Improving hypertension management in my practice

358

Current Practice

Pratique courante

Practice Tips

Improving hypertension

management in my practice

Michelle Greiver

I 

of  the  population  reports  having  been  diagnosed  with  hypertension.¹  Various  guidelines  now  recommend  get- ting BP to 140/90 mm Hg or lower, and 130/80 mm Hg  or lower for those with diabetes mellitus.^2,3 Studies have  shown that many patients do not have good BP control.⁴  As such, I have made several changes to improve hyper- tension management in my practice.

Office blood pressure measurement

It is recommended that patients be sitting with their backs  supported and feet on the ground when having their BP  measured.⁵I used to measure BP with the patient sitting  on my examining table, which is not ideal.

I  recently  bought  a  validated  automated  BP  moni- tor  (ABPM)—the  BpTru⁶—and  there  is  a  comfortable  chair,  with  armrests,  for  patients.  I  decided  to  do  this  after receiving a BpTru for 2 weeks as part of a resident  research  project.  The  “BP  chair”  is  located  beside  the  practice scale and stadiometer, so all vitals get done in  one area. Directly in patients’ line of sight there is a note  in  large  print  reminding  them  that  they  should  have  a  5-minute  rest  before  having  their  BP  taken;  sit  with  their feet flat on the floor and their back supported; have  avoided  smoking  or  drinking  coffee  in  the  past  30  min- utes; remain quiet while BP is being taken; and have no  need to go to the bathroom. 

My  staff  take  BP  measurements  during  annual  checkups  and  diabetes  or  hypertension  management  appointments.  They  often  point  out  and  reiterate  the  recommendations on the wall. The ABPM takes several  readings  at  2-minute  intervals.  The  machine  discards  the first reading; it will show the average BP reading at  the push of a button. My secretary records this average  in the patient’s chart.

My  scheduler  has  several  colours  for  different  appointment  types  (eg,  annual  checkups  or  diabetes  management  follow-up)  so  that  my  secretary  knows  what  vitals  to  measure  when  the  patient  comes  in.  If  I  need additional BP measurements, I will ask my patient  to  drop  in  to  get  an  ABPM  reading  from  my  secretary,  even if I am unavailable or out of the office.

Home monitoring

Guidelines also recommend home BP monitoring, as this  can  be  a  more  accurate  predictor  of  long-term  morbid- ity.^7,8  The  Canadian  Hypertension  Society  has  approved 

several  different  monitors  (www.hypertension.ca/

chep/public/appareilsBPva.html); I use the LifeSource  uA-767 Plus. I own 2 home BP monitors, which I lend to  patients for home BP readings. The machine stores the  readings  and  can  later  display  the  average  BP.  If  nec- essary,  I  recommend  my  patients  purchase  the  device  (it  costs  about  $120  and  is  available  or  can  be  ordered  from  most  pharmacies  and  large  general  stores)  and  ask them to bring the machine to my office at their next  appointment  for  validation.  Home  BP  measurements  should be, on average, 135/85 mm Hg or lower. Many of  my  patients  now  self-monitor  and  bring  their  home  BP  readings for shared review.

Electronic medical records

An  electronic  medical  record  (EMr)  is  another  tool  I  use  in  hypertension  management.  The  EMr  has  sev- eral  prerecorded  links  to  websites,  such  as  the  DASH  eating  plan  at www.nhlbi.nih.gov/health/public/

heart/hbp/dash  or  the  Heart  and  Stroke  Foundation  BP  Action  Plan  at ww2.heartandstroke.ca/hs_bp2.

asp. When my patients are in, I will sometimes ask for  their  permission  to  e-mail  them  these  links.  When  I  copy  and  paste  the  link  into  the  e-mail,  it  is  automati- cally noted in the clinical record. Without an EMr, the  links can be sent at a later time if the patient provides  an e-mail address and consent.

I  also  use  electronic  flow  sheets  for  monitoring  BP  measurements. Blood pressure, weight, body mass index,  and waist circumference are automatically duplicated in  the flow sheet as they are entered; however, medication  changes are entered manually. This allows me to moni- tor  and  to  show  my  patients  the  effect  of  lifestyle  and  medication changes over time. I sometimes print a copy  of the flow sheet for the patient.

Conclusion

Automated  BP  monitors,  home  BP  monitors,  and  EMrs  make  hypertension  treatment  and  management  more  effective  and  more  efficient.  Automated  BP  monitors  can  improve  the  quality  of  hypertension  management,  as  guidelines  are  followed  more  consistently;  they  also 

We encourage readers to share some of their practice experience: the neat little tricks that solve difficult clinical situations. Practice Tips can be submitted on-line at http://mc.manuscriptcentral.com/cfp or through the CFP website www.cfp.ca under “for authors.”

Vol 54: march • mars 2008  Canadian Family Physician•Le Médecin de famille canadien 

359

Case Report

save  time  for  physicians.  Home  BP  monitors  can  help  patients take control of their BP management. Electronic  medical  records  can  help  with  patient  education;  auto- mated  flow  sheets  make  follow-up  of  multiple  param- eters much easier. I now spend less time taking patients’ 

BP measurements myself, but I think I’m achieving bet- ter results. 

acknowledgment

I would like to thank my staff, Marzena Drag, Karen Rothshild, and Francesca Schwamborn, for helping me to improve the care of my patients.

competing interests None declared

Dr Greiver is a family physician at North York General Hospital in Toronto, Ont.

references

1. Canadian Institute for Health Information. 

Health indicators 2006. Ottawa, ON: Canadian  Institute for Health Information; 2006. Available  from: www.statcan.ca/english/freepub/82- 221-XIE/2006001/tables/1hlthsta/cond2.

htm#high. Accessed 2008 Jan 14.

2. Harris SB, Lank CN. recommendations from the  Canadian Diabetes Association. 2003 guidelines  for prevention and management of diabetes  and related cardiovascular risk factors. Can Fam Physician 2004;50:425-33.

3. Canadian Hypertension Education Program. 

Management and prevention of hypertension in Canada: 2007 recommendations. Kingston, ON: 

Canadian Hypertension Society; 2007. Available  from: www.hypertension.ca/chep/en/

SlideKits.asp. Accessed 2008 Jan 14.

4. Joffres Mr, Hamet P, MacLean Dr, L’italien GJ, Fodor G. Distribution of blood  pressure and hypertension in Canada and the united States. Am J Hypertens  2001;14(11 Pt 1):1099-105.

5. Pickering TG, Hall JE, Appel LJ, Falkner BE, Hill MN, Jones DH, et al. 

recommendations for blood pressure measurement in humans: an AHA  scientific statement from the Council on High Blood Pressure research  Professional and Public Education Subcommittee. J Clin Hypertens  (Greenwich) 2005;7(2):102-9.

6. Culleton BF, McKay DW, Campbell Nr. Performance of the automated BpTru  measurement device in the assessment of white-coat hypertension and  white-coat effect. Blood Press Monit 2006;11(1):37-42.

7. Clement DL, De Buyzere ML, De Bacquer DA, de Leeuw PW, Duprez DA,  Fagard rH, et al. Prognostic value of ambulatory blood-pressure recordings  in patients with treated hypertension. N Engl J Med 2003;348(24):2407-15.

8. Asayama K, Ohkubo T, Kikuya M, Metoki H, Hoshi H, Hashimoto J, et  al. Prediction of stroke by self-measurement of blood pressure at home  versus casual screening blood pressure measurement in relation to the  Joint National Committee 7 classification: the Ohasama study. Stroke  2004;35(10):2356-61.

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