Transcript Sheehan_Lecture #2

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
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43-yr old Caucasian female
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6-yr history of HTN
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Concomitant medical conditions
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Type 2 DM for 5 years
Mixed dyslipidemia
Attorney
Laura’s Lifestyle History
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Non-smoker
EtOH consumption of 3-4 drinks/day
pending stress of court
Exercise
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None: except “walking around the courtroom”
Diet: unstructured; never saw RD
Laura’s Family History
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Father
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Alive age 64
T2DM and CHF
Mother
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Alive and well without medical conditions
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2 sisters, both with T2DM and obesity
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2 children alive and well
Laura’ Medications
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Recently stopped her medications of
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HCTZ 25 mg qd
Lisinopril 10 mg qd
Metformin ER 1000 mg q pm
Laura’s Physical Exam
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Wt 242 lbs for a ht of 66 in; BMI = 39
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BP 144/96 mmHg; pulse 88/minute
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Skin: acanthosis nigricans, facial hirsutism
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CVS: no ectopy or murmurs
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Lungs: clear to auscultation/percussion
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Abdomen: obese, non-tender, no masses, no renal bruits,
waist circumference 36 in
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Extremities: 2+ pedal pulses, no edema
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Neuro: intact vibration/pinprick sensation with 2+ deep
tendon reflexes
Laura’s Laboratory Findings
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HbA1c: 9.2% (ref < 6.0%)
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Lipid panel
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Total cholesterol: 244 mg/dl
HDL-C: 36 mg/dl
Triglyerides: 412 mg/dl
LDL-C: unable to be caluclated
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Electrolytes: normal
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Serum creatinine: 0.71 mg/dl
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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
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Scheduled for evaluation with RD/CDE and and
physician
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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
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Returns for follow-up 4 months later
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BP: 152/98 mmHg; pulse 84/minute
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Remainder of physical exam unaltered
with no weight loss
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Admits to rarely performing HBGM
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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
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Asymptomatic nature of HTN
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Myths about HTN
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Dosing schedule
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Medication side effects and costs
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Inadequate patient education
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Depression
Barriers to HTN Control:
Clinician Factors
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Failure to address patient concerns
Failure to provide patient education and
define goals
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Clinical inertia
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Clinician as poor lifestyle “role model”
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Paternalistic approach
Patient Education:
How can we treat my HTN?
YOU
THE PATIENT
Physician
Dietitian
Nurse
Practitioner
Family
Health Belief Model
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Developed by Rosenstock and refined by Becker
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Involves
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Perceived
Perceived
Perceived
Perceived
susceptibility
severity
benefits
risks
Becker, MH. Health Educ Monographs 1974, 2:324-473.
Health Belief Model:
Perceived Susceptibility
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“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
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“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
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“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
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“I don’t want to have to follow a diet or exercise.
That’s deprivation and not fair!”
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“I can’t remember to take medications”
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“Don’t expect me to take a medication more than once
a day”
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“My drug co-pays are so high!”
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“I don’t like medications. They have lots of side
effects”
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“My Aunt Susie took medication for her high blood
pressure and she still died young”
Patient Education:
What is HTN?
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What is HTN?
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High BP, NOT high tension/stress
What does BP measure?
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What does SBP represent?
What does DBP represent?
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What are normal BPs?
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How high is too high?
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What are the signs and symptoms of HTN?
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What are my BP goals?
Patient Education:
Why do I need to control my HTN?
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LVH and congestive heart failure
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Renal failure, dialysis, transplantation
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Hypertensive ophthalmopathy
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Hypertensive encephalopathy
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DM as coronary equivalent; worsening complications
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Stroke
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Death, or worse, disability
When Medication Cost is a
Major Player
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Use generics when able
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Use combination medications
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Medication samples
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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
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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
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Listen to the results of the definitive
randomized clinical study when it is
published
Trekking without 100% of
the Answers
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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
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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
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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
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Ask about pain medications
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Recognize depression and other psychiatric
illnesses
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Be open to changing regimens
Optimize the BP Health Care
Delivery System
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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
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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