HJAR Jul/Aug 2023

CHANGING THE CARE: HIGH BLOOD PRESSURE 28 JUL / AUG 2023 I  HEALTHCARE JOURNAL OF ARKANSAS   history. It should be noted that social history was initially dominated by understanding spe- cific patient behaviors, like quantity and type of alcohol consumption or tobacco use. And then eventually as the AIDS epidemic came into be- ing, sexual behaviors and illicit drug use were included to assess their risk of acquiring HIV infection. Understanding the social determi- nants of health as barriers to self-management of chronic conditions wasn’t even much of a consideration at this point. Neither, for that matter, was actually holding ourselves account- able for how well a given chronic condition was managed. Asking such questions as what percentage of my patients have their blood pressure controlled was nearly unheard of. After obtaining the social history, emphasis was placed on gathering a review of systems, sort of a collection of “afterthoughts” of infor- mation not collected in the history of present illness, that could inform the diagnostic pro- cess and contribute to any alteration of the evaluation and treatment plan. Next came the physical exam. Some of the older and wiser physicians among us have bemoaned the de- cline of the physical exam’s importance, even as some of the newer, younger clinicians came to rely more on expensive advanced imaging and laboratory results over physical examina- tion skills. What may become lost in these musings about diminished physical exam skills is how the aging population, the increased in- cidence and prevalence of chronic conditions, and the rising costs of healthcare — multifacto- rial in origin — all combined to create a set of economic pressures that often translated into dictums such as needing to see “just two more patients a day” to generate the same level of economic return for a primary care practice. As the daily volume of patients increased, we began to see an inverse correlation with the amount of time available to obtain detailed historical information and perform a compre- hensive physical exam. These time constraints were less impactful to specialists whose ques- tions are limited to a finite area of concern with their exam hyper focused on their specific area of expertise. For primary care, however, the concept of not enough hours in the day was born. It started with not enough time to go to the hospital and see their “sick” patients but has now evolved into not enough time to manage their burgeoning panel sizes, creating problems in patient access, experience, and quality of care. In some cases, PCPs began to find themselves serving as a triage function where they diagnosed minor acute ailments and referred anything more complex to a spe- cialist. The diminishing rewards of primary care combined with the growing disparity between specialty and primary care incomes resulted in fewer medical students choosing primary care. The resultant shortage, along with the rising number of PCPs leaving practices for concierge care or administrative roles only ex- acerbated the problem for all those left behind. Furthermore, medical training was and is al- most entirely focused on helping aspiring clini- cians learn both the art and science of medicine where diagnosis and treatment of acute illness and management of complications of uncon- trolled chronic conditions remain the dominant focus. This type of training is obviously neces- sary, and I do not question its importance. But we must confront the reality of the present, and that our prevailing approach to clinical care has largely been reactive and downstream. The reference “downstream” refers to the parable where two friends are walking along a riverbank, and one friend sees a child com- ing downstream in danger of drowning. Both friends jump into the water to rescue and bring the child safely to shore only to recognize yet another child coming downstream, followed by another and then another in rapid succession. Even as the two friends cannot keep up with the flood of drowning children, one friend gets out of the water and starts running upstream. The friend who is still in the water yells after the other, “where are you going? Aren’t you going to help me rescue these drowning children?” The other friend yells “I’m going upstream to tackle the guy whose throwing these kids in the water!” It is a parable that every practicing primary care provider can relate to all too well. GOINGUPSTREAMTO TACKLE THE PROBLEM Since atherosclerotic cardiovascular and cerebrovascular disease (ASCVD) are the lead- ing causes of death and disability respectively in this country, it makes sense to start with a discussion of heart attacks and strokes as being the classic examples of our healthcare system’s focus on downstream solutions over upstream prevention. Risk factors for ASCVD include, but are not limited to, the upstream chronic con- ditions of hypertension (high blood pressure), diabetes mellitus, dyslipidemia, obesity, and chronic kidney disease, along with cigarette smoking. In part because of prevailing eco- nomic models, hospitals tend to invest heavily in cardiac catheterization labs that enable coro- nary artery stent placement as a treatment for acute heart attack and will also pay exorbitantly to make sure they have cardiothoracic surgeons on staff for emergent and elective cardiac by- pass surgery. There is no question that both coronary stents and cardiac surgery can be life- saving — just as it is possible to save the life of a drowning child by diving in the water during an acute crisis — but if one child after another continues to be thrown in the water, exhaust- ing the energy and capacity of available re- sources to save them, it is much more efficient and effective to conceptualize new solutions to tackle the upstream problem differently. And we have very solid evidence that when you adequately manage and control chronic conditions effectively, you can reduce the risk of consequent cardiovascular complications, like heart attack and stroke, along with their associ- ated costs to society. When you achieve >90% rates of control or success rates across multiple risk factors — such as blood pressure <140/90 (preferably even <130/80) plus A1C < 8.0 plus smoking cessation plus statin therapy plus weight reduction in appropriate patients — we can reduce the number of heart attacks, strokes, specialty visits, procedures, surgeries, hospital- izations, and emergency room visits, especially when you achieve those rates concurrently. IMPROVING HYPERTENSION MANAGEMENT There are studies showing that fewer than 50% of people in this country have their blood pressure controlled. So, let’s start with hyper- tension control, largely just because it is so incredibly easy to achieve rates of >90% con- trol across a population, even within current economic models. The essential ingredients are all the elements we have been discussing in the past few articles. First, it takes a shift in the cultural mindset of the physician where they are willing and engaged in being held ac- countable for their own performance. Those physicians who still view their role as “telling” a patient what blood pressure medications to take and expecting patient “compliance” will struggle. The first prerequisite is to understand