Aug 26, 2017 | Healthy Tips
4 WAYS TO ENGAGE HYPERTENSIVE PATIENTS
Jerry Penso, MD, MBA – Chief Quality and Medical Officer at the American Medical Group Association
Medical professionals have known about the risks of poorly controlled hypertension for over a century and effective treatments have been available for more than 50 years. Yet according to the Centres for Disease Control and Prevention, less than half of the 68 million American adults with hypertension have their condition under control, and nearly 20 percent are unaware they have it.
Blood pressure control has been challenging mainly because it is a “silent” condition in terms of physical symptoms. For this reason, patients may not adhere to recommended medication or lifestyle regimens, physicians may not treat hypertension as an urgent issue, and the disease may not get the public attention that other diseases receive.
Our current health system is also primarily designed to address acute medical problems, not chronic conditions that require team-based, longitudinal care with advanced information technology and patient-centred care.
To address hypertension and other pressing chronic conditions, the American Medical Group Foundation (the non-profit research arm of the American Medical Group Association) has launched a multi-year initiative, the Chronic Care Challenge. This program leverages best practices in disease management and population health. Measure Up/Pressure Down, the program’s first campaign brings together nearly 150 medical groups and health systems to achieve a goal of 80 percent of patients in control of their high blood pressure by 2016.
Groups across the nation, including Cleveland Clinic, Geisinger Health System, Kaiser Permanente and Mayo Clinic, are implementing up to eight evidence-based care processes that were developed by the campaign to achieve this aim. These processes have been proven to work in healthcare settings and have resulted in successful improvement rates among groups.
Medical practices and health systems of all sizes can easily implement these campaign strategies to identify and engage hypertensive patients. Following are some of the methods that Measure Up/Pressure Down’s participating medical groups around the country are using to improve control rates among their patients:
1. Retrain direct care staff in accurate blood pressure measurements
Studies show that every day, hundreds of patients with hypertension visit their doctor’s office and leave without having the disease diagnosed or addressed. To properly identify hypertensive patients, direct care staff must be trained in accurate blood pressure measurement. This training, as well as annual certifications, should cover techniques for patient positioning, selection of cuff size, obtaining a valid blood pressure measurement, recording it accurately and reporting abnormal results. For example, Cornerstone Health Care in North Carolina has developed two training videos to demonstrate the differences between accurate and inaccurate techniques for its team members. Additional topics to address during training sessions may include knowledge of proper techniques and different types of observer biases, processes to properly maintain and calibrate equipment, and interpretation of measurements including an understanding of the variability of blood pressure depending on the time of day, exercise and timing of medications.
2. Keep track and reach the patients most in need of care
Effective care for chronic illness is virtually impossible without information systems that ensure ready access to key data on individual patients as well as populations of patients. A comprehensive clinical registry can enhance the care of individual patients by providing timely reminders for needed services, with summarized data used to track and plan care. At the practice level, a registry can identify groups of patients needing additional care and facilitate performance monitoring. Populated with electronic health records (EHRs), registries can provide: patient lists for specific conditions; decision support tools at the point of care to make providers aware of a patient’s hypertensive status and recommended care; exemption reports to identify hypertensive patients not meeting management goals which can be used to drive patient outreach efforts; and progress reports examining provider, staff and site performance.
Summit Medical Group, a physician-owned multispecialty practice in New Jersey, uses its EHR to develop these patient lists. On a monthly basis, color-coded lists are disseminated internally to indicate the blood pressure control of individual patients. Physicians and staff use these documents to conduct targeted outreach, schedule screenings, and appointments and re-engage patients in their care.
3. Begin engagement from the office door
Office visits provide multiple opportunities to educate patients about hypertension. Practices participating in the Measure Up/Pressure Down campaign incorporate blood pressure control into each of these patient encounters:
Check-in. As patients update medical records and insurance information, they also fill out a questionnaire to help identify blood pressure knowledge, goals and barriers that can inform the provider-patient conversation.
Waiting room. Educational materials in the waiting room cover topics related to blood pressure including lifestyle changes and medication adherence. Many groups also broadcast blood pressure-specific videos and public service announcements on waiting room televisions, while others display educational resources, like the Measure Up/Pressure Down Circulation Nation: Your Roadmap to Managing High Blood Pressure patient booklet.
