Hypertension: Docs Lead Charge in South Carolina

Primary-care providers are on the frontlines in improving public health today, especially when it comes to reducing the burden of cardiovascular disease (CVD).

But it helps to have a road map, said Brent Egan, MD, at the 19^th Annual Conference on Hypertension, Diabetes and Dyslipidemia in Charleston, SC.

“Current guidelines may lay out what good patient-care looks like, but doesn’t show how to get there,” he said. “We need new approaches to create a good patient experience, given realistic patient behavior and constraints.”

He has a map in mind--one drawn in South Carolina..

Egan, medical director of the Care Coordination Institute in Greenville, SC, and a professor at University of South Carolina said he led an effort to change behavior and CVD risk in South Carolina in 1995. At the time, South Carolina ranked 50 out of a list of 51 (the states plus Washington DC) for CVD levels and had been there since the 1930s. Egan’s team reached out to physicians across state to change practice and raise the use of evidence-based strategies for treating CVD.

“Now there are more ASH [American Society of Hypertension] hypertension specialists in SC than any other state,” Egan said, and, partly as a result of having so many physicians with that training, South Carolina rose in the rankings to 34. Community involvement was also key.

Mindful of the fact that as he spoke at the meeting, people just blocks away were attending funerals of church-goers killed in the attack on the Emanuel AME church, Egan said community outreach is also very important. He said he often worked with members of African American churches, getting their help in spreading the prevention message to this at-risk population.

And they have succeeded, he said, with church members getting others in the congregation to take better care of themselves and reduce their risk of CVD.

The success was particularly poignant to Egan. “The African Americans who live in South Carolina have been told that they are the worst at everything since they were little kids,” he said.

But their success in making this program work has been a milestone, he said. These patients have been more inspired by the outcomes than the doctors, Egan said.

Many expressed pride in what they achieved, a feeling he shares.

“They’re no longer the worst and it’s at something very important,” Egan said.

He believes that such public health campaigns should be replicated.

Egan pointed out that, increasingly, primary-care doctors have to pick up the slack left because public health messaging has fallen off from what it was in the 1960s and 1970s.

During those decades, the U.S. saw significant reductions in dietary and lifestyle risks such as sodium and fat intake and he credits public health messaging.

“Coronary heart disease fell by 38% in that short time and more than 50% could be attributed to positive change in behavior rather than in the care received,” Egan said.

Population health is largely determined by factors that are not addressed by health care, including individual behavior, social environment, physical environment and genetics. Health care makes up only 20% of determinants, said Egan. Instead, he said, “We’re putting most of our money into 20% of the determinants of chronic disease,” he said.

In the UK, government spends far less on medical care but more on public health and gets better outcomes, Egan added.

“In the U.S., more people have chronic conditions such as hypertension,” said Egan. “But instead of trying to reduce the number of people with these conditions on a population level, we just treat more and more people who get sick.”

Adherence is a big issue, one that can be partly addressed in the primary care setting, he said.

He stresses techniques like focusing on and addressing patients’ missed appointments, initiating home self-monitoring, and using ‘teach-back’ techniques, that is, asking patients to explain what they heard leads to greatly improved outcomes. It is also import to use “shared decision-making”, involving patients in making treatment choices.

These practices are part of running “patient-centered medical homes”, he said.

There will still be barriers to patient adherence, Egan said. Those may include low literacy, lack of insurance, and cultural beliefs. One particularly difficult barrier occurs when people—likely because they are forced to live paycheck-to-paycheck-- do not assign value to taking steps that may benefit them in the future.

In one experiment in which people were given a choice between instant cash immediately or more money years later, most people said they preferred the former.

“Anything greater than 2 years in the future had no value to people today,” Egan said.