By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Join me in taking control of hypertension across our nation. Together, we’ve got this.”

–Jerome M. Adams, Surgeon General of the United States

Control of hypertension has been shown to reduce heart attacks and strokes, reducing both morbidity and mortality.

On a population basis, blood pressure control in the US has worsened from 53.8% under control in 2014, to 43.7% under control in 2018 (JAMA, September 22/29, 2020). This has led the U.S. surgeon general to declare a Call to Action on Hypertension Control. The goal of the U.S. Department of Health and Human Service’s Million Hearts campaign is to have 80% of patients with hypertension under good control, defined as a blood pressure of under 140/90.

Unfortunately, COVID-19 is likely carrying us further away from this goal. Patients with telemedicine visits only have their blood pressure assessed only 9.6% of the time, compared to 69.7% of the time during office-based visits. (October 2, 2020 edition of JAMA Network Open Access)

About 25% of adult PHC members have a diagnosis of hypertension. From pharmacy data, 17% are taking at least one blood pressure (BP) medication. Their level of blood pressure control, in 2019, averaged around 65%, much better than the 43.7% rate found nationally by JAMA, but far below the 80% goal of the Million Hearts campaign. This 80% goal is achievable, as shown by six of our larger primary care providers whose hypertension control rates were better than 80% last year:

Fairchild Medical Center (Yreka, Siskiyou county):       89%

Northbay Center for Primary Care (Solano county):      84%

Kaiser Permanente, in Marin and Sonoma counties:    82%

Shasta Community Health Centers (Shasta county):    82%

Petaluma Health Centers (Sonoma county):                  82%

Sutter Lakeside (Lake county):                                       81%

Before the 1980s, diabetes self-management (including patient monitoring of their own blood sugar), was NOT the standard of care. Patients had their blood sugar measured in the laboratory or in the doctor’s office. Since the 1980s, it has become standard of care for all persons with diabetes to monitor their own blood sugars.

Blood pressure monitoring today is where blood sugar monitoring was in the 1970s. It is time to empower patients to monitor their own blood pressure at home. One of the strategies listed by the Surgeon General is to “Empower and equip patients to use self-measured blood pressure monitoring.” The Million Hearts campaign describes the evidence base showing better blood pressure control with home monitoring, combined with a medical team that uses this data to take action.

Partnership HealthPlan of California (PHC) covers home blood pressure monitors for our members. These can be obtained from a community pharmacy with a prescription/order from the Primary Care Physician (PCP), until December 31, when the state pharmacy carve out kicks in. Medi-Cal Rx will be administered through the Fee-For-Service (FFS) delivery system. For more information and to apply for your Practice ID number, visit their website. Additionally, we have a direct distribution pilot for BP monitors on a first-come, first-served basis. Interested providers will need to complete the DME Request Form on our website. This program will be continued and expanded in the year to come.

Petaluma Health Center had a best practice with us. Instead of reminding their clinicians to remember to prescribe BP monitors, they sent a text message to all their PHC patients with hypertension and asked them to respond if they wanted a home BP monitor. This was an effort to reduce the exposure to COVID-19, by reducing the trips into the office to check their blood pressure. About 10% of those texted responded with a request for a BP monitor. Petaluma Health Center set up a streamlined system to send the orders to PHC (through our direct distribution pilot), and we delivered the devices directly to the patients’ home.

We hope you will consider an active outreach campaign like this, for your patients with hypertension. As our Surgeon General says, “Together, we’ve got this!”

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Beware of words – they are dangerous things. They change color like the chameleon, and they return like a boomerang.”

–Dr. William Osler

The words we choose to use in our interactions with patients convey underlying meaning. Sometimes this underlying meaning can affect patient decision-making in unintentional ways.

In an editorial in the September 8, 2020 edition of JAMA, entitled “Improving Physician Communication About Treatment Decisions: Reconsideration of “Risks vs Benefits,” the authors argue that the commonly-used phrase “risks vs benefits” implies that harms from a procedure are possible, but the benefits are assured. This asymmetry would be corrected by using the phrase, “weighing the chance of harm and chance of benefit” of a particular intervention.

One physician responded to the editorial, noting that additionally, the “chance of harm if nothing is done” must also be accounted for, if a complete picture of the probabilities to be weighed is to be presented.

This may be the most accurate presentation of everything a patient must consider, but humans have difficulty understanding what the probability of an outcome really means. Experts in shared decision-making recommend using visual representations of probability, or comparing the probability to something more understandable, like the probability of a car accident while driving home.

Such devices may still be too hard to grasp for patients seeking certainty when making decisions. Such a desire for certainly is a big driver of vaccine hesitancy, in which the absence of certainty of safety of an intervention is used to default to not taking action.

Logically, a decision of whether to act or not should balance the chances of harm or benefit of the intervention, accounting for the chances of harm of no action. In reality human brains are generally wired to choose to not take action if they are not certain of what they want. Psychologists call this omission bias, the tendency to favor an act of omission (inaction) over one of commission (action).

Of course, this is just one of many biases, which come into play in the clinical interaction between clinician and patient that may impact the patient’s willingness to undergo an intervention.

Nonetheless, changing our language from “weighing risks vs benefits” to “considering the chance of harm and the chance of benefit of the intervention with the chance of harm of doing nothing” may help some patients weigh their options in making therapeutic decisions.