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Bridging the Gaps: Strategies for Helping Patients Accomplish Change John P. Sheehan, MD, FACE, FACN Associate Clinical Professor of Medicine Case Western Reserve University Medical Director North Coast Institute of Diabetes and Endocrinology, Inc. Cleveland, OH Case of Laura 43-yr old Caucasian female 6-yr history of HTN Concomitant medical conditions Type 2 DM for 5 years Mixed dyslipidemia Attorney Laura’s Lifestyle History Non-smoker EtOH consumption of 3-4 drinks/day pending stress of court Exercise None: except “walking around the courtroom” Diet: unstructured; never saw RD Laura’s Family History Father Alive age 64 T2DM and CHF Mother Alive and well without medical conditions 2 sisters, both with T2DM and obesity 2 children alive and well Laura’ Medications Recently stopped her medications of HCTZ 25 mg qd Lisinopril 10 mg qd Metformin ER 1000 mg q pm Laura’s Physical Exam Wt 242 lbs for a ht of 66 in; BMI = 39 BP 144/96 mmHg; pulse 88/minute Skin: acanthosis nigricans, facial hirsutism CVS: no ectopy or murmurs Lungs: clear to auscultation/percussion Abdomen: obese, non-tender, no masses, no renal bruits, waist circumference 36 in Extremities: 2+ pedal pulses, no edema Neuro: intact vibration/pinprick sensation with 2+ deep tendon reflexes Laura’s Laboratory Findings HbA1c: 9.2% (ref < 6.0%) Lipid panel Total cholesterol: 244 mg/dl HDL-C: 36 mg/dl Triglyerides: 412 mg/dl LDL-C: unable to be caluclated Electrolytes: normal Serum creatinine: 0.71 mg/dl Urine microalbumin/creatinine ratio: 34 mcg albumin/mg creatinine ARQ #1 What is Laura’s BP goal based upon JNC 7 Guidelines? 1. SBP < 130 mmHg and DBP < 80 mmHg 2. SBP < 140 mmHg and DBP < 90 mmHg 3. SBP < 140 mmHg and DBP < 80 mmHg 4. SBP < 130 mmHg and DBP < 85 mmHg 5. None of the above Laura Scheduled for evaluation with RD/CDE and and physician 1200 kcal low fat ADA diet with emphasis on DASH composition provided Patient agrees to increase physical activity re walking 30 minutes 5 days/week HBGM once daily, alternating times of day Instructed to re-start meds “No shows” for 2-month follow-up appointment with physician Laura Returns for follow-up 4 months later BP: 152/98 mmHg; pulse 84/minute Remainder of physical exam unaltered with no weight loss Admits to rarely performing HBGM States “your medications don’t work!” ARQ # 2: Why is Laura failing to achieve her BP goal? 1. Current antihypertensive doses are insufficient 2. Non-compliance with antihypertensives 3. Laura has a secondary cause to her HTN 4. Failure to embrace therapeutic lifestyle changes 5. 1 and 4 6. 2 and 4 7. 3 and 4 Barriers to HTN Control: Patient Factors Asymptomatic nature of HTN Myths about HTN Dosing schedule Medication side effects and costs Inadequate patient education Depression Barriers to HTN Control: Clinician Factors Failure to address patient concerns Failure to provide patient education and define goals Clinical inertia Clinician as poor lifestyle “role model” Paternalistic approach Patient Education: How can we treat my HTN? YOU THE PATIENT Physician Dietitian Nurse Practitioner Family Health Belief Model Developed by Rosenstock and refined by Becker Involves Perceived Perceived Perceived Perceived susceptibility severity benefits risks Becker, MH. Health Educ Monographs 1974, 2:324-473. Health Belief Model: Perceived Susceptibility “What is my risk of getting high blood pressure? My grandma lived to 96 and she just died of ‘old age.’ ” “If I have high blood pressure, I won’t get any complications. ‘I’m unique.’ ” Health Belief Model: Perceived Severity “Is high blood pressure really that big of a deal? I don’t feel any different.” “If my kidneys fail from high blood pressure, can’t I just get a transplant?” “No one in my family has heart disease. My heart can take anything!” Health Belief Model: Perceived Benefits “Why bother with diet and exercise? I can just take medications.” “Will I feel any better on blood pressure medication? My husband takes blood pressure medication and he doesn’t feel any different. In fact, he’s has ED” “Will I be healthier if I control my blood pressure?” Health Belief Model: Perceived Risks “I don’t want to have to follow a diet or exercise. That’s deprivation and not fair!” “I can’t remember to take medications” “Don’t expect me to take a medication more than once a day” “My drug co-pays are so high!” “I don’t like medications. They have lots of side effects” “My Aunt Susie took medication for her high blood pressure and she still died young” Patient Education: What is HTN? What is HTN? High BP, NOT high tension/stress What does BP measure? What does SBP represent? What does DBP represent? What are normal BPs? How high is too high? What are the signs and symptoms of HTN? What are my BP goals? Patient Education: Why do I need to control my HTN? LVH and congestive heart failure Renal failure, dialysis, transplantation Hypertensive ophthalmopathy Hypertensive encephalopathy DM as coronary equivalent; worsening complications Stroke Death, or worse, disability When Medication Cost is a Major Player Use generics when able Use combination medications Medication samples Pharmaceutical company patient assistance programs Which “Care” Path to Trek Along? C ontrol A ccountability R esponsibility E ffort C ouch potato A te and drank R efused self control E xericise -NO The “Wrong” Path to Trek Along The “Wrong” Path If patients give clinicians inaccurate and incomplete information regarding HBGM, self-BP monitoring, compliance, they are highly likely to receive, in return, inaccurate advice The “Right” Path to Trek Along