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Running head: A PROACTIVE Approach to Managing Blood Pressure NORTHWESTERN UNIVERSITY A PROACTIVE Approach to Managing Blood Pressure Session 2 Assignment Maria Almacen 1/19/2014 406-DL Clinical Decision Support System A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE Table of Contents A PROACTIVE Approach to Managing Blood Pressure ............................................................................. 2 Step1 – PROactive: The Problem, Reframe, and Objective ........................................................................ 3 1. 1 Define the Problem (P) .................................................................................................................... 3 1.2 Reframe from multiple perspectives (R) ............................................................................................. 5 1.3 Focus on the Objective (O) ................................................................................................................. 6 Step 2 proACTive: The Alternatives, Consequences, and Trade-offs ......................................................... 6 2.1 Consider all relevant alternatives (A) ................................................................................................. 6 2.2 Model the Consequences and Estimate the Chances (C) .................................................................... 9 2.3 Identify and Estimate the Value Trade-offs (T) .................................................................................. 9 Step 3 – proactIVE: Integration, Valuation, Exploration and Evaluation .................................................. 13 3.1 Integrate the Evidence and Values (I) ............................................................................................... 13 3.2 Optimize the Expected Value (V) ..................................................................................................... 14 3.3 Explore the Assumptions and Evaluate Uncertainty (E)................................................................... 15 A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE A PROACTIVE Approach to Managing Blood Pressure About two years ago during an annual OB-GYNE check-up, doctor’s assistant noted that Ms. Smith’s (not real name) blood pressure was high. Ms. Smith thought that it was a fluke since she was under stress just hours before her appointment. Months later, Ms. Smith went for an annual physical exam with her primary physician. The medical assistant took her blood pressure and said that it was on the high side. The nurse practitioner prescribed her Chlorthalidone. She purchased the prescribed medication but rarely took it. Ms. Smith thought she could manage without it. After a few months, she went to see a cardiologist just to know more about her elevated blood pressure. She thought there must be a mistake since she is not obese, exercised more, and ate healthier than she used to. Some cardiac tests were done. The cardiologist thought Ms. Smith did not have to take Chlorthalidone. So she completely stopped. Six months or so later, she did her annual check-up. Again the medical assistant said that Ms. Smith’s blood pressure was high. Soon, Ms. Smith became anxious about why she is having high blood pressure. She started to worry whether she really has hypertension. And if so, why and what will happen next? Ms. Smith’s primary physician prescribed Chlorthalidone once again and referred her to a cardiologist. She had blood work, EKG, echocardiogram, and stress test. Results were insignificant. They said that her heart was fine. The cardiologist was not concerned although he advised Ms. Smith to take Chlorthalidone to manage her blood pressure. Ms. Smith asked for alternatives to her prescribed medications. The cardiologist emphasized that taking the recommended medication was the best approach at that time. Ms. Smith started taking Chlorthalidone once a day but would skip a dose when her blood pressure was normal or on the low side. Sometimes she would just simply forget taking the medication. She would take A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE it again when she feels the symptoms such as tingling sensation on her body, stressed feelings, headache, palpitation, and most especially when her blood pressure is high. After a few months, she experienced severe stress and exhaustion that her blood pressure remained high. Ms. Smith went to see her cardiologist again. He recommended taking the medication regularly or he will have to add another medication on the next visit if her blood pressure remains elevated. I would like to use the PROACTIVE approach as described by Glasziou and Hunink (2012) in managing Ms. Smith’s high blood pressure. Step1 – PROactive: The Problem, Reframe, and Objective 1. 