Tackling the burden of hypertension in Canada

Shared care

It is important to emphasize that all health professional groups must work toward optimizing hypertension prevention, detection, lifestyle modification, treatment, and adherence. Coordination of services in the diverse array of community settings where patient care can be most efficiently provided is likely to provide the best patient outcomes; this reinforces the importance of integrating the skills and knowledge of nurses, pharmacists, and physicians. The overlapping skill sets of each profession can facilitate optimal use of health care resources by allowing various care delivery options.

Each health care professional has training that allows him or her to make a unique contribution to patient care decisions; the concept that the “whole is greater than the sum of its parts” should be embraced. Physicians, nurses, and pharmacists are all capable of obtaining an accurate blood pressure measurement, but the management plan for an individual patient is often dependent on a variety of other factors. Each practitioner can play a key role in identifying, communicating, and taking responsibility for the collective treatment plan. It is expected that any patient information affecting the treatment plan be appropriately documented and communicated with all team members; CHEP supports and encourages shared responsibility for patients with or at risk for hypertension.

Table 1 highlights some of the skill sets among health professional groups; although this list is not intended to be all-inclusive, it represents a starting point for initiating discussion within the primary care community. We believe it is important to provide uniform messages tailored to each patient and his or her expectations and to effectively communicate the ongoing care concerns for our shared patients.

Building blocks

The burden of hypertension, both detected and undetected, is too great for health care professionals not to work together for the sake of the patients, whom we all serve. Underdetection, issues of patient adherence and clinical inertia, and the complexity of treatment in the presence of other diseases impede our ability to gain better control rates nationally. By sharing responsibility with other health care professionals, like nurses and pharmacists, we can shift some of the burden of care from the family physician. Indeed, a recent systematic review concluded that using a team approach in the treatment of hypertension was the single most effective intervention to improve quality of care.5

Pharmacists, nurses, and other appropriate health care providers must be ready and willing to accept additional responsibility, but they also need to feel empowered to take on additional tasks. In addition, patients need to be educated about expectations from various health care professionals and how these groups can have a greater role and responsibility for their care. The ultimate goal is to enable patients to become ambassadors for their own hypertension management and to approach the appropriate health care professional for ongoing support and education when required.

The Romanow Report,6 released in 2002, identified 4 essential building blocks for the delivery of primary health care. These included continuity of care, early detection and action, better information on needs and outcomes, and stronger incentives and approaches for health care providers to participate in primary care. The report also emphasized the importance of collaborative teams and networks in future primary care models. Making this happen effectively is now our collective responsibility. We need to stop talking about it and start doing it.

Each year CHEP has done an excellent job updating the recommendations on the screening, diagnosis, and treatment of hypertension. Moreover, CHEP has endorsed the development of profession-specific guidelines for hypertension management with family physicians,7,8 pharmacists,9 and nurses.10 Evidence-based recommendations to assist patients in understanding and managing hypertension have also been developed.11 These guidelines encourage shared care and responsibility-taking, and provide accurate and timely information to support good management decisions for our patients. The CHEP website, www.hypertension.ca, contains many resources for health care providers and patients alike. Using these tools and incorporating them into your practice will provide an excellent framework for many relevant discussions.

All in all

The 2008 Annual Update to the CHEP guidelines promotes empowering patients to be more involved in their own self-management. Successfully achieving this will require the united efforts of all primary health care providers. Communication among team members will be of paramount importance, so that treatment goals are clearly understood, aligned, and reinforced by all team members. We encourage local groups, including other health care professionals such as dietitians, social workers, and exercise therapists, to begin this dialogue. It is important to develop communication techniques that will work in each specific setting. We challenge you to think about the way you currently provide care and whether or not you are maximizing the benefits of a collaborative, multidisciplinary approach to hypertension management.

Consider these questions..

Think about the way you currently provide care, and ask yourself the following questions:

• Do I routinely screen all my patients for hypertension?

• Do I routinely screen for hypertension in patients known to be high risk (eg, patients with diabetes, patients with a history of coronary artery disease)?

• Do I routinely discuss important lifestyle modifications to decrease the risk of hypertension?

Ask yourself the following questions when treating patients with hypertension:

• Are treatment goals documented?

• Do my patients know how to properly measure their blood pressure at home?

• Do my patients adhere to medication and lifestyle recommendations?

• Are treatment goals maintained over the long term?