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Will Running the Numbers First Violate the Principles of Patient-Centered Care?
- Lawrence S. Phillips, MD; and
- Jennifer G. Twombly, MD
- From the Veterans' Affairs Medical Center, Decatur, GA 30033, and Emory University School of Medicine, Atlanta, GA 30322.
IN RESPONSE:
We thank the responders to our editorial for their thoughtful concerns, but we believe that hypertension management needs improvement and we would like to address the issues raised in these letters.
Although “clinical inertia” can be a pejorative term, acknowledging our own deficiencies (1) was a key first step in improving our care (2). Requiring that every detail of recommendations for care be based on evidence from clinical trials can lead to evidence-based paralysis (3)—failure to act in the absence of specific trial-based evidence. The goal of systolic blood pressure of less than 140 mm Hg is well supported (4). Although intensification of therapy promotes polypharmacy and risks nonadherence, these are part of the cost of better hypertension management. Fortunately, emphasis by the provider increases adherence (5, 6): If we don't mention blood pressure, patients may conclude that it's not important, but if we emphasize its importance, patients will be more likely to take hypertension medications.
Addressing blood pressure (an “index condition”) at the start of visits might seem to go against having visits be patient-centered, but patients might emphasize symptomatic over asymptomatic problems. Finding the best balance is not simple, and it is our responsibility to help patients appreciate the importance of such disorders as hypertension and diabetes. Although blood pressure shouldn't dominate, it shouldn't be overlooked; our paradigm of “running the numbers first” should help avoid errors of omission. We also recognize that fluctuations in systolic blood pressure can be substantial, especially in elderly persons and patients with type 1 diabetes, but variability usually decreases when blood pressure is better controlled. Accordingly, it is reasonable to recommend that blood pressure above goal always prompt intensification unless there are problems, such as orthostasis.
We agree that complications from hypertension are linked more tightly to ambulatory blood pressure than to measurements in the office, but ambulatory blood pressure isn't always available, and we don't know how best to use these values. The risk from office systolic blood pressure greater than or equal to 140 mm Hg corresponds to that of a lower average ambulatory pressure (7) or a lower first morning pressure (8), but it isn't clear exactly how low ambulatory pressures must be to be reassuring. Our paradigm responds to office blood pressure–based guidelines (4) and was designed to be universally applicable.
Our understanding of the basis for clinical inertia has been advanced by the demonstration of contributions from “clinical uncertainty” (9) and “competing demands” (10), but it's been almost 7 years since the concept was promulgated (11). We believe that rather than doing further studies on mechanisms, it's time to focus on overcoming clinical inertia. The management paradigm we offer should help us to move forward.
Lawrence S. Phillips, MD
Jennifer G. Twombly, MD
Veterans' Affairs Medical Center
Decatur, GA 30033
Emory University School of Medicine
Atlanta, GA 30322
Article and Author Information
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Potential Financial Conflicts of Interest: None disclosed.