1 Define the Problem (P) The problem is how to manage blood pressure while preventing serious complications. What would happen if Ms. Smith does not take action? Table 1 below lists the known consequences of high blood pressure. The table is based on a list of consequences of uncontrolled high blood pressure provided by Mayo Clinic (2011). Table 1. Table of Consequences of Uncontrolled High Blood Pressure Organ Damage Rationale Arteries Aneurysm (Aortic- The continuous force of blood through a sapped or stressed most common artery causes a segment of its wall to form a protuberance form) that may rupture causing internal bleeding (Mayo Clinic, 2011). Arteriosclerosis and The constant stress placed by the force of blood causes Atherosclerosis thickened and stiff arterial walls (Mayo Clinic, 2011). Fats A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE from diet inflowing the circulation may collect at the thickened walls (Arteriosclerosis) resulting to obstruction (Atherosclerosis) of blood flow to organs (Mayo Clinic, 2011). Heart Coronary artery Depleted blood supply due to narrowed coronary arteries disease causes chest pain, arrhythmias, and heart attack (Mayo Clinic, 2011). Left ventricular The increase in pressure needed to force blood through the hypertrophy arteries causes the left heart to enlarge. The thickened and stiff left heart becomes limited in its pumping ability that increases one’s risk to heart attack, heart failure, or sudden cardiac death (Mayo Clinic, 2011). Heart failure The prolonged stress of high blood pressure causing weakness of the heart muscle that is exacerbated by heart attacks brings about heart failure (Mayo Clinic, 2011). Brain Transient ischemic Frequently an indication of a potential full-blown stroke, attack (TIA) ministroke is a brief, temporary disruption of blood supply to the brain primarily caused by atherosclerosis or blood clot arising from high blood pressure. Stroke Weakening, narrowing, rupturing, and clot formation of arteries in the brain caused by uncontrolled high blood pressure leads to depletion of oxygen and nutrients to part of the brain (Mayo Clinic, 2011). A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE Mild cognitive Interruption of blood flow to the brain owing to high blood impairment and pressure leads to complications with memory, intellectual Dementia and reasoning ability, speaking, vision, and movement (Mayo Clinic, 2011). Kidneys Glomerulosclerosis, High blood pressure can damage the large arteries leading to kidney artery the kidney and the glomeruli (tiny vessels) of the kidney aneurysm, kidney responsible for filtering and eliminating blood wastes (Mayo failure Clinic, 2011). 1.2 Reframe from multiple perspectives (R) Patient perspective. Two years ago, Ms. Smith was in denial that she has primary hypertension. She thought she was completely healthy as evidenced by her normal late pregnancy and normal weight. With age, she had improved her diet by increasing fruit intake and decreasing fatty food intake. Ms. Smith is more active later in life until she enrolled in graduate school. She put off exercise on busy days caring for two children and attending to other demands of life. Ms. Smith’s belief that she could control her blood pressure with little or no medication is mainly driven by her concern for its side-effects. She wanted to manage her blood pressure employing a more natural approach such as healthier diet (high-fiber, low-sodium, lowfat), regular exercise, and effective stress management. Ms. Smith noticed that when she does not sleep enough, her blood pressure becomes elevated. And when her blood pressure is high, she could not sleep long or well enough. A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE Health caregiver’s perspectives. Physician’s and nurse practitioner’s perspective is that taking the prescribed drug regularly is important to prevent the list of complications mentioned in the Table of Consequences above. Payer’s perspectives. The payer is concerned about the financial repercussions of an uncontrolled high blood pressure. 1.3 Focus on the Objective (O) The main objective of the problem is to control or manage blood pressure in order to prevent serious adverse events and complications mentioned in the Table of Consequence while reducing the side-effects. Step 2 proACTive: The Alternatives, Consequences, and Trade-offs 2.1 Consider all relevant alternatives (A) The problem is high blood pressure and its current and future effects if left unmanaged. The following are several alternatives to consider: Wait-and-see plus manage lifestyle; Follow prescribed medication or treatment now; or Seek further information to manage lifestyle and follow prescribed medication or treatment. 2.1.1 Wait-and-see plus manage lifestyle. Wait-and-see approach avoids any side- effects of prescribed medication. However, if the blood pressure remains high for a prolonged period of time, not only can it cause severe discomfort (such as headaches, palpitations, altered rest and sleep, altered activities of daily living) but it can also cause irreparable damage to major A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE organs of the body such as the brain, kidneys, and the heart as described in the Table of Consequences of Uncontrolled High Blood Pressure. 2.1.2 Take prescribed treatment or medication. This choice requires the patient to seek and strictly follow the treatment as prescribed by the physician. The most conservative or first line of drug prescribed by physicians is a thiazide diuretic (Institute for Clinical Systems, 2012). Both of Ms. Smith’s primary physician and cardiologist recommended Chlorthalidone. As a patient, she has no access to their guidelines. There are, however, online resources that provide guidelines to managing hypertension such as the one developed by the Institute for Clinical Systems Improvement (2012). 