National Guidelines for Controlling High Blood Pressure: Who’s Paying Attention?

Newswise — In 2003, the National Heart, Lung, and Blood Institute of the National Institutes for Health released their Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Known as JNC 7, this reports provides doctors and nurses guidelines on best approaches to the prevention and management of hypertension.(1)

Researchers of a study presented today at ISHIB2006 wanted to find out the level at which providers were using the guidelines and if patients were reaching blood pressure and lifestyle choice goals set by JNC 7. Their results are encouraging: 77% of the providers were in concordance with the guidelines and almost half of the study participants (41%) were at recommended high blood pressure goal levels (Table 1). Previous studies have found a great variation in provider use of recommendations ranging from 26%-72%,(2) and patient achievement of blood pressure goals has been found to be as low as 33%.(3)

Rosalind M. Peters, PhD, RN and Ramona Benkert, PhD, RN from Wayne State University College of Nursing, co-investigators of the study, extracted data from charts of 104 low-income African American patients receiving care in two primary care clinics within an urban university health center. Peters and Benkert developed the Hypertension Quality Index (HQI) to measure compliance with JNC 7 and examined the HQI scores to determine how well nurse practitioners and doctors complied with the guidelines to achieve blood pressure goals among patients. Within this HQI framework, the researchers examined four areas of concordance with JNC 7 recommendation: 1) cardiovascular risk assessment; 2) lifestyle modification; 3) pharmacological treatment; and 4) follow-up care. An overall concordance (total quality index) was also determined. (See Table)

While other studies have been conducted to determine compliance rates with previous versions of the NHLBI hypertension guidelines, these results are the first of its kind to find out that there are differences in the way physicians care for their patients vs how nurse practitioners provide care. Only one previous study compared nurse practitioner care to physician care of high blood pressure. That study found no difference by provider type for systolic blood pressure, but nurse practitioner patients had lower diastolic pressures.(4)

In today's study, while the researchers found no differences in the quality of care provided between nurse practitioners and physicians, they did find differences in their practice styles. Doctors were more likely to treat high blood pressure by prescribing a higher total number of medications and nurse practitioners were more likely to document teaching patients about lifestyle factors that influence blood pressure. Nurse practitioners documented lifestyle modification teaching 74% of the time, while physicians only documented lifestyle teaching 48% of the time. "This finding suggests that a collaborative model of care, combining the strengths of both doctors and nurse practitioners may be what we need to improve the level of care for hypertensive patients," recommended Dr. Peters.

Researchers of this study also believe the limited documentation of teaching points to the difficulty of balancing quality of care in a pay-for-performance model of reimbursement.(5) "With the current systems focused on rewarding for the number of patients seen in an hour, there is a real disincentive to spend time teaching and counseling," Peters said. The study supports the Institute of Medicine report on quality of care(6) and other research(7) that suggests that, until electronic health records and other such technological advances become standard within health systems and a balance between productivity and quality assessments are the norm, documentation of teaching and counseling will be a challenge to the quality monitoring process.

These scientific findings were presented today at the 21st International Interdisciplinary Conference on Hypertension and Related Cardiovascular Risk Factors in Ethnic Populations as Abstract 014. The abstract appears below. Additional conference information and news from the conference can be found at http://www.ishib.org/ISHIB2006.

ISHIB2006 is jointly sponsored by ISHIB and the American Society of Hypertension (ASH). ISHIB (The International Society on Hypertension in Blacks) is a nonprofit, professional medical membership organization devoted to improving the health and life expectancy of ethnic populations. ISHIB was founded in Atlanta, Georgia, in 1986 to respond to the problem of high blood pressure among ethnic populations. Each year, its international interdisciplinary conference presents advancements in the treatment and prevention of cardiovascular diseases and reducing the health disparities among ethnic minority populations. In addition to US conference locations, other sites for the conference have included Toronto, London, the US Virgin Island, Kenya, Cameroon, and Brazil.

References1. Chobanian AV, Bakris GL, Black HR, et al. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.2. Milchak JL, Carter BL, James PA, Ardery G. Measuring adherence to practice guidelines for the management of hypertension: an evaluation of the literature. Hypertension. 2004;44:602-608.3. Spranger CB, Ries AJ, Berge CA, Radford NB, Victor RG. Identifying gaps between guidelines and clinical practice in the evaluation and treatment of patients with hypertension. Am J Med. 2004;117:14-18.4. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians a randomized trial. JAMA. 2000;283:59-68.5. Rosenthal MB, Frank RG. Whati is the empirical basis for paying for quality in health care? Medical Care Research and Review, 2006: 63, 135-157.6. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001; National Academy Press: Washington DC.7. Wilson MS, Joiner KA, Inzucchi, SE, Mulligan GJ, et al. Improving clinical productivity in the academic setting: A novel incentive plan based on utility theory. Academic Medicine. 2006; 81-306-316.