One set of guidelines says to loosen up blood pressure
control to prevent consequences such as falls. Almost in reaction there appears
a new study that indicates a need to, perhaps, tighten up control to reduce the
potential for stroke or heart disease. When British GPs were paid more to
address BP there did not seem to be gains, other than better pay for
participating GPs. Time after time we seem to have cutting edge studies that
are pro-intervention. They remain until longer and bigger studies come out
years later indicating problems or limitations involving the once “cutting
edge” pro-intervention studies.
The lives of millions of people can be impacted by
hypertension guidelines. How can we best deal with blood pressure issues?
The answer is not likely to be found in guidelines, quality
measures, reports, or the latest studies.
The answer is more about process and less about print.
The problem with guidelines
that are too liberal or too conservative is the same – they are too distant
from the real world. The real problem remains the failure to include many of
those most important to the process.
The real world in
health care is what is happening at home. What is the real world for elderly
patients? What happens when you get up at night to go to the bathroom? Do you
get up at night more because of your medications or because of how you take
them? Do your physicians coordinate the addition and subtraction of medications
– including drugs that impact blood pressure or fluid volumes? With more and
more medications there are more potential interactions. What happens when you
get up from a chair or sofa? When you lose 10 or 15 pounds, do your medications
drop your blood pressure to dangerous levels? Do you even have contact with a
health care professional to help look out for the problem of weight loss and
medications that are suddenly too effective?
We know about the
benefits of blood pressure control, but do we know about the consequences of
too much control?
Sadly we know less
about the risk of blood pressure that is kept too low, the risk that a fall
that may belife or lifestyle ending will occur.For example, should our blood
pressure goals be more aggressive in men or in those with proven bone stability
while being less aggressive with those likely to suffer greater consequences becaue
they have osteopenia, osteoporosis, or other conditions? We often assume linear
increase in risk, but this may not be the case.
What Is Missing from
“Guidelines?”
With control of BP or
coagulation or other treatments that defeat how the body adjusts to change, the
patient and family must have the best understanding regarding what the drugs do
and how the drugs impact their particular body and situations.
Large scale studies
can be helpful, but the studies need to be relevant. Studies should reflect the
real world. After three hundred recent home visits, observations indicated a
few with perhaps lax control that may, just may have problems in 1, 5, or 10
years. There are also a different few of the 300 who are having falls or
symptoms that suggest the potential for falls - with the potential of immediate
consequences. Many large studies examine only the outcome of interest to the
researchers – such as the rate of strokes in people with uncontrolled blood
pressure – rather than the overall rate of harm or death to the people
involved. In addition, many studies exclude from participation people who have
the risk factors most likely to cause them harm. Studies that do examine all
outcomes (“all-cause morbidity and mortality”) are of more value, and we need
to be sure that the people we are treating in the “real world” are similar to
those studied.
And then there is the
problem of getting reliable BP measurements at the office or at home. How many people
do we overtreat based on office-only measurements when lower home BP
measurements are more relevant? How do we best use ambulatory measurements? Are
these accessed and priced in ways that can make a difference?
A final reflection may
be more relevant. In the 5 or 6 minutes of face-to-face time that is often all
that exists, given current payment design, how do we get to know our patients
well enough in our office environment to optimize BP control while minimizing
the consequences to them as they live in their world? How do we teach them
enough to loosen up medication when necessary to help prevent falls?
Addressing Problems
and Solutions
One thing is certain.
As long as research is distant and irrelevant, guidelines will contribute to
too much negative consequence and not enough gain.
Practice-based
research could contribute. But the real potential involves home-based research.
The irrelevance of the academic setting and even the office was suggested by
the founders of family medicine. What matters most is far away from university
hospitals and NIH researchers. Lest we forget, the home – and the community -- is
where it all happens.
Follow
up to come:
Why
the Home is the Best Unit of Analysis for Research
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