2.1.3. Seek alternatives and complementary treatment in addition to prescribed medication or medical treatment. Unfortunately, some physicians focus only on prescribing medication and diagnostic procedures. By experience, some doctors fail to discuss the significance of stress levels, quality and amount of sleep, nutrition or diet, exercise or daily level of activities in managing the medical conditions and the overall health of patients. After prescribing medications, some physicians do not talk about “improving” certain areas of the patient’s lifestyle or refer them to nutritionists and other health professionals. Some physicians do not provide handouts or discussions on recommended lifestyles. Typically, there would be a television in the waiting room to entertain patients with news and current events. Most physician offices and clinics do not utilize the television to educate patients in the waiting area to promote lifestyle choices that that can help achieve better treatment outcomes. They can delve on topics such as nutrition, physical activities to improve quality and amount of sleep, and ways to decrease stress. Information such as the complications of the wait-and-see option for uncontrolled high blood pressure is a good topic to educate patients while in the waiting room. A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE I had an opportunity to ask a cardiologist regarding the use of wearable devices to monitor or track patient’s level of activities, heart rate, and blood pressure. The physician said that they do not use such devices or utilize CDSS, because they are not reimbursed for such monitoring. They, however, follow the guidelines set to manage blood pressure. The following are some suggestions found during online search to manage blood pressure: Improve dietary habits. Increase intake of fruits and vegetables, whole grains and nuts, fish and poultry; reduce intake of sweets, red meat, foods high in total cholesterol and saturated fat; increase intake of food high in “magnesium, potassium, and calcium” will help maintain or control blood pressure (Web MD, n.d.). Increase physical activity (Web MD, n.d.). The American Heart Association (AHA, 2012) recommends performing moderate-to vigorous-intensity activity for a total of 150 minutes a day. The activity should be intense enough that one cannot talk while exercising, but not too hard that one is out-of-breath (AHA, 2012). If time is an issue, then allot 30 minutes a day, and even divide it into 10 to 15 minute segments a day (AHA, 2012). According to a study on the Epidemiology of Uncontrolled Hypertension in the United States by Wang and Vasan (2005), it is recognized that multidisciplinary efforts are not being fully utilized to help control or manage high blood pressure. Nutritionists may help in the assessment and managing dietary changes needed by individuals. Trainers or physical therapists may help in increasing levels of activity or promoting exercise and weight reduction. Psychologists may help in reducing levels of stress and improving quality and amount of sleep among individuals. A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE 2.2 Model the Consequences and Estimate the Chances (C) The natural course of high blood pressure is already outlined in the Table of Consequence. The following is a diagram of Chance Tree: Diagram of Chance Tree for Uncontrolled High Blood Pressure Controlled 0.10 Wait and See 1 Organ damage 0.990 0 No damage 0.010 1 Uncontrolled 0.90 Organ damage 0.010 0 No damage 0.990 1 Organ damage 0.990 0 No damage 0.010 1 Controlled 0.70 High Blood Pressure Follow medical treatment only (usually tests and medications) Uncontrolled 0.30 Controlled 0.90 Seek alternative and complementary treatment in addition to medical treatment No damage 1 Organ damage 0.990 0 No damage 0.010 1 Uncontrolled 0.10 2.3 Identify and Estimate the Value Trade-offs (T) The question in this category is which of the three alternative choices to managing high blood pressure will have the lowest probability of survival without complications of damage to major organs (heart, brain, and kidneys). The wait-and-see with self-managed approach to blood pressure is a way of seeking alternative approach. This prevents patients from taking medications that may have significant adverse side-effects. This approach allows patients to start looking into lifestyle changes to manage high blood pressure. However, immediate lowering of A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE blood pressure is not guaranteed. The second choice (follow medical treatment only) will ensure immediate decrease of blood pressure but drug dependence and serious side-effects are significant concerns. The third option of combined alternative and complementary treatment to the medical treatment is another approach but it takes time and effort on the patient to seek other alternatives in addition to the medical approach. The table of effects shows a cost analysis, benefits, and adverse consequences of each three choices to managing blood pressure. Table of Effects of the three alternatives to managing blood pressure on the quality of life, complications, and cost. Wait-and-see with Follow medical Seek alternative and Alternative treatment treatment only complementary only (medication, non- treatment in addition invasive or invasive to medical treatment treatment) Quality of Life Fair or Worse. (+10- Better (+50-70%) Best (+80-90%) 20%) Quality of life This approach This approach will is unsure since high immediately help the patient to blood pressure addresses high blood feel better as a result causes a lot of pressure and of better quality and discomfort such as improves the quality quantity of sleep, headache, poor of life. more time to rest and temperament, feeling relax with no tired and unable to headaches and A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE function well at work palpitations. Thus or at home. This better quality of life. approach may not immediately or successfully lower blood pressure for days and increases the risk to short term complications. Long term complication High (-80-90%). Moderate (-40-60%). Low (-10-20%). It is quite risky to However this