HbA1c: 5.8% BP: 110/68 LDL-C: 65 mg/dl Help Your Patients Choose the Right Path Along which to Trek HOW ???? Clinicians, Keep Pace With the Times and the Medical Evidence Go with the bulk of the evidence Can’t necessarily wait for the definitive randomized clinical study before you act: if you wait too long, it may be too late Listen to the results of the definitive randomized clinical study when it is published Trekking without 100% of the Answers The science and practice of medicine continues to evolve Patients need to trek with the experts – the “AAA of HTN” to update “road conditions” Evaluation, review and interpretation of available knowledge leads to CURRENT BEST PRACTICE RECOMMENDATIONS Trekking for Survival: Provide Positive Reinforcement Adopt an attitude of concern coupled with hope and interest in your patient’s future Provide positive feedback If BP not at goal, ask about behaviors to achieve BP control Schedule more frequent follow-up appointments Clinician Awareness Optimize your lifestyle to be a good role model to your patients Encourage patients to bring all (including OTC) medications in their original containers to each visit Ask about pain medications Recognize depression and other psychiatric illnesses Be open to changing regimens Optimize the BP Health Care Delivery System Ensure that next follow-up appointment is scheduled prior to patient leaving office Use appointment reminders via telephone calls or cards Use a system to follow-up patients who noshow or late cancel for appointments Conclusion: Trekking for Survival Use available technology to the MAX Keep up with evolving science and technology to achieve BP and CVD risk factor goals It is SURVIVAL OF THE FITTEST! ARQ #3: In your practice, the most common cause of failure to reach BP goal is (select one): 1. Medication non-compliance for whatever reason 2. Therapeutic lifestyle change noncompliance 3. Occult or overt depression 4. Other ARQ #4: In your practice, medication noncompliance is most commonly caused by (select one): 1. Cost/co-pays 2. Dosing frequency 3. Fear of potential adverse effects 4. Actual adverse effects, such as fatigue or erectile dysfunction 5. Patient uncertainty of medication benefits 6. Other Hypertension Post-Test Questions Which of the following statements is NOT true? 1. 2. 3. 4. 5. 6. Most patients who have hypertension are not at goal. Those patients who are normotensive at age 55 have a 90% probability of becoming hypertensive. In persons older than 50 years, systolic blood pressure greater than 140 mmHg is a more important CVD risk factor than diastolic blood pressure. Those with a systolic BP of 130-149 mmHg or a diastolic BP of 90-99 should be considered as pre-hypertensive. If blood pressure is > 20/10 mmHg above goal, consideration should be given to initiating more than one agent, one of which should be a thiazide-type diuretic. None of the above Juan is a 31 year old Hispanic male who comes to see you complaining of a cough and mild fatigue. On taking his vital signs his blood pressure is noted to be elevated to 146/92 mm Hg. Which of the following is the most appropriate course of action? 1. Recommend that he begin therapy with a thiazide diuretic 2. Recommend that he begin therapy with an ACE inhibitor or ARB 3. Recommend that he avoid salt and return for a re-check on his blood pressure 4. None of the above Melanie is a 47 year old obese African American female smoker who comes in for a visit. You have taken care of this patient for over three years. Her only other major co-morbidity is asthma for which she takes a combination LABD/corticosteroid inhaler. One year ago, she was diagnosed with hypertension and started on a thiazide diuretic. This visit her BP is 149/94 mm Hg which is consistent with her two previous visits. Which of the following is NOT a reasonable choice for continuation of her care? 1. 2. 3. 4. 5. Recommendations for lifestyle and dietary modification Increase her dosage of the thiazide diuretic Add an ACE inhibitor Add a b-blocker A and C W.C. is a 57-year-old man with type 2 diabetes first diagnosed 2 years ago. Other medical problems include obesity and hypothyroidism. He has a history of heavy alcohol use but quit drinking alcohol 2 years ago. He presents now for routine follow-up and is noted to have a blood pressure of 168/100 mm Hg. He is asymptomatic. Which is the most appropriate treatment option? 1. 2. 3. 4. 5. Begin therapy with a calcium channel blocker Begin therapy with a combination of an ACE inhibitor and a thiazide diuretic Discuss lifestyle and dietary modifications 1&3 2&3 Brad is a 54-year-old obese man with moderate to severe hypertension. You initially prescribed amlodipine and adjusted the dose upward to 10 mg/day, but his systolic blood pressure remained considerably elevated (192/88 mm Hg). You added atenolol, 50 mg/day, and his systolic blood pressure was still not controlled (170/80 mm Hg). The patient takes 400 mg of ibuprofen once or twice a day for low back pain and over-the-counter sleep aids. He drinks alcohol in moderate amounts and smokes a pack of cigarettes a day. Results of routine laboratory tests, including fasting plasma glucose and lipid levels, are within normal limits. The patient has noted bothersome pedal edema and admits to feeling somewhat depressed lately. What would NOT be appropriate for this patient with refractory hypertension? 1. 2. 3. 4. 5. Recommend significant lifestyle modification including smoking cessation. Ask patient and family whether or not he snores. Continue his present medications Add a thiazide-type diuretic Add an ACE inhibitor or ARB