Reprinted from the Archives of Internal Medicine

Copyright 1977, American Medical Association

December 1977, Volume 137

The Mismanagement
of Hypertension

n this issue of the ARCHIVES (p
1707), Alderman and Ochs docu-
ment major deficiencies found in the
long-term management of hyperten-
sive patients treated in the outpatient
department of a large teaching hospi-
tal. In reviewing the records of the
clinic, they found that half of the
hypertensive patients were unavail-
able for follow-up within six months
of the initial visit. Of those who
remained, less than 25% achieved a
reduction of blood pressure to below
160/95 mm Hg. Furthermore, publica-
tion of controlled clinical trials demon-
strating conclusively the effectiveness
of drug treatment in hypertension
failed to have any impact on the
already unsatisfactory management
of the clinic patients.

 

See also p 1707.

 

Finnerty et al' attempted to un-
cover the reasons for the large
number of dropouts from their teach-
ing clinic. Their method was to ques-
tion the patients who had dropped out.
The patients complained that they
were treated like second-class citizens.
They said they waited three hours to
see a strange doctor for five minutes
who knew nothing of their case
history and then waited two more
hours to have their prescriptions
filled. To correct the problem, Finner-
ty and colleagues replaced the rotat-
ing house-staff physicians with nurse
specialists and trained nurse as-
sistants. Each patient was assigned to
a given nurse or nurse assistant who
always saw that patient. To eliminate
waiting time, patients were seen by
appointment and medications were
prepackaged the day before the clinic
visit. A physician served as overall
supervisor and consultant. As a result
of the prompt and personalized atten-

Arch Intern Med—-Vol 137, Dec 1977

tion, there was a dramatic decrease in
the rate of dropouts and a comparable
increase in compliance.

Apparently, many patients can be
taught to comply, but for some to
continue to comply, there is need for
constant reinforcement. For example,
Wilber and Barrow’ greatly increased
compliance by employing nurses to
make home visits. Once the program
was dropped, however, most of the
patients reverted to their former
habits. McKenney, a pharmacist, and
his co-workers* interviewed patients
during each of their clinic visits,
providing them with general informa-
tion on hypertension and _ specific
details on each of their medications.
They questioned the patients on
compliance and sought out side
effects. When indicated, they recom-
mended changes to the attending
physician. Compliance increased from
25% to 79% during the interview pro-
gram, but after the program was
dropped compliance fell to 42%.

Too often our best efforts to gain
compliance go for naught in asympto-
matic hypertensive patients. Such
patients often remain unimpressed
with the seriousness of their condi-
tion. Sackett et al,’ for example, were
unable to improve compliance in a
group of industrial workers despite an
elaborate teaching program that in-
cluded quizzes to make certain that
the information was learned. In fact,
according to Sackett et al, the only
intervention that significantly im-
proved compliance under controlled
conditions was the use of blood pres-
sure recordings in the home. I have
used this technique for many years*
and have similarly found it to be a
useful way to increase compliance.

It is evident that a university
hospital clinic operating in a tradi-
tional manner can no longer be

Printed and Published in the United States of America

regarded as an acceptable modality
for delivering prevention treatment
in hypertension. And yet, it is not
desirable in a teaching institution to
exclude the student or physician in
training from gaining experience in
the long-term management of hyper-
tension. We have attempted to meet
this problem in our hypertension clinic
by allowing the nurse specialists to
take over the primary care of the
patients with uncomplicated hyper-
tension. However, the house-staff
physicians are available on call to
handle any unusual problems that
may arise. In addition, those patients
with complicated problems are seen
primarily by house-staff physicians.
Such patients also are seen by the
nurse specialists, who conduct inter-
views with respect to side effects,
compliance, and other problems. In
addition, the nurse specialists main-
tain an ongoing program of education
in the need for continuing treatment,
and serve as contacts to whom the
patient can relate over a long period
of time. A satellite pharmacy is
provided so that patients will not be
required to wait for their drugs.

If improvements are to be made,
the first step is to recognize that the
traditional hypertension clinic is inad-
equate to provide effective long-term
treatment. Hopefully, such recogni-
tion will then be followed by changes
designed to cope with the most impor-
tant and most difficult problem in
long-term care, the motivation of the
patients to continue treatment for an
indefinite period of time.

Epwarp D. Freis, MD
Washington, DC

References

1. Finnerty FA Jr, Shaw LW, Himmelsbach
CK: Hypertension in the inner city: II. Detection
and follow-up. Circulation 47:76, 1973.

2. Wilber JA, Barrow JG: Reducing elevated
blood pressure: Experience found in a commun-
ity. Minn Med 52:1303-1306, 1969.

8. McKenney JM, Slining JM, Henderson HR
et al: The effect of clinical pharmacy on patients
with essential hypertension. Circulation 48:1104,
1978.

4. Sackett DL, Haynes RB, Gibson ES, et al:
Randomized clinical trial of strategies for im-
proving medication compliance in primary hyper-
tension. Lancet 1:1205, 1975.

5. Freis ED: The discrepancy between home
and office recordings of blood pressure in
patients under treatment with pentropyrrolidin-
ium: Importance of home recordings in adjusting
dosage. Med Ann DC 23:368, 1954.

Editorials 1669