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Improving hypertension management in my practice

I see many people with high blood pressure (BP); 14.4% of the population reports having been diagnosed with hypertension.¹ Various guidelines now recommend getting 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 hypertension 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.⁵ I used to measure BP with the patient sitting on my examining table, which is not ideal.

I recently bought a validated automated BP monitor (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 minutes; 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 morbidity.^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 necessary, 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 several 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 automatically 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 monitor 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 save time for physicians. Home BP monitors can help patients take control of their BP management. Electronic medical records can help with patient education; automated flow sheets make follow-up of multiple parameters much easier. I now spend less time taking patients’ BP measurements myself, but I think I’m achieving better 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

Footnotes

Competing interests

None declared

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."

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.[Free Full Text]
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.[Medline]
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.[Medline]
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.[Medline]
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.[Abstract/Free Full Text]
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.[Abstract/Free Full Text]

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