This approach does take this approach, approach does not not only address the since the guarantee immediate issue of complications maintaining the controlling the blood attached to prolonged blood pressure with pressure, but it also high blood pressure same treatment in the addresses the long- may be irreversible. long-term. term goals. A person is more at risk with increased age. Therefore, learning how to control blood pressure at the early stage of primary A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE hypertension may help the patients maintain blood pressure with no medication or minimal medication as they age. Cost High (-80-90%) Moderate (-40— Low (-10-20%) Cost is related to 60%) Cost is related to complications from Cost is related to reduced physician prolonged doctor’s visit, visit, a fewer or no uncontrolled high medicine, laboratory medications, physical blood pressure. This tests and procedures, trainer (to learn includes physician surgery and therapy exercises, initiate visits, medication, if coupled with exercise or weight hospitalization, and complications. loss program), procedures (tests, nutritionist or recipe therapies, or books (to learn surgeries). better eating habits), psychologist and self-help books (to learn ways to reduce stress such as A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE improving quality and quantity of sleep time and reduce technology time – television, phone, and computers). Step 3 – proactIVE: Integration, Valuation, Exploration and Evaluation 3.1 Integrate the Evidence and Values (I) To integrate the evidence and the values, I calculated the average outcome value based on the decision tree backwards from the right hand side to the left hand side as follows: Wait-and-see. With wait-and-see, there is 0.109 chance of survival without organ damage. (0.10+0.009=0.109). Controlled. 1x0.1=0.10 Uncontrolled. 1x0.01=0.01x0.9=0.009 Follow medical treatment only. With follow medical treatment only, there is 0.69 chance of survival without organ damage (0.69+0.003=0.69). Controlled. Damage. 0x0.001=0 No damage. 1x0.99=0.99x0.7=0.69 Uncontrolled. Damage. 0x0.99=0 No damage. 1x.01=0.01x0.3=0.003 A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE Seek alternative and complementary treatment in addition to medical treatment. With the combination of alternative, complementary, and medical treatment, there is a 0.90 survival without organ damage in the control of blood pressure (0.9+0.001=0.90). Controlled. No damage. 1x0.9=0.9 Uncontrolled. Damage. 0x0.99=0 No damage. 1x0.01=0.01x0.1=0.001 3.2 Optimize the Expected Value (V) In addition to the averaging out, the long-term effects, cost, and quality of life of each approach was also calculated. It turned out that Option 3 (Combined alternative, complementary treatment in addition to medical treatment) obtained the highest score of 60%, which indicates the best approach as shown in the following scores: Wait-and-see: -60% Follow medical treatment: 30% Seek alternatives and complementary treatment in addition to medical treatment: 60% Applying the PROACTIVE approach and considering the consequences of all three choices to managing high blood pressure, the third choice (seek alternative and complementary treatment in addition to medical treatment) is the best choice to control blood pressure with less risks of organ damage. The rolled back decision tree showed that seeking alternative and complementary treatment with the medical treatment has the best score (0.90) among the three strategies. A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE 3.3 Explore the Assumptions and Evaluate Uncertainty (E) The only uncertainty I can identify is the unknown side-effects of the drug of choice, and the body’s response to the drug or treatment. Also, if the estimates in my model are not accurate, the patient may have a higher possibility of developing organ damage despite choosing the third option of seeking alternative and complementary treatment in addition to medical treatment. But I still believe that combining approved or non-contraindicating alternatives and complementary treatments in addition to the medical treatment will optimize the control of blood pressure. Perhaps when health insurers and the federal government eventually reimburse the monitoring of ambulatory blood pressure on a daily or regular basis, specialists will be more proactive in helping patients manage their lifestyles. “Follow medical treatment only” may then become the best choice of the three as the physician will treat the patient not just by medications or procedures alone but by employing a holistic approach to managing high blood pressure. A PROACTIVE APPROACH TO MANAGING BLOOD PRESSURE References Complementary and alternative treatments for high blood pressure. (n.d.). Retrieved from http://www.webmd.com/hypertension-high-blood-pressure/guide/hypertensioncomplementary-alternative-treatments Glasziou, P., & Hunink, M. (2012). Decision making in health and medicine - integrating evidence and values. (p. 26). New York: Cambridge University Press. High blood pressure dangers: hypertension's effects on your body. (Jan, 21 2011). Retrieved from http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/highblood-pressure/art-20045868 Institute for Clinical Systems Improvement-Nonprofit Organization. (2012, November). Hypertension diagnosis and treatment. Retrieved from http://www.guideline.gov/content.aspx?id=39321&search=controlling blood pressure Wang, T., & Vasan, R. (n.d.). Epidemiology of uncontrolled hypertension in the United States. Retrieved from http://circ.ahajournals.org/content/112/11/1651.full