Download A PROACTIVE Approach to Managing Blood Pressure

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