higher blood pressure was used as the final clinic blood pressure.
Evaluation and Treatment Strategies
An evaluation for secondary causes of hypertension was initiated for all patients with risk factors or a suggestive history or physical examination. Thirty-four (68%) patients were evaluated for secondary hypertension. Standardized protocols for each presumed diagnosis were followed according to the accessibility and quality of various diagnostic tests in our hospi tal. For example, an abdominal MRI and/or captopril renogram was the test of choice for diagnosis of renal artery stenosis, depending on the individual characteristics of the patient. An individualized treatment plan addressed behavior modification, self-management skills, and medical therapy.
Medication decisions were guided by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI). Unless contraindicated, all patients received a beta-blocker and a diuretic. Patients with a history of heart failure or diabetes routinely received angiotensin-converting-enzyme inhibitors. To simplify therapy, treatment protocols emphasized once-daily dosing and the least number of medications; thus, doses were maximized before additional medications were added to the regimen. A minority of patients received home blood pressure monitors based on supply, the patient’s ability to perform measurements accurately, and the need to exclude white-coat hypertension.
All patients also received one-on-one education with a nurse health educator, pharmacist, and nutritionist about hypertension, exercise, weight loss, nutrition, and techniques to improve adherence to medications. Using a standard curriculum, educational topics were tailored to individual needs.
Follow-up visits were scheduled every 2 weeks for the first month and then monthly until the blood pressure was successfully controlled. At each visit, patients were encouraged to bring their medication bottles so that adherence to the prescribed medication regimen could be monitored. Both the physician and nurse reinforced the need for medication adherence, assessed patient understanding of proper dosing, and explained possible side effects. In addition, educational objectives were reevaluated and aggressively pursued through review of videotapes, written materials, and one-on-one counseling.
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The endpoint for clinic participation was maintaining a target blood pressure of less than 140/90 (130/85 for patients) for two consecutive clinic visits. When this goal was achieved, the patient was discharged back to the primary care provider for ongoing care.
When patients were discharged from the clinic and referred back to their primary care physician, we repeated the initial survey to assess change in knowledge and attitudes about hypertension and its management. Patients also rated the perceived effectiveness of ten different aspects of the clinic and identified the interventions they considered most useful in achieving blood pressure control.