ASK DR. BAUGHAN                                                         January 14, 2000

THE FUTURE OF HYPERTENSION

At a recent conference I attended in Boston, one of the speakers addressed ways we might change the delivery of health care for patients with chronic diseases such as hypertension, diabetes and hypercholesterolemia.  Since he was thinking along the same lines I have been musing, I was very impressed with him.  Medical practice is full of customs just like other aspects of life, and some tension or conflict is often necessary to get us to re-examine our habits.  Sometimes that tension is economic - “Can we or do we need to do something less expensively?” - sometimes quality driven ‘- “Can we do it better a different way?” and sometimes by time pressures, such as when a doctor retires and another leaves town making it difficult to offer enough appointment times to care for the number of patients in a community.

What is the custom of hypertension treatment?  A patient comes to the office.  Their blood pressure is taken, maybe twice.  The doctor may listen to their heart and lungs.  A prescription is written or refilled.  Maybe laboratory tests are done.  A follow-up visit is arranged for weeks or months depending on the blood pressure reading and the doctor’s and patient’s expectation and habit.

Let’s re-examine the rationale for the process, then each step of the process.  Why do we treat hypertension (high blood pressure)?  We have long term studies that show that we can decrease strokes if we keep blood pressure in normal ranges.  We have decent evidence that we can decrease heart attacks, congestive heart failure, and kidney failure if we control high blood pressure. 

Now the steps.  How difficult is it to measure blood pressure?  Not difficult.  There are some common errors, but most anyone can be taught to measure blood pressure.  There are digital machines that usually work well that can even remove some of the subjective aspects of it.  Periodic checking of the equipment is necessary.  Many patients are now measuring their pressure at home.  Daily or weekly readings are certainly more useful than readings once every few months in a doctor’s office, admittedly an artificial situation.

How do we know if any of the end-organs (brain, heart, kidneys) are being affected?  Usually by asking the patient questions or by obtaining blood and urine tests.  Only in more advanced stages of the problems will the physical examination reveal something.

So far, is the physician’s presence necessary?  Not necessarily.  If the blood pressure is elevated, if new signs and symptoms develop, or if a test is abnormal, then a decision is necessary.  Now the physician’s knowledge is needed.  Does this decision-making require a face-to-face meeting between doctor and patient?  Not necessarily.  So could much more of the management of hypertension (and similarly diabetes and hypercholesterolemia) be done over the telephone, e-mail, and in the near future - video e-mail?  Yes.

What might be lost?  Would some of the personal aspects of the doctor-patient relationship be missing?  Maybe.  For those who want the personal contact, an office visit may be important.  For those who find making an appointment and taking time off from the other aspects of their life bothersome, this change might be welcome.

The immediate concern voiced at the conference to these ideas was, “But I cannot bill for a phone call.”  Some changes in how we finance health care are inevitable.  This is where pre-paid health care would encourage such changes.  If the doctor is paid the same whether he/she sees the patients once a year or ten time times a year, the doctor will become much more imaginative in making care time-efficient without sacrificing quality.  Or, imaginative insurers and patients can become willing to pay for phone management when lost time from work will be decreased.  I invite your comments on the positive and negative possible consequences for such a change.