FUTURE OF
WEB-BASED HYPERTENSION INTERVENTIONS
By the year 2025, it is predicted that more than 1.5
billion people around the world will have hypertension accounting for nearly
half of heart disease risk and three-quarters of stroke risk. With new
web-based technologies emerging as potential treatment options, how will we
change our approach to care. Welcome to The Clinician's Roundtable. I am your
host, Dr. Mark Nolan Hill, Professor of Surgery and Practicing General Surgeon
and our guest is Dr. Beverly Green from the Group Health Center For Health
Studies in Seattle. Dr. Green is the lead investigator of research published
in JAMA on innovative web-based interventions for patients with uncontrolled
hypertension.
DR. MARK NOLAN HILL:
Welcome Dr. Green.
DR. BEVERLY GREEN:
Hello.
DR. MARK NOLAN HILL:
We are discussing the future of web-based hypertension
interventions. Dr. Green tell us a bit about your background. How did you get
involved with particularly this type of research?
DR. BEVERLY GREEN:
I am a family physician and hypertension is the most common
diagnosis family physicians make and so many visits, even though they are not
for hypertension include that diagnosis and on an average day, I might see 3 to
5 or maybe ever more patients that I have to address blood pressure with. So
its extremely common. In addition to being a family physician, I have a degree
in public health and epidemiology and with my public health background I am
always interested in large public health problems and hypertension certainly
fit that groove. It’s a good mix between family practice and public health.
Also because we don’t do very well in controlling hypertension and I was very
curious to understand why that wasn't be able to do it better.
DR. MARK NOLAN HILL:
How do you determine that you are not doing well in
controlling hypertension?
DR. BEVERLY GREEN:
You can do chart audits, that’s the old fashioned way, the
way we can do it with an electronic medical records we can actually look at
blood pressures and we are doing a study where we look at that and if you
include pre-hypertension, the new diagnosis at any visit about 60% to 70% of
patients will have at least pre-hypertension if not uncontrolled hypertension,
which is about 40% of visits, which just astounded us.
DR. MARK NOLAN HILL:
And how did you come up with the ideas, specifically in your
research project?
DR. BEVERLY GREEN:
We already had an electronic medical record and we were
using secure e-mail. We also had pharmacists that were very successful who are
doing phone-based clinical interventions like increasing patients statins to
get LDL below 100, putting patients with diabetes on lisinopril. So we knew we
had experiences and I had personal experience with how great the pharmacists
are at group health.
DR. MARK NOLAN HILL:
Has the FDA approved any of the technology that was used in
your research?
DR. BEVERLY GREEN:
I am not sure about blood pressure monitors whether they
need FDA approval, but I believe they do and yes and they have been validated
in peer-review journals as being very accurate and there is probably only a 1
to 3 mm difference between a very well done mercury assessment and a valid
automated blood pressure machine.
DR. MARK NOLAN HILL:
If this type of management progresses, as I expected<_____>
based on your research, what will it take for our insurance companies to begin
paying for these measures?
DR. BEVERLY GREEN:
I think an overhaul and a new way to think about care, it is
possible that risk adjustment might help to some degree because it will take it
away from the service of actual visits, but I am not quite sure what it will
take, but I think this kind of study increases the noticeability of the value
of providing care in the ways that we already are over the telephone and over
the web and we are going to have more and more of this.
DR. MARK NOLAN HILL:
How do physicians look at their own financial aspect of
medicine with respect to this new evolving technology?
DR. BEVERLY GREEN:
Well group health is a managed care organization, so the
physicians see a set panel that are in the group health owned clinics, so to
them secure messaging is just one more thing in their day and they don’t get
any particular compensation whether they have extra patients or extra secure
e-mails. I do sometimes think depending on the physician having a bunch of
e-mails is an imposition, particularly if the patient load doesn’t decrease,
but I think that has been recognized in our organization as we have gotten
these tools that physicians need to have adequate time or they need adequate
assistance like pharmacists or nurses that look at the e-mail first. So if the
patient just wants a refill, the physician doesn’t have to deal with that
e-mail.
DR. MARK NOLAN HILL:
If you have just joined us, you are listening to The
Clinician's Roundtable, I am your host, Dr. Mark Nolan Hill and our guest is
Dr. Beverly Green, from the Group Health Center for Health Studies in Seattle.
We are discussing the future of web-based hypertension interventions.
Dr. Green can you give us your prediction on how this
program will impact hypertension care on a much larger and even global scale?
DR. BEVERLY GREEN:
I think it has the potential to make big differences,
particularly in the areas where resources to have a care visit is less. It is
not hard to provide the technology, the machines are cheap even if the patient
can have one on their own at home, they are in a small community their could be
a place where they could go within, a little health center where they could go
and they could work remotely with other providers on a global level in
developing countries and we know that hypertension is a huge problem in Asia.
DR. MARK NOLAN HILL:
Now you have mentioned that this research is certainly
suitable for hypertension. Why particularly hypertension and what other
diseases might it also be useful for?
DR. BEVERLY GREEN:
We think it can be applied to most chronic conditions and
even some of the acute concerns of patients such as preparing for an
appendectomy or the followup care afterwards for surgery, and I believe there
was one study that showed increased satisfaction. Patients when they were
allowed to have those services with their surgeons, so we think it has broad
applications.
DR. MARK NOLAN HILL:
Did you specifically choose hypertension because of the poor
control or because of the relative ease of logistics fitting into your study?
DR. BEVERLY GREEN:
We both lined up at the right time and we ran with it, both
were important, that people aren’t well controlled and that we have these new
resources.
