Medicine
Several years ago, I cared for an elderly woman with heart failure, diabetes, and high blood pressure who had at least one major health problem at every office visit. I'd get her blood sugar levels under control only to find that her blood pressure had risen dangerously. I'd adjust blood pressure medications only to find her short of breath with swollen legs—a sign of worsening heart failure—at her follow-up appointment. The trouble was, I had no idea how well she followed my instructions in between visits which occurred every month or two. Had her blood pressure been soaring at home for the past few weeks or only during the hour she was in my office? I had no way of knowing.
Family physicians often have a tough time monitoring chronic health conditions, which leads to poor management of those conditions. Only half of the 65 million Americans with hypertension have achieved good control, according to a recent commentary in the American Journal of Managed Care. And it's not hard to understand why: A patient's blood pressure at an office visit may not be an accurate reflection of what the reading typically is at home; in fact, it's often much higher, leading doctors to coin the term "white coat hypertension." Knowing this, doctors are often reluctant to increase medication doses or add new medications; we're afraid of lowering blood pressure too much, which can make patients lightheaded and cause them to stop taking their medications altogether.
Given this unacceptable situation, family doctors need to adopt a new model of care that includes more frequent contacts with patients and adjustment of medications based on blood pressure monitoring at home, stress the authors of the AJMC paper who are affiliated with the University of California at San Francisco. They suggest that hypertensive patients receive home monitors to check their blood pressure on a daily basis and record the readings in a paper or electronic log. Nurses, medical assistants, or other "health coaches" should call patients every two weeks in between office visits to check on their blood pressure readings and provide counseling on lifestyle changes, such as starting an exercise program or reducing dietary sodium. If a patient's home blood pressure readings are too high, a medication dose can be increased using standard protocols that are pre-approved by the doctor. This model is supported by research: A 2008 study published in the Journal of the American Medical Association found that patients who received home blood pressure monitors and regular contacts from a pharmacist through a secure Web site were significantly more likely to achieve blood pressure control after one year compared to patients who weren't monitoring themselves.
Of course, remote monitoring or telemedicine for chronic health conditions has applications beyond blood pressure management. Remote devices can send the results of blood sugar readings or body weight measurements, in addition to blood pressure readings, from your home directly to your doctor's office. Studies conducted by the Veterans Health Administration have demonstrated that daily body weight measurements on scales remotely linked to doctor's offices can help reduce re-admission rates for heart failure patients, a major factor in reducing ballooning health care costs. In fact, 12 states now require that health insurance plans cover telemedicine services, and 25 states reimburse doctors for telemedicine services through their Medicaid programs.
Even in states that don't mandate coverage for home health monitoring, many health insurers are introducing pilot programs that provide free equipment to selected patients, provided that their doctors show they're utilizing the data to improve care. If you have high blood pressure or another chronic health condition that might benefit from monitoring in between office visits, it's worth checking with your doctor and insurance provider about options that could be available to you at little or no cost.
**
The above post was first published on my Healthcare Headaches blog at USNews.com.
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Medicine
Telemedicine: more than what the doctor ordered
Several years ago, I cared for an elderly woman with heart failure, diabetes, and high blood pressure who had at least one major health problem at every office visit. I'd get her blood sugar levels under control only to find that her blood pressure had risen dangerously. I'd adjust blood pressure medications only to find her short of breath with swollen legs—a sign of worsening heart failure—at her follow-up appointment. The trouble was, I had no idea how well she followed my instructions in between visits which occurred every month or two. Had her blood pressure been soaring at home for the past few weeks or only during the hour she was in my office? I had no way of knowing.
Family physicians often have a tough time monitoring chronic health conditions, which leads to poor management of those conditions. Only half of the 65 million Americans with hypertension have achieved good control, according to a recent commentary in the American Journal of Managed Care. And it's not hard to understand why: A patient's blood pressure at an office visit may not be an accurate reflection of what the reading typically is at home; in fact, it's often much higher, leading doctors to coin the term "white coat hypertension." Knowing this, doctors are often reluctant to increase medication doses or add new medications; we're afraid of lowering blood pressure too much, which can make patients lightheaded and cause them to stop taking their medications altogether.
Given this unacceptable situation, family doctors need to adopt a new model of care that includes more frequent contacts with patients and adjustment of medications based on blood pressure monitoring at home, stress the authors of the AJMC paper who are affiliated with the University of California at San Francisco. They suggest that hypertensive patients receive home monitors to check their blood pressure on a daily basis and record the readings in a paper or electronic log. Nurses, medical assistants, or other "health coaches" should call patients every two weeks in between office visits to check on their blood pressure readings and provide counseling on lifestyle changes, such as starting an exercise program or reducing dietary sodium. If a patient's home blood pressure readings are too high, a medication dose can be increased using standard protocols that are pre-approved by the doctor. This model is supported by research: A 2008 study published in the Journal of the American Medical Association found that patients who received home blood pressure monitors and regular contacts from a pharmacist through a secure Web site were significantly more likely to achieve blood pressure control after one year compared to patients who weren't monitoring themselves.
Of course, remote monitoring or telemedicine for chronic health conditions has applications beyond blood pressure management. Remote devices can send the results of blood sugar readings or body weight measurements, in addition to blood pressure readings, from your home directly to your doctor's office. Studies conducted by the Veterans Health Administration have demonstrated that daily body weight measurements on scales remotely linked to doctor's offices can help reduce re-admission rates for heart failure patients, a major factor in reducing ballooning health care costs. In fact, 12 states now require that health insurance plans cover telemedicine services, and 25 states reimburse doctors for telemedicine services through their Medicaid programs.
Even in states that don't mandate coverage for home health monitoring, many health insurers are introducing pilot programs that provide free equipment to selected patients, provided that their doctors show they're utilizing the data to improve care. If you have high blood pressure or another chronic health condition that might benefit from monitoring in between office visits, it's worth checking with your doctor and insurance provider about options that could be available to you at little or no cost.
**
The above post was first published on my Healthcare Headaches blog at USNews.com.
- Conservative, Liberal, Or Relevant Blood Pressure? We Need Studies That Are Really Relevant...
The following is a guest post from Robert Bowman, MD 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...
- Walk, Don't Run To Implement Sprint Findings In Primary Care
My latest Medscape commentary concerns the primary care implications of the SPRINT trial of lower systolic blood pressure goals in patients at high risk for cardiovascular disease, whose initial findings appeared last week in the New England Journal of...
- Can Treating Mild Hypertension Be Too Much Medicine?
As part of a plan to improve our practice's quality of care for patients with high blood pressure, my office's nurse announces at every morning huddle which patients on that day's schedule had a blood pressure measurement of greater than 140/90...
- Healthy Lifestyle Counseling Challenges
I once used to see patients in a clinical practice located next door to a popular fast food restaurant. My office hours usually began in the early afternoon and ended about 9 p.m.. Whenever I was pressed for time or hadn't packed a dinner, I'd...
- Guest Blog: Home Glucose Testing In Type 2 Diabetes
Dr. Ed Pullen is a family physician who sees patients at Sound Family Medicine in Puyallup, WA. The following piece is excerpted from a previously published post on his blog, DrPullen.com. ** Home glucose monitoring in non-insulin treated type 2 diabetes...