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Uncertainty or Good Judgement
Submit responseLetter to Editors Annals of Internal Medicine Sent July 7, 2008 Ré Uncertainty in management of hypertension in diabetes. Kerr et al and editorial by Phillips.
The article by Kerr et al (1) is a valuable description of choices made by physicians in the VA health care clinics for treatment of hypertension in diabetic patients. Such studies are useful in trying to understand physician behavior in relation to recommendations from guidelines, such as the JNC-7 (2). However, the authors’ interpretation of their results and the opinions given in the accompanying editorial by Phillips and Twombly (3) should not go unchallenged as they fail to recognize advances in the role of home blood pressures for management of hypertension.
In about half of the visits, providers relied on screening blood pressures for their treatment decisions regarding hypertension. Is this a reflection of uncertainty or awareness that screening pressures may be inaccurate for treatment decisions in individual cases? The providers who used either home pressures or additional clinic pressures may have been uncertain about the accuracy or the screening pressures, but the basis of their choice to use additional pressures is medically sound and, in fact, recommended. In this case uncertainty reflects better judgment. In particular, the case for relying on home blood pressures for treatment choices is well supported by a robust evidence base(4;5). Relying on limited blood pressure measurements from clinics alone, enhances the likelihood of regression dilution with the potential consequences of over- treatment or undertreatment.
Effective management of hypertension, especially in diabetics, is clearly a mainstay of preventive cardiovascular medicine. The VA health care system has been a major resource for both the clinical trials and the demonstration that control can be achieved in clinic populations. That being the case, attention must now be paid to optimization of all the complex issues of individual patient care for more accurate assessment of usual blood pressure and more nuanced recognition of decisions that will maximize patient satisfaction and prevention of future disease.
References
(1) Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148:717-27.
(2) Chobanian AV, Bakris GL, Black HR, Green L, Izzo JLJr, Jones DW et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: The JNC 7 Report. JAMA. 2003;289:2560-2572.
(3) Phillips LS, Twombly JG. It's time to overcome clinical inertia. Ann Intern Med. 2008;148:783-85.
(4) Verberk WJ, Kroon AA, Kessels AG, de Leeuw PW. Home blood pressure measurement: a systematic review. J Am Coll Cardiol. 2005;46:743- 51.
(5) Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D. Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring. A Joint Scientific Statement From the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008.
Lawrence R Krakoff MD Professor of Medicine Mount Sinai School of Medicine New York NY 10029 E-mail Lawrence.krakoff@mssm.edu
Conflict of Interest:
None declared
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Tobacco Use qualifies as a Concordant Condition
Submit responsePerhaps Kerr and colleagues should have classified tobacco use as a concordant condition (1). It is a chronic disease characterized by relapses and remissions (2) that is associated with some of the concordant conditions included in the study. Besides, smoking may be more prevalent among Veterans (3), possibly driven by previous Department of Defense practices offering tobacco to soldiers at a discount (4).
References
1. Kerr EA, Zikmund-Fisher BJ, Klamerus ML, Subramanian U, Hogan MM, Hofer TP. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148(10):717-27.
2. Steinberg MB, Schmelzer AC, Richardson DL, Foulds J. The case for treating tobacco dependence as a chronic disease. Ann Intern Med. 2008;148(7):554-6.
3. Ross JS, Keyhani S, Keenan PS, et al. Use of Recommended Ambulatory Care Services: Is the Veterans Affairs Quality Gap Narrowing? Archives of Internal Medicine. 2008;168(9):950-958.
4. Smith EA, Blackman VS, Malone RE. Death at a discount: how the tobacco industry thwarted tobacco control policies in US military commissaries. Tobacco Control. 2007;16(1):38-46.
Conflict of Interest:
None declared
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Additional Factors Causing Inertia
Submit responseI agree with many of the conclusions offered by Kerr et al regarding medical inertia. It is concerning that despite the knowledge of the benefits of blood pressure, blood sugar, and cholesterol control in the diabetic patient, the percent of patients that achieve medical goals is low. Many factors as outlined in the article contribute to this phenomenom. However, a major factor that wasn't studied in this article is medical insurance. It's been well established that those will less insurance are less likely to get the standard of care. Paz and colleagues studied risk factors for noncompliance with ophthalmologic exam in diabetics. They found, among other factors, the lack of insurance gave an odds ratio of 2.5 (95% CI, 1.7-3.7) for noncompliance. It's conceivable that physicians are consciously or unconsciously influenced by patient's insurance status when deciding to optimize or intensify medical management. Are we indirectly deciding who gets the best care? Are these decisions being made for us before the patient even comes into the clinic? How much does the presence of formulary restrictions and prior authorizations play a role? I'm concerned that we may be hardwiring our own thought processes around this issue more than we realize.
References: Paz et al. Noncompliance with vision care guidelines in Latinos with type 2 diabetes mellitus: the Los Angeles Latino Eye Study. Ophthalmology. 113(8):1372-7, 2006 Aug.
Conflict of Interest:
None declared
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It must just happen to be spotted.
Submit responseThe article "The Role of Clinical Uncertainty in Treatment Decisions for Diabetic Patients with Uncontrolled Blood Pressure" by Eve A. Kerr et al is certainly interesting and clinically significant. As a generalist, I have a number of patients who have prescribed antihypertensive drugs. As mentioned, I also tend to delay changing my strategy of the antihypertensive therapy. Certainly we know the clinical uncertainty of the true blood pressure, and the uncertainty always means to us, just "elevated." White coats, timing or the way of measurement would usually produce increased blood pressure. Rarely found the cause of happen to bring down the blood pressure clinically. We want to believe that the high blood pressure just happen to be spotted, it must be lower in an ordinary way.
Conflict of Interest:
None declared