DR. MARK NOLAN HILL:
Do you think that there will be limitations in terms of the
patient population being facile enough to deal with the new electronic age of
computers and the internet.
DR. BEVERLY GREEN:
Well we did look at computer access and there were 20% of
the people that we called and asked them if they wanted to come in for a screening
visit, didn’t have access to computer by not having internet or an e-mail
address and those people tended to have lower educational levels, older and
more likely to be from ethnic or racial minority groups. So we know that there
is a group that will be excluded. However, as the generations age, the younger
generation are being exposed in school. We think that this digital divide will
narrow over time and more and more people will be very savvy with these tools
and, in fact, they will probably use their telephone rather than a computer and
that they won't have to write in their blood pressures, there will be ways to
automatically transmit the numbers and that patients will actually demand these
types of services not just for blood pressure, but for making appointments, for
communication, for refills, for knowing more about their health conditions.
DR. MARK NOLAN HILL:
The American Heart Association has unveiled the Blood
Pressure Management Center, what's that all about?
DR. BEVERLY GREEN:
On of the things about their comments that I was a little
concerned about was that they figure that if people went to this web site and
had all these tools, it would be enough. Ours occurred in the integrated
medical system and I think that needs to be proven that you just can make a
nice fancy web site that downloads blood pressures and transmits them that are
worth the same.
DR. MARK NOLAN HILL:
Are there any groups across the country that are doing
similar things that you are doing?
DR. BEVERLY GREEN:
Yes.
DR. MARK NOLAN HILL:
Tell us about that please.
DR. BEVERLY GREEN:
I know of other people that are extending the research to
include other conditions and other people that are including high blood
pressure in populations that have other conditions such as diabetes and heart
disease.
DR. MARK NOLAN HILL:
And are their findings likewise as good as yours.
DR. BEVERLY GREEN:
Well they haven’t completed. Ours is the first study that
was completed, so I haven’t seen the results on any other blood pressure
because they are just starting. In terms of other chronic conditions, actually
we were the first large randomized controlled trials for any chronic
conditions. So I hope there aren’t results yet. There are other things like
process measures and patient satisfaction, but not treatment outcomes.
DR. MARK NOLAN HILL:
With so many diseases that our care has been wonderful in
terms of decreasing morbidity and mortality and really improving patients
health so much, why does it seem that we are doing such a poor job with
hypertension?
DR. BEVERLY GREEN:
I think it is complex, as I mentioned before, it is not
always the priority on the patients list when they come in for visit and there
is often plenty of excuses when the doctor discovers that it might be elevated
or they may not even notice that in their busy day, it happens to me frequently.
At the end of the day, I am finishing my charting, and I say oops that patient
had a pretty high blood pressure and I didn’t even see it and I think that
happens, but even when I do see it and address it with patients, we might both
decide as because they are having a headache day or they didn’t take their
medicine right that day or find some other reason not to change and intensify
the medications or tell them to come back and we will have them check it again
to make sure it is up twice and a lot of time is lost and the patient may never
come back. The other factor is, what is that the patients do at home, do they
take their medicines, and the electronic medical record actually is very nice
way to see if the patient is taking their medications. Even if they don’t fill
it within a closed system, you can count the days in between refills and if
they are late on their refills consistently late, then you know that they are
not taking their medicine everyday and then you can address that issue in
particular.
DR. MARK NOLAN HILL:
On a practical matter, we talk about sustained hypertension
when patients take their own blood pressures at home. How do you determine
that one blood pressure may be spurious and another may be part of a trend?
DR. BEVERLY GREEN:
Well that is a very good question. Blood pressure is highly
variable and particularly the higher the blood pressure goes and can vary as
much as 30 points in one day in one individual with high blood pressure, more
typically it doesn’t vary that much, but wouldn’t be unusual for it to vary 10
points, so we think that the more blood pressures you get, the better and how
do you average all those blood pressures. Well, a couple of things. Usually
when a patient comes in to their doctor, they bring a card. What do you do
with that card. You sit there and stare at it for a while and don’t know what
to do with it. In our study, we actually had some workarounds because the
thing is that all this can be done electronically to an average, you can trend,
you can look for deviations that aren’t expected, that are out of the 95th
percentile and throw those numbers out when they are very much outliers and
machines can do this. We did a workaround where the numbers we got, we did
that for them and we averaged and we trended and it was actually put on a
graphics that already existed and our patients shared medical records where the
patient can look at their trend over time.
DR. MARK NOLAN HILL:
Just curious, what accounts for the variability of all those
points within one day of a patient with hypertension?
DR. BEVERLY GREEN:
We know that biphasic blood pressure is highest in the
morning and it goes down during sleep. We know all kinds of activities like
physical activity raise blood pressure, drinking coffee, smoking. So there is
a lot of factors for us that changes blood pressure is reactive, it is part of
heart function and those things affect the numbers. When you are at rest for a
long time and really relax and for the day it might be the lowest.
DR. MARK NOLAN HILL:
And you think that pharmacists will play a more proactive
and reactive role as you have in your study?
DR. BEVERLY GREEN:
I don’t know if it will be pharmacists per se, but I know
that the team concept will become more and more important.
DR. MARK NOLAN HILL:
I want to thank our guest, Dr. Beverly Green. We have been
discussing the future of web-based hypertension interventions.
I am Dr. Mark Nolan Hill and you have been listening to
the Clinician's Roundtable on ReachMD XM157, the Channel for Medical Professionals.
Be sure to visit our web site at reachmd.com featuring on-demand podcasts of
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