HJAR Jul/Aug 2023

HEALTHCARE JOURNAL OF ARKANSAS I  JUL / AUG 2023 29 that patients — just like us physicians — are fal- lible and forgetful, and that our job is to deeply understand their questions, concerns, motiva- tions, hesitations, and barriers to reliably taking blood pressure medications. Setting expecta- tions up front and informing them that a typi- cal patient with high blood pressure requires at least 2 to 3 medications to achieve reliable control is also important. Implementing sys- tems and processes to ensure that patients return in a timely manner to have their blood pressure rechecked at specified intervals or that they purchase a home blood pressure cuff and report back the numbers is also essential. If a patient is using a home blood pressure cuff to monitor their pressures, they need to make sure that it is a validated instrument, which can be done by instructing them to go to www.validatebp.org to make sure their home cuff is reliable. The provider and patient also need to understand that lower dosages of multiple medications is a better strategy than maximizing the dose of each drug individually before add- ing an additional agent. This strategy has the benefit of reducing the risks of potential side effects while con- comitantly realizing that the greatest impact on blood pressure control for each medication occurs at the lower and midrange doses, with only mod- est amounts of additional benefit at the highest dosages (but with great- er risk of side effects at higher doses). And providers also need to appreci- ate that blood pressure lability — the tendency for blood pressure to fluc- tuate over 24 hours as shorter acting agents’ effectiveness begin to wane — requires the use of longer acting, more potent agents whenever possible. Also important to BP lability is an in- dividual’s susceptibility to salt intake. Under- standing this salt sensitivity is very important, especially here in the South, where any good cook knows that salt is one of the most impor- tant ingredients in our cuisine. One reason the concept is so important is that high salt intake can ultimately become correlated with higher levels of a hormone in our bloodstream known as aldosterone. Aldosterone, which plays a vital role in helping maintain our total fluid balance, can have direct inflammatory and fibrotic ef- fects on our organs, independent of its effect on blood pressure. These inflammatory and fibrotic effects can accelerate the aging pro- cess and hasten the development of cardio- vascular disease like heart attacks and strokes. Aldosterone excess states are common, and yet some drugs that effectively block aldoste- rone are dramatically underutilized. Therefore, because of the prevalence of accelerated ag- ing effects of aldosterone excess, even among those providers and systems achieving >80- 90% control rates, there is likely considerable room for improvement in the composition of anti-hypertensive regimens when consider- ing such factors as potency, duration of ac- tion, side effect profile, salt susceptibility, and anti-inflammatory effects of certain drugs. Indeed, one of the biggest problems that we face in healthcare is clinically unwarranted practice pattern variation — in other words, the individual variability among providers in how they practice medicine. Gaps in knowl- edge and differences in operational processes at the provider level can lead to high levels of variation and, in this case, how a given provider manages high blood pressure. Structured care pathways are a potential solution to this prob- lem. Providers might push back and feel like their autonomy is threatened. I’m not opposed to provider autonomy as long as we are hold- ing ourselves accountable for outcomes and not hiding behind excuses. Follow- ing specified care pathways is most applicable when knowledge of the management of a given condition is so evolved that it becomes explicit and can be captured as a structured series of if/then steps, otherwise known as a “sequential care pro- cess.” Hypertension management lends itself beautifully to this type of process. Sequential care processes should be differentiated from “itera- tive care processes.” Outlined in his book, Designing Health Care: Using Operations Management to Improve Performance and Delivery , Richard Bohmer, MD, a physician who served on the faculty of Harvard Business School, has conducted extensive re- search in this area. He successfully collected real-world evidence show- ing how improving operational pro- cesses can be used to improve health outcomes and reduce avoidable medical expenditures. Iterative care processes have traditionally been the norm in medicine, where the focus on diagnostic evaluation of acute condi- tions requires the tacit knowledge of each provider to reason through a series of iterative and recursive steps, where each step in the process informs the next. A classic example is the ability of a great clinician to sort through unstructured informa- tion, such as a patient presenting with a fever of unknown origin. But as our understanding of how to manage chronic conditions becomes progressively more evolved, the need for this type of reasoning through an unstructured, it- erative care process becomes outmoded. What is even more important than the process uti- lized, however, is understanding the outcome generated. Outcomes that utilize iterative care processes depend on individual knowledge and practice patterns of a provider, while out- “Following specified care pathways is most applicable when knowledge of the management of a given condition is so evolved that it becomes explicit and can be captured as a structured series of if/then steps, otherwise known as a ‘sequential care process.’ Hypertension management lends itself beautifully to this type of process.”