Summary

Around half of patients who have diabetes do not get any extra treatment when they present with high blood pressure, according to a new study. The underlying reason is a 'clinical inertia' where doctors are not sure what they should do. Clear guidelines would help them to treat their patients better.

Introduction

Although there are many medications that can treat high blood pressure, and lifestyle modifications can help as well, the fact is that many of those with the condition go without either treatment or advice. Doctors could prescribe medication or add new drugs to those already prescribed, or they could monitor lifestyle advice. Their failure to do so has been called 'clinical inertia'. There are various reasons why this might occur, one of which is a lack of knowledge of the patient's 'true' blood pressure. Readings vary widely - whether taken in the doctor's office, or at home by the patient. Lack of treatment of high blood pressure might have serious consequences for the patient, because it is a risk factor for cardiovascular and kidney disease. This is even more the case for a patient with diabetes. Therefore, researchers at the University of Michigan Health System looked at how diabetic patients with high blood pressure were treated, and the reasons why.

What was done

The researchers studied 1,169 people with diabetes seen by 92 different primary care providers in Veterans Association primary care clinics in three different states. Most of the care providers were doctors, but there were also some nurse practitioners and physician assistants. All the patients had a blood pressure reading that was over 140/90 mm Hg. The national goal is for people with diabetes to have a reading that is less than 130/80 mm Hg. Changes of treatment prescribed by the healthcare provider were recorded. Both patients and providers filled in a questionnaire to find out why various decisions were made.

What was found

Around half of the patients received a change in their blood pressure treatment as a result of their visit to the clinic. This could have been a change in dosage, a change in medication or a plan to follow up. There was wide variation among clinics in whether a treatment change would be ordered. A major factor in this was uncertainty about the patient's true blood pressure reading. Sometimes it was repeated in the clinic, sometimes not. In some cases, the patient had been taking their own readings with a home blood pressure monitor and this tended to influence the decision on whether or not to change medication. A complicating factor is that there are no guidelines on how often patients should record their own blood pressure. Also, patients attending the clinic for a reason other than blood pressure tended not to receive a treatment change.

What this study means

The researchers say that diabetic patients may be missing out on optimal management of their blood pressure which, in turn, may affect their long term health. Clearer guidelines need to be devised on what meaning to attach to patients' own blood pressure measurements and those taken in the doctor's office. This will then help the healthcare provider make better decisions on when some fine-tuning of medication is called for.