Managing Hypertension: Lifestyle Modification and Pay for Performance

Basile, who was an investigator in the ACCORD trial, argued that ACCORD demonstrated the impressive blood pressure reduction that can be achieved through an aggressive treatment regimen. (Participants in the intensive-therapy group had visits scheduled to monitor their blood pressure once a month for the first four months and every two months thereafter and received an average of 3.4 medications during the trial’s first year, while those in the standard-therapy group had visits scheduled at months one and four, and every four months thereafter, and received an average of 2.1 medications in the first year.) “It only took 1.3 more medications to get to that goal of less than 120,” he said. “With the proper system in place, seeing patients more often, and with patients that want to help us help them, we are able to meet these low blood pressure goals.”

Since producing such ambitious results is so labor intensive and tends to require getting patients to modify their lifestyles, Salgo asked whether hard-working primary

care providers have the necessary time and resources to produce them.

“Once again, it’s a systems problem,” Basile replied, pointing out that the only way for lifestyle modification to succeed is to have dietitians and other professionals available to monitor patients. “If we’re really going to be serious about lifestyle, we’ve got to be able to bundle the care we give to patients so that there are other people outside of the primary care or specialist provider who are seeing the patient.”

Ferdinand added that some changes along these lines could be ushered in by the 2010 health care reform law. “One of the components of the Affordable Care Act is that there is money in it for access to preventive services where physicians would be paid for the intellectual intervention related to prevention,” he said, pointing out that treating hypertension could also help save a great deal of money if it prevents patients from proceeding to develop end-stage renal disease, which requires treatment with expensive dialysis, or heart failure. “Society has to get away from this idea that when you spend money giving people insurance, paying for preventive services, that’s money wasted. That’s money saved.”

“Are there particular challenges to lifestyle modification based on gender and ethnicity?” asked Salgo.

“The medical-economic milieu patients find themselves in is clearly important,” said Watson. “If we’re asking them to eat according to the DASH [Dietary Approaches to Stop Hypertension] eating plan, then they need to have access to fresh fruits and vegetables. And if they live in a food desert, that’s going to be a lot harder. So we have to know our patients and know their environment.”

Guidelines for Treating Hypertension

Salgo then shifted the conversation to guidelines for treating hypertension. “JNC was first published in 1976,” he said. “How well are the guidelines understood and used in practice now? Is there something missing that you wish was in them?”

“I think there’s been good penetration of the guidelines into the practicing community,” said Ferdinand. “The definition of hypertension—140/90—is the hallmark of the way the JNC committees have been able to educate providers.” Other contributions, he added, include the idea of pre-hypertension, the blood pressure goal of 130/80 for some patients, and the general recommendation of thiazide diuretics as the initial medication for hypertension. In terms of what is missing from the guidelines, Ferdinand noted that there could be more practical advice for encouraging lifestyle modification, prescribing medications in combination, and countering physician inertia.

Basile argued that what is needed, in addition to better systems of care, is better monitoring of physician performance. “Here in South Carolina, and throughout the Southeast, we have developed an EMR system with which we send report cards to clinicians to let them know how their patients are doing,” he said. “It’s extremely motivating to clinicians. When they are told that they’re not doing as well in the control rates of hypertension compared with their colleagues, they are motivated to do better.… And eventually, I think clinicians have to be paid for their performance. If a particular clinician is going to be working with patients out of the office to improve blood pressure control because of their passion or their commitment, they have to be rewarded for it.”

With JNC 8 scheduled to be discussed at the American Heart Association conference in Orlando in November and released early in 2012, Salgo asked whether the new guidelines might adopt lower blood pressure goals for certain types of patient.

“My short answer is no,” said Ferdinand. “There is not going to be a hard, fixed goal for patients with diabetes, and similarly, I don’t think there’s going to be a hard, fixed goal for patients with renal disease.” He added that the ISHIB Working Group he was a part of had proposed a blood pressure goal of under 130/80 for patients with diabetes, renal disease, and other forms of cardiovascular risk, including microalbuminuria, carotid disease, peripheral arterial disease, and left ventricle hypertrophy.

“I think the key word in JNC 8 is going to be individualization,” said Basile, noting that the American Diabetes Association’s 2011 guidelines for the first time endorsed a systolic blood pressure goal of either above or below 130 depending on the patient. The problem, he added, is that “For the individual patient, regardless of skin color, we have a very difficult time individualizing risk. We do not have a good risk algorithm that we can use to really understand what a patient with hypertension’s individual risk is.” As an example, he described a hypothetical patient whose systolic blood pressure had been reduced from 172 to 144 and asked, “What is the incremental benefit versus the incremental risk of adding another drug to get to less than 140?”

We want to know what you think:Which areas of lifestyle modification are most difficult for your hypertension patients?Should physicians treating patients with hypertension be paid based on their performance?

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