Exam room. Some practices, such as Colorado Springs Health Partners and University of Utah Health Care, display posters near blood pressure cuffs that showcase accurate measurement. These signs help patients understand the rationale for staff requests (e.g., if a patient doesn’t remove a jacket as requested, their blood pressure measurement will fluctuate by 10-40 mmHg), remind staff the importance of accurate measurements and empower patients to take an active role in their own health.
Post-exam. Research suggests patients may understand and retain only half of the information discussed with a provider. Groups often provide customized materials to help patients understand and share this health information. For example, patients at Billings Clinic receive the “Your Blood Pressure Report Card” at each visit, which includes highlighted patient data from the EHR (including recent blood pressure readings, arm circumference, and weight measurements) as well as lifestyle goals and actionable tips.
4. Engage patients outside the office
The true test of engagement and adherence is when patients leave the doctor’s office and manage their conditions on their own. It is crucial to first determine the extent to which individual patients understand hypertension and how involved they want to be in their self-management.
For patients who are willing and able to plan and take action, practices and groups have implemented:
Home blood pressure monitoring. ThedaCare Physicians, a community health system in Wisconsin, equips patients with free home blood pressure monitors. Patients learn tips for accurate readings, measure and record blood pressure on a regular basis and share results with their provider for medication adjustments or lifestyle changes. California-based Arch Health Partners provides its patients with a wallet-sized tracking card to record readings.
Health coaches. In Iowa, Mercy Clinics, Inc. embedded health nurses into the system to work with diabetic patients (many with hypertension). Guided by patient data and chart review, coaches reached out to those with poor hypertension control and helped them manage their conditions with food diaries and one-on-one motivational coaching.
Mobile apps. Marshfield Clinic Research Foundation in Wisconsin developed the Heart Health Mobile app, which provides a quick heart health check, motivates users to obtain a more accurate assessment with blood pressure and cholesterol values and directs users to nearby locations offering affordable, convenient blood pressure screenings.
Learn more about these evidence-based care processes, and discover what medical groups and health systems are doing to achieve progress in improving hypertension rates from their success stories. In addition, all tools mentioned here are available for free in the Measure Up/Pressure Down Provider Toolkit.
Jerry Penso, MD, MBA, is chief quality and medical officer at the American Medical Group Association. He oversees quality initiatives through the American Medical Group Foundation, a 501(c)3 nonprofit, including best practices in care collaborative and the Chronic Care Challenge. Follow the campaign at @MUPDcampaign.
Aug 26, 2017 | Healthy Tips
ROLL UP YOUR SLEEVES… WHAT IS HIGH BLOOD PRESSURE AND HOW TO PREVENT IT
Did you know one in three young adults have high blood pressure? More than 32% of women! This costs the nation billions annually in direct medical expenses. The sad part is that 20% of people don’t even know they have it!
What is high blood pressure?
Blood pressure is the force that blood puts on the walls of your blood vessels as blood flows through them. This naturally rises and falls throughout your day, but when it’s high, it makes your heart work too hard. Like the pipes in a house, your arteries can fail if they are under too much pressure… your risk of heart disease and stroke increases.
How do you prevent high blood pressure?
Eat right: Fine tune your diet… read nutrition labels, and use herbs and spices instead of salt to flavour your food!
Be active.: It only takes 30 minutes of physical activity a day to lower your blood pressure!
Reduce stress: This has a HUGE impact on your mind and body. Find healthy ways to cope with stress!
Stop alcohol
Communicate: Write down your concerns in a journal. Talk to your doctor! Ask questions.
Stop tobacco use: Every cigarette you smoke and tobacco you chew raises your blood pressure – as does second hand smoke affect your loved ones’.
Track your numbers: Check your blood pressure often. Know your numbers! Avoid doing things (like drinking coffee) before you get checked. I always make that mistake!
Manage all your health issues: High blood pressure can worsen other conditions.
Take your medication: It only works when you actually take it – every day at the same time.
Know your risks: Know what you can control – your weight, diet, activity level, tobacco and alcohol use – and can’t control – your age, gender, race, and family history.
NOTE: you can have high blood pressure and not know it! You may have heard people call it the silent killer. This is why it’s so important to have your blood pressure checked regularly.
As you probably already know, it’s incredibly easy to get your blood pressure checked, and totally painless. You can have yours checked by your doctor, and many pharmacies have free screenings throughout the year.
Aug 25, 2017 | Healthy Tips
Overview
Cardiovascular diseases (CVDs) are often called “silent killers” because heart attacks and strokes are a common first warning sign of an underlying disease. High blood pressure is the most frequent and most important risk factor for CVDs. Its prevalence is estimated to be about 20 million in the African Region.
The most common symptom of coronary artery disease is angina. Angina is often described as a pressure, heaviness, discomfort, aching, burning or a painful feeling in the chest. The symptoms can often be mistaken for indigestion or heartburn.
Behavioural risk factors are responsible for about 80% of coronary heart disease and stroke. The major causes of cardiovascular diseases are tobacco use, physical inactivity, an unhealthy diet and harmful use of alcohol. CVDs occur almost equally between men and women.
Raised blood pressure, raised cholesterol, and overweight and obesity are often outcomes of inadequate lifestyles in the Region. The reduction of salt in the diet, consuming fruits and vegetables, and managing stress are effective ways to reduce the risks of cardiovascular diseases.
Other CVDs include peripheral artery disease, rheumatic heart disease, congenital heart disease and heart failure. Poverty, lack of education, and unplanned urbanization can increase exposure to cardiovascular risk factors.
Factsheet
Key Facts
CVDs are the number 1 cause of death globally: more people die annually from CVDs than from any other cause.
An estimated 17.7 million people died from CVDs in 2015, representing 31% of all global deaths. Of these deaths, an estimated 7.4 million were due to coronary heart disease and 6.7 million were due to stroke.
Over three quarters of CVD deaths take place in low- and middle-income countries.
Out of the 17 million premature deaths (under the age of 70) due to no communicable diseases in 2015, 82% are in low- and middle-income countries, and 37% are caused by CVDs.
Most cardiovascular diseases can be prevented by addressing behavioural risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol using population-wide strategies.
People with cardiovascular disease or who are at high cardiovascular risk (due to the presence of one or more risk factors such as hypertension, diabetes, hyperlipidaemia or already established disease) need early detection and management using counselling and medicines, as appropriate.
What are cardiovascular diseases?
Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels and they include:
coronary heart disease – disease of the blood vessels supplying the heart muscle;
cerebrovascular disease – disease of the blood vessels supplying the brain;
peripheral arterial disease – disease of blood vessels supplying the arms and legs;
rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria;
congenital heart disease – malformations of heart structure existing at birth;
deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs.
Heart attacks and strokes are usually acute events and are mainly caused by a blockage that prevents blood from flowing to the heart or brain. The most common reason for this is a build-up of fatty deposits on the inner walls of the blood vessels that supply the heart or brain. Strokes can also be caused by bleeding from a blood vessel in the brain or from blood clots. The cause of heart attacks and strokes are usually the presence of a combination of risk factors, such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol, hypertension, diabetes and hyperlipidaemia.
What are the risk factors for cardiovascular disease?
The most important behavioural risk factors of heart disease and stroke are unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol. The effects of behavioural risk factors may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity. These “intermediate risks factors” can be measured in primary care facilities and indicate an increased risk of developing a heart attack, stroke, heart failure and other complications.
Cessation of tobacco use, reduction of salt in the diet, consuming fruits and vegetables, regular physical activity and avoiding harmful use of alcohol have been shown to reduce the risk of cardiovascular disease. In addition, drug treatment of diabetes, hypertension and high blood lipids may be necessary to reduce cardiovascular risk and prevent heart attacks and strokes. Health policies that create conducive environments for making healthy choices affordable and available are essential for motivating people to adopt and sustain healthy behaviour.
There are also a number of underlying determinants of CVDs or “the causes of the causes”. These are a reflection of the major forces driving social, economic and cultural change – globalization, urbanization and population ageing. Other determinants of CVDs include poverty, stress and hereditary factors.
What are common symptoms of cardiovascular diseases?
Symptoms of heart attacks and strokes
Often, there are no symptoms of the underlying disease of the blood vessels. A heart attack or stroke may be the first warning of underlying disease. Symptoms of a heart attack include: pain or discomfort in the centre of the chest; pain or discomfort in the arms, the left shoulder, elbows, jaw, or back.
In addition, the person may experience difficulty in breathing or shortness of breath; feeling sick or vomiting; feeling light-headed or faint; breaking into a cold sweat; and becoming pale. Women are more likely to have shortness of breath, nausea, vomiting, and back or jaw pain.
The most common symptom of a stroke is sudden weakness of the face, arm, or leg, most often on one side of the body. Other symptoms include sudden onset of: numbness of the face, arm, or leg, especially on one side of the body; confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known cause; and
fainting or unconsciousness. People experiencing these symptoms should seek medical care immediately.
What is rheumatic heart disease?
Rheumatic heart disease is caused by damage to the heart valves and heart muscle from the inflammation and scarring caused by rheumatic fever. Rheumatic fever is caused by an abnormal response of the body to infection with streptococcal bacteria, which usually begins as a sore throat or tonsillitis in children.
Rheumatic fever mostly affects children in developing countries, especially where poverty is widespread. Globally, about 2% of deaths from cardiovascular diseases is related to rheumatic heart disease.
Symptoms of rheumatic heart disease
Symptoms of rheumatic heart disease include: shortness of breath, fatigue, irregular heartbeats, chest pain and fainting.
Symptoms of rheumatic fever include: fever, pain and swelling of the joints, nausea, stomach cramps and vomiting.
Why are cardiovascular diseases a development issue in low- and middle-income countries?
At least three quarters of the world’s deaths from CVDs occur in low- and middle-income countries.
People in low- and middle-income countries often do not have the benefit of integrated primary health care programmes for early detection and treatment of people with risk factors compared to people in high-income countries.
People in low- and middle-income countries who suffer from CVDs and other no communicable diseases have less access to effective and equitable health care services which respond to their needs. As a result, many people in low- and middle-income countries are detected late in the course of the disease and die younger from CVDs and other no communicable diseases, often in their most productive years.
The poorest people in low- and middle-income countries are affected most. At the household level, sufficient evidence is emerging to prove that CVDs and other no communicable diseases contribute to poverty due to catastrophic health spending and high out-of-pocket expenditure.
At macro-economic level, CVDs place a heavy burden on the economies of low- and middle-income countries.
How can the burden of cardiovascular diseases be reduced?
“Best buys” or very cost effective interventions that are feasible to be implemented even in low-resource settings have been identified by WHO for prevention and control of cardiovascular diseases. They include two types of interventions: population-wide and individual, which are recommended to be used in combination to reduce the greatest cardiovascular disease burden.
Examples of population-wide interventions that can be implemented to reduce CVDs include: comprehensive tobacco control policies taxation to reduce the intake of foods that are high in fat, sugar and salt building walking and cycle paths to increase physical activity
strategies to reduce harmful use of alcohol providing healthy school meals to children.
At the individual level, for prevention of first heart attacks and strokes, individual health-care interventions need to be targeted to those at high total cardiovascular risk or those with single risk factor levels above traditional thresholds, such as hypertension and hypercholesterolemia. The former approach is more cost-effective than the latter and has the potential to substantially reduce cardiovascular events. This approach is feasible in primary care in low-resource settings, including by non-physician health workers.
For secondary prevention of cardiovascular disease in those with established disease, including diabetes, treatment with the following medications are necessary:
aspirin
beta-blockers
angiotensin-converting enzyme inhibitors
statins.
The benefits of these interventions are largely independent, but when used together with smoking cessation, nearly 75% of recurrent vascular events may be prevented. Currently there are major gaps in the implementation of these interventions particularly at the primary health care level.
In addition, costly surgical operations are sometimes required to treat CVDs. They include:
coronary artery bypass, balloon angioplasty (where a small balloon-like device is threaded through an artery to open the blockage); valve repair and replacement;
heart transplantation; artificial heart operations
Medical devices are required to treat some CVDs. Such devices include pacemakers, prosthetic valves, and patches for closing holes in